Electromechanical vortex filaments during cardiac fibrillation.

The self-organized dynamics of vortex-like rotating waves, which are also known as scroll waves, are the basis of the formation of complex spatiotemporal patterns in many excitable chemical and biological systems. In the heart, filament-like phase singularities that are associated with three-dimensional scroll waves are considered to be the organizing centres of life-threatening cardiac arrhythmias. The mechanisms that underlie the onset, maintenance and control of electromechanical turbulence in the heart are inherently three-dimensional phenomena. However, it has not previously been possible to visualize the three-dimensional spatiotemporal dynamics of scroll waves inside cardiac tissues. Here we show that three-dimensional mechanical scroll waves and filament-like phase singularities can be observed deep inside the contracting heart wall using high-resolution four-dimensional ultrasound-based strain imaging. We found that mechanical phase singularities co-exist with electrical phase singularities during cardiac fibrillation. We investigated the dynamics of electrical and mechanical phase singularities by simultaneously measuring the membrane potential, intracellular calcium concentration and mechanical contractions of the heart. We show that cardiac fibrillation can be characterized using the three-dimensional spatiotemporal dynamics of mechanical phase singularities, which arise inside the fibrillating contracting ventricular wall. We demonstrate that electrical and mechanical phase singularities show complex interactions and we characterize their dynamics in terms of trajectories, topological charge and lifetime. We anticipate that our findings will provide novel perspectives for non-invasive diagnostic imaging and therapeutic applications.

Subungual melanoma: Management in the modern era.

Subungual melanoma is a rare subtype of cutaneous melanoma that arises from the structures of the nail apparatus. It presents most commonly in older patients and at an advanced stage. A retrospective review of all patients with subungual melanoma in a single institution over a 15-year period was performed. In total, 54 patients were included (26 males, average age 62.9 years), of which 28 cases involved the upper limb. Median tumour thickness was 4.5 mm. Eighteen patients had lymph node metastasis at diagnosis, including 11 of 36 patients with positive sentinel lymph node biopsy. Median survival was 4.6 years. Subungual melanoma has a poor prognosis that is strongly associated with presence of nodal disease at diagnosis. Sentinel lymph node biopsy should be considered to determine stage and prognosis.

Lidocaine converts acute vagally associated atrial fibrillation to sinus rhythm in German Shepherd dogs with inherited arrhythmias.

BACKGROUND: Lidocaine is most frequently used to treat ventricular arrhythmias. However, lidocaine may have an antiarrhythmic effect for certain supraventricular arrhythmias. HYPOTHESIS: We hypothesized that lidocaine would be effective in converting experimentally induced atrial fibrillation (AF) to sinus rhythm and that a decrease in the dominant frequency (DF) and an increase in the organization as judged by the spectral entropy (SE) would occur over the course of the conversion. ANIMALS: Seven German Shepherd (GS) Dogs. METHODS: Dogs were anesthetized with fentanyl and pentobarbital. AF was induced with standard pacing protocols while left and right atrial monophasic action potentials (MAP) were recorded. The power spectra from the MAP recordings were analyzed to determine DF and SE during treatment with boluses of 2 mg/kg lidocaine. RESULTS: Lidocaine converted AF to sinus rhythm in all dogs and all episodes (n = 19). Conversion time was 27-87 seconds. After atropine, sustained AF was not induced; however, 5 episodes of atrial tachycardia resulted, and 3 were converted with lidocaine. Frequency domain analysis of 12 conversion sequences showed that left and right DF of the MAP signals decreased from the time of injection to conversion to sinus rhythm (P < .001). Mean SE indicated a gradient between the left and right atria (P = .003) that did not change during conversion. CONCLUSIONS AND CLINICAL IMPORTANCE: Vagally associated AF in GS dogs is terminated with lidocaine. Lidocaine is likely an effective treatment in clinical dogs with vagally associated AF.

Depolarization and decreased surface expression of K+ channels contribute to NSAID-inhibition of intestinal restitution.

