(Circulation. 2000;102:2886.)
© 2000 American Heart Association, Inc.
Basic Science Reports |
Electrophysiological Deterioration During Long-Duration Ventricular Fibrillation
Presented in part at the 47th Meeting of the American College of Cardiology, March 29–April 1, 1998, and the 72nd Scientific Sessions of the American Heart Association, Atlanta, Ga, November 7–10, 1999, and published in abstract form (JACC. 1998;31:97A) (Circulation. 1999;100:I-90).
From the Department of Physiology and Biophysics, Georgetown University, and the Department of Veterans Affairs Medical Center, Washington, DC.
Correspondence to Oscar H. Tovar, MD, VA Medical Center 151P, 50 Irving St NW, Washington, DC 20422. E-mail otovar01{at}georgetown.edu
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Abstract |
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Background—Probability of survival from sudden cardiac arrest caused by ventricular fibrillation (VF) decreases rapidly with fibrillation duration. We hypothesized that cellular ischemia/fibrillation-induced electrophysiological deterioration underlies decreased survival.
Methods and Results—We determined fibrillation monophasic action
potential (MAP) morphology including action potential frequency
content, duration, cycle length, developing diastolic
intervals, and amplitude as a function of ischemic fibrillation
duration in 10 isolated rabbit hearts. We also correlated ECG frequency
(used clinically) and MAP amplitude and frequency. Fibrillation cycle
length and diastole duration increased, whereas
APD100 shortened significantly with time
(P<0.001). Between 1 and 3 minutes,
diastole appeared primarily as the result of
APD100 shortening, with only small changes in cycle length.
Between 2 and 5 minutes, diastole increased primarily as
the result of increased cycle length. Diastole developed
progressively from 5% of VF cycles at 5 seconds to 
100% of VF
cycles by 120 seconds (P<0.001). Diastole
increased from 1% of cycle length at 5 seconds to 62% at 5 minutes.
Its duration increased from 4.7 ms at 5 seconds to 90 ms at 5 minutes
(P<0.001). Both MAP and ECG 1/frequency closely
correlated with fibrillation cycle length.
Conclusions—These results show a rapid and progressive electrophysiological deterioration during fibrillation, leading to electrical diastole between fibrillation action potentials. This rapid deterioration may explain the decreased probability of successful resuscitation after prolonged fibrillation. Therefore, a greater understanding of cellular deterioration during fibrillation may lead to improved resuscitation methods, including development of specific defibrillator waveforms for out-of-hospital cardiac arrest.
Key Words: death, sudden • defibrillation • electrophysiology • resuscitation • fibrillation
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Introduction |
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The duration of fibrillation is a critical determinant of successful resuscitation, defined as defibrillation with restoration of perfusing rhythm, as well as survival. Internal defibrillation with implantable cardioverter-defibrillators, in which the defibrillation shock is delivered within 30 seconds, has reduced the sudden death mortality rate to 1% per year.1 In contrast, after out-of-hospital cardiac arrest, survival is poor, either because the shock fails to defibrillate, because the successful shock is followed by asystole or electromechanical dissociation rather than a perfusing rhythm,2 or because of late deaths occurring after hospital admission. Survival to discharge decreases dramatically to 43% after 4 minutes of fibrillation, 18% at 5 to 9 minutes, 8% at 10 to 14 minutes, and only 5% for times >14 minutes.3
A review of out-of-hospital cardiac arrest studies from 1967 to 1988 in 29 cities (worldwide)4 suggested that without cardiopulmonary resuscitation, survival decreases by 10% for each minute from the time of collapse until 10 minutes of fibrillation. A study of cardiac arrest in Las Vegas casinos showed that the time from the 911 call to shock was 3 minutes longer for nonsurvivors (12.46±9.58 minutes) than for survivors (9.88±5.88 minutes).5 Even at 4 minutes, only 36% survived. This probability decreased 5% for each minute without defibrillation. A recent and comprehensive study of 39 emergency medical service systems and 33 124 patients showed higher survival for defibrillation response times of <6 minutes than for times of 6 to 11 minutes.6
During prolonged ventricular fibrillation (VF), substantial metabolic changes occur in myocytes exposed to high-frequency activations characteristic of fibrillation and ischemia. These changes in electrophysiological properties of myocytes can result in defibrillation failure or postdefibrillation asystole or contractile dysfunction (including electromechanical dissociation) leading to resuscitation failure even if the heart is "successfully" defibrillated.2 To understand cellular mechanisms underlying the ECG deterioration produced by long-duration VF that is associated with decreased probability of successful defibrillation and survival,7 8 we correlated changes in the ECG with alterations in cellular electrophysiology, including fibrillation action potential morphology, amplitude, and frequency content, as a function of ischemic fibrillation duration.
