There has been a significant progress in our understanding of the molecular mechanisms by which calcium (Ca 2+ ) ions mediate various types of cardiac arrhythmias. A growing list of inherited gene defects can cause potentially lethal cardiac arrhythmia syndromes, including catecholaminergic polymorphic ventricular tachycardia, congenital long QT syndrome, and hypertrophic cardiomyopathy. In addition, acquired deficits of multiple Ca 2+ -handling proteins can contribute to the pathogenesis of arrhythmias in patients with various types of heart disease. In this review article, we will first review the key role of Ca 2+ in normal cardiac function—in particular, excitation–contraction coupling and normal electric rhythms. The functional involvement of Ca 2+ in distinct arrhythmia mechanisms will be discussed, followed by various inherited arrhythmia syndromes caused by mutations in Ca 2+ -handling proteins. Finally, we will discuss how changes in the expression of regulation of Ca 2+ channels and transporters can cause acquired arrhythmias, and how these mechanisms might be targeted for therapeutic purposes.

Calcium Signaling and Cardiac Arrhythmias.

The QT interval, an electrocardiographic measure reflecting myocardial repolarization, is a heritable trait. QT prolongation is a risk factor for ventricular arrhythmias and sudden cardiac death (SCD) and could indicate the presence of the potentially lethal mendelian long-QT syndrome (LQTS). Using a genome-wide association and replication study in up to 100,000 individuals, we identified 35 common variant loci associated with QT interval that collectively explain ∼8-10% of QT-interval variation and highlight the importance of calcium regulation in myocardial repolarization. Rare variant analysis of 6 new QT interval-associated loci in 298 unrelated probands with LQTS identified coding variants not found in controls but of uncertain causality and therefore requiring validation. Several newly identified loci encode proteins that physically interact with other recognized repolarization proteins. Our integration of common variant association, expression and orthogonal protein-protein interaction screens provides new insights into cardiac electrophysiology and identifies new candidate genes for ventricular arrhythmias, LQTS and SCD.

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Genetic association study of QT interval highlights role for calcium signaling pathways in myocardial repolarization

Over the last decade, mouse models have become a popular instrument for studying cardiac arrhythmias. This review assesses in which respects a mouse heart is a miniature human heart, a suitable model for studying mechanisms of cardiac arrhythmias in humans and in which respects human and murine hearts differ. Section I considers the issue of scaling of mammalian cardiac (electro) physiology to body mass. Then, we summarize differences between mice and humans in cardiac activation (section II) and the currents underlying the action potential in the murine working myocardium (section III). Changes in cardiac electrophysiology in mouse models of heart disease are briefly outlined in section IV, while section V discusses technical considerations pertaining to recording cardiac electrical activity in mice. Finally, section VI offers general considerations on the influence of cardiac size on the mechanisms of tachy-arrhythmias.

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Cardiac electrophysiology in mice: a matter of size.

Early afterdepolarizations (EADs) are secondary voltage depolarizations during the repolarizing phase of the action potential, which can cause lethal cardiac arrhythmias. The occurrence of EADs requires a reduction in outward current and/or an increase in inward current, a condition called reduced repolarization reserve. However, this generalized condition is not sufficient for EAD genesis and does not explain the voltage oscillations manifesting as EADs. Here, we summarize recent progress that uses dynamical theory to build on and advance our understanding of EADs beyond the concept of repolarization reserve, towards the goal of developing a holistic and integrative view of EADs and their role in arrhythmogenesis. We first introduce concepts from nonlinear dynamics that are relevant to EADs, namely, Hopf bifurcation leading to oscillations and basin of attraction of an equilibrium or oscillatory state. We then present a theory of phase-2 EADs in nonlinear dynamics, which includes the formation of quasi-equilibrium states at the plateau voltage, their stabilities, and the bifurcations leading to and terminating the oscillations. This theory shows that the L-type calcium channel plays a unique role in causing the nonlinear dynamical behaviours necessary for EADs. We also summarize different mechanisms of phase-3 EADs. Based on the dynamical theory, we discuss the roles of each of the major ionic currents in the genesis of EADs, and potential therapeutic targets.

