Cable properties and propagation velocity in a long single chain of simulated myocardial cells.

BACKGROUND: Propagation of simulated action potentials (APs) was previously studied in short single chains and in two-dimensional sheets of myocardial cells 123. The present study was undertaken to examine propagation in a long single chain of cells of various lengths, and with varying numbers of gap-junction (g-j) channels, and to compare propagation velocity with the cable properties such as the length constant (lambda). METHODS AND RESULTS: Simulations were carried out using the PSpice program as previously described. When the electric field (EF) mechanism was dominant (0, 1, and 10 gj-channels), the longer the chain length, the faster the overall velocity (theta(ov)). There seems to be no simple explanation for this phenomenon. In contrast, when the local-circuit current mechanism was dominant (100 gj-channels or more), theta(ov) was slightly slowed with lengthening of the chain. Increasing the number of gj-channels produced an increase in theta(ov) and caused the firing order to become more uniform. The end-effect was more pronounced at longer chain lengths and at greater number of gj-channels. When there were no or only few gj-channels (namely, 0, 10, or 30), the voltage change (DeltaV(m)) in the two contiguous cells (#50 & #52) to the cell injected with current (#51) was nearly zero, i.e., there was a sharp discontinuity in voltage between the adjacent cells. When there were many gj-channels (e.g., 300, 1000, 3000), there was an exponential decay of voltage on either side of the injected cell, with the length constant (lambda) increasing at higher numbers of gj-channels. The effect of increasing the number of gj-channels on increasing lambda was relatively small compared to the larger effect on theta(ov). theta(ov) became very non-physiological at 300 gj-channels or higher. CONCLUSION: Thus, when there were only 0, 1, or 10 gj-channels, theta(ov) increased with increase in chain length, whereas at 100 gj-channels or higher, theta(ov) did not increase with chain length. When there were only 0, 10, or 30 gj-channels, there was a very sharp decrease in DeltaV(m) in the two contiguous cells on either side of the injected cell, whereas at 300, 1000, or 3000 gj-channels, the voltage decay was exponential along the length of the chain. The effect of increasing the number of gj-channels on spread of current was relatively small compared to the large effect on theta(ov).

Transverse propagation in an expanded PSpice model for cardiac muscle with gap-junction ion channels.

Transverse propagation was previously found to occur in a two-dimensional model of cardiac muscle using the PSpice software program for electronic circuit design and analysis. Longitudinal propagation within each chain, and transverse propagation between parallel chains, occurred even when there were no gap-junction (g-j) channels inserted between the simulated myocardial cells either longitudinally or transversely. In those studies, there were pronounced edge (boundary) effects and end-effects even within single chains. Transverse velocity increased with increase in model size. The present study was performed to examine boundary effects on transverse propagation velocity when the length of the chains was held constant at 10 cells and the number of parallel chains was varied from 3 to 5, to 7, to 10, and to 20. The number of g-j channels was either zero, both longitudinally and transversely (0/0), or 100/100. Some experiments were also made at 100/0, 1/1, and 10/10. Transverse velocity and overall velocity (both longitudinal and transverse components) was calculated from the measured total propagation time (TPT), i.e., the elapsed time between when the first action potential (AP) and the last AP crossed the zero potential level. The transverse g-j channels were placed only at the ends of each chain, such that propagation would occur in a zigzag pattern. Electrical stimulation was applied intracellularly between cells A1 and A2. It was found that, with no g-j channels (0/0), overall velocity increased almost linearly when more and more chains were placed in parallel. In contrast, with many g-j channels (100/100), there was a much flatter relationship between overall velocity and number of parallel chains. The difference in velocities with 0/0 channels and 100/100 channels was reduced as the number of chains was increased. In conclusion, edges have important effects on propagation velocity (overall and transverse) in cardiac muscle simulations.

Propagation velocity profile in a cross-section of a cardiac muscle bundle from PSpice simulation.