Non-steroidal anti-inflammatory drugs (NSAIDs) contribute to gastrointestinal ulcer formation by inhibiting epithelial cell migration and mucosal restitution; however, the drug-affected signaling pathways are poorly defined. We investigated whether NSAID inhibition of intestinal epithelial migration is associated with depletion of intracellular polyamines, depolarization of membrane potential (E(m)) and altered surface expression of K(+) channels. Epithelial cell migration in response to the wounding of confluent IEC-6 and IEC-Cdx2 monolayers was reduced by indomethacin (100 microM), phenylbutazone (100 microM) and NS-398 (100 microM) but not by SC-560 (1 microM). NSAID-inhibition of intestinal cell migration was not associated with depletion of intracellular polyamines. Treatment of IEC-6 and IEC-Cdx2 cells with indomethacin, phenylbutazone and NS-398 induced significant depolarization of E(m), whereas treatment with SC-560 had no effect on E(m). The E(m) of IEC-Cdx2 cells was: -38.5+/-1.8 mV under control conditions; -35.9+/-1.6 mV after treatment with SC-560; -18.8+/-1.2 mV after treatment with indomethacin; and -23.7+/-1.4 mV after treatment with NS-398. Whereas SC-560 had no significant effects on the total cellular expression of K(v)1.4 channel protein, indomethacin and NS-398 decreased not only the total cellular expression of K(v)1.4, but also the cell surface expression of both K(v)1.4 and K(v)1.6 channel subunits in IEC-Cdx2. Both K(v)1.4 and K(v)1.6 channel proteins were immunoprecipitated by K(v)1.4 antibody from IEC-Cdx2 lysates, indicating that these subunits co-assemble to form heteromeric K(v) channels. These results suggest that NSAID inhibition of epithelial cell migration is independent of polyamine-depletion, and is associated with depolarization of E(m) and decreased surface expression of heteromeric K(v)1 channels.

Upregulation of cardiac cell plasma membrane calcium pump in a canine model of Chagas disease.

We have previously demonstrated that cardiac myocytes isolated from the hearts of adult dogs develop rapid repetitive cytosolic Ca2+ transients, membrane depolarization, and cell contraction by mobilization of sarcoplasmic reticulum Ca2+ stores when exposed to a soluble factor from the trypomastigotes of Trypanosoma cruzi. These findings led us to investigate the regulatory mechanisms of cytosolic Ca2+ in cardiac tissues from dogs chronically infected with T. cruzi. Expression of the plasma membrane calcium pump (PMCA) RNA and protein was determined by Northern and Western blotting, respectively, followed by densitometric analyses. A 642-bp PMCA 1b complementary DNA probe derived from canine epicardial tissue hybridized to 2 major transcripts (7.3 and 5.3 kb) in canine epicardium. Expression of the dominant transcript (7.3 kb) was 77% greater in cardiac tissues obtained from dogs with chronic T. cruzi infection (140 days after inoculation) in comparison with constitutive expression levels in normal dogs. Monoclonal antibody 5F10, known to recognize all isoforms of the PMCA, was used to detect expression of the PMCA protein in epicardial tissue. Expression of a 142-kDa protein was increased by 58% in the cardiac tissues of infected dogs when compared with those from uninfected dogs. To establish a link between the upregulation of PMCA in dogs chronically infected with Chagas disease and the ventricular-based arrhythmias and myocardial failure that occur during this stage of disease both in dogs and humans, further study will be required.

Effects of [K(+)](o) on electrical restitution and activation dynamics during ventricular fibrillation.

To test whether hyperkalemia suppresses ventricular fibrillation (VF) by reducing the slope of the action potential duration (APD) restitution relation, we determined the effects of the extracellular K(+) concentration ([K(+)](o)) ([KCl] = 2.7-12 mM) on the restitution of APD and maximum upstroke velocity (V(max)) the magnitude of APD alternans and spatiotemporal organization during VF in isolated canine ventricle. As [KCl] was increased incrementally from 2.7 to 12 mM, V(max) was reduced progressively. Increasing [KCl] from 2.7 to 10 mM decreased the slope of the APD restitution relation at long, but not short, diastolic intervals (DI), decreased the range of DI over which the slope was >/=1, and reduced the maximum amplitude of APD alternans. At [KCl] = 12 mM, the range of DI over which the APD restitution slope was >/=1 increased, and the maximum amplitude of APD alternans increased. For [KCl] = 4-8 mM, the persistence of APD alternans at short DI was associated with maintenance of VF. For [KCl] = 10-12 mM, the spontaneous frequency during VF was reduced, and activation occurred predominantly at longer DI. The lack of APD alternans at longer DI was associated with conversion of VF to a periodic rhythm. These results provide additional evidence for the importance of APD restitution kinetics in the development of VF.

