Mechanisms Underlying Spontaneous and Induced Ventricular Arrhythmias in Patients With Idiopathic Dilated Cardiomyopathy
From the Cardiovascular Division, Washington University School of Medicine St. Louis, Mo.
Correspondence to Steven M. Pogwizd, MD, Section of Cardiology, University of Illinois at Chicago, 840 S Wood St M/C 787, Chicago, IL 60612.
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionReferences |
|---|
Background—To define the electrophysiological mechanism(s) of inducible and spontaneously occurring ventricular arrhythmias associated with nonischemic cardiomyopathy, 3-dimensional intraoperative mapping from 156 intramural sites was performed in 6 patients with idiopathic dilated cardiomyopathy undergoing cardiac transplantation.
Methods and Results—Electrode density was sufficient to determine the mechanism for 52 of 74 beats of nonsustained ventricular tachycardia (VT) induced by programmed stimulation and 9 of 11 beats of spontaneous ventricular arrhythmias. The first, second, and third extrastimuli (S2 through S4) conducted with progressively greater degrees of conduction delay (total activation times [TAs] of 144±5, 166±5, and 194±5 ms, respectively) owing to slow conduction and on occasion intramural block. The first beats of induced VT arose from subendocardial or subepicardial sites distant from areas of marked conduction delay by a focal mechanism on the basis of the absence of intervening electrical activity between the termination of the last extrastimulus and the initiation of VT (123±31 ms). Subsequent beats arose by a focal mechanism and conducted with a TA of 127±6 ms (P=NS versus initiating beats of VT [118±9 ms]). Spontaneous ventricular arrhythmias initiated in the subendocardium by a focal mechanism and conducted with a TA of 138±5 ms. Tissue analysis demonstrated a variable degree of interstitial fibrosis at sites of focal activation. Sites of conduction delay or block typically exhibited marked interstitial and/or replacement fibrosis but were spatially distant from sites initiating VT.
Conclusions—Spontaneous and induced ventricular arrhythmias in patients with end-stage idiopathic cardiomyopathy can arise in the subendocardium or subepicardium by a focal mechanism.
Key Words: tachycardia • heart failure • mapping
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Patients with idiopathic dilated cardiomyopathy (IDCM) demonstrate a high incidence of ventricular arrhythmias1 and are at increased risk of sudden death from ventricular tachycardia (VT) and ventricular fibrillation.2 Treatment with pharmacological agents has been empirical, ineffective, and frequently proarrhythmic and limited by the paucity of data on electrophysiological mechanisms.3
Myocardium from patients with IDCM demonstrates altered epicardial conduction,4 5 especially in response to programmed electrical stimulation, suggesting, albeit indirectly, a substrate for reentrant rhythms. However, nonreentrant mechanisms such as triggered activity arising from delayed afterdepolarizations (DADs) or early afterdepolarizations (EADs) could initiate ventricular arrhythmias, especially in light of findings that DADs and EADs can be induced in myocardium obtained from patients with end-stage cardiomyopathy.6
We have previously performed 3-dimensional cardiac mapping in patients with coronary artery disease undergoing surgical ablation of VT.7 8 9 We demonstrated that sustained and nonsustained VT induced by programmed stimulation initiated by intramural reentry in half the cases and by a focal mechanism in half the cases. In the present study, we performed intraoperative mapping just before explantation of the heart in patients with IDCM undergoing cardiac transplantation to define the mechanism(s) of initiation for beats of VT induced by programmed stimulation and for spontaneously occurring ventricular arrhythmias.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Patients Studied
Six patients (5 men, 1 woman) with end-stage IDCM undergoing cardiac transplantation were studied. Their mean age was 50±4 years. All patients demonstrated premature ventricular complexes (PVCs), ventricular couplets, and nonsustained VT (
11
beats) on Holter monitoring
(Table
). Patient 2 had syncope.
None was being treated with antiarrhythmic agents. The mean left
ventricular ejection fraction was 15±4%. The protocol was
approved by the Institutional Review Board at Washington University.
