(Circulation. 1999;100:1450-1459.)
© 1999 American Heart Association, Inc.
Basic Science Reports |
Role of Papillary Muscle in the Generation and Maintenance of Reentry During Ventricular Tachycardia and Fibrillation in Isolated Swine Right Ventricle
From the Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center (Y.-H.K., M.Y., T.-J.W., M.V., M.-H.L., T.O., O.V., R.N.D., H.S.K., P.-S.C.), and the Division of Cardiology, Departments of Medicine, Physiology, and Physiological Science (F.X., Z.Q., A.G., J.N.W.) and Pathology (M.C.F.), UCLA School of Medicine, Los Angeles, Calif; and Korea University, Seoul, Korea (Y.-H.K.). Dr Kim is now at the Division of Cardiology, Department of Medicine, Korea University, Seoul, Korea.
Correspondence to Peng-Sheng Chen, MD, Room 5342, CSMC, 8700 Beverly Blvd, Los Angeles, CA 90048. E-mail chenp{at}csmc.edu
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Abstract |
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Background—The role of papillary muscle (PM) in the generation and maintenance of reentry is unclear.
Methods and Results—Computerized mapping (477 bipolar electrodes, 1.6-mm resolution) was performed in fibrillating right ventricles (RVs) of swine in vitro. During ventricular fibrillation (VF), reentrant wave fronts often transiently anchored to the PM. Tissue mass reduction was then performed in 10 RVs until VF converted to ventricular tachycardia (VT). In an additional 6 RVs, procainamide infusion converted VF to VT. Maps showed that 77% (34 of 44) of all VT episodes were associated with a single reentrant wave front anchored to the PM. Purkinje fiber potentials preceded the local myocardial activation, and these potentials were recorded mostly around the PM. When PM was trimmed to the level of endocardium (n=4), sustained VT was no longer inducible. Transmembrane potential recordings (n=5) at the PM revealed full action potential during pacing, without evidence of ischemia. Computer simulation studies confirmed the role of PM as a spiral wave anchoring site that stabilized wave conduction.
Conclusions—We conclude that PM is important in the generation and maintenance of reentry during VT and VF.
Key Words: death, sudden • electrophysiology • waves • procainamide • antiarrhythmia agents
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Introduction |
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The safety factor of impulse propagation depends on the relation between the source (amount of current available in the propagating wave front) and the sink (structure that determines current density when the wave front arrives).1 2 3 The papillary muscle (PM) is an electrically active tissue. For an electrical impulse to propagate from the ventricle to the PM, the electrical charge it carries (source) must excite both the ventricular muscle downstream and the PM that inserts into the ventricular tissue. In this scenario, the PM serves as an additional sink for impulse propagation. This additional sink may decrease the safety factor of impulse propagation and result in conduction block. Recently, we reported4 that procainamide exerts its antiarrhythmic drug action by preventing spontaneous wave breaks and proposed that this finding may explain the observation that procainamide converts ventricular fibrillation (VF) to ventricular tachycardia (VT) in some patients.5 6 The purpose of the present study was to test the following hypotheses in isolated swine right ventricle (RV): (1) PM serves as a site of conduction block that leads to reentry; (2) PM serves as a site of anchoring for reentry, resulting in a sustained VT; and (3) procainamide converts VF to sustained VT by preventing spontaneous wave breaks and by facilitating the anchoring of a single reentrant wave front to the PM.
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Methods |
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In Vitro VF Model
Details of this model have been reported elsewhere.7 Briefly, farm pigs (34 to 65 kg) were used in the study. The ventricles usually fibrillated during excision, and fibrillation continued in the excised RV. The right coronary artery was cannulated and perfused with Tyrode's solution (37±0.5°C, pH 7.35) equilibrated with 95% O2 and 5% CO2 at a flow rate of 30 mL/min. The flow rate was roughly equivalent to 1 mL · g ventricular wt-1 · min-1. At the bottom of the tissue bath was a built-in electrode array containing 477 bipolar recording electrodes in 21 columns and 25 rows. A pseudo-ECG was recorded by a pair of bipolar electrodes with widely spaced (>3 cm) bipoles. Transmembrane potential (TMP) was recorded with standard glass microelectrodes.8
Protocol 1: VT After Tissue Mass Reduction
Eleven RVs were included in this protocol. The chordae tendineae
and a portion of the anterolateral PM were removed to facilitate the
endocardial mapping (Figure 1
, A and B).