Electrical restitution and spatiotemporal organization during ventricular fibrillation.

Despite recent advances in our understanding of the mechanism for ventricular fibrillation (VF), important electrophysiological aspects of the development of VF still are poorly defined. It has been suggested that the onset of VF involves the disintegration of a single spiral wave into many self-perpetuating waves. It has been further suggested that such a process requires that the slope of the electrical restitution relation be >/=1. The same theory anticipates that a single spiral wave will be stable (not disintegrate) if the maximum slope of the restitution relation is <1. We have shown previously that the slope of the restitution relation during rapid pacing and during VF is >/=1 in canine ventricle. We now show that drugs that reduce the slope of the restitution relation (diacetyl monoxime and verapamil) prevent the induction of VF and convert existing VF into a periodic rhythm. In contrast, a drug that does not reduce the slope of the restitution relation (procainamide) does not prevent the induction of VF, nor does it regularize VF. These results indicate that the kinetics of electrical restitution is a key determinant of VF. Moreover, they suggest novel approaches to preventing the induction or maintenance of VF.

Restoration of transient outward current by norepinephrine in cultured canine cardiac myocytes.

The mechanism for the reduction of the transient outward K+ current (Ito) in diseased myocardium is unknown. To identify potential mechanisms, the reduction of Ito and its subsequent restoration by norepinephrine (NE) were studied in cultured canine epicardial myocytes. After myocytes were cultured for 9 days (day 9), Ito density was decreased compared with density on the day of isolation (day 0) (3.2 +/- 0.4 vs. 10.4 +/- 0.4 pA/pF; mean +/- SE). The time constant of current decay (taudecay) was increased, the time course of recovery from inactivation was prolonged, and the half-inactivation voltage (V1/2) was shifted to less negative potentials. Exposure of myocytes on day 8 to 1 microM NE or isoproterenol (Iso) for 1 h had no acute effect on Ito but restored Ito density to 7.6 +/- 1.2 or 9.7 +/- 2.3 pA/pF, respectively, on day 9. Recovery from inactivation and taudecay remained slowed, and V1/2 remained shifted to less negative potentials. The effects of NE and Iso were blocked by actinomycin D and were not mimicked by phenylephrine or phorbol ester. A-23187 (1 microM) also restored Ito. Thus beta-adrenergic agonists restored normal Ito density, but not normal Ito kinetics, in cultured epicardial myocytes, possibly via increased intracellular Ca2+ concentration.

Dynamic restitution of action potential duration during electrical alternans and ventricular fibrillation.

The restitution kinetics of action potential duration (APD) were investigated in paced canine Purkinje fibers (P; n = 9) and endocardial muscle (M; n = 9), in isolated, perfused canine left ventricles during ventricular fibrillation (VF; n = 4), and in endocardial muscle paced at VF cycle lengths (simulated VF; n = 4). Restitution was assessed with the use of two protocols: delivery of a single extrastimulus after a train of stimuli at cycle length = 300 ms (standard protocol), and fixed pacing at short cycle lengths (100-300 ms) that induced APD alternans (dynamic protocol). The dynamic protocol yielded a monotone increasing restitution function with a maximal slope of 1.13 +/- 0.13 in M and 1.14 +/- 0.17 in P. Iteration of this function reproduced the APD dynamics found experimentally, including persistent APD alternans. In contrast, the standard protocol yielded a restitution relation with a maximal slope of 0.57 +/- 0.18 in M and 0.84 +/- 0.20 in P, and iteration of this function did not reproduce the APD dynamics. During VF, the restitution kinetics at short diastolic interval were similar to those determined with the dynamic protocol (maximal slope: 1.72 +/- 0.47 in VF and 1.44 +/- 0.49 in simulated VF). Thus APD dynamics at short coupling intervals during fixed pacing and during VF were accounted for by the dynamic, but not the standard, restitution relation. These results provide further evidence for a strong relationship among the kinetics of electrical restitution, the occurrence of APD alternans, and complex APD dynamics during VF.