Informed consent was obtained from each patient.
|
Three-Dimensional Intraoperative Mapping
Transmural and transseptal ventricular mapping was
performed as described previously.7 8 9 Surface
ECGs I, aVF, and V5R were monitored. Twenty
minutes before explantation, 39 plunge-needle electrodes were placed in
the left and right ventricles and interventricular septum.
Electrodes were evenly distributed. Interelectrode distance averaged
0.5 to 1.5 cm between endocardial sites, 1 to 3 cm between epicardial
sites, and 2.5 to 8 mm between sites of focal initiation and
immediately adjacent sites. Each electrode contained 4 bipolar pairs
separated by 2.5 mm, with an interbipole distance of 500
µm. Electrograms were recorded from 156 intramural sites.
Epicardial pacing plaques were sutured to the right and left
ventricles. Programmed stimulation from the right and left ventricles
was performed (basic cycle length, 400 ms) with single, double, and
triple extrastimuli for 15 minutes until the donor heart arrived in
the operating room. Bipolar electrograms were sampled at 2 kHz,
filtered (40 to 500 Hz), amplified, digitized, and stored on a
high-density recorder.7 8 9 The recipient
heart was removed with the electrodes in place. Electrode localization
(Figure 1), electrogram analysis,
and construction of 3-dimensional activation maps were performed as
previously described.7 8 9
|
Beats during induced or spontaneous arrhythmias were assigned a
macroreentrant mechanism7 8 9 10 11 12 when (1) there was
continuous depolarization from the preceding beat, (2) the site of
initiation of a beat was adjacent to the site of termination of the
preceding beat, and (3) the conduction velocity of the activation
wave front from the site of termination of the preceding beat to the
site of initiation of the ectopic beat was similar to the conduction
velocity of the terminal portion of the activation wave front of the
preceding beat. A mechanism was defined as
focal7 8 9 12 when the site of initiation
demonstrated radial spread of activation and was remote from the site
of termination of the preceding beat with no intervening
depolarizations despite 
4 intermediate recording sites. The
finding of a focal mechanism was not considered to exclude the
possibility of microreentry.
The coupling interval (CI) of beat n was the difference in activation times between the initiation of beat n and that of the preceding beat (n-1). Total activation time (TA) was the difference between the activation times recorded at the sites of latest and earliest activity.
Histological Analysis
After explantation and electrode localization, hearts were fixed
in formalin (including perfusion of the coronary arteries). On
the basis of analyses of the activation maps, 1x1x0.3-cm
blocks of myocardium were excised from selected sites of
focal activation, sites of slow conduction and block, and sites that
were neither. Paraffin-fixed sections (12 µm thick) were cut and
fixed with hematoxylin and eosin or Masson's trichrome stain for light
microscopy.
Statistical Analysis
Data are presented as mean±SEM unless otherwise stated.
Student's t test was used to identify significant
differences (P<0.05) in CIs or TAs of programmed
extrastimuli or induced or spontaneous ventricular
arrhythmias.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Nineteen VTs (74 VT beats) were induced. The longest was 7 beats, and the average length was 3.9±1 beats. Electrode density was sufficient to define the mechanism for 52 VT beats.
Extrastimuli
Drivetrain beats (S1s) conducted throughout
the heart with a TA of 143±3 ms. The first, second, and third
extrastimuli (S2 through
S4) conducted with progressively greater
conduction delay (Figure 2)
(TAs of 144±5, 166±5, and 194±5 ms, respectively). Conduction delay
during the last extrastimulus was as high as 223 ms. Progressive delay
in response to closely coupled extrastimuli was due to slow conduction
and intramural conduction block and was observed in 58% of cases. As
illustrated in Figure 3, conduction
between immediately adjacent sites A (in level 3) and B'(in level 2) in
patient 2 during the last S1 beat took 53 ms.
