Incessant Atrial Tachycardia From the Left Atrial Appendage Treated With Appendage Ligation.

A previously healthy man presented in shock due to incessant tachycardia. He ultimately required extracorporeal membrane oxygenation for support and clipping of his appendage for arrhythmia control. This case highlights the importance of early recognition of cardiogenic shock, aggressive hemodynamic support, and a multidisciplinary approach to managing these challenging arrhythmias.

In Vivo Findings of a Novel Focal Ablation Catheter: Focused Electric Field Catheter Tip.

Current catheter designs used for radiofrequency (RF) in cardiac tissue achieve limited ablation depth as lesion size is driven heavily by resistive heating at the tissue surface. A catheter with a truncated, dome-shaped tip with a toroidal surface designed for focal RF ablation was recently described. This in vivo study compares lesion characteristics between a second-generation focused electric field (FEF) catheter vs a standard irrigated catheter using RF energy in a beating heart model. We performed in vivo ablations using RF energy with the FEF ablation catheter tip (Focused Therapeutics) and an irrigated Blazer catheter (Boston Scientific) under identical power, duration, and irrigation rates. In addition, RF dosing at high power and duration was examined using the FEF catheter. Intracardiac echocardiography was used to evaluate steam pops and catheter tip angle relative to the tissue surface. Studies were terminal and lesion size was measured following 2,3,5-triphenyltetrazolium chloride staining. Ablations were performed in 6 swine (FEF, n = 31; control, n = 8). FEF ablation lesions (n = 7) were deeper (15.6 ± 2.6 mm vs 7.5 ± 1.9 mm; P < 0.001) and wider (18.4 ± 2.9 mm vs 12.6 ± 2.4 mm; P < 0.001) than lesions delivered with the control irrigated catheter (n = 8) under the same parameters. Thirty-two percent (n = 10 of 31) of lesions delivered from the left ventricle endocardial surface using the FEF catheter were transmural. No steam pops were observed with delivery of FEF lesions (n = 31). The angle of incidence did not significantly affect FEF lesion size. In this in vivo preclinical study, the FEF catheter, which provides focused energy delivery, resulted in significantly larger lesions than the irrigated control catheter without steam pops. Approximately one-third of ablations with the FEF catheter delivered from the endocardial left ventricular surface resulted in transmural lesions.

Circulating MicroRNA-30d Is Associated With Response to Cardiac Resynchronization Therapy in Heart Failure and Regulates Cardiomyocyte Apoptosis: A Translational Pilot Study.

BACKGROUND: Biomarkers that predict response to cardiac resynchronization therapy (CRT) in heart failure patients with dyssynchrony (HFDYS) would be clinically important. Circulating extracellular microRNAs (miRNAs) have emerged as novel biomarkers that may also play important functional roles, but their relevance as markers for CRT response has not been examined. METHODS AND RESULTS: Comprehensive miRNA polymerase chain reaction arrays were used to assess baseline levels of 766 plasma miRNAs in patients undergoing clinically indicated CRT in an initial discovery set (n=12) with and without subsequent echocardiographic improvement at 6 months after CRT. Validation of candidate miRNAs in 61 additional patients confirmed that baseline plasma miR-30d was associated with CRT response (defined as an increase in left ventricular ejection fraction ≥10%). MiR-30d was enriched in coronary sinus blood and increased in late-contracting myocardium in a canine model of HFDYS, indicating cardiac origin with maximal expression in areas of high mechanical stress. We examined the functional effects of miR-30d in cultured cardiomyocytes and determined that miR-30d is expressed in cardiomyocytes and released in vesicles in response to mechanical stress. Overexpression of miR-30d in cultured cardiomyocytes led to cardiomyocyte growth and protected against apoptosis by targeting the mitogen-associated kinase 4, a downstream effector of tumor necrosis factor. In HFDYS patients, miR-30d plasma levels inversely correlated with high-sensitivity troponin T, a marker of myocardial necrosis. CONCLUSIONS: Baseline plasma miR-30d level is associated with response to CRT in HFDYS in this translational pilot study. MiR-30d increase in cardiomyocytes correlates with areas of increased wall stress in HFDYS and is protective against deleterious tumor necrosis factor signaling.