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Methods |
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Characterization of Fibrillation
We determined time-dependent changes in cycle length (CL), action potential duration (APD100), and the development of "electrical diastole" during ischemic VF. In this study, we used the term diastole to describe phase 4 of the action potential (commonly called diastole).9 We correlated fibrillation action potential amplitude and frequency and verified the agreement between the frequency analysis of monophasic action potential (MAP) and ECG and manual measurements of local MAP recordings.
Isolated Heart Preparation
The Langendorff preparation for the isolated heart model has
been previously described.10 In brief, 10 French Lop
rabbits weighing between 3.9 and 5.7 kg (4.9±0.14 kg) were
anesthetized intravenously with pentobarbital (50
mg/kg) followed by 1000 IU of heparin. Heart weight ranged from 10.7 to
18.8 g (14.8±0.7 g, mean±SEM). Intracavitary temperature was
monitored by a thermocouple placed in the right ventricle and was
maintained at 37.0±0.5°C. Hearts were perfused with a modified
Krebs-Henseleit bicarbonate buffer containing (in mmol/L) NaCl
110, NaHCO3 32,
NaH2PO4 1.2, Na pyruvate 2,
KCl 4, dextrose 5.5, MgSO4 1.2,
CaCl2 2.5, and 10 IU/L regular pork insulin. The
perfusate was gassed with 95% O2, 5%
CO2 to achieve pH 7.4,
PO2 600 mm Hg, and
PCO2 40 mm Hg.
Perfusate pH, PO2, and
PCO2 were monitored throughout the
experiment and maintained within optimal limits.
Instrumentation and Experimental Protocol
A catheter was placed in the right ventricle for inducing
fibrillation. Two custom platinum platinum-black epicardial patch
electrodes (Guidant Corp) were placed on the epicardial surface for
defibrillation. The heart was then submerged into Krebs solution in a
glass chamber. Distant electrodes were placed on the walls of the
container for recording a bipolar ECG. The ECG was filtered by
setting the high- and low-pass filters at 1 and 300 Hz, respectively.
Epicardial MAPs (EP Technologies) were recorded from the base of
the right or left ventricular free wall with a MAP
electrode placed halfway between the defibrillating electrodes. All
data were recorded and stored digitally on a PC computer.
VF was induced with a 1- to 2-second, 60-Hz AC pulse and was defined by chaotic irregular ECG recordings. Ischemia was produced by stopping the Langendorff perfusion immediately after fibrillation induction.
Definitions
The following definitions have been previously used and
described.11 Fibrillation CL was defined as the time
between the upstroke of one action potential and the upstroke of the
next action potential. Fibrillation APD100 was
defined as the time between the action potential upstroke and the
intersection of a hand-drawn extrapolated slope of maximum
repolarization (the steepest slope during repolarization) with the
baseline. Diastole was defined as the average time interval
(with only those diastolic intervals >0 ms) between the
end of one action potential (measured as described under APD) and the
upstroke of the next action potential included in a 1-second segment of
fibrillation (10 action potentials).
Measurements and Data Analysis
In 5 hearts, the parameters of CL,
APD100, and diastole were determined
by averaging measurements from 5 successive action potentials at 5
seconds and 1, 2, 3, 4, and 5 minutes of VF for each episode.
Correlation between local MAP fibrillation amplitude and frequency was determined by averaging the peak-to-peak amplitude of each action potential (measured manually) during the first 10-second segment of each minute of VF. The first measurement was obtained 10 seconds (0.16 minutes) after the onset of VF when fibrillation was well established. Later measurements were normalized to the 10-second amplitude measurement. Frequency analysis of MAP recordings was performed with the use of fast Fourier transforms during the first 10 seconds of each minute of VF between 10 seconds and 5 minutes.
