Multichannel modulation of depolarizing and repolarizing ion currents increases the positive rate-dependent action potential prolongation.

Prolongation of the action potential duration (APD) could prevent reentrant arrhythmias if prolongation occurs at the fast excitation rates of tachycardia with minimal prolongation at slow excitation rates (i.e., if prolongation is positive rate-dependent). APD prolongation by current anti-arrhythmic agents is either reverse (larger APD prolongation at slow rates than at fast rates) or neutral (similar APD prolongation at slow and fast rates), which may not result in an effective anti-arrhythmic action. In this report we show that, in computer models of the human ventricular action potential, the combined modulation of both depolarizing and repolarizing ion currents results in a stronger positive rate-dependent APD prolongation than modulation of repolarizing potassium currents. A robust positive rate-dependent APD prolongation correlates with an acceleration of phase 2 repolarization and a deceleration of phase 3 repolarization, which leads to a triangulation of the action potential. A positive rate-dependent APD prolongation decreases the repolarization reserve with respect to control, which can be managed by interventions that prolong APD at fast excitation rates and shorten APD at slow excitation rates. For both computer models of the action potential, ICaL and IK1 are the most important ion currents to achieve a positive rate-dependent APD prolongation. In conclusion, multichannel modulation of depolarizing and repolarizing ion currents, with ion channel activators and blockers, results in a robust APD prolongation at fast excitation rates, which should be anti-arrhythmic, while minimizing APD prolongation at slow heart rates, which should reduce pro-arrhythmic risks.

Positive rate-dependent action potential prolongation by modulating potassium ion channels.

Pharmacological agents that prolong action potential duration (APD) to a larger extent at slow rates than at the fast excitation rates typical of ventricular tachycardia exhibit reverse rate dependence. Reverse rate dependence has been linked to the lack of efficacy of class III agents at preventing arrhythmias because the doses required to have an antiarrhythmic effect at fast rates may have pro-arrhythmic effects at slow rates due to an excessive APD prolongation. In this report, we show that, in computer models of the ventricular action potential, APD prolongation by accelerating phase 2 repolarization (by increasing IKs ) and decelerating phase 3 repolarization (by blocking IKr and IK1 ) results in a robust positive rate dependence (i.e., larger APD prolongation at fast rates than at slow rates). In contrast, APD prolongation by blocking a specific potassium channel type results in reverse rate dependence or a moderate positive rate dependence. Interventions that result in a strong positive rate dependence tend to decrease the repolarization reserve because they require substantial IK1 block. However, limiting IK1 block to ~50% results in a strong positive rate dependence with moderate decrease in repolarization reserve. In conclusion, the use of a combination of IKs activators and IKr and IK1 blockers could result in APD prolongation that potentially maximizes antiarrhythmic effects (by maximizing APD prolongation at fast excitation rates) and minimizes pro-arrhythmic effects (by minimizing APD prolongation at slow excitation rates).

Post-repolarization refractoriness increases vulnerability to block and initiation of reentrant impulses in heterogeneous infarcted myocardium.

UNLABELLED: Myocardial infarction causes remodeling of the tissue structure and the density and kinetics of several ion channels in the cell membrane. Heterogeneities in refractory period (ERP) have been shown to occur in the infarct border zone and have been proposed to lead to initiation of arrhythmias. The purpose of this study is to quantify the window of vulnerability (WV) to block and initiation of reentrant impulses in myocardium with ERP heterogeneities using computer simulations. We found that ERP transitions at the border between normal ventricular cells (NZ) with different ERPs are smooth, whereas ERP transitions between NZ and infarct border zone cells (IZ) are abrupt. The profile of the ERP transitions is a combination of electrotonic interaction between NZ and IZ cells and the characteristic post-repolarization refractoriness (PRR) of IZ cells. ERP heterogeneities between NZ and IZ cells are more vulnerable to block and initiation of reentrant impulses than ERP heterogeneities between NZ cells. The relationship between coupling intervals of premature impulses (V1V2) and coupling intervals between premature and first reentrant impulses (V2T1) at NZ/NZ and NZ/IZ borders is inverse (i.e. the longer the coupling intervals of premature impulses the shorter the coupling interval between the premature and first reentrant impulses); this is in contrast with the reported V1V2/V2T1 relationship measured during initiation of reentrant impulses in canine infarcted hearts which is direct. IN CONCLUSION: (1) ERP transitions at the NZ-IZ border are abrupt as a consequence of PRR; (2) PRR increases the vulnerability to block and initiation of reentrant impulses in heterogeneous myocardium; (3) V1V2/V2T1 relationships measured at ERP heterogeneities in the computer model and in experimental canine infarcts are not consistent. Therefore, it is likely that other mechanisms like micro and/or macro structural heterogeneities also contribute to initiation of reentrant impulses in infarcted hearts.