BACKGROUND: The effect of depth on propagation velocity within a bundle of cardiac muscle fibers is likely to be an important factor in the genesis of some heart arrhythmias. MODEL AND METHODS: The velocity profile of simulated action potentials propagated down a bundle of parallel cardiac muscle fibers was examined in a cross-section of the bundle using a PSpice model. The model (20 x 10) consisted of 20 chains in parallel, each chain being 10 cells in length. All 20 chains were stimulated simultaneously at the left end of the bundle using rectangular current pulses (0.25 nA, 0.25 ms duration) applied intracellularly. The simulated bundle was symmetrical at the top and bottom (including two grounds), and voltage markers were placed intracellularly only in cells 1, 5 and 10 of each chain to limit the total number of traces to 60. All electrical parameters were standard values; the variables were (1) the number of longitudinal gap-junction (G-j) channels (0, 1, 10, 100), (2) the longitudinal resistance between the parallel chains (Rol2) (reflecting the closeness of the packing of the chains), and (3) the bundle termination resistance at the two ends of the bundle (RBT). The standard values for Rol2 and RBT were 200 KOmega. RESULTS: The velocity profile was bell-shaped when there was 0 or only 1 gj-channel. With standard Rol2 and RBT values, the velocity at the surface of the bundle (theta1 and theta20) was more than double (2.15 x) that at the core of the bundle (theta10, theta11). This surface:core ratio of velocities was dependent on the values of Rol2 and RBT. When Rol2 was lowered 10-fold, theta1 increased slightly and theta2decreased slightly. When there were 100 gj-channels, the velocity profile was flat, i.e. the velocity at the core was about the same as that at the surface. Both velocities were more than 10-fold higher than in the absence of gj-channels. Varying Rol2 and RBT had almost no effect. When there were 10 gj-channels, the cross-sectional velocity profile was bullet-shaped, but with a low surface/core ratio, with standard Rol2 and RBT values. CONCLUSION: When there were no or few gj-channels (0 or 1), the profile was bell-shaped with the core velocity less than half that at the surface. In contrast, when there were many gj-channels (100), the profile was flat. Therefore, when some gj-channels close under pathophysiological conditions, this marked velocity profile could contribute to the genesis of arrhythmias.

Effect of transverse gap-junction channels on transverse propagation in an enlarged PSpice model of cardiac muscle.

BACKGROUND: In previous PSpice modeling studies of simulated action potentials (APs) in parallel chains of cardiac muscle, it was found that transverse propagation could occur between adjacent chains in the absence of gap-junction (gj) channels, presumably by the electric field (EF) generated in the narrow interstitial space between the chains. Transverse propagation was sometimes erratic, the more distal chains firing out of order. METHODS: In the present study, the propagation of complete APs was studied in a 2-dimensional network of 100 cardiac muscle cells (10 x 10 model). Various numbers of gj-channels (assumed to be 100 pS each) were inserted across the junctions between the longitudinal cells of each chain and between adjacent chains (only at the end cells of each chain). The shunt resistance produced by the gj-channels (Rgj) was varied from 100,000 M omega (0 gj-channels) to 1,000 M omega (10 channels), 100 M omega (100 channels) and 10 M omega (1,000 channels). Total propagation time (TPT) was measured as the difference between the times when the AP rising phase of the first cell (cell # A1) and the last cell (in the J chain) crossed 0 mV. When there were no gj-channels, the excitation was transmitted between cells by the EF, i.e., the negative potential generated in the narrow junctional clefts (e.g., 100 angstroms) when the prejunctional membrane fired an AP. For the EF mechanism to work, the prejunctional membrane must fire a fraction of a millisecond before the adjacent surface membrane. When there were many gj-channels (e.g., 100 or 1,000), the excitation was transmitted by local-circuit current flow from one cell to the next through these channels. RESULTS: TPT was measured as a function of four different numbers of transverse gj-channels, namely 0, 10, 100 and 1,000, and four different numbers of longitudinal gj-channels, namely 0, 10, 100 and 1,000. Thus, 16 different measurements were made. It was found that increasing the number of transverse channels had no effect on TPT when the number of longitudinal channels was low (i.e., 0 or 10). In contrast, when the number of longitudinal gj-channels was high (e.g., 100 or 1,000), then increasing the number of transverse channels decreased TPT markedly. CONCLUSION: Thus, complete APs could propagate along a network of 100 cardiac muscle cells even when no gj-channels were present between the cells. Insertion of transverse gj-channels greatly speeded propagation through the 10 x 10 network when there were also many longitudinal gj-channels.

Repolarization of the action potential enabled by Na+ channel deactivation in PSpice simulation of cardiac muscle propagation.