Isolation, culture, and functional characterization of adult mouse cardiomyoctyes.

The use of primary cardiomyocytes (CMs) in culture has provided a powerful complement to murine models of heart disease in advancing our understanding of heart disease. In particular, the ability to study ion homeostasis, ion channel function, cellular excitability and excitation-contraction coupling and their alterations in diseased conditions and by disease-causing mutations have led to significant insights into cardiac diseases. Furthermore, the lack of an adequate immortalized cell line to mimic adult CMs, and the limitations of neonatal CMs (which lack many of the structural and functional biomechanics characteristic of adult CMs) in culture have hampered our understanding of the complex interplay between signaling pathways, ion channels and contractile properties in the adult heart strengthening the importance of studying adult isolated cardiomyocytes. Here, we present methods for the isolation, culture, manipulation of gene expression by adenoviral-expressed proteins, and subsequent functional analysis of cardiomyocytes from the adult mouse. The use of these techniques will help to develop mechanistic insight into signaling pathways that regulate cellular excitability, Ca(2+) dynamics and contractility and provide a much more physiologically relevant characterization of cardiovascular disease.

Intracardiac echocardiography and fluoroscopy guided percutaneous left ventricular pseudoaneurysm closure.

Left ventricular (LV) pseudoaneurysm is a rare complication after myocardial infarction and cardiac surgery. Standard treatment remains surgical correction; however, percutaneous closure has been attempted in high risk surgical patients. We report a case of three dimensional echocardiography and cardiac CT defined LV pseudoaneurysm which was closed percutaneously using intracardiac echocardiography (ICE) and fluoroscopy guidance. Appropriate planning and guidance proved essential to the procedure with an excellent outcome. Percutaneous closure of LV pseudoaneurysms is safe and feasible in high risk surgical patients and with appropriate imaging modalities may be an alternative to surgical correction.

Mutation in the S3 segment of KCNQ1 results in familial lone atrial fibrillation.

BACKGROUND: Mutations in several ion channel genes have been reported to cause rare cases of familial atrial fibrillation (AF). OBJECTIVE: The purpose of this study was to determine the genetic basis for AF in a family with autosomal dominant AF. METHODS: Family members were evaluated by 12-lead ECG, echocardiogram, signal-averaged P-wave analysis, and laboratory studies. Fourteen family members in AF-324 were studied. Six individuals had AF, with a mean age at onset of 32 years (range 16-59 years). RESULTS: Compared with unaffected family members, those with AF had a longer mean QRS duration (100 vs 86 ms, P = .015) but no difference in the corrected QT interval (423 +/- 15 ms vs 421 +/- 21 ms). The known loci for AF and other cardiovascular diseases were evaluated. Evidence of linkage was obtained with marker D11S4088 located within KCNQ1, and a highly conserved serine in the third transmembrane region was found to be mutated to a proline (S209P). Compared to the wild-type channel, the S209P mutant activates more rapidly, deactivates more slowly, and has a hyperpolarizing shift in the voltage activation curve. A fraction of the mutant channels are constitutively open at all voltages, resulting in a net increase in I(Ks) current. CONCLUSION: We identified a family with lone AF due to a mutation in the highly conserved S3 domain of KCNQ1, a region of the channel not previously implicated in the pathogenesis of AF.

Functional interactions between KCNE1 C-terminus and the KCNQ1 channel.