The PM site was thicker than the surrounding ventricular
tissue (Figure 1C). This tissue block was subsequently called
the "isolated RV." Scissors were used to cut out a 1.5x3-cm or
1x4-cm portion of the fibrillating RV from the boundary of the tissue
distal to the perfusion site. If VF continued, an additional tissue was
cut out from the fibrillating RV. In 9 RVs, the cutting spared the PM.
In 2 RVs, PM was removed during the first cut. This process continued
until the VF either terminated or was converted to VT. The VT was then
terminated by rapid ventricular pacing or by defibrillation
shocks. Attempts were then made to reinduce VT by rapid electrical
stimulation. Sustained VT was defined as a VT that lasted >30 seconds
with largely uniform electrogram morphology.
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Protocol 2: Effects of Procainamide Infusion
Six RVs were studied with this protocol. After endocardial
mapping studies of baseline VF, the effects of procainamide 5
µg/mL on the activation patterns were evaluated. The patterns of
activation were mapped 5 minutes, 10 minutes, and 15 minutes after the
beginning of the infusion. The procainamide concentration was
progressively increased up to 15 µg/mL or when VF converted to VT.
Procainamide was then washed out with infusion of drug-free
Tyrode's solution, and the patterns of activation were again
mapped.
Protocol 3: Effects of PM Resection
Four RVs with intact PM were studied with this protocol. The
tissue was placed in the bath endocardial side up. After baseline
patterns of epicardial VF activation had been obtained, the RV mass was
gradually reduced by cutting until VF converted to VT. The VT was
terminated by overdrive pacing. VF was then reinduced to determine
whether it could spontaneously convert to VT. After that, PM was
removed so that it was level with the endocardium. Attempts were then
made to reinduce VF or VT by premature stimulations and by rapid
pacing.
Protocol 4: TMP and Effective Refractory Period of the PM
In 5 RVs, TMP recordings were made during different
pacing rates from the surface of the PM, from the base (cut surface) of
the PM, and from the endocardium 10 to 12 mm away from the PM. The
effective refractory period was determined from multiple sites in the
PM and away from the PM at a pacing cycle length (CL) of 400 ms. Both
S1 and S2 were given at the
same site with twice the diastolic threshold currents and
5-ms pulse duration.
Computer Simulations
Our computer simulations were carried out with the Luo-Rudy
Phase I ventricular myocyte cell model9 with
some parameter modifications:
(gNa)max was set to 10,
(gSI)max to 0.055, and
(gK)max to 0.338 to yield an action potential
duration of 250 ms and other physiologically
realistic parameter values. This cell model was then
coupled into sheets of various sizes (see figure legends). The
resulting model was numerically integrated by use of a forward Euler
procedure10 whose space step
dx=dy=dz=0.02 cm and whose time step
varied from 0.01 to 0.1 ms. All calculations were carried out on a DEC
Alpha workstation.
Data Analyses
Analyses of mapping data were performed according to our
previously described algorithm.7 11 We defined anchoring
of reentrant wave fronts to PM as a mode of activation when the tip of
consecutive reentrant wave fronts followed a path corresponding to the
boundary of the PM. The tip of the reentrant wavefront was the red dot
closest to the core during the dynamic display of
reentry.8 12
For wavelet numbers, we first counted the total number of wavelets over the entire 8-second period and the average number of activations recorded on each channel over the same time period. We then divided the number of wavelets by the number of activations to obtain the average number of wavelets per activation. In addition, we also determined the maximum number of wavelets at any instant of VF.
All data are presented as mean±SD, and Student's t
test was used to compare the means. ANOVA with the Newman-Keuls test
was used when multiple comparisons were performed.13
Linear regression analysis was performed to determine the
relationship between PM area and core size of reentrant wave front and
the relationship between PM area and the CL of VT anchored to PM. A
value of P
0.05 was considered significant.
Histopathological Examination
At the conclusion of the experiments, the tissues were fixed in
10% buffered formalin. PM area (the area at the junction of the PM at
the contact site with the ventricular wall) was measured by
a planimeter. Transmural sections were taken to evaluate the thickness
of PM and fiber orientation. The tissues were processed routinely for
histopathological examinations.