BACKGROUND: In previous studies on propagation of simulated action potentials (APs) in cardiac muscle using PSpice modeling, we reported that a second black-box (BB) could not be inserted into the K+ leg of the basic membrane unit because that caused the PSpice program to become very unstable. Therefore, only the rising phase of the APs could be simulated. This restriction was acceptable since only the mechanism of transmission of excitation from one cell to the next was being investigated. METHODS AND RESULTS: We have now been able to repolarize the AP by inserting a second BB into the Na+ leg of the basic units. This second BB effectively mimicked deactivation of the Na+ channel conductance. This produced repolarization of the AP, not by activation of K+ conductance, but by deactivation of the Na+ conductance. The propagation of complete APs was studied in a chain (strand) of 10 cardiac muscle cells, in which various numbers of gap-junction (gj) channels (assumed to be 100 pS each) were inserted across the cell junctions. The shunt resistance across the junctions produced by the gj-channels (Rgj) was varied from 100,000 M? (0 gj-channels) to 10,000 M? (1 gj-channel), to 1,000 M? (10 channels), to 100 M? (100 channels), and 10 M? (1000 channels). The velocity of propagation (theta, in cm/s) was calculated from the measured total propagation time (TPT, the time difference between when the AP rising phase of the first cell and the last cell crossed -20 mV, assuming a cell length of 150 microm. When there were no gj-channels, or only a few, the transmission of excitation between cells was produced by the electric field (EF), i.e. the negative junctional cleft potential, that is generated in the narrow junctional clefts (e.g. 100 A) when the prejunctional membrane fires an AP. When there were many gj-channels (e.g. 1000 or 10,000), the transmission of excitation was produced by local-circuit current flow from one cell to the next through the gj-channels. CONCLUSION: We have now been able to simulate complete APs in cardiac muscle cells that could propagate along a single chain of 10 cells, even when there were no gj-channels between the cells.

Action potential repolarization enabled by Ca++ channel deactivation in PSpice simulation of smooth muscle propagation.

BACKGROUND: Previously, only the rising phase of the action potential (AP) in cardiac muscle and smooth muscle could be simulated due to the instability of PSpice upon insertion of a second black box (BB) into the K+ leg of the basic membrane unit. This restriction was acceptable because only the transmission of excitation from one cell to the next was investigated. METHODS: In the current work, the repolarization of the AP was accomplished by inserting a second BB into the Ca++ leg of the basic membrane unit. Repolarization of the AP was produced, not through an activation of the K+ channel conductance, but rather through a mimicking of the deactivation of the Ca++ channel conductance. Propagation of complete APs was studied in a chain (strand) of 10 smooth muscle cells, in which various numbers of gap-junction (gj) channels (assumed to be 100 pS each) were inserted across the cell junctions. RESULTS: The shunt resistance across the junctions produced by the gj-channels (Rgj) was varied from 100,000 MOmega (0 gj-channels) to 10,000 MOmega (1 gj-channel), to 1,000 MOmega (10 channels), to 100 MOmega (100 channels), to 10 MOmega (1000 channels), and to 1.0 MOmega (10,000 channels). Velocity of propagation (theta, in cm/sec) was calculated from the measured total propagation time (TPT, the time difference between when the AP rising phase of the first cell and the last cell crossed -20 mV), assuming a constant cell length of 200 microm. When there were no gj-channels, or only one, the transmission of excitation between cells was produced by the electric field (EF), i.e., the negative junctional cleft potential, that is generated in the narrow junctional clefts (e.g., 100 A) when the prejunctional membrane fires an AP (a fraction of a millisecond before the adjacent surface membrane). There were significant end-effects at the termination of the strand, such that the last cell (cell #10) failed to fire, or fired after a prolonged delay. This end-effect was abolished when the strand termination resistance (Rbt) was increased from 1.0 KOmega to 600 MOmega. When there were 1000 or 10,000 gj-channels, the transmission of excitation was produced by local-circuit current flow from one cell to the next through the gj-channels. DISCUSSION: In summary, it is now possible to simulate complete APs in smooth muscle cells that could propagate along a single chain of 10 cells, even when there were no gj-channels between the cells.

Boundary effects influence velocity of transverse propagation of simulated cardiac action potentials.