Dynamics of propagation of premature impulses in structurally remodeled infarcted myocardium: a computational analysis.

UNLABELLED: Initiation of cardiac arrhythmias typically follows one or more premature impulses either occurring spontaneously or applied externally. In this study, we characterize the dynamics of propagation of single (S2) and double premature impulses (S3), and the mechanisms of block of premature impulses at structural heterogeneities caused by remodeling of gap junctional conductance (Gj) in infarcted myocardium. Using a sub-cellular computer model of infarcted tissue, we found that |INa,max|, prematurity (coupling interval with the previous impulse), and conduction velocity (CV) of premature impulses change dynamically as they propagate away from the site of initiation. There are fundamental differences between the dynamics of propagation of S2 and S3 premature impulses: for S2 impulses |INa,max| recovers fast, prematurity decreases and CV increases as propagation proceeds; for S3 impulses low values of |INa,max| persist, prematurity could increase, and CV could decrease as impulses propagate away from the site of initiation. As a consequence it is more likely that S3 impulses block at sites of structural heterogeneities causing source/sink mismatch than S2 impulses block. Whether premature impulses block at Gj heterogeneities or not is also determined by the values of Gj (and the space constant λ) in the regions proximal and distal to the heterogeneity: when λ in the direction of propagation increases >40%, premature impulses could block. The maximum slope of CV restitution curves for S2 impulses is larger than for S3 impulses. IN CONCLUSION: (1) The dynamics of propagation of premature impulses make more likely that S3 impulses block at sites of structural heterogeneities than S2 impulses block; (2) Structural heterogeneities causing an increase in λ (or CV) of >40% could result in block of premature impulses; (3) A decrease in the maximum slope of CV restitution curves of propagating premature impulses is indicative of an increased potential for block at structural heterogeneities.

Effect of heterogeneities in the cellular microstructure on propagation of the cardiac action potential.

Cardiac arrhythmias are initiated in regions that undergo cellular remodeling as a result of disease. Using a sub-cellular model of myocardium, we studied the mechanism of block caused by tissue microstructure remodeling: cell geometry [quantified as length/width (L/W) cell ratio] and cell-to-cell coupling (G(j)). Heterogeneities in cell L/W ratio and G ( j ) lead to block when excitability is reduced and the corresponding space constant λ (in the direction of propagation) increases by >40 %. Tissue architectures with elongated cells (i.e. large cell L/W ratios) that are better coupled (i.e. large G(j)) are less prone to block at sites of regional heterogeneities in cell geometry and/or cell coupling than tissue architectures consisting of cells with smaller L/W ratios and/or poorer coupling. Whether an increase in tissue anisotropic ratio (ANR) is arrhythmogenic or not depends on the cellular mechanism of the increase: ANR leads to an increased risk of block when G(j) decreases, but to a decreased risk of block when cell L/W ratio increases. Our findings are useful to understand the mechanisms of block in cardiac pathologies that result in tissue architecture remodeling.

Myofibroblasts cause heterogeneous Cx43 reduction and are unlikely to be coupled to myocytes in the healing canine infarct.

Following myocardial infarction (MI) inflammatory responses transform cardiac fibroblasts to myofibroblasts, which in vitro studies show form heterocellular gap junctions with cardiac myocytes via Connexin43 (Cx43). The ability to form heterocellular junctions in the intact heart and the impact of these junctions on propagation is unclear. We used a canine model of MI and characterized the distribution and quantity of myofibroblasts in surviving epicardial cells [epicardial border zone (EBZ)]. We found a significant increase in myofibroblasts within the EBZ and no gap junction plaques between myofibroblasts and myocytes. Because myofibroblasts produce IL-1ß, which downregulates Cx43, we asked whether myofibroblast proliferation causes loss of Cx43 near myofibroblast clusters. In vitro studies showed that IL-1ß caused loss of Cx43 and reduced coupling. Western blot showed a significant increase of IL-1ß in the EBZ, and immunohistochemistry showed a loss of Cx43 in regions of myofibroblasts in the intact heart. Additionally, dye studies in intact heart showed no coupling between myocytes and myofibroblasts. To quantify the effect of myofibroblasts on propagation we used a two-dimensional subcellular computer model of the EBZ, which showed that heterogeneities in myofibroblast density lead to conduction abnormalities. In conclusion, an increase of myofibroblasts in the infarcted heart causes heterogeneous Cx43 levels, possibly as a result of the release of IL-1ß and decreased cell-cell communication, which leads to conduction abnormalities following MI.