However, during S2, S3, and
S4 (S4 is shown in Figure 3), there was intramural conduction block between sites A and B', with
slow conduction primarily over the pathway A-B-C-D-E-F-B'. Conduction
delay between adjacent sites A and B' of up to 145 ms (during
S4) occurred with progressively more premature
extrastimuli. In contrast, conduction between sites A and B' during the
first (T1) (Figure 3) and subsequent beats of VT
(data not shown) was rapid.
|
, S3 
, and S4 
and
first beat of induced VT [T1] 
) for patients 2 (top)
and 6 (bottom).
|
Initiation of VT by Programmed Stimulation
All the VTs initiated in the subendocardium or the subepicardium
by a focal mechanism on the basis of the absence of intervening
electrical activity between the termination of the preceding beat and
the initiation of the next (123±31 ms). In every case, the site of
focal initiation was surrounded on all sides by closely adjacent
electrodes.
As shown in Figure 4, S4 initiated at a subendocardial site in the apex
(level III). Activation spread basally, terminating at a subendocardial
site in the base of the lateral left ventricle with a TA of 159 ms.
T1 initiated at an endocardial site in the apex
in level III 142 ms later, with no intervening electrical activity.
This observation is also shown in Figure 5, in which the site of terminal
activation of S4 is labeled A and the site of
initiation of T1 is denoted as S; there was no
intervening electrical activity at intramural sites B-R or any other
site in the heart.
|
|
In 5 VTs, T1 arose focally in the subepicardium.
In each instance, the initiation site was the same as the site of
earliest activation for S4 (located 3 to 5
mm away from the left ventricular epicardial pacing
plaque). As shown in Figure 6, S4 initiated in the apical subepicardium in level
IV and propagated basally, terminating 200 ms later at the base of the
left ventricle. T1 arose at the same apical
epicardial site as S4 by a focal mechanism with
no intervening electrical activity from the termination of
S4 to the initiation of T1.
Spread of activation to immediately adjacent (2.5 to 8 mm)
intramural electrodes was rapid with no evidence of slow conduction,
fractionation, or conduction block.
|
The T1s conducted with a TA of 118±9 ms,
significantly less than that of the preceding terminal extrastimulus
(186±8 ms, P<0.001), and a prolonged CI of 317±16 ms. As
Figure 2
shows, the extent of conduction delay of
T1 varied among patients but was inversely
related to its CI. Even areas of marked conduction delay and intramural
block during the extrastimuli demonstrated rapid activation during the
late coupled initiating beat of VT. In Figure 3, T1 initiated by a focal mechanism at a CI of 362
ms. In contrast to the marked conduction delay (TA, 216 ms) and block
(between sites A and B') during S4, conduction
during T1 was rapid (TA, 73 ms) with no block
between A and B'.
Maintenance of VT
Subsequent beats of VT demonstrated a CI of 252±8 ms
(P=0.004 versus initiating beats of VT [317±16 ms]). The
TA of maintenance beats of VT averaged 127±6 ms
(P=0.376 versus initiating beats) but ranged from 69 to 203
ms. The extent of conduction delay during VT was inversely related to
the CI of the beat of VT (data not shown).
In all cases, maintenance of VT was due to focal activation
often arising from multiple sites throughout the heart. Beats of VT
could arise from 4 different subendocardial or subepicardial sites
from the left or right ventricle. For example, the 7-beat VT shown in
Figure 7 initiated at subepicardial site
A, the next 2 beats (T2 and
T3) from subepicardial site B, beats 4 through 6
(T4 through T6) from
subendocardial site C in the basal left ventricle, and beat 7
(T7) from endocardial site D in the right
ventricle.
|
In 2 instances, focal activation during the maintenance of VT
arose from the midmyocardium. As shown in Figure 8, beat T3 in
patient 1 initiated at midmyocardial site B and spread to adjacent
subendocardial site A and subepicardial site C, as well as to adjacent
sites D and E in level III and adjacent sites F in level II and G in
level IV.
|
Termination of VT
The CI of terminating beats of VT averaged 268±16 ms
(P=0.343 versus those of maintenance beats of VT).