BACKGROUND: We previously demonstrated that transverse propagation of excitation (cardiac action potentials simulated with PSpice) could occur in the absence of low-resistance connections (gap--junction channels) between parallel chains of myocardial cells. The transverse transmission of excitation between the chains was strongly dependent on the longitudinal resistance of the interstitial fluid space between the chains: the higher this resistance, the closer the packing of the parallel chains within the bundle. The earlier experiments were carried out with 2-dimensional sheets of cells: 2 x 3, 3 x 4, and 5 x 5 models (where the first number is the number of parallel chains and the second is the number of cells in each chain). The purpose of the present study was to enlarge the model size to 7 x 7, thus enabling the transverse velocities to be compared in models of different sizes (where all circuit parameters are identical in all models). This procedure should enable the significance of the role of edge (boundary) effects in transverse propagation to be determined. RESULTS: It was found that transverse velocity increased with increase in model size. This held true whether stimulation was applied to the entire first chain of cells or only to the first cell of the first chain. It also held true for retrograde propagation (stimulation of the last chain). The transverse resistance at the two ends of the bundle had almost no effect on transverse velocity until it was increased to very high values (e.g., 100 or 1,000 megohms). CONCLUSION: Because the larger the model size, the smaller the relative edge area, we conclude that the edge effects slow the transverse velocity.

Propagated repolarization of simulated action potentials in cardiac muscle and smooth muscle.

BACKGROUND: Propagation of repolarization is a phenomenon that occurs in cardiac muscle. We wanted to test whether this phenomenon would also occur in our model of simulated action potentials (APs) of cardiac muscle (CM) and smooth muscle (SM) generated with the PSpice program. METHODS: A linear chain of 5 cells was used, with intracellular stimulation of cell #1 for the antegrade propagation and of cell #5 for the retrograde propagation. The hyperpolarizing stimulus parameters applied for termination of the AP in cell #5 were varied over a wide range in order to generate strength / duration (S/D) curves. Because it was not possible to insert a second "black box" (voltage-controlled current source) into the basic units representing segments of excitable membrane that would allow the cells to respond to small hyperpolarizing voltages, gap-junction (g.j.) channels had to be inserted between the cells, represented by inserting a resistor (Rgj) across the four cell junctions. RESULTS: Application of sufficient hyperpolarizing current to cell #5 to bring its membrane potential (Vm) to within the range of the sigmoidal curve of the Na+ conductance (CM) or Ca++ conductance (SM) terminated the AP in cell #5 in an all-or-none fashion. If there were no g.j. channels (Rgj = infinity), then only cell #5 repolarized to its stable resting potential (RP; -80 mV for CM and -55 mV for SM). The positive junctional cleft potential (VJC) produced only a small hyperpolarization of cell #4. However, if many g.j. channels were inserted, more hyperpolarizing current was required (for a constant duration) to repolarize cell #5, but repolarization then propagated into cells 4, 3, 2, and 1. When duration of the pulses was varied, a typical S/D curve, characteristic of excitable membranes, was produced. The chronaxie measured from the S/D curve was about 1.0 ms, similar to that obtained for muscle membranes. CONCLUSIONS: These experiments demonstrate that normal antegrade propagation of excitation can occur in the complete absence of g.j. channels, and therefore no low-resistance pathways between cells, by the electric field (negative VJC) developed in the narrow junctional clefts. Because it was not possible to insert a second black-box into the basic units that would allow the cells to respond to small hyperpolarizing voltages, only cell #5 (the cell injected with hyperpolarizing pulses) repolarized in an all-or-none manner. But addition of many g.j. channels allowed repolarization to propagate in a retrograde direction over all 5 cells.

Gap-junction channels inhibit transverse propagation in cardiac muscle.

The effect of adding many gap-junctions (g-j) channels between contiguous cells in a linear chain on transverse propagation between parallel chains was examined in a 5 x 5 model (5 parallel chains of 5 cells each) for cardiac muscle. The action potential upstrokes were simulated using the PSpice program for circuit analysis. Either a single cell was stimulated (cell A1) or the entire chain was stimulated simultaneously (A-chain). Transverse velocity was calculated from the total propagation time (TPT) from when the first AP crossed a Vm of -20 mV and the last AP crossed -20 mV. The number of g-j channels per junction was varied from zero to 100, 1,000 and 10,000 (Rgj of infinity, 100 MOmega, 10 MOmega, 1.0 MOmega, respectively). The longitudinal resistance of the interstitial fluid (ISF) space between the parallel chains (Rol2) was varied between 200 KOmega (standard value) and 1.0, 5.0, and 10 MOmega. The higher the Rol2 value, the tighter the packing of the chains. It was found that adding many g-j channels inhibited transverse propagation by blocking activation of all 5 chains, unless Rol2 was greatly increased above the standard value of 200 KOmega. This was true for either method of stimulation. This was explained by, when there is strong longitudinal coupling between all 5 cells of a chain awaiting excitation, there must be more transfer energy (i.e., more current) to simultaneously excite all 5 cells of a chain.