Characterization of gap junction remodeling in epicardial border zone of healing canine infarcts and electrophysiological effects of partial reversal by rotigaptide.

BACKGROUND: The border zone of healing myocardial infarcts is an arrhythmogenic substrate, partly the result of structural and functional remodeling of the ventricular gap junction protein, Connexin43 (Cx43). Cx43 in arrhythmogenic substrates is a potential target for antiarrhythmic therapy. METHODS AND RESULTS: We characterized Cx43 remodeling in the epicardial border zone (EBZ) of healing canine infarcts 5 days after coronary occlusion and examined whether the gap junction-specific agent rotigaptide could reverse it. Cx43 remodeling in the EBZ was characterized by a decrease in Cx43 protein, lateralization, and increased Cx43 phosphorylation at serine (S) 368. Rotigaptide partially reversed the loss of Cx43 but did not affect the increase in S368 phosphorylation, nor did it reverse Cx43 lateralization. Rotigaptide did not prevent conduction slowing in the EBZ, nor did it decrease the induction of sustained ventricular tachycardia by programmed stimulation, although it did decrease the EBZ effective refractory period. CONCLUSIONS: We conclude that partial reversal of Cx43 remodeling in healing infarct border zone may not be sufficient to restore normal conduction or prevent arrhythmias.

Effect of cell geometry on conduction velocity in a subcellular model of myocardium.

We have studied the effect of cell geometry on propagation velocity of the cardiac impulse using a subcellular computer model of myocardium. Variation of cell size has only small effects on longitudinal and transverse conduction velocities, when the ratio of cell length/width is constant, for cell sizes (length x width) between (60 microm x 20 microm) and (120 microm x 40 microm). The results were not dependent on gap-junction conductance (range 0.25-1 microS), gap-junction distribution, or the specific tissue architecture. Longitudinal conduction velocity increased with the cell length/width ratio and transverse velocity decreased. The cell length/width ratio was a good estimator of the anisotropic ratio. In conclusion, cell length/width ratio is more important than cell size in determining conduction velocity.

The Renin-Angiotensin system mediates the effects of stretch on conduction velocity, connexin43 expression, and redistribution in intact ventricle.

UNLABELLED: Effect of Stretch on Conduction and Cx43. INTRODUCTION: In disease states such as heart failure, myocardial infarction, and hypertrophy, changes in the expression and location of Connexin43 (Cx43) occur (Cx43 remodeling), and may predispose to arrhythmias. Stretch may be an important stimulus to Cx43 remodeling; however, it has only been investigated in neonatal cell cultures, which have different physiological properties than adult myocytes. We hypothesized that localized stretch in vivo causes Cx43 remodeling, with associated changes in conduction, mediated by the renin-angiotensin system (RAS). METHODS AND RESULTS: In an open-chest canine model, a device was used to stretch part of the right ventricle (RV) by 22% for 6 hours. Activation mapping using a 312-electrode array was performed before and after stretch. Regional stretch did not change longitudinal conduction velocity (post-stretch vs baseline: 51.5 ± 5.2 vs 55.3 ± 8.1 cm/s, P = 0.24, n = 11), but significantly reduced transverse conduction velocity (28.7 ± 2.5 vs 35.4 ± 5.4 cm/s, P < 0.01). It also reduced total Cx43 expression, by Western blotting, compared with nonstretched RV of the same animal (86.1 ± 32.2 vs 100 ± 19.4%, P < 0.02, n = 11). Cx43 labeling redistributed to the lateral cell borders. Stretch caused a small but significant increase in the proportion of the dephosphorylated form of Cx43 (stretch 9.95 ± 1.4% vs control 8.74 ± 1.2%, P < 0.05). Olmesartan, an angiotensin II blocker, prevented the stretch-induced changes in Cx43 levels, localization, and conduction. CONCLUSION: Myocardial stretch in vivo has opposite effects to that in neonatal myocytes in vitro. Stretch in vivo causes conduction changes associated with Cx43 remodeling that are likely caused by local stretch-induced activation of the RAS.