Memory models for the electrical properties of local cardiac systems.

A series of related new models for the local dynamics of cardiac tissue is introduced. The models are based on a simple memory-like quantity that is used to determine the relationship among the durations and amplitudes of the stimulated action potentials. The first of these models produces period-doubling and chaos, consistent with constant pacing experiments, when standard restitution dynamics would predict stability of the primary 1:1 pattern. Analysis of the associated one-dimensional map suggests how various physiological parameters affect the period-doubling sequence. Many of these relationships have been observed in experiments. The remaining models extend the formalism of the first to account for the Hopf bifurcation of 2:2 patterns observed in experiments. One of these models reproduces the bifurcation sequence, 1:1, 2:2, Hopf bifurcation of 2:2, 2:2 and 2:1 seen in experiments as the pacing interval is decreased. The models clarify the dynamics involved in determining the amplitudes and durations of successive action potentials. Results from these models together with comparison with the experiment strongly suggest that quantities with time constants of the order of 50 and 400 ms exist and affect action potential formation in heart tissue.

Decreased density of Ito in left ventricular myocytes from German shepherd dogs with inherited arrhythmias.

INTRODUCTION: A colony of inbred German shepherd dogs with inherited ventricular arrhythmias has been established. METHODS AND RESULTS: The inward rectifier (IK1), the slow delayed rectifier (IKs), and the transient outward current (I(to)) were recorded from epicardial myocytes, and Ito was recorded from Purkinje myocytes isolated from the left ventricles of dogs mildly or severely affected with arrhythmias, and unaffected relatives. There were no differences between unaffected and severely affected dogs in the densities of either IK1 or IKs. Peak Ito density at +40 mV was reduced by 49% in epicardial myocytes from severely affected dogs. I(to) density was also reduced in a subset of Purkinje myocytes. Boltzmann analysis of steady-state inactivation showed no differences between groups in slope factor. V1/2, the half-inactivation voltage, was shifted by +6.2 mV in epicardial cells from severely affected versus unaffected dogs. In addition, the time constant for I(to) decay was reduced in mildly and severely affected dogs compared to unaffected dogs. CONCLUSION: Altered density and inactivation of I(to) are associated with the presence of severe ventricular arrhythmias in inbred dogs at risk for sudden death.

Time- and rate-dependent alterations of the QT interval precede the onset of torsade de pointes in patients with acquired QT prolongation.

OBJECTIVES: The purpose of this study was to determine whether the QT interval dynamics that precede torsade de pointes are consistent with the initiation of this arrhythmia by early afterdepolarization-induced triggered activity. BACKGROUND: Early afterdepolarization-induced triggered activity has been suggested as an electrophysiologic mechanism for torsade de pointes. Consequently, the initiation of torsade de pointes should involve time- and rate-dependent alterations of ventricular repolarization similar to those known to modulate the development of early afterdepolarizations. METHODS: RR and QT intervals were measured in digitized 24-h ambulatory electrocardiographic recordings obtained from seven patients with acquired prolongation of ventricular repolarization. Each patient had one or more episodes of torsade de pointes. The relation between RR and QT intervals was determined before, during and after multiple episodes of torsade de pointes. RESULTS: In patients with multiple episodes of ventricular arrhythmias, the onset of the arrhythmias was associated with a critical prolongation of the QT interval. In some episodes, prolongation of the QT interval was associated with sudden prolongation of the sinus cycle length, whereas in other episodes, the QT interval prolonged progressively at a constant cycle length. CONCLUSIONS: The association between a critically prolonged QT interval and the onset of ventricular arrhythmias suggests that the initial complex of torsade de pointes is an early afterdepolarization-induced triggered response. However, prolongation of the QT interval itself was not sufficient to account for the initiation of torsade de pointes, suggesting that other, as yet unidentified factors are required.