The KCNE1 gene product (minK protein) associates with the cardiac KvLQT1 potassium channel (encoded by KCNQ1) to create the cardiac slowly activating delayed rectifier, I(Ks). Mutations throughout both genes are linked to the hereditary cardiac arrhythmias in the Long QT Syndrome (LQTS). KCNE1 exerts its specific regulation of KCNQ1 activation via interactions between membrane-spanning segments of the two proteins. Less detailed attention has been focused on the role of the KCNE1 C-terminus in regulating channel behavior. We analyzed the effects of an LQT5 point mutation (D76N) and the truncation of the entire C-terminus (Delta70) on channel regulation, assembly and interaction. Both mutations significantly shifted voltage dependence of activation in the depolarizing direction and decreased I(Ks) current density. They also accelerated rates of channel deactivation but notably, did not affect activation kinetics. Truncation of the C-terminus reduced the apparent affinity of KCNE1 for KCNQ1, resulting in impaired channel formation and presentation of KCNQ1/KCNE1 complexes to the surface. Complete saturation of KCNQ1 channels with KCNE1-Delta70 could be achieved by relative over-expression of the KCNE subunit. Rate-dependent facilitation of K(+) conductance, a key property of I(Ks) that enables action potential shortening at higher heart rates, was defective for both KCNE1 C-terminal mutations, and may contribute to the clinical phenotype of arrhythmias triggered by heart rate elevations during exercise in LQTS mutations. These results support several roles for KCNE1 C-terminus interaction with KCNQ1: regulation of channel assembly, open-state destabilization, and kinetics of channel deactivation.

Cardiac conduction disturbances and ventricular tachycardia after prolonged propofol infusion in an infant.

We report an infant who, after prolonged intravenous propofol infusion for treatment of status epilepticus, developed dramatic cardiac conduction disturbances and tachyarrhythmias in the setting of only mild metabolic acidosis and good ventricular function. Certain electrocardiographic findings were similar to those observed in the Brugada syndrome as well as in adult patients with propofol toxicity who suffered fatal ventricular arrhythmias. This case illustrates that serious arrhythmias can occur during prolonged high-dose propofol infusion in young patients, probably through a direct electrophysiologic membrane effect.

S641 contributes HERG K+ channel inactivation.

The kinetics of voltage-dependent inactivation of the rapidly activating delayed rectifier, IKr, are unique among K+ channels. The human ether-a-gogo-related gene (HERG) encodes the pore-forming subunit of IKr and shares a high degree of homology with ether-a-gogo (EAG) channels that do not inactivate. Within those segments thought to contribute to the channel pore, HERG possesses several serine residues that are not present in EAG channels. Two of these serines, S620 and S631, are known to be required for inactivation. We now show that a third serine, S641, which resides in the outer portion of the sixth transmembrane segment, is also critical for normal inactivation. As with the other serines, S641 is also involved in maintaining ion selectivity of the HERG channel and alters sensitivity to block by E4031. Larger charged or polar substitutions (S641D and S641T) disrupted C-type inactivation in HERG. Smaller aliphatic and more conservative substitutions (S641A and S641C) facilitated C-type inactivation. Our data show that, like S620 and S631, S641 is another key residue for the rapid inactivation. The altered inactivation of mutations at S620, S631, and S641 were dominant, suggesting that a network of hydroxyl side chains is required for the unique inactivation, permeation, and rectification of HERG channels.

KCNE1 binds to the KCNQ1 pore to regulate potassium channel activity.

Potassium channels control the resting membrane potential and excitability of biological tissues. Many voltage-gated potassium channels are controlled through interactions with accessory subunits of the KCNE family through mechanisms still not known. Gating of mammalian channel KCNQ1 is dramatically regulated by KCNE subunits. We have found that multiple segments of the channel pore structure bind to the accessory protein KCNE1. The sites that confer KCNE1 binding are necessary for the functional interaction, and all sites must be present in the channel together for proper regulation by the accessory subunit. Specific gating control is localized to a single site of interaction between the ion channel and accessory subunit. Thus, direct physical interaction with the ion channel pore is the basis of KCNE1 regulation of K+ channels.

An LQT mutant minK alters KvLQT1 trafficking.