The mean TA of the terminating beats was 128±9 ms (P=0.58
versus those of maintenance beats of VT) and ranged from 64 to
195 ms. The terminal beats of VT arose in the subendocardium by a focal
mechanism. As shown in Figure 9, the
fifth beat of VT (T5) arose at a subendocardial
site in the apex in level III, conducted basally and rightward with a
TA of 156 ms, and terminated at the base of the right ventricle. The
last beat of VT (T6) initiated at a
subendocardial site at the base of the anterior left ventricle in level
I 180 ms later by a focal mechanism; the TA of this beat was 168
ms.
|
Spontaneous Ventricular Arrhythmias
Holter recordings obtained from 5 patients before
transplantation demonstrated PVCs (370 beats per hour), couplets, and
nonsustained VTs. During intraoperative mapping, 6 PVCs, 1 couplet, and
1 three-beat VT (a total of 11 ventricular beats)
occurred spontaneously and were mapped. The ectopic beats mapped
were similar in frequency and QRS morphology to those recorded
(Figure 10).
|
Sinus beats preceding these arrhythmias initiated in the septum and conducted with a TA of 113±10 ms. The activation sequence and the TA of these sinus beats were identical to those that did not precede ventricular arrhythmias (TA of 112±6 ms, P=0.428). The mechanism of initiation could be defined for 9 of the 11 beats. In each case, initiation was due to a focal mechanism arising from the subendocardium with no evidence of reentry. The ectopic beats conducted with a TA of 138±5 ms.
The initiation of the 3-beat VT is shown in Figures 11 and 12. After termination of the preceding
sinus beat (NS) in the midlateral left ventricle in level II (Figure 11), T1 arose from an apical subendocardial site
by a focal mechanism, as judged by the absence of intervening
electrical activity for 665 ms from the termination of NS to the
initiation of T1 (see Figure 12). Beats
T2 and T3 also arose by a
focal mechanism from apical subendocardial sites, with
T3 initiating at the same site as
T1. Each beat terminated in the basal
posterolateral left ventricle with no evidence of reentry.
|
|
Pathology
Myocardial tissues from sites of focal activation, sites of slow
conduction and block, and sites that demonstrated neither focal
activation nor conduction alteration were analyzed. Patchy
interstitial fibrosis was a consistent finding in
all hearts examined. The interstitial fibrosis predominated
in the subendocardial regions and in many cases was minimal to absent
in the subepicardial regions. However, in 2 patients, extensive patchy
subepicardial fibrosis was noted.
Focal activation arose from a number of myocardial sites in the
subendocardium and at times from subepicardial sites. These sites
exhibited a variable degree of interstitial fibrosis,
with some demonstrating minimal to no fibrosis (Figure 13, row 1), some showing moderate
fibrosis (Figure 13, row 2), and other regions having more extensive
fibrosis (Figure 13, row 3). This variability in the extent of fibrosis
at initiation sites was similar to that in tissue from other sites that
demonstrated neither focal initiation nor slow conduction.
|
A consistent finding at sites of slow conduction and
nontransmural block was extensive interstitial fibrosis in
continuous linear bundles extending from the subendocardium to the
midmyocardium (Figure 14, row 1). This finding was not evident at adjacent sites that did not
demonstrate conduction alterations or at sites from other regions
without conduction delay or block. Furthermore, some sites of
conduction block exhibited regions of replacement fibrosis (Figure 14, row 2) that may have contributed to the altered pattern of conduction.
Subendocardial and midmyocardial sites at which nontransmural
conduction block occurred during the terminal extrastimulus were also
characterized by regions (1 to 3 mm thick) of extensive
replacement fibrosis (Figure 14, row 3). Analysis of fiber
orientation demonstrated that conduction block occurred primarily in a
direction transverse to fiber orientation.
|
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
The results of this study demonstrate that PVCs and nonsustained VTs induced by programmed stimulation or occurring spontaneously in patients with end-stage IDCM initiate primarily in the subendocardium by a focal mechanism without evidence of macroreentry. Although there was evidence of functional conduction delay and block in the epicardium and on occasion in the midmyocardium and subendocardium, the sites of delay and block were consistently distant from sites of focal initiation. These findings contrast with those we reported for nonsustained and sustained VT in patients with ischemic cardiomyopathy,7 8 9 which initiated by intramural reentry in half the cases, suggesting that focal mechanisms play a much greater role than reentry in ventricular arrhythmias in patients with IDCM. Thus, approaches to the prevention and treatment of focal mechanisms may be beneficial.