Age dependence of the development of ventricular arrhythmias in a canine model of sudden cardiac death.

OBJECTIVES: The age-dependence of the development of ventricular arrhythmias was studied in German shepherd dogs with inherited ventricular arrhythmias and sudden death. BACKGROUND: A colony of German shepherd dogs has been established that exhibit inherited ventricular arrhythmias and sudden death. The incidence of arrhythmias increases with age. Because ventricular tachycardia is associated with bradycardia, it was hypothesized that the increased incidence of arrhythmias was related to age-dependent slowing of heart rate. METHODS: Arrhythmia counts and RR intervals were measured from serial ambulatory ECG recordings obtained in 71 dogs (1-48 weeks). In addition, 19 dogs were challenged with phenylephrine (10 micrograms/kg i.v.) at 15, 28, and 45 weeks of age, 10 dogs were challenged with epinephrine (1 microgram/kg i.v.) at 3, 5, 7, 9, 11, 18, and 28 weeks of age, and 10 dogs were challenged at 28 weeks with epinephrine (2.5 micrograms/kg i.v.), before and after propranolol (0.5 mg/kg i.v.). RESULTS: The incidence and severity of ventricular arrhythmias increased between 7 and 28 weeks of age and decreased between 28 and 44 weeks of age. The age-dependent increase in the incidence of ventricular tachycardia was associated with age-dependent reductions in sinus rate. Baroreflex-mediated slowing of the heart rate unmasked arrhythmias in young animals that did not spontaneously display arrthythmias and exacerbated existing arrhythmias in older animals. However, the magnitude of baroreflex-induced bradycardia was similar from 7-18 weeks of age, yet the incidence of arrhythmias increased progressively. Moreover, the waning of ventricular arrhythmias in older animals was not associated with more rapid sinus rates. CONCLUSION: The risk for sudden death in dogs with inherited ventricular arrhythmias increases with age in part because of age-dependent slowing of heart rate and in part because of other heart-rate-independent factors. The correspondence between the development of ventricular tachycardia and sinus pauses is consistent with the hypothesis that ventricular arrhythmias are initiated by early afterdepolarization-induced triggered activity.

Memory and complex dynamics in cardiac Purkinje fibers.

The contribution of cumulative changes in action potential duration (memory) to complex cellular electrophysiological behavior was investigated in canine cardiac Purkinje fibers. Complex behavior induced during constant pacing was caused by reciprocal interactions between the time to full repolarization (TFR), where TFR = response duration + latency, and the diastolic interval (DI). The relationship between TFR and the preceding DI during complex behavior differed from that obtained using a standard restitution protocol. In particular, higher-order periodicities and chaos were produced in fibers in which the restitution curve lacked the prerequisites for such behavior. To investigate whether shifts in the restitution curve might be expected during rapid pacing, the relationship between TFR of a test response (TFR(n + 1)) and the immediately preceding response (TFR(n)) was determined. For any fixed DI(n), reduction of TFR(n) from 240 to 130 ms was accompanied by a corresponding reduction of TFR(n + 1), whereas as TFR(n) was reduced further to 120 ms, TFR(n + 1) increased. Because of the dependence of TFR(n + 1) on TFR(n) (memory) and on the preceding DI(n) (restitution), the slope of the low-dimensional relationship between TFR(n + 1) and DI(n) at a constant pacing cycle length depended on the slopes of the restitution and memory functions. These results suggest that rapid accumulation and dissipation of memory may contribute importantly to complex electrical behavior in cardiac tissue.

Restoration of the transient outward potassium current by noradrenaline in chagasic canine epicardium.