Cardiac I(Ks), the slowly activated delayed-rectifier K(+) current, is produced by the protein complex composed of alpha- and beta-subunits: KvLQT1 and minK. Mutations of genes encoding KvLQT1 and minK are responsible for the hereditary long QT syndrome (loci LQT1 and LQT5, respectively). MinK-L51H fails to traffic to the cell surface, thereby failing to produce effective I(Ks). We examined the effects that minK-L51H and an endoplasmic reticulum (ER)-targeted minK (minK-ER) exerted over the electrophysiology and biosynthesis of coexpressed KvLQT1. Both minK-L51H and minK-ER were sequestered primarily in the ER as confirmed by lack of plasma membrane expression. Glycosylation and immunofluorescence patterns of minK-L51H were qualitatively different for minK-ER, suggesting differences in trafficking. Cotransfection with the minK mutants resulted in reduced surface expression of KvLQT1 as assayed by whole cell voltage clamp and immunofluorescence. MinK-L51H reduced current amplitude by 91% compared with wild-type (WT) minK/KvLQT1, and the residual current was identical to KvLQT1 without minK. The phenotype of minK-L51H on I(Ks) was not dominant because coexpressed WT minK rescued the current and surface expression. Collectively, our data suggest that ER quality control prevents minK-L51H/KvLQT1 complexes from trafficking to the plasma membrane, resulting in decreased I(Ks). This is the first demonstration that a minK LQT mutation is capable of conferring trafficking defects onto its associated alpha-subunit.

KCNE regulation of KvLQT1 channels: structure-function correlates.

K(+) channels play a central role in determining resting membrane potential and cellular excitability. There is growing recognition that the channels exist not as independent units but as macromolecular complexes able to integrate a plethora of cellular signals to fine-tune channel activities. Interaction of K(+) channels with accessory proteins and subunits is increasingly reported as providing mechanisms for channels to respond to a variety of stimuli beyond just changes in membrane potential. One such association is that between some voltage-gated K(+) channels and the proteins encoded by the KCNE family of genes. The significance of these interactions is manifest in reports of genetic disorders such as the Long QT Syndrome linked to KCNE mutations and proarrhythmic drug susceptibilities from KCNE polymorphisms. The mechanism by which KCNE-encoded proteins control channel behavior is an emerging story. This article reviews some of the recent work addressing the prototypical KCNE-channel interaction between minK and KvLQT1.

A single transmembrane site in the KCNE-encoded proteins controls the specificity of KvLQT1 channel gating.

KCNEs are a family of genes encoding small integral membrane proteins whose role in governing voltage-gated potassium channel gating is emerging. Whether each member of this homologous family interacts with channel proteins in the same manner is unknown; however, it is clear that the functional effect of each KCNE on channel gating is different. The specificity of KCNE1 (minK) and KCNE3 control of activation of the potassium channel KvLQT1 maps to a triplet of amino acids within the KCNE transmembrane domain by chimera analysis. We now define the structural determinants of functional specificity within this triplet. The central amino acid of the triplet (Thr-58 of minK and Val-72 of KCNE3) is essential for the specific control of voltage-dependent channel activation characteristics of both minK and KCNE3. Using site-directed mutations that substitute minK and KCNE3 residues, we determined that a hydroxylated central amino acid is necessary for the slow sigmoidal activation produced by minK. The precise spacing of the hydroxyl group was required for minK-like activation. An aliphatic amino acid substituted at position 58 of minK is capable of reproducing KCNE3-like kinetics and voltage-independent constitutive current activation. The bulk of the central residue is another critical parameter, indicating precise positioning of this portion of the KCNE proteins within the channel complex. An intermediate phenotype produced by several smaller aliphatic-substituted mutants yields conditional voltage independence that is distinct from the voltage-dependent gating process, suggesting that KCNE3 traps the channel in a stable open state. From these results, we propose a model of KCNE-potassium channel interaction where the functional consequence depends on the precise contact at a single amino acid.