Effect of constant-DI pacing on single cell pacing dynamics.

Cardiac alternans, beat-to-beat alternations in action potential duration, is a precursor to fatal arrhythmias such as ventricular fibrillation. Previous research has shown that voltage driven alternans can be suppressed by application of a constant diastolic interval (DI) pacing protocol. However, the effect of constant-DI pacing on cardiac cell dynamics and its interaction with the intracellular calcium cycle remains to be determined. Therefore, we aimed to examine the effects of constant-DI pacing on the dynamical behavior of a single-cell numerical model of cardiac action potential and the influence of voltage-calcium (V-Ca) coupling on it. Single cell dynamics were analyzed in the vicinity of the bifurcation point using a hybrid pacing protocol, a combination of constant-basic cycle length (BCL) and constant-DI pacing. We demonstrated that in a small region beneath the bifurcation point, constant-DI pacing caused the cardiac cell to remain alternans-free after switching to the constant-BCL pacing, thus introducing a region of bistability (RB). The size of the RB increased with stronger V-Ca coupling and was diminished with weaker V-Ca coupling. Overall, our findings demonstrate that the application of constant-DI pacing on cardiac cells with strong V-Ca coupling may induce permanent changes to cardiac cell dynamics increasing the utility of constant-DI pacing.

Improved Multiscale Entropy Technique with Nearest-Neighbor Moving-Average Kernel for Nonlinear and Nonstationary Short-Time Biomedical Signal Analysis.

Analysis of biomedical signals can yield invaluable information for prognosis, diagnosis, therapy evaluation, risk assessment, and disease prevention which is often recorded as short time series data that challenges existing complexity classification algorithms such as Shannon entropy (SE) and other techniques. The purpose of this study was to improve previously developed multiscale entropy (MSE) technique by incorporating nearest-neighbor moving-average kernel, which can be used for analysis of nonlinear and non-stationary short time series physiological data. The approach was tested for robustness with respect to noise analysis using simulated sinusoidal and ECG waveforms. Feasibility of MSE to discriminate between normal sinus rhythm (NSR) and atrial fibrillation (AF) was tested on a single-lead ECG. In addition, the MSE algorithm was applied to identify pivot points of rotors that were induced in ex vivo isolated rabbit hearts. The improved MSE technique robustly estimated the complexity of the signal compared to that of SE with various noises, discriminated NSR and AF on single-lead ECG, and precisely identified the pivot points of ex vivo rotors by providing better contrast between the rotor core and the peripheral region. The improved MSE technique can provide efficient complexity analysis of variety of nonlinear and nonstationary short-time biomedical signals.

Constant DI pacing suppresses cardiac alternans formation in numerical cable models.

Cardiac repolarization alternans describe the sequential alternation of the action potential duration (APD) and can develop during rapid pacing. In the ventricles, such alternans may rapidly turn into life risking arrhythmias under conditions of spatial heterogeneity. Thus, suppression of alternans by artificial pacing protocols, or alternans control, has been the subject of numerous theoretical, numerical, and experimental studies. Yet, previous attempts that were inspired by chaos control theories were successful only for a short spatial extent (<2 cm) from the pacing electrode. Previously, we demonstrated in a single cell model that pacing with a constant diastolic interval (DI) can suppress the formation of alternans at high rates of activation. We attributed this effect to the elimination of feedback between the pacing cycle length and the last APD, effectively preventing restitution-dependent alternans from developing. Here, we extend this idea into cable models to study the extent by which constant DI pacing can control alternans during wave propagation conditions. Constant DI pacing was applied to ventricular cable models of up to 5 cm, using human kinetics. Our results show that constant DI pacing significantly shifts the onset of both cardiac alternans and conduction blocks to higher pacing rates in comparison to pacing with constant cycle length. We also demonstrate that constant DI pacing reduces the propensity of spatially discordant alternans, a precursor of wavebreaks. We finally found that the protective effect of constant DI pacing is stronger for increased electrotonic coupling along the fiber in the sense that the onset of alternans is further shifted to higher activation rates. Overall, these results support the potential clinical applicability of such type of pacing in improving protocols of implanted pacemakers, in order to reduce the risk of life-threatening arrhythmias. Future research should be conducted in order to experimentally validate these promising results.