Spontaneous Ventricular Arrhythmias
We mapped spontaneously occurring PVCs, couplets, and beats of VT
that were similar in frequency and QRS morphology to those documented
by Holter monitoring. We10 11 12 and
others13 have demonstrated that insertion of
needle electrodes does not lead to spontaneous ectopy. Thus, the
arrhythmias mapped are representative of those
that these patients experienced clinically and provide the first
demonstration of electrophysiological
mechanisms of spontaneous PVCs and VT in the human heart. Our finding
that these arrhythmias initiated by a focal mechanism is
consistent with our recent observation that spontaneous PVCs
and VT initiate by a nonreentrant mechanism in a rabbit model of
nonischemic
cardiomyopathy.11
Focal Mechanisms
Although focal initiation arises primarily in the subendocardium,
initiation of some beats in the epicardium (Figure 6) suggests that
focal activation does not necessarily arise from Purkinje fibers.
Furthermore, the finding that VT initiates sometimes in the
midmyocardium (Figure 8) suggests, albeit indirectly, that
focal activation could arise from M cells.14 The
focal mechanism observed in this study is similar to that underlying
nonsustained8 9 and sustained monomorphic
VT7 in patients with coronary artery
disease.
The nature of the focal mechanism remains unknown. Although microreentry is possible, our results suggest that this is unlikely. In all cases, the sites of termination and the sites of initiation of the subsequent beats were distant from each other and separated by a number of intermediate transmural recording sites that demonstrated no electrical activity in the intervening time interval. In addition, activation from sites of focal initiation propagated radially and rapidly with no evidence of conduction slowing to adjacent electrode sites that were an average of 2.5 to 8 mm away. On the basis of the refractory properties of the myocardium, the presence of a microreentrant circuit small enough that it would not be detected by our mapping technique (path length <1.5 cm) would require conduction velocities an order of magnitude slower than the slowest velocities we observed. We have found that the sites of focal activation of VT frequently vary from beat to beat, but sites of focal activation never occurred at sites of early breakthrough during sinus rhythm. Thus, bundle-branch reentry is unlikely.
The focal initiation of VT may result from triggered activity arising from either EADs or DADs.15 Myocardium from patients with end-stage heart failure demonstrates prolongation of action potential duration (likely the result of decreases in the transient outward current and delayed rectifier current16 ) that could contribute to EADs.6 Moreover, superfused trabeculae and isolated cardiac myocytes from patients with heart failure exhibit alterations in calcium flux, including increased diastolic levels of intracellular calcium, abnormal sarcoplasmic reticulum calcium uptake, decreased expression of sarcoplasmic reticulum calcium ATPase,17 and more recently increased expression of sodium-calcium exchange.18 These alterations may contribute to elevations in intracellular calcium, activation of a transient inward current, and development of DADs that have been demonstrated in vitro.6 17
Anatomic-Electrophysiological Comparison
No clear histological substrate characterized the
sites of focal initiation. The degree of interstitial and
replacement fibrosis was quite variable. These findings in the
human heart are similar to those in a rabbit model of
nonischemic heart failure.11
Our findings of conduction slowing and block expand on the results of Anderson et al.5 In their study, mapping limited to 64 sites over a portion of the epicardium of the left ventricle was performed in patients with IDCM. Consequently, the extent of conduction delay during extrastimuli and beats of VT was underestimated, the contribution of intramural conduction and conduction block could not be assessed, and arrhythmia mechanisms could not be defined. Using 3-dimensional mapping, we found marked intramural conduction delay in some but not all hearts from our patients with IDCM. However, we found that marked conduction delay consistently occurred distant from sites at which subsequent beats of VT initiated and did not contribute to the initiation of the VTs mapped. Slow conduction and block could ultimately contribute to sustained VT or the transition to ventricular fibrillation, given that 3-dimensional mapping of the transition from VT to ventricular fibrillation under a variety of pathophysiological conditions10 has demonstrated that acceleration of VT (whether caused by reentrant or nonreentrant mechanisms) leads to the development of multiple, simultaneous intramural reentrant circuits that are the hallmark of ventricular fibrillation.