1. The transient outward potassium current (Ito) is reduced in canine epicardial myocytes during the acute stage of infection with Trypanosoma cruzi (Chagas' disease). Sympathetic nerve terminals are also destroyed during the acute stage of this disease. To test whether the reduction of Ito is related to the absence of sympathetic innervation, acutely infected isolated epicardial myocytes were exposed in vitro to the sympathetic neurotransmitter noradrenaline (NA) and the effects of NA exposure on Ito were determined. 2. Continuous exposure to NA (1.0 microM) for 0-6 h had no effect on Ito density, whereas exposure to NA for 24 h significantly increased Ito density. Ito was also restored 24 h after a 1 h exposure to NA. Cell capacitance was not significantly affected by NA. 3. The alpha1-adrenergic receptor antagonist prazosin (0.1 microM) blocked the effects of NA on Ito, but the beta-adrenergic receptor antagonist propranolol (20 microM) did not. The beta-adrenergic receptor agonist isoprenaline (1 microM) had no effect on Ito. 4. Restoration of Ito by NA was prevented by pretreatment with neomycin (100 microM), a phospholipase C inhibitor, but not by pretreatment with 100-400 ng ml(-1) pertussis toxin (PTX). 5. The protein kinase C (PKC) activator phorbol 12-myristate 13-acetate (0.1 microM) mimicked the effect of NA on Ito, whereas the inactive analogue 4alpha-phorbol (20 microM) had no effect on Ito. Pretreatment with bisindolylmaleimide (0.1 microM), a specific PKC inhibitor, completely blocked the effect of NA on Ito. 6. Thus, NA restores Ito in chagasic canine epicardial myocytes. The induction of Ito by NA appears to result from alpha1-adrenergic stimulation of PKC via a PTX-insensitive signalling cascade. These results suggest that the reduction of Ito in chagasic myocytes during the acute stage of Chagas' disease may reflect the lack of the trophic effects of sympathetic innervation.

An animal model of spontaneous arrhythmic death.

Ventricular arrhythmias and the proclivity for sudden death have been identified in German shepherd dogs. This disorder is inherited, and affected animals can be consistently produced from an established colony. The arrhythmias are most prevalent in young dogs between 22 and 26 weeks of age, with death most frequent at this same age. Death occurs most frequently during presumed sleep or at rest after exercise or excitement. The QT interval is not prolonged; however, more frequent notching of the T wave exists in affected dogs compared to control dogs. Polymorphic rapid nonsustained ventricular tachycardia occurs most frequently following long RR intervals. Accordingly, perturbations that decrease the heart rate or enhance sinus arrhythmia increase the incidence of ventricular arrhythmias. Because the arrhythmias are age, behavior, and heart rate dependent, the autonomic nervous system may play a role in their generation. As determined by metaiodobenzyl-guanidine scintigraphy and immunocytochemical staining of tyrosine hydroxylase, cardiac sympathetic innervation is regionally deficient in affected dogs. Evidence suggests that initiation of the ventricular arrhythmias is caused by early afterdepolarization (EAD)-induced triggered activity originating from left ventricular Purkinje fibers. Alpha 1-adrenergic stimulation provokes EADs in the Purkinje fibers and ventricular arrhythmias in the dogs. The development of EADs may be related to heterogeneity of repolarizing currents (Ito in particular) in affected dogs. From this canine model of spontaneous ventricular arrhythmias, the opportunity exists to investigate the interplay between abnormal development of cardiac innervation and the genesis of lethal ventricular arrhythmias.

Strategy for control of complex low-dimensional dynamics in cardiac tissue.

Heart rate-dependent alterations in the duration of the electrically active state of cardiac cells, the action potential, are an important determinant of lethal heart rhythm disorders. The relationship between action potential duration and heart rate can be modelled as a nonlinear one-dimensional map. Iteration of the map over a range of physiologically relevant heart rates produces complex changes in action potential duration, including period doubling bifurcations, chaos and period doubling reversals. We present a computer algorithm that ensures, over the same range of heart rates, uniform state variable values (action potential durations) by application of small perturbing stimuli at appropriate intervals. The algorithm succeeds, even though the only parameter in the system (the heart rate) is immutable. Control of the dynamics is achieved by exploiting the inexcitability of the cardiac cells immediately after stimulation. This algorithm may have applications for the prevention of cardiac rhythm disturbances.