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Early afterdepolarizations in cardiac myocytes: beyond reduced repolarization reserve

Hypertension and atrial fibrillation (AF) are 2 important public health priorities. Their prevalence is increasing worldwide, and the 2 conditions often coexist in the same patient. Hypertension and AF are strikingly related to an excess risk of cardiovascular disease and death. Hypertension ultimately increases the risk of AF, and because of its high prevalence in the population, it accounts for more cases of AF than other risk factors. Among patients with established AF, hypertension is present in about 60% to 80% of individuals. Despite the well-known association between hypertension and AF, several pathogenetic mechanisms underlying the higher risk of AF in hypertensive patients are still incompletely known. From an epidemiological standpoint, it is unclear whether the increasing risk of AF with blood pressure (BP) is linear or threshold. It is uncertain whether an intensive control of BP or the use of specific antihypertensive drugs, such as those inhibiting the renin-angiotensin-aldosterone system, reduces the risk of subsequent AF in hypertensive patients in sinus rhythm. Finally, in spite of the observational evidence suggesting a progressive relation between BP levels and the risk of thromboembolism and bleeding in patients with hypertension and AF, the extent to which BP should be lowered in these patients, including those who undergo catheter ablation, remains uncertain. This article summarizes the main basic mechanisms through which hypertension is believed to promote AF. It also explores epidemiological data supporting an evolutionary pathway from hypertension to AF, including the emerging evidence favoring an intensive BP control or the use of drugs, which inhibit the renin-angiotensin-aldosterone system to reduce the risk of AF. Finally, it examines the impact of non-vitamin K antagonist oral anticoagulants compared with warfarin in relation to hypertension.

Hypertension and Atrial Fibrillation: Doubts and Certainties From Basic and Clinical Studies.

Several case reports suggest QT prolongation leading to ventricular arrhythmias with fatal outcome after intoxication with the μ-opioid receptor agonist and anti-diarrheal agent loperamide. The number of cases of loperamide misuse are growing due to its potential stimulating effects. Loperamide intoxications can be treated by naloxone. However, previous reports described a further QT prolongation associated with naloxone administration. Therefore, the aim of this study was to investigate the effects of loperamide and naloxone on the cardiac electrophysiology in a sensitive whole-heart model. Twenty-six hearts of New Zealand White rabbits were retrogradely perfused in a modified Langendorff apparatus. Monophasic action potentials were recorded by endo- and epicardially positioned catheters. Hearts were stimulated at different cycle lengths, thereby obtaining action potential duration at 90% of repolarization (APD90) and QT intervals. Programmed ventricular stimulation was used to assess ventricular vulnerability. Fourteen hearts were perfused with ascending concentrations of loperamide (0.2 μM, 0.35 μM, and 0.5 μM) after obtaining baseline data. Another 12 hearts were treated with naloxone (0.1 μM, 0.5 μM, 2 μM). Loperamide led to a significant increase in QT interval, APD90, and ventricular tachycardia (VT) episodes. In contrast, naloxone led to a decrease in QT interval and APD90. Accordingly, the number of VT episodes was unaltered. To the best of our knowledge, this is the first experimental study that investigated the effects of loperamide and naloxone in a whole-heart model. Loperamide led to a significant increase in action potential duration and QT interval. Simultaneously, the number of ventricular tachycardias was significantly increased. In contrast, naloxone led to a shortening of the action potential duration without altering arrhythmia susceptibility.

Divergent Electrophysiological Effects of Loperamide and Naloxone in a Sensitive Whole-Heart Model.

Background The first-line therapy for atrioventricular nodal reentry tachycardia (AVNRT) is catheter-based slow pathway modulation. If AVNRT is not inducible during an electrophysiological study, an empirical slow pathway modulation (ESPM) may be considered in patients with dual atrioventricular nodal physiology and/or a typical electrocardiogram (ECG). Methods We screened 149 symptomatic patients who underwent ESPM in our department between 1993 and 2013. All patients fulfilled the following criteria: (1) either dual atrioventricular nodal (AVN) physiology with up to 2 AVN echo beats or characteristic ECG documentation or both, (2) noninducibility of AVNRT by programmed stimulation, and (3) completion of a telephone questionnaire for long-term follow-up. Out of this population we retrospectively investigated 13 patients who were primarily noninducible but in whom an AVNRT occurred during or after radiofrequency (RF) delivery. Results When AVNRT occurred, the procedure lost its empirical character, and RF delivery was continued until the procedural endpoint of noninducibility of AVNRT. This endpoint was reached in all but one patient (92%). After a follow-up of 73 ± 15 months, this patient was the only one who reported no benefit from the procedure. Conclusions Out of 149 initially noninducible patients, a considerable number (9%) exhibited AVNRT during or after RF delivery. These patients crossed over from empirical to controlled slow pathway modulation resulting in a good clinical outcome. Our observations should encourage electrophysiologists to repeat programmed stimulation even after initial empirical RF delivery to retest for inducibility.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/clc.22797

Occurrence of primarily noninducible atrioventricular nodal reentry tachycardia after radiofrequency delivery in the slow pathway region during empirical slow pathway modulation.