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Results |
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The baseline VF was characterized by a maximum of 4.6±0.7 and a mean of 3.1±0.6 wavelets per activation. With tissue mass reduction and with procainamide infusion, the maximum and mean numbers of wavelets decreased to 3.6±0.5 and 2.0±0.4 (P<0.05) and 3.2±0.4 and 2.1±0.7 (P<0.01), respectively, immediately before VF converted to VT. In protocols 1 and 3, when the RV (34.1±6.8 g) was reduced to 16.1±2.0 g, VF converted to VT. In protocol 2 (n=6), procainamide concentrations associated with VF to VT conversion were 15 µg/mL (n=3), 10 µg/mL (n=2), and 5 µg/mL (n=1). Maps showed that 77% of all VT episodes (34 of 44) were due to a single wave front that anchored to the PM. Anchoring of a single reentrant wave front was seen in 28 of 44 episodes (63.6%) of VT. In 6 episodes (13.6%), repetitive breakthrough pattern near the PM was associated with VT. In the remaining 10 episodes (23%), reentrant wave front was present but the core was not near the PM.
Protocol 1
Role of PM During VF
Reentrant wave fronts were observed in 49 episodes of VF in
17 tissues (average 3.0±1.2 episodes/tissue) at baseline. Of these
reentrant wave fronts, 77.6% (38 of 49 episodes) transiently anchored
to PM. With the tissue mass reduction, the number of rotations of an
anchored reentrant wave front increased from 1.5±1.4 to 4.4±2.7
(P<0.05) before converting to VT. Figure 2 shows a reentrant wave front during VF
rotated in a clockwise direction (white arrows, A through F) before
drifting toward the right lower portion of the tissue (G). A new wave
front (double pink arrows) appeared and induced separation of the tip
of the original wave front (double white arrows) from the PM, forcing
the latter wave front to meander toward the boundary (H through L)
before termination (M and N). Panel O shows the path of the original
wave front.
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PM and Sustained VT
Figure 3 shows an example of
reentrant wave fronts anchored to the PM, resulting in VT. Figure 3A
shows the endocardium. B through E show reentrant wave front rotating
in a counterclockwise direction around the PM. The core of reentrant
wave front (red circle) corresponds roughly to the PM in A. The core
area measured 25.5 mm2, which was larger
than the PM area (16.0 mm2). The tip of the
reentrant wave front attached to the PM. F is a diagram showing all the
recording sites (a through f) during reentrant excitation in a
counterclockwise direction. G shows actual electrograms recorded
from sites a through f in F. The reentrant wave front followed this
trajectory around PM in a stable fashion. There was no beat-to-beat
variation of the reentrant pathways.
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In contrast to the area remote from the PM (a, b, c, and f),
electrograms near the root of the PM, d and e, show double potentials
with a discrete sharp first potential (marked by asterisk) followed by
a wider second potential. These double potentials were recorded
mostly around the PM, as shown in H and I (electrograms b through e).
This sharp first potential in these same electrodes also preceded
broader or wider potential by 10 to 14 ms during
S1 pacing (J, electrograms c through e). However,
at certain sites near b (b') and d (d'), this relationship was
reversed. The intervals between the 2 were 15 to 17 ms. In regions
remote from the PM, double potentials either were absent (as in site k)
or were not separated by discrete interactivation intervals (site l).
The center of the root of PM remained electrically quiescent
(electrograms f, g, and j), <10% of the amplitude recorded at the
periphery (h), or exhibited 2:1 block (i) during sustained reentry. All
these sites underwent full activation during regular pacing (Figure 4J, electrograms f through j). Figure 4L
shows the distribution of double potentials during this episode of VT.
The area registering double potentials extends from the edge of
PM insertion to the surrounding portion of the endocardium. No
double potentials were registered at the base of PM.
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Effect of Removal of the Tissue Containing PM on the Pattern
of Activation
In 2 RVs, the PM was placed outside the mapping electrode
array, as shown in Figure 4
. During sustained VT in the first
tissue (A), the patterns of activation in the mapped region showed a
planar wave (C through E). When the tissue including PM was cut away
(G), VT was converted to polymorphic VT before spontaneous
termination (F and M). Maps showed a single reentrant wave front whose
tip meandered toward the lower edge of the tissue (H through L) and
terminated at the boundary (M). After this, repeated attempts failed to
reinduce sustained VT. In a second tissue, cutting away the PM
converted VF to VT, which then spontaneously converted back to VF.