Transverse propagation of action potentials between parallel chains of cardiac muscle and smooth muscle cells in PSpice simulations.

BACKGROUND: We previously examined transverse propagation of action potentials between 2 and 3 parallel chain of cardiac muscle cells (CMC) simulated using the PSpice program. The present study was done to examine transverse propagation between 5 parallel chains in an expanded model of CMC and smooth muscle cells (SMC). METHODS: Excitation was transmitted from cell to cell along a strand of 5 cells not connected by low-resistance tunnels (gap-junction connexons). The entire surface membrane of each cell fired nearly simultaneously, and nearly all the propagation time was spent at the cell junctions, the junctional delay time being about 0.3-0.5 ms (CMC) or 0.8-1.6 ms (SMC). A negative cleft potential (Vjc) develops in the narrow junctional clefts, whose magnitude depends on the radial cleft resistance (Rjc), which depolarizes the postjunctional membrane (post-JM) to threshold. Propagation velocity (theta) increased with amplitude of Vjc. Therefore, one mechanism for the transfer of excitation from one cell to the next is by the electric field (EF) that is generated in the junctional cleft when the pre-JM fires. In the present study, 5 parallel stands of 5 cells each (5 x 5 model) were used. RESULTS: With electrical stimulation of the first cell of the first strand (cell A1), propagation rapidly spread down that chain and then jumped to the second strand (B chain), followed by jumping to the third, fourth, and fifth strands (C, D, E chains). The rapidity by which the parallel chains became activated depended on the longitudinal resistance of the narrow extracellular cleft between the parallel strands (Rol2); the higher the Rol2 resistance, the faster the theta. The transverse resistance of the cleft (Ror2) had almost no effect. Increasing Rjc decreases the total propagation time (TPT) over the 25-cell network. When the first cell of the third strand (cell C1) was stimulated, propagation spread down the C chain and jumped to the other two strands (B and D) nearly simultaneously. CONCLUSIONS: Transverse propagation of excitation occurred at multiple points along the chain as longitudinal propagation was occurring, causing the APs in the contiguous chains to become bunched up. Transverse propagation was more erratic and labile in SMC compared to CMC. Transverse transmission of excitation did not require low-resistance connections between the chains, but instead depended on the value of Rol2. The tighter the packing of the chains facilitated transverse propagation.

Activation of intestinal smooth muscle cells by interstitial cells of Cajal in simulation studies.

Activation of a two-dimensional sheet network (5 parallel chains of 5 cells each) of simulated intestinal smooth muscle cells (SMCs) by one interstitial cell of Cajal (ICC) was modeled by PSpice simulation. The network of 25 cells was not interconnected by gap-junction channels; instead, excitation was transmitted by the electric field that develops in the junctional clefts (JC) when the prejunctional membrane fires an action potential (AP). Transverse propagation between the parallel chains occurs similarly. The ICC cell was connected to cell E5 of the network [5th cell of the 5th (E) chain] via a high-resistance junction. The stimulating current, applied to the ICC cell interior, was made to resemble the endogenous undershooting slow wave (I(SW)). An I(SW) of 2.4 nA (over a rise time of 4 ms) took the ICC cell from a resting potential (RP) of -80 mV to a membrane potential of -41 mV. The slow wave produced a large negative cleft potential in the JC (V(JC); ICC-E5). The V(jc) brought the postjunctional membrane of E5 to threshold, causing this cell to fire an AP. This, in turn, propagated throughout the SMC network. If the ICC cell was given an RP of -55 mV (like SMC) and a slow wave of 40 mV amplitude (I(SW) of 1.8 nA), it still activated the SMC network. This was also true when the ICC cell was made excitable (developing an overshooting, fast-rising AP). In summary, one ICC cell displaying a slow wave was capable of activating a network of SMC in the absence of gap junctions.