In another 5 hearts, a more detailed analysis of the development of diastole during the first 2 minutes of fibrillation was obtained by counting the number of diastoles during 1-second segments of VF every 20 seconds until diastole was completely established (a period of diastole followed each action potential). The results were expressed as a percentage of fibrillation cycles containing diastole. In the same segments, CL, APD, and the duration of any occurring diastoles were measured from 5 action potentials and then averaged for each episode. This analysis was complemented with spectral analysis of the MAP and ECG recordings by means of fast Fourier transforms of a 10-second window every 20 seconds, and dominant frequencies were determined.
To minimize subjectivity in the measurements, a second investigator repeated all measurements in 20% of episodes selected randomly. Results are expressed as mean± SEM. Statistical differences were determined with 1- and 2-way ANOVA. Differences were considered significant at P<0.05.
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Results |
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Figure 1A
shows MAPs during 5
minutes of VF. The upper panel shows a 1-second recording
during normal sinus rhythm (NSR) just before induction of VF. The
second panel shows VF at 5 seconds (0.08 minutes), when fibrillation
was well established. The following panels show recordings at
the beginning of each minute.
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At 5 seconds of fibrillation, action potentials immediately followed repolarization from the previous action potential. At 1-minute fibrillation, action potentials were slightly shorter and were occasionally followed by short periods of diastole. By 2 minutes, CL was longer and action potentials continued to shorten, thereby producing regular intervals of diastole. During the next 3 minutes of fibrillation, CL increased progressively with time, whereas APD decreased. This produced increasingly long diastolic intervals. Simultaneously with the prolongation of diastole, a progressive decrease of voltage amplitude occurred. The correlation between mean normalized MAP amplitude and mean normalized MAP frequency as function of fibrillation duration was linear (R=0.96, P<0.001), but the slope differed from the unity line because MAP frequency decreased more rapidly than MAP amplitude.
Examples of the ECG recorded during NSR and at 0.08 and 5 minutes
of fibrillation are shown in Figure 1B
. The ECG tracings in the
figure confirm that the heart remains in fibrillation at 5 minutes and
show the decrease in both frequency and peak-to-peak amplitude observed
after long-duration fibrillation. The MAP signals show the
corresponding action potential shortening and development of
diastole.
Figure 2 shows CL, APD, and
diastolic interval as a function of time in fibrillation.
At up to 2 minutes of fibrillation, diastole increased
primarily because of action potential shortening, with only a small
change in CL. APD decreased significantly from 87.6±2.7 ms at 5
seconds to 54.5±2.2 ms at 5 minutes (P<0.001). Between 2
and 3 minutes, diastolic intervals continued to increase
rapidly, but now the change was due primarily to a sudden change in CL.
After 3 minutes, CL increased slowly with time, whereas APD
simultaneously decreased. CL increased significantly from
88.6±2.6 ms at 5 seconds to 144.9±4.3 ms at 5 minutes
(P<0.001). The combined effect produced
diastolic intervals that increased continuously from
4.7±1.7 ms at 5 seconds to 90.4±4.0 ms at 5 minutes
(P<0.001).
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), diastole
(DS, •), and CL (
) as function of fibrillation duration. Adapted
from Tovar and Jones. JACC. 1998;31:97-A. Abstract.
Figure 3 shows the percentage of total CL
spent in diastole as a function of ischemic
fibrillation duration. At short fibrillation durations (5 seconds),
little or no time was spent in diastole. However, by 5
minutes of fibrillation, 62% of the total CL was spent in
diastole.
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Diastole after each fibrillation action potential was
completely established by 2 minutes of fibrillation. To examine the
time course for diastole development in more detail, we
examined tracings at shorter intervals during this time. Figure 4 shows 1-second tracings of MAPs
recorded during NSR and every 20 seconds for the first 2 minutes of
fibrillation. At 5 seconds, short periods of diastole
appeared only twice. Both probability of occurrence and duration of
diastole increased as fibrillation continued. After 100
seconds of fibrillation, a significant period of diastole
was present after almost every action potential.
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Diastole occurred in 5% of fibrillation cycles at 5
seconds and became completely established (100% of fibrillation
cycles) by 100 to 120 seconds (P<0.001). Mean
diastole duration increased from 3.4±2.2 ms at 5 seconds
to 48.4±6.4 ms at 2 minutes (P<0.001), as shown in Figure 5.