Study Limitations
Spatial resolution of the electrodes and the time available for
mapping limited the volume of data recorded. However, spatial
resolution was sufficient to delineate the mechanism for 52 of 74 beats
of VT and was comparable to that in our previous
studies.7 8 9 In those studies, we were able to
define the mechanisms of arrhythmias in patients and to define
intramural reentrant circuits in the left and right ventricles and
interventricular septum as small as 1.5 cm in diameter. In
the present study, a similar 15-minute interval was sufficient to
induce 19 VTs in these 6 patients and record spontaneously
occurring ventricular arrhythmias.
Although nonsustained VT was induced in 3 of the 6 patients, sustained
VT was induced in none. There are 2 possible explanations. First, the
period of programmed stimulation (1 cycle length, no isoproterenol) was
inadequate to initiate sustained VT. Second, only 1 patient with IDCM
in this study had a prior history of syncope, and none had sustained
VT. Sustained VT is induced by programmed stimulation in 
15% of
patients with nonischemic
cardiomyopathy,19 whereas
nearly one half of all patients with cardiomyopathy
will ultimately suffer sudden death.2 The
induction of nonsustained VT, although not predictive of the
development of sustained VT, nonetheless characterizes an
electrophysiological-anatomic
substrate7 8 9 ultimately leading to sudden death
in many of these patients. In addition, in patients with severe heart
failure, spontaneously occurring nonsustained VT is an independent
marker of increased mortality and sudden death, and the absence of
nonsustained VT indicates a low probability of sudden
death.20 All the patients in the present
study had nonsustained VT clinically.
|
Acknowledgments |
|---|
This work was supported in part by NIH grants HL-46929 (Dr Pogwizd) and HL-50295 (Dr Cain). We appreciate the technical assistance of H. Dieter Ambos and thank Barbara Donnelly for preparation of the manuscript.
Received March 16, 1998; revision received July 22, 1998; accepted July 30, 1998.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
1. Kjekshus J. Arrhythmias and mortality in congestive heart failure. Am J Cardiol. 1990;65:42I–48I.[Medline] [Order article via Infotrieve]
2.
Packer M. Sudden unexpected death in patients with
congestive heart failure: a second frontier. Circulation. 1985;72:681–685.
3. Blanck Z, Akhtar M. Therapy of ventricular tachycardia in patients with nonischemic cardiomyopathies. J Cardiovasc Electrophysiol. 1996;7:671–683.[Medline] [Order article via Infotrieve]
4. DeBakker JMT, van Capelle FJL, Janse MJ, Tasseron S, Vermeulen JT, De Jonge N, Lahpor JR. Fractionated electrograms in dilated cardiomyopathy: origin and relation to abnormal conduction. J Am Coll Cardiol. 1996;27:1071–1078.[Abstract]
5. Anderson KP, Walker R, Urie P, Ershler PR, Lux RL, Karwandee SV. Myocardial electrical propagation in patients with idiopathic dilated cardiomyopathy. J Clin Invest. 1993;92:122–140.
6. Vermeulen JT, McGuire MA, Opthof T, Coronel R, De Bakker JMT, Klopping C, Janse MJ. Triggered activity and automaticity in ventricular trabeculae of failing human and rabbit hearts. Cardiovasc Res. 1994;28:1547–1554.[Medline] [Order article via Infotrieve]
7.
Pogwizd SM, Hoyt RH, Saffitz JE, Corr PB, Cox JL, Cain
ME. Reentrant and focal mechanisms underlying ventricular
tachycardia in the human heart. Circulation. 1992;86:1872–1887.
8.