After cardioversion, multiple attempts induced either nonsustained VT
or VT that spontaneously degenerated to VF. These findings are
compatible with the notion that removal of the tissue containing PM
eliminated the site of stable stationary anchoring of reentrant wave
front.
The mean PM area (17.9±3.8 mm2) was significantly (P<0.01, n=11) smaller than the core size of reentrant wave front (28.8±5.9 mm2). There was a positive correlation between the PM area and the core size (r=0.8, P<0.01) and between the core size and the CL of VT (r=0.7, P<0.05). These findings demonstrate that the core size and the CL of reentrant wave fronts are influenced by the size of the underlying PM to which reentry is anchored.
Initiation of Reentry by a Premature Stimulus
Figure 5A shows an example of TMPs
and pseudo-ECGs when VT was induced by
S1-S2 stimuli. The arrows
in a through h in TMP recordings correspond to the time
(ms) above each frame in C. A single premature stimulus
(S2) applied to the epicardium, near the center
of the mapped tissue, induced VT. Figure 5B shows the tissue
specimen. Figure 5C, a through c, shows static frames of dynamic
display during S1 pacing. Panels d through h show
the impulse induced by S2 blocked along the
region indicated by 2 red lines, resulting in reentry. In all RVs in
which VT was induced by a single premature stimulus, the sites of
conduction block were located at the junction of the PM and the RV free
wall.
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Protocol 2
In all RVs, continuous infusion of procainamide resulted
in the conversion from VF to sustained VT (Figure 6). Before conversion of VF to VT,
procainamide increased the CL of VF from 76±8 to 93±14 ms
(P<0.05). Mean action potential duration at 90% and 50%
repolarization (APD90 and
APD50) increased from 63±6 to 78±11 ms
(P<0.05) and from 47±3 to 61±9 ms (P<0.05),
respectively. The action potential amplitude (61±13 mV) and
(dV/dt)max (33±20 V/s) were not significantly
changed after procainamide infusion (58±7 mV and 35±8 V/s,
respectively). The CL of VT (193±76 ms) was not significantly
different from the CL of VT seen in protocol 1. Maps showed that all
episodes of VT that occurred during procainamide infusion were
associated with a single reentrant wave front anchored to the PM. The
core size was 22.5±8.1 mm2, which
correlated well (r=0.93, P<0.05) with the PM
area.
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After procainamide was washed out with drug-free Tyrode's solution for 34±8 minutes, VT either spontaneously degenerated into VF (n=4) or was convertible to VF by rapid pacing (n=2). The maximum and mean numbers of VF wavelets after procainamide washout were 4.3±0.9 and 2.9±0.8, respectively (P=NS versus baseline VF).
Protocol 3
In 4 RVs, we studied the patterns of activation during VT and VF
before and after PM resection. With intact PM, sustained VT was
associated with anchoring of reentrant wave front to the PM. After
termination of the VT, VF was reinducible and there was spontaneous
conversion of VF to VT. Pseudo-ECG during sustained reentry showed a
uniform morphology and a constant CL, compatible with VT. After PM
resection, sustained VT was no longer inducible. Even with further
tissue mass reduction, sustained VT could not be induced.
Protocol 4
The effective refractory period at the PM was 236±19 ms, and at
endocardial sites remote from the PM it was 248±20 ms
(P=NS). Normal action potentials were registered on the PM
(before cut) in 5 tissues and at the cut surface of the PM in 3 tissues
studied (Table ). Figure 7 shows TMP recordings from the
base (cut surface) of the PM and at the endocardium at 2 different
pacing rates (400- and 230-ms CLs). The sharp upstroke and the long
duration of AP are incompatible with ischemia or cell
damage.
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Histopathological Studies
The isolated RVs, including the PM, were grossly normal at the end
of the experiment (Figure 1D). There was no sign of injury or
autolysis. The trichrome stain showed no evidence of hypereosinophilia.