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As shown in Figure 6, the manually
measured VF CL (MAP) increased significantly from 82.3±2.4 ms at 5
seconds to 111±5.4 ms at 2 minutes of fibrillation
(P<0.05). The inverse of the ECG and MAP mean dominant
frequencies were statistically similar to the manually measured MAP CL
(P=NS by ANOVA).
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Discussion |
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Out-of-Hospital Survival After 5 Minutes of Fibrillation
Approximately 1000 patients daily have sudden cardiac arrest caused by VF in the United States,12 and
90% of these
cases occur out of the hospital.13 Despite the proven
efficacy of fast defibrillation with conventional systems (emergency
medical service), even patients defibrillated at 4 minutes from the
emergency call have only 36% to 43% probability of
survival.3 5 Every minute counts in out-of-hospital
defibrillation. However, there is a limit to shortening time from
collapse to shock, and even within 5 minutes, many lives are
lost.5 6 An understanding of how VF changes as a function
of time can lead to improved methods to counteract its deterioration
and improve success of resuscitation and survival.
ECG Changes During First 5 Minutes of Fibrillation
During VF in swine, the median ECG frequency decreases from 13.5
Hz at the beginning of VF to 4 Hz at 10 minutes.14 ECG
frequency alone may predict the outcome of defibrillation in humans.
Swartz et al15 showed that in the early seconds of
fibrillation, in which defibrillation with implantable
cardioverter-defibrillators usually succeeds, fibrillation frequency
(inverse of MAP CL) is 4.7 Hz. Stewart et al8 showed that
in humans, decreased VF frequency is associated with decreasing
probability of survival. In that study, the ECG mean dominant frequency
of survivors was 5.2±0.3 Hz and of nonsurvivors was 3.1±0.3 Hz.
Another clinical study that used semiautomatic defibrillators showed
that successful shocks were associated with an ECG dominant frequency
of 4.56±0.99 Hz compared with 3.31±1.57 Hz for unsuccessful
shocks.7
In addition to the predictive value of ECG frequency for successful resuscitation, higher ECG amplitudes have been associated with a greater probability of defibrillation and restoration of spontaneous circulation.7 16 In one study, the VF amplitude was 1.40±0.50 mV for successful shocks versus 1.16±0.68 mV for unsuccessful shocks. A problem with ECG amplitude is that this depends on the direction of the main fibrillation vector, producing a wide intersubject variability.7 The combination of the ECG frequency and amplitude has also been used to predict the probability of successful defibrillation and restoration of circulation.17
Our present results are consistent with the above studies.
We found that fibrillation frequency decreased from 11.8 Hz at 10
seconds of fibrillation to 7.1 Hz at 5 minutes of fibrillation. This
decrease in frequency with fibrillation duration is similar to that in
pigs.14 As shown in Figure 1, there was also a
progressive decrease in MAP amplitude during fibrillation similar to
that observed in the ECG. Mean epicardial action potential amplitude
decreased linearly with mean excitation frequency during the 5 minutes
of VF.
In our study, the inverse of the dominant frequency of both MAP and ECG
recordings and manual measurements of fibrillation CL were
consistently similar and demonstrated a significant difference
between 5 seconds and 2 minutes of fibrillation (Figure 6).
However, our manual measurements of MAP recordings added a new
dimension to our understanding of
electrophysiological deterioration during
fibrillation by showing that the frequency changes observed in situ
signify the development of large diastolic intervals
between fibrillation action potentials. This additional information
could not be obtained with the use of conventional analysis in
the frequency domain of MAP and ECG signals alone.
Cellular Electrophysiological Deterioration
During First 5 Minutes of Fibrillation
At the onset of VF and during the first few seconds, action
potentials are activated one after another with little or no
period of diastole in humans15 as well as in
animal models.11 18 19 However, we showed that significant
changes in fibrillation action potential characteristics take place
during the first minutes after the onset of fibrillation and that these
changes affect defibrillation efficacy.11 20
In the present study, we showed that during the first 5 minutes of
VF, a progressive action potential shortening accompanied by
lengthening of CL and diastole occurs. Diastole
is very rare and of short duration during the first seconds of
fibrillation, a time when clinical resuscitation is likely to be
successful and survival is high. During the first 2 minutes,
diastole occurrence and duration increase (Figure 5)
as a consequence of APD shortening with only a small change in cycle
length. Between 2 and 3 minutes, there is a marked prolongation in CL
(Figure 2). After 3 minutes, CL and diastole
continue to increase progressively, whereas APD decreases slowly. After
5 minutes of fibrillation, a time when clinical resuscitation is likely
to fail and survival is poor, diastole has reached 62% of
the total CL (Figure 3).