Pogwizd SM, Chung MK, Cain ME. Termination of
ventricular tachycardia in the human heart:
insights from three-dimensional mapping of nonsustained and sustained
ventricular tachycardia.
Circulation. 1997;95:2528–2540.
9.
Chung MK, Pogwizd SM, Miller DP, Cain ME.
Three-dimensional mapping of the initiation of nonsustained
ventricular tachycardia in the human heart.
Circulation. 1997;95:2517–2527.
10.
Pogwizd SM, Corr PB. Electrophysiologic mechanisms
underlying arrhythmias due to reperfusion of ischemic
myocardium. Circulation. 1987;76:404–426.
11.
Pogwizd SM. Nonreentrant mechanisms underlying
spontaneous ventricular arrhythmias in a model of
nonischemic heart failure in rabbits. Circulation. 1995;92:1034–1048.
12.
Pogwizd SM. Focal mechanisms underlying
ventricular tachycardia during prolonged
ischemic cardiomyopathy.
Circulation. 1994;90:1441–1458.
13.
El-Sherif N, Caref EB, Hong C, Yin H, Restivo M. The
electrophysiological mechanism of
ventricular arrhythmias in the long QT syndrome:
tridimensional mapping of activation and recovery patterns. Circ
Res. 1996;79:474–492.
14.
Sicouri S, Antzelevitch C. A subpopulation of cells
with unique electrophysiological properties
in the deep subepicardium of the canine ventricle: the M cell.
Circ Res. 1991;68:1729–1741.
15. Wit AL, Rosen MR. Afterdepolarizations and triggered activity: distinction from automaticity as an arrhythmogenic mechanism. In: Fozzard HA, Habert E, Jennings RB, Katz AM, Morgan HE, eds. The Heart and Cardiovascular System: Scientific Foundations. 2nd ed. New York, NY: Raven Press; 1992:2113–2163.
16.
Beuckelmann DJ, Nabauer M, Erdmann E. Alterations of
K+ currents in isolated human
ventricular myocytes from patients with terminal heart
failure. Circ Res. 1993;73:379–385.
17.
Pogwizd SM, Corr PB. Biochemical and
electrophysiological alterations underlying
ventricular arrhythmias in the failing heart.
Eur Heart J. 1994;15:145–154.
18.
Studer R, Reinecke H, Bilger J, Eschenhagen T, Bohm M,
Hasenfuss G, Just H, Holtz J, Drexler H. Gene expression of the cardiac
Na+-Ca2+ exchanger in
end-stage human heart failure. Circ Res. 1994;75:443–453.
19. Lindsay BD, Osborn JL, Schechtman KB, Kenzora JL, Ambos HD, Cain ME. Prospective detection of vulnerability to sustained ventricular tachycardia in patients awaiting cardiac transplantation. Am J Cardiol. 1992;69:619–624.[Medline] [Order article via Infotrieve]
20.
Doval HC, Nul DR, Grancelli HO, Varini SD, Soifer S,
Corrado G, Dubner S, Scapin O, Perrone SV, for the GESICA-GEMA
Investigators. Nonsustained ventricular
tachycardia in severe heart failure: independent marker of
increased mortality due to sudden death. Circulation. 1996;94:3198–3203.