Extracellular space attenuates the effect of gap junctional remodeling on wave propagation: a computational study.

UNLABELLED: Ionic channels and gap junctions are remodeled in cells from the 5-day epicardial border zone (EBZ) of the healing canine infarct. The main objective of the study was to determine the effect of gap junctional conductance (Gj) remodeling and Cx43 redistribution to the lateral membrane on conduction velocity (theta) and anisotropic ratio, and how gap junctional remodeling is modulated by the extracellular space. We first implemented subcellular monodomain and two-domain computer models of normal epicardium (NZ) to understand how extracellular space modulates the relationship between Gj and theta in NZ. We found that the extracellular space flattens the Gj-theta relationship, thus theta becomes less sensitive to changes in Gj. We then investigated the functional consequences of Gj remodeling and Cx43 distribution in subcellular computer models of cells of the outer pathway (IZo) and central pathway (IZc) of reentrant circuits. In IZo cells, side-to-side (transverse) Gj is 10% the value in NZ cells. Such Gj remodeling causes a 45% decrease in transverse theta (theta(T)). Inclusion of an extracellular space reduces the decrease in theta(T) to 31%. In IZc cells, Cx43 redistribution along the lateral membrane results in a 29% increase in theta(T). That increase in theta(T) is a consequence of the decrease in access resistance to the Cx43 plaques that occur with the Cx43 redistribution. Extracellular space reduces the increase in theta(T) to 10%. IN CONCLUSION: 1), The extracellular space included in normal epicardial simulations flattens the Gj-theta relationship with theta becoming less sensitive to changes in Gj. 2), The extracellular space attenuates the effects of gap junction epicardial border zone remodeling (i.e., Gj reduction and Cx43 lateralization) on theta(T).

Heterogeneous gap junction remodeling in reentrant circuits in the epicardial border zone of the healing canine infarct.

BACKGROUND: The epicardial border zone (EBZ) of surviving myocytes in the healing, 4- to 5-day-old canine infarct is an arrhythmogenic substrate characterized by both structural and functional remodeling of Cx43. Unknown is whether the remodeling of gap junction conductance is heterogeneous in the EBZ like that of sarcolemmal ion channel remodeling and how remodeling of the gap junction influences conduction and anisotropy. METHODS AND RESULTS: Ventricular tachycardia was initiated by programmed stimulation in healing canine infarcted hearts. Reentrant circuits were mapped and the central common pathway (CCP) and outer pathway (OP) regions localized. Epimyocardium removed from the CCP was disaggregated to generate myocyte pairs for conductance measurements. Cx43 distribution was determined by immunofluorescent confocal microscopy. While transverse coupling (gap junction conductance) was markedly decreased in OP cells, CCP cells with lateralized Cx43 gap junctions showed normal conductance. Longitudinal coupling in both OP and CCP was no different than normal. Consistent with conductance measurements, the anisotropic ratio in the CCP was similar to that of normal tissue. In the OP it was increased. Despite normal longitudinal and transverse conductance and anisotropic ratio, longitudinal and transverse conduction velocities were decreased in the CCP with respect to normal epicardium, possibly as a result of the remodeling of sarcolemmal ion channels in this region. CONCLUSIONS: Gap junction conductance and distribution is heterogeneous in different regions of reentrant circuits. Lateralization of Cx43 gap junctions in CCP of reentrant circuits is associated with normal transverse conductance between cell pairs. In contrast, absence of lateralization in OP is associated with reduced transverse conductance. Despite normal anisotropic ratio, conduction velocity in CCP region remains slower than normal. This suggests that the effects of Cx43 remodeling in the infarcted heart should be interpreted in conjunction with other types of remodeling occurring in the EBZ (i.e. sarcolemmal ion channels).

Heterogeneous gap junction remodeling stabilizes reentrant circuits in the epicardial border zone of the healing canine infarct: a computational study.