Background: Dual atrioventricular nodal physiology can cause atrioventricular nodal reentrant tachycardia (ANVRT). However, dual AVN physiology can sometimes also cause atrial extrasystole by 1:2 separate AV conduction via the fast and the slow pathway. This arrhythmia may be treated by radiofrequency modulation of the slow pathway (SPM). So far, only case reports have been published. We here present procedural characteristics and long-term follow-up in a series of five patients who underwent SPM for the treatment of 1:2 AVN conduction.

Outcome: A population of 2927 patients who underwent SPM in our institution between 1994 and 2012 was screened for 1:2 AVN conduction. Five patients (2 male; mean age 55±14 yrs) were identified. All patients were highly symptomatic with palpitations. ECG documentation of 1:2 supraventricular extrasystole had been obtained in all patients. During electrophysiological study dual AVN physiology with separate AV nodal conduction via the fast and slow pathway in a 1:2 pattern was revealed in four patients. Mean fast pathway conduction measured as the AH interval was 149±70 ms while mean slow pathway conduction was 536±99 ms. In none of the 5 patients AVNRT was inducible. SPM was performed in all patients with the endpoint of absence of 1:2 conduction, which was tested by programmed atrial stimulation including orciprenaline challenge. In one patient, no dual AVN physiology was inducible despite extensive programmed stimulation and application of chatecholamines. On the ground of typical ECG documentation and severe symptoms, empirical SPM was performed in this case. There were no complications in any of the patients. Long term follow up (69.6±54.8 months) was performed by a telephone questionnaire. 4 patients were free of symptoms. The patient with empirical SPM remained symptomatic; however, he also reported improvement of clinical symptoms due to lower frequency of occurrence and shorter duration of episodes.

Conclusion: 1:2 AVN conduction is a rhythm disorder that can be highly symptomatic. Although rare, this diagnosis should be considered in patients with palpitations and ECG documentation compatible with 1:2 AV conduction. Our data show that in this clinical setting catheter ablation is an effective and safe therapy with good long term outcome.

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Supraventricular extrasystole due to 1:2 atrioventricular conduction: procedural characteristics and long term follow-up of slow pathway modulation

Background Ablation emerged as first line therapy in the treatment of various arrhythmias. Nevertheless, in older patients (pts), decision is often made pro drug treatment as more complications and less benefit are suspected. Hypothesis We hypothesized that different kind of ablations can be performed safely regardless of the pts age. Methods We enrolled all pts aged >80 years (yrs) who underwent ablation for three different arrhythmias (atrial flutter [AFL], atrioventricular nodal re-entry tachycardia [AVNRT], ventricular tachycardia [VT]) between August 2002 and December 2018. Procedural data and outcome were compared with matched groups aged 60 to 80 years and 40 to 60 years, respectively. Periprocedural and in-hospital complications were analyzed. Results The analysis included 1191 patients (397 pts per group: 63% AFL, 23% AVNRT, 14% VT) who underwent ablation. Acute success was high in all types of arrhythmias irrespective of age (>80, 60-80, 40-60 years: AFL 97%/98%/98%, AVNRT 97%/95%/97%, VT 82%/86%/93%). Rate of periprocedural complications were similar in all groups treated for AFL and AVNRT. For VT ablations significant differences were noted between pts > 80 or 60 to 80 years and those aged 40-60 years (16.1%/14.3%/3.6%). Most complications were infections and groin haematoma. No strokes, iatrogenic atrioventricular blocks and deaths related to the ablation occurred. Conclusion Ablation appears safe in pts > 80 years. Success rates were comparable to matched younger cohorts. A significant difference was observed for VT patients.

Nils Bögeholz

Papers

Divergent Electrophysiological Effects of Loperamide and Naloxone in a Sensitive Whole-Heart Model.

Occurrence of primarily noninducible atrioventricular nodal reentry tachycardia after radiofrequency delivery in the slow pathway region during empirical slow pathway modulation.

Supraventricular extrasystole due to 1:2 atrioventricular conduction: procedural characteristics and long term follow-up of slow pathway modulation

Outcome of catheter ablation in the very elderly-insights from a large matched analysis

Monitoring the decay of the current of injury (COI): A re-visited parameter to predict performance of transvenous pacemaker leads