Combined electric field and gap junctions on propagation of action potentials in cardiac muscle and smooth muscle in PSpice simulation.

Propagation of action potentials in cardiac muscle and smooth muscle were simulated using the PSpice program. Excitation was transmitted from cell to cell along a strand of 6 cells (cardiac muscle) or 10 cells (smooth muscle) either not connected (control) or connected by low-resistance tunnels (gap-junction connexons). A significant negative cleft potential (V(jv) ) develops in the narrow junctional cleft when the pre-JM fires. V(jc) depolarizes the postjunctional membrane (post-JM) to threshold by a patch-clamp action. With few connecting tunnels, cell-to-cell transmission by the EF mechanism was facilitated. With many tunnels, propagation was dominated by the low-resistance mechanism, and propagation velocity (theta) became very fast and nonphysiological. In conclusion, when the 2 mechanisms for cell-to-cell transfer of excitation were combined, the two mechanisms facilitated each other in a synergistic manner. When there were many connecting tunnels, the tunnel mechanism was dominant.

Propagation of action potentials between parallel chains of cardiac muscle cells in PSpice simulation.

Propagation of action potentials between parallel chains of cardiac muscle cells was simulated using the PSpice program. Excitation was transmitted from cell to cell along a strand of three or four cells not connected by low-resistance tunnels (gap-junction connexons) in parallel with one or two similar strands. Thus, two models were used: a 2 x 3 model (two parallel chains of three cells each) and a 3 x 4 model (three parallel chains of four cells each). The entire surface membrane of each cell fired nearly simultaneously, and nearly all the propagation time was spent at the cell junctions, thus giving a staircase-shaped propagation profile. The junctional delay time between contiguous cells in a chain was about 0.2-0.5 ms. A significant negative cleft potential develops in the narrow junctional clefts, whose magnitude depends on several factors, including the radial cleft resistance (Rjc). The cleft potential (Vjc) depolarizes the postjunctional membrane to threshold by a patch-clamp action. Therefore, one mechanism for the transfer of excitation from one cell to the next is by the electric field (EF) that is generated in the junctional cleft when the prejunctional membrane fires. Propagation velocity increased with elevation of Rjc. With electrical stimulation of the first cell of the first strand (cell A1), propagation rapidly spread down that chain and then jumped to the second strand (B chain), followed by jumping to the third strand (C chain) when present. The rapidity by which the parallel chains became activated depended on the longitudinal resistance of the narrow extracellular cleft between the parallel strands (Rol2). The higher the Rol2 resistance, the faster the propagation (lower propagation time) over the cardiac muscle sheet (2-dimensional). The transverse resistance of the cleft had no effect. When the first cell of the second strand (cell B1) was stimulated, propagation spread down the B chain and jumped to the other two strands (A and C) nearly simultaneously. When cell C1 was stimulated, propagation traveled down the C chain and jumped to the B chain, followed by excitation of the A chain. Thus, there was transverse propagation of excitation as longitudinal propagation was occurring. Therefore, transmission of excitation by the EF mechanism can occur between myocardial cells lying closely parallel to one another without the requirement of a specialized junction.

Levosimendan increases L-type Ca(2+) current via phosphodiesterase-3 inhibition in human cardiac myocytes.

To evaluate the potency of levosimendan, a newly developed cardiotonic agent, as a phosphodiesterase-3 inhibitor, we examined its effects on the L-type Ca(2+) current (I(Ca,L)) in single human atrial cells using the whole-cell voltage-clamp method. Levosimendan significantly increased I(Ca,L) in a concentration-dependent manner (E(max), 139.0 +/- 1.8%; EC(50), 54 +/- 3.6 nM). The increase in I(Ca,L) induced by 1 microM levosimendan was significantly greater in human atrial cells (136.7 +/- 11.0%, n=8) than in rabbit atrial cells (23.5 +/- 3.5%, n=6) (depolarization to +10 mV in each case). In rat atrial and ventricular cells, I(Ca,L) was unaffected by 1-10 microM levosimendan. These results indicate that the selective phosphodiesterase-3 inhibitor levosimendan increases cardiac-cell I(Ca,L) significantly more strongly in human than in rabbit and rat. It seems likely that the positive inotropic effect of levosimendan on the human myocardium depends on an increase in I(Ca,L) that is modulated by adenosine 3'5'-cyclic monophosphate (cAMP)-dependent phosphorylation.