The ventricular tachycardias (VTs) that originate in the 5-day epicardial border zone (EBZ) of the healing canine infarcted heart are due to reentrant excitation. In cells surviving in the EBZ, both sarcolemmal ionic channels and gap junction conductance and distribution are remodeled. We previously showed that the heterogeneities in sodium current (I(Na)) and L-type calcium channel current (I(CaL)) of the center and outer pathway cells result in a homogenization of the refractory period that in turn stabilizes reentrant VTs for approximately 10 beats. To understand how heterogeneities in transverse gap junctional conductance remodeling reported experimentally contribute to the stability of these tachycardias, we studied the dynamics of reentering waves in two-dimensional computer models of the EBZ. First we used a computer model with homogeneous ionic channel properties [infarcted border zone cell model (IZ)]. These simulations show that, in the absence of heterogeneities in ionic channel properties, reentrant waves tend to drift to localized regions of uncoupling and stabilize there. Second, we used a computer model with a more realistic representation of the heterogeneous EBZ, including cellular models for both the center (IZ(c)) and outer (IZ(o)) pathway cells. These simulations show that neither a region of uniform uncoupling nor a step transition between two regions with different side-to-side (transverse) cell coupling stabilizes reentry in this substrate. However, an area of localized uncoupling did stabilize reentry in such a model. We propose that in addition to the heterogeneities in I(Na) and I(CaL) properties, heterogeneities in gap junctional conductance in the EBZ causing regions of localized uncoupling stabilize VT in the EBZ. Previous experimental in situ activation maps of the 5-day EBZ show that the lines of block form in regions of slow transverse propagation. This is consistent with our findings that areas of localized uncoupling stabilize reentry.

Remodeling in cells from different regions of the reentrant circuit during ventricular tachycardia.

BACKGROUND: Anisotropic reentrant excitation occurs in the remodeled substrate of the epicardial border zone (EBZ) of the 5-day infarcted canine heart. Reentry is stabilized because of the formation of functional lines of block. We hypothesized that regional differences of ionic currents in cells of the EBZ form these lines of block. Therefore, we first mapped reentrant circuits of sustained tachycardias, then dispersed cells (infarct zone cells, IZs) from the central common pathway of the circuit (IZc) as well as from the other side of the line of block (outer pathway, IZo) for study. METHODS AND RESULTS: We mapped reentrant circuits in the EBZ of infarcted hearts during sustained ventricular tachycardias (>30 seconds, n=17 episodes, cycle lengths=218+/-7.9 ms). INa density was reduced in both IZc and IZo, and the kinetic properties of IZc INa were markedly altered versus IZo. Structural remodeling of the sodium channel protein Nav1.5 occurred in IZs, with cell surface localization differing from normal cells. Both IZc and IZo have similar but reduced ICaL, whereas IZc showed changes in Ca2+ current kinetics with an acceleration of current decay. Computer simulations of the 2D EBZ showed that incorporating only differences between INa in IZc and IZo prevented stability of the reentrant circuit. Incorporating only differences between ICaL in the IZc and IZo cells also prevented stability of the circuit. However, incorporating both INa and ICaL current differences stabilized the simulated reentrant circuit, and lines of block formed between the 2 distinct regions. CONCLUSIONS: Despite differences in INa and ICaL properties in cells of the center and outer pathways of a reentrant circuit, the resulting changes in effective refractory periods tend to stabilize reentry in this remodeled substrate.

Beta receptor blockade potentiates the antiarrhythmic actions of d-sotalol on reentrant ventricular tachycardia in a canine model of myocardial infarction.

INTRODUCTION: The importance of beta receptor blockade for the antiarrhythmic action of sotalol has not been completely elucidated. We determined how beta receptor blockade interacts with the effects of potassium channel blockade on reentrant circuits. METHODS AND RESULTS: Sustained ventricular tachycardia was induced by programmed stimulation in dogs 4 days after left anterior coronary artery occlusion and reentrant circuits in the epicardial border zone (EBZ) mapped. The effects of the beta receptor-blocking drug, esmolol, the potassium channel-blocking drug d-sotalol, which lacks beta receptor-blocking effects, and the combination of the two drugs on the reentrant circuits that cause tachycardia were determined. Esmolol did not alter the ability to induce tachycardia. Small changes in the location or extent of lines of block in reentrant circuits accounted for small decreases or increases in tachycardia cycle lengths. d-Sotalol prolonged the lines of block in reentrant circuits, slowed propagation around the circuits, and prolonged tachycardia cycle length, but it did not stop tachycardia or prevent the induction of tachycardia. The combination of esmolol and d-sotalol prevented the initiation of sustained tachycardia. The stimulated premature impulse either blocked before reentering or traversed the circuit several times prior to blocking in a region of fractionated electrograms. The addition of esmolol to d-sotalol abolished the reverse use-dependent effects of d-sotalol alone on effective refractory period (ERP) and significantly prolonged ERP in the area of the reentrant circuit. CONCLUSION: Beta receptor blockade is important for the antiarrhythmic effects of d,l-sotalol on reentrant ventricular tachycardia in this model. The mechanism is speculative but may involve potentiation of d-sotalol actions to prolong ERP or effects on gap junctions.