During prolonged VF, substantial metabolic changes occur in myocytes exposed to ischemia and the high-frequency activations characteristic of fibrillation, including intracellular/extracellular ionic imbalances and opening of KATP sarcolemmal channels. During ischemia alone in the absence of fibrillation, these cellular alterations produce slowed conduction and/or postrepolarization refractoriness.21 During ischemic fibrillation, these alterations can be expected to develop more rapidly because of continuously occurring fibrillation action potentials.
In the absence of ischemia, the refractory period ends during repolarization. However, as ischemia develops during prolonged fibrillation, postrepolarization refractoriness develops and the refractory period continues long after repolarization.21 22 The prolonged refractory period can now be the limiting factor in determining the rate of fibrillation action potential formation. Because repolarization takes place before the end of the refractory period, the resulting interval before the next action potential may become the period of diastole.
Clinical Implications
An understanding of how VF evolves with time can lead to improved
electrical and pharmacological methods, for example, improved
defibrillator waveforms specifically designed for cells with
deteriorated electrophysiological
characteristics, to counteract its deterioration and prevent postshock
dysfunction and therefore improve the success of defibrillation and
resuscitation. Biphasic defibrillation shocks are more effective than
monophasic shocks at fibrillation durations of 1 minute in
rabbits,11 5 minutes in dogs,23 and in humans
for out-of-hospital defibrillation.24 Biphasic waveform
success at long fibrillation durations can be explained in part by its
better ability to stimulate at low intensities during the refractory
period25 26 as well as its better ability to excite
depolarized cells.27 Because 62% of the fibrillation CL
is spent in diastole by 5 minutes of fibrillation, the
probability that the shock interacts with cells during
diastole and probably during periods of postrepolarization
refractoriness increases significantly during long-duration
fibrillation. Under each of these conditions, the first phase of the
biphasic waveform causes membrane
hyperpolarization/repolarization either when
delivered during the action potential26 or during the
depolarized diastolic period between action
potentials,27 thereby allowing sodium channel recovery
from inactivation.28 The second pulse then creates a
well-formed response to terminate fibrillation at much lower
intensities than could the monophasic depolarizing pulse alone.
However, after long-duration fibrillation, even when defibrillation is successful it may not lead to a perfusing rhythm or to survival because of shock-induced and/or ischemia-induced dysfunction. Low-intensity biphasic shocks, when compared with high-intensity monophasic shocks, produce fewer postshock ECG abnormalities in humans at short fibrillation duration,29 better postresuscitation myocardial function in pigs after 4 to 7 minutes of fibrillation,30 and less cellular dysfunction.31 32
Limitations
Most of the research to improve our understanding of VF is
conducted in animal models because of obvious limitations for
conducting the same research in humans. The extension of the
present results to humans should be considered cautiously because
of the differences in species. However, significant similarities in
ionic currents and cellular kinetics between human
ventricular myocytes and rabbit ventricular
myocytes,33 in addition to the similarities in the
patterns of decreased fibrillation frequency and amplitude with
increasing fibrillation duration observed in humans and rabbits,
suggest that the rabbit heart can provide a realistic model to help us
understand deterioration of VF as a function of time.
A second limitation is the possible subjectivity in determining fibrillation APD and diastolic intervals manually. However, control measurements by a second investigator showed agreement within 10% of the total measurements.
Summary
These results show that during VF, cellular electrophysiology
deteriorates rapidly and progressively with time. This rapid
deterioration can explain the rapidly increasing difficulty for
defibrillation and resuscitation with increasing fibrillation duration.
Therefore, an improved understanding of cellular
electrophysiological deterioration can
contribute to optimization of electrical and pharmacological
interventions during VF and increase the probability of successful
resuscitation during out-of-hospital cardiac arrest.
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Acknowledgments |
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This work was supported in part by National Institutes of Health grants USPHS HL-24606 and USPHS HL-49089. We thank Nettie Knight for expert technical assistance.
Received April 17, 2000; revision received June 22, 2000; accepted June 28, 2000.
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