Novel approaches for quantitative electrogram analysis for intraprocedural guidance for catheter ablation: A case of a patient with persistent atrial fibrillation.

PURPOSE: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia that causes stroke affecting more than 2.3 million people in the US and is increasing in prevalence due to ageing population causing a new global epidemic. Catheter ablation with pulmonary vein isolation (PVI) to terminate AF is successful for paroxysmal AF but suffers limitations with persistent AF patients as current mapping methods cannot identify AF active substrates outside of PVI region. Recent evidences in the mechanistic understating of AF pathophysiology suggest that ectopic activity, localized re-entrant circuit with fibrillatory propagation and multiple circuit re-entries may all be involved in human AF. The authors developed novel electrogram analysis methods and validated using optical mapping data from isolated rabbit hearts to accurately identify rotor pivot points. The purpose of this study was to assess the feasibility of generating patient-specific 3D maps for intraprocedural guidance for catheter ablation using intracardiac electrograms from a persistent AF patient using novel electrogram analysis methods. METHODS: A persistent AF patient with clinical appointment for AF ablation was recruited for this study with IRB approval. 1055 electrograms throughout the left and right atrium were obtained for offline analysis with the novel approaches such as multiscale entropy, multiscale frequency, recurrence period density entropy, kurtosis and empirical mode decomposition to generate patient specific 3D maps. 3D Shannon Entropy, Renyi Entropy and Dominant frequency maps were also generated for comparison purposes along with local activation time and complex fractionated electrogram analysis maps. RESULTS: Patient specific 3D maps were obtained for each of the different approach. The 3D maps indicate potential active sites outside the PVI region. However, presence of rotors cannot be confirmed and validation of these approaches is required on a larger dataset. CONCLUSIONS: Conventional catheter mapping system can be used for generating patient specific 3D maps with short time series analysis using the novel approaches.

Condition for alternans and stability of the 1:1 response pattern in a "memory" model of paced cardiac dynamics.

We analyze a mathematical model of paced cardiac muscle consisting of a map relating the duration of an action potential to the preceding diastolic interval as well as the preceding action potential duration, thereby containing some degree of "memory." The model displays rate-dependent restitution so that the dynamic and S1-S2 restitution curves are different, a manifestation of memory in the model. We derive a criterion for the stability of the 1:1 response pattern displayed by this model. It is found that the stability criterion depends on the slope of both the dynamic and S1-S2 restitution curves, and that the pattern can be stable even when the individual slopes are greater or less than one. We discuss the relation between the stability criterion and the slope of the constant-BCL restitution curve. The criterion can also be used to determine the bifurcation from the 1:1 response pattern to alternans. We demonstrate that the criterion can be evaluated readily in experiments using a simple pacing protocol, thus establishing a method for determining whether actual myocardium is accurately described by such a mapping model. We illustrate our results by considering a specific map recently derived from a three-current membrane model and find that the stability of the 1:1 pattern is accurately described by our criterion. In addition, a numerical experiment is performed using the three-current model to illustrate the application of the pacing protocol and the evaluation of the criterion.

Analysis of the Fenton-Karma model through an approximation by a one-dimensional map.

The Fenton-Karma model is a simplification of complex ionic models of cardiac membrane that reproduces quantitatively many of the characteristics of heart cells; its behavior is simple enough to be understood analytically. In this paper, a map is derived that approximates the response of the Fenton-Karma model to stimulation in zero spatial dimensions. This map contains some amount of memory, describing the action potential duration as a function of the previous diastolic interval and the previous action potential duration. Results obtained from iteration of the map and numerical simulations of the Fenton-Karma model are in good agreement. In particular, the iterated map admits different types of solutions corresponding to various dynamical behavior of the cardiac cell, such as 1:1 and 2:1 patterns. (c) 2002 American Institute of Physics.