Hematoxylin and eosin–stained sections showed no myocardial cell
abnormalities. There was focal edema in some sections.
Computer Simulations
Computer simulations confirmed the role of PM attachments as
spiral-wave anchoring sites, which act to stabilize wave conduction. In
a larger piece of tissue with a PM-like ridge (Figure 8, panel I), corresponding to the
baseline experimental condition, the spiral wave broke up into a
sustained, multispiral, fibrillation-like state, replicating the
baseline experimental condition. But when the tissue model is cut to a
smaller size and the remaining tissue does not contain a ridge-like
structure (Figure 8, II), the spiral wave does not anchor. A
transient fibrillation-like state is created, which ultimately
terminates at the tissue boundaries, replicating the experimental
results shown in Figure 4, G through M. If a ridge is
present in this small tissue (Figure 8, III), the spiral
wave anchors and the behavior becomes periodic, again replicating the
experimental finding (Figure 3).
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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There are 2 major findings in this study. The first is that the PM, which is a naturally occurring anatomic obstacle, serves as a site for wave break during the initiation of reentry. The second is that the PM also serves as a site for stable anchoring of reentrant wave front, leading to the conversion from VF to VT after reduction of wave front number either by tissue mass reduction or by procainamide infusion.
Source-Sink Mismatch and the Formation of Reentry
We propose that the source-sink mismatch created by the PM
partially explains the results of this study. The safety factor of
impulse propagation depends on the relation between the source (amount
of current available in the propagating wave front) and the sink
(structure that determines current density when the wave front
arrives).1 2 3 An abrupt increase of current load (sink)
may reduce the safety factor of propagation, resulting in wave break
and the formation of reentry.14 15 PM, which creates a
sudden increase of muscle thickness, increases the current sink for the
incoming wave front. As a result, conduction block occurs at the site
of source-sink mismatch, resulting in the formation of reentry.
The source-sink mismatch may also explain the role of PM in anchoring the reentrant wave front, which facilitates the conversion from VF to VT in this model. It is known that an artificially created anatomic obstacle can determine the dynamic behavior of a functional reentrant wave front16 and that the effects of an obstacle on the reentrant wave front is determined in part by the size of the obstacle.8 An important finding in our study was that a naturally occurring anatomic obstacle, the PM, is apparently a large enough anatomic obstacle to anchor reentrant wave front.
Importance of Tissue Mass and Number of Wavelets
The source-sink mismatch alone cannot fully explain the results of
the present study. We found that the anchoring of reentry alone is
insufficient to convert VF to VT at baseline, because the anchored wave
front is often terminated by the interference of other wavelets that
exist during fibrillation. For VF to convert to VT, either the tissue
size has to be reduced or the
electrophysiological characteristics of the
tissue have to be altered. We also recently demonstrated in the same
animal model that tissue mass reduction results in a decreased number
of wandering wavelets.7 Kwan et al4 also
showed that during procainamide infusion, the number of
wavelets in canine VF is significantly reduced compared with baseline.
If the number of wavelets is reduced to a critical number either by
mass reduction or by procainamide, the wave front anchored to
the PM survives longer because of decreased interference. Eventually,
it takes over the electrical activation of the entire ventricles,
resulting in VT. This critical number of wavelets was <3.6 in the
mapped area during tissue mass reduction and <3.2 in the mapped area
during procainamide infusion. We propose that the reduced
number of wavelets below a critical value is important in facilitating
the spontaneous conversion from VF to VT in this model.
Conclusions
We conclude that a PM ridge provides a large electrical sink for
reentrant wave fronts (spiral waves) to anchor, resulting in sustained
VT. Whether or not this phenomenon underlies the mechanism of
idiopathic VT in the normal ventricles or contributes to the
proarrhythmic effects of procainamide and other antiarrhythmic
agents is unclear.
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Acknowledgments |
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This study was done during the tenure of a Fellowship Grant from the Department of Medicine, Korea University (Dr Kim); the Pinsky Endowment (Dr Fishbein); the Kawata and Laubisch Endowments, UCLA (Dr Weiss); a Cedars-Sinai ECHO Foundation Award (Dr Karagueuzian); and a Pauline and Harold Price Endowment and an AHA Wyeth-Ayerst Established Investigatorship Award (Dr Chen) and was supported in part by NIH grants P50-HL-52319, HL-50259, and HL-44880; AHA grants 9750623N and 9950464N; a UC-TRDRP 6RT-0020; and the Ralph M. Parsons Foundation, Los Angeles, Calif. We thank Dustan Hough, Avile McCullen, Meiling Yuan, Hsun-Lun A. Huang, Lucas Huang, Nina Wang, and Gregory Fishbein for their technical assistance and Elaine Lebowitz for her secretarial assistance.