Electrical remodeling of the epicardial border zone in the canine infarcted heart: a computational analysis.

The density and kinetics of several ionic currents of cells isolated from the epicardial border zone of the infarcted heart (IZs) are markedly different from cells from the noninfarcted canine epicardium (NZs). To understand how these changes in channel function affect the action potential of the IZ cell as well as its response to antiarrhythmic agents, we developed a new ionic model of the action potential of a cell that survives in the infarct (IZ) and one of a normal epicardial cell (NZ) using formulations based on experimental measurements. The difference in action potential duration (APD) between NZ and IZ cells during steady-state stimulation (basic cycle length = 250 ms) was 6 ms (156 ms in NZ and 162 ms in IZ). However, because IZs exhibit postrepolarization refractoriness, the difference in the effective refractory period (ERP), calculated using a propagation model of a single fiber of 100 cells, was 43 ms (156 ms in NZ and 199 ms in IZ). Either an increase in L-type Ca(2+) current (to simulate the effects of BAY Y5959) or a decrease of both or either delayed rectifier currents (e.g., to simulate the effects of azimilide, sotalol, and chromanol) had significant effects on NZ ERP. In contrast, the effects of these agents in IZs were minor, in agreement with measurements in the in situ canine infarcted heart. Therefore 1) because IZs exhibit postrepolarization refractoriness, conclusions drawn from APD measurements cannot be extrapolated directly to ERPs; 2) ionic currents that are the major determinants of APD and the ERP in NZs are less important in IZs; and 3) differential effects of either BAY Y5959 or azimilide in NZs versus IZs are predicted to decrease ERP dispersion and in so doing prevent initiation of arrhythmias in a substrate of inhomogeneous APD/ERPs.

Electrophysiological consequences of human IKs channel expression in adult murine heart.

We expressed human delayed rectifier K(+) cardiac current (I(Ks)) channels in the murine heart, which lacks native I(Ks), to determine their electrophysiological role. Mice expressing human I(Ks) channels were anesthetized, and an electrocardiogram and monophasic action potentials (MAP) recorded from the left ventricle. Sinus rate was not different between wild-type mice (WT) and transgenic mice (TG). Infusion of isoproterenol accelerated WT heart rate but not TG. Lack of TG sinus rate responsiveness may have resulted from accumulated outward current in I(Ks) channels in sinus node. Ventricular MAP duration of TG mice to 50% repolarization (APD(50)) during ventricular pacing was shorter than WT, likely resulting from outward current through I(Ks) channels. TG APD(50) showed enhanced responsiveness (shortening) to isoproterenol compared with WT. Ventricular tachyarrhythmias were initiated in TG mice by programmed stimulation but not in WT and were accelerated by isoproterenol. I(Ks) channels impart beta-adrenergic sensitivity to the ventricles and may be responsible for ventricular tachyarrhythmias.

Correlation of repolarization of ventricular monophasic action potential with ECG in the murine heart.

Transgenic mice have become important experimental models in the investigation of mechanisms causing cardiac arrhythmias because of the ability to create strains with alterations in repolarizing membrane currents. It is important to relate alterations in membrane currents in cells to their phenotypic expression on the electrocardiogram (ECG). The murine ECG, however, has unusual characteristics that make interpretation of the phenotypic expression of changes in ventricular repolarization uncertain. The major deflection representing the QRS (referred to as "a") is often followed by a secondary slower deflection ("b") and sometimes a subtle third deflection ("c"). To determine whether the second or third deflections or both represent ventricular repolarization, we recorded the ventricular monophasic action potential (MAP) in open-chest mice and correlated repolarization with the ECG. There was no significant correlation by linear regression, between action potential duration to 50% or 90% repolarization (APD(50) or APD(90)), respectively, of the MAP and either the interval from onset of Q to onset of b (Qb interval) or onset of c (Qc interval). Administration of 4-aminopyridine (4-AP) significantly prolonged APD(50) and APD(90) and the Qb interval, indicating that this deflection on the ECG represents part of ventricular repolarization. After 4-AP, the c wave disappeared, also suggesting that it represents a component of ventricular repolarization. Although it appears that both the b and c waves that follow the Q wave on the ECG represent ventricular repolarization, neither correlates exactly with APD(90) of the MAP. Therefore, an accurate measurement of complete repolarization of the murine ventricle cannot be obtained from the surface ECG.