Received February 6, 1999; revision received May 19, 1999; accepted May 26, 1999.
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C. Omichi, S. T. Lamp, S.-F. Lin, J. Yang, A. Baher, S. Zhou, M. Attin, M.-H. Lee, H. S. Karagueuzian, B. Kogan, et al. Intracellular Ca dynamics in ventricular fibrillation Am J Physiol Heart Circ Physiol, May 1, 2004; 286(5): H1836 - H1844. [Abstract] [Full Text] [PDF]
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H.-N. Pak, Y.-S. Oh, Y.-B. Liu, T.-J. Wu, H. S. Karagueuzian, S.-F. Lin, and P.-S. Chen Catheter Ablation of Ventricular Fibrillation in Rabbit Ventricles Treated With {beta}-Blockers Circulation, December 23, 2003; 108(25): 3149 - 3156. [Abstract] [Full Text] [PDF]
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P.-S. Chen, T.-J. Wu, C.-T. Ting, H. S. Karagueuzian, A. Garfinkel, S.-F. Lin, and J. N. Weiss A Tale of Two Fibrillations Circulation, November 11, 2003; 108(19): 2298 - 2303. [Full Text] [PDF]
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M. Valderrabano, P.-S. Chen, and S.-F. Lin Spatial Distribution of Phase Singularities in Ventricular Fibrillation Circulation, July 22, 2003; 108(3): 354 - 359. [Abstract] [Full Text] [PDF]
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M. Haissaguerre, M. Shoda, P. Jais, A. Nogami, D. C. Shah, J. Kautzner, T. Arentz, D. Kalushe, D. Lamaison, M. Griffith, et al. Mapping and Ablation of Idiopathic Ventricular Fibrillation Circulation, August 20, 2002; 106(8): 962 - 967. [Abstract] [Full Text] [PDF]
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M.-H. Lee, Z. Qu, G. A. Fishbein, S. T. Lamp, E. H. Chang, T. Ohara, O. Voroshilovsky, J. R. Kil, A. R. Hamzei, N. C. Wang, et al. Patterns of wave break during ventricular fibrillation in isolated swine right ventricle Am J Physiol Heart Circ Physiol, July 1, 2001; 281(1): H253 - H265. [Abstract] [Full Text] [PDF]
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P.-S. Chen, H. S. Karagueuzian, and Y.-H. Kim Papillary muscle hypothesis of idiopathic left ventricular tachycardia J. Am. Coll. Cardiol., April 1, 2001; 37(5): 1475 - 1476. [Full Text] [PDF]
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T. Ohara, K. Ohara, J.-M. Cao, M.-H. Lee, M. C. Fishbein, W. J. Mandel, P.-S. Chen, and H. S. Karagueuzian Increased Wave Break During Ventricular Fibrillation in the Epicardial Border Zone of Hearts With Healed Myocardial Infarction Circulation, March 13, 2001; 103(10): 1465 - 1472. [Abstract] [Full Text] [PDF]
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M. Valderrabano, Y.-H. Kim, M. Yashima, T.-J. Wu, H. S. Karagueuzian, and P.-S. Chen Obstacle-induced transition from ventricular fibrillation to tachycardia in isolated swine right ventricles: Insights into the transition dynamics and implications for the critical mass J. Am. Coll. Cardiol., November 15, 2000; 36(6): 2000 - 2008. [Abstract] [Full Text] [PDF]
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M. Valderrabano, M.-H. Lee, T. Ohara, A. C. Lai, M. C. Fishbein, S.-F. Lin, H. S. Karagueuzian, and P.-S. Chen Dynamics of Intramural and Transmural Reentry During Ventricular Fibrillation in Isolated Swine Ventricles Circ. Res., April 27, 2001; 88(8): 839 - 848. [Abstract] [Full Text] [PDF]
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