This article has been cited by other articles:
 |
|
 |
|
  G. S. Hoeker, R. P. Katra, L. D. Wilson, B. N. Plummer, and K. R. Laurita Spontaneous calcium release in tissue from the failing canine heart Am J Physiol Heart Circ Physiol, October 1, 2009; 297(4): H1235 - H1242. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
W. Chen, J. A. Wasserstrom, and Y. Shiferaw Role of coupled gating between cardiac ryanodine receptors in the genesis of triggered arrhythmias Am J Physiol Heart Circ Physiol, July 1, 2009; 297(1): H171 - H180. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. Stewart, O. V. Aslanidi, D. Noble, P. J. Noble, M. R. Boyett, and H. Zhang Mathematical models of the electrical action potential of Purkinje fibre cells Phil Trans R Soc A, June 13, 2009; 367(1896): 2225 - 2255. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Miura, Y. Wakayama, H. Endoh, M. Nakano, Y. Sugai, M. Hirose, H. E.D.J. ter Keurs, and H. Shimokawa Spatial non-uniformity of excitation-contraction coupling can enhance arrhythmogenic-delayed afterdepolarizations in rat cardiac muscle Cardiovasc Res, October 1, 2008; 80(1): 55 - 61. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 Y. Rudy, M. J. Ackerman, D. M. Bers, C. E. Clancy, S. R. Houser, B. London, A. D. McCulloch, D. A. Przywara, R. L. Rasmusson, R. J. Solaro, et al. Systems Approach to Understanding Electromechanical Activity in the Human Heart: A National Heart, Lung, and Blood Institute Workshop Summary Circulation, September 9, 2008; 118(11): 1202 - 1211. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. C. Wu, R. G. Weiss, D. R. Thiemann, K. Kitagawa, A. Schmidt, D. Dalal, S. Lai, D. A. Bluemke, G. Gerstenblith, E. Marban, et al. Late gadolinium enhancement by cardiovascular magnetic resonance heralds an adverse prognosis in nonischemic cardiomyopathy. J. Am. Coll. Cardiol., June 24, 2008; 51(25): 2414 - 2421. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. DeSantiago, X. Ai, M. Islam, G. Acuna, M. T. Ziolo, D. M. Bers, and S. M. Pogwizd Arrhythmogenic Effects of {beta}2-Adrenergic Stimulation in the Failing Heart Are Attributable to Enhanced Sarcoplasmic Reticulum Ca Load Circ. Res., June 6, 2008; 102(11): 1389 - 1397. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. M. Den Ruijter, G. Berecki, A. O. Verkerk, D. Bakker, A. Baartscheer, C. A. Schumacher, C. N.W. Belterman, N. de Jonge, J. W.T. Fiolet, I. A. Brouwer, et al. Acute Administration of Fish Oil Inhibits Triggered Activity in Isolated Myocytes From Rabbits and Patients With Heart Failure Circulation, January 29, 2008; 117(4): 536 - 544. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Masse, E. Downar, V. Chauhan, E. Sevaptsidis, and K. Nanthakumar Ventricular fibrillation in myopathic human hearts: mechanistic insights from in vivo global endocardial and epicardial mapping Am J Physiol Heart Circ Physiol, June 1, 2007; 292(6): H2589 - H2597. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. P. Katra, T. Oya, G. S. Hoeker, and K. R. Laurita Ryanodine receptor dysfunction and triggered activity in the heart Am J Physiol Heart Circ Physiol, May 1, 2007; 292(5): H2144 - H2151. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. E. Anderson Multiple downstream proarrhythmic targets for calmodulin kinase II: Moving beyond an ion channel-centric focus Cardiovasc Res, March 1, 2007; 73(4): 657 - 666. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. M. Bers Altered Cardiac Myocyte Ca Regulation In Heart Failure. Physiology, December 1, 2006; 21(6): 380 - 387. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. Stempien-Otero, A. Plawman, J. Meznarich, T. Dyamenahalli, G. Otsuka, and D. A. Dichek Mechanisms of Cardiac Fibrosis Induced by Urokinase Plasminogen Activator J. Biol. Chem., June 2, 2006; 281(22): 15345 - 15351. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Pott and J. I. Goldhaber Is the Ryanodine Receptor a Target for Antiarrhythmic Therapy? Circ. Res., May 26, 2006; 98(10): 1232 - 1233. [Full Text] [PDF]
|
|
|
|
|
|
J. P. Daubert, W. Zareba, W. J. Hall, C. Schuger, A. Corsello, A. R. Leon, M. L. Andrews, S. McNitt, D. T. Huang, A. J. Moss, et al. Predictive Value of Ventricular Arrhythmia Inducibility for Subsequent Ventricular Tachycardia or Ventricular Fibrillation in Multicenter Automatic Defibrillator Implantation Trial (MADIT) II Patients J. Am. Coll. Cardiol., January 3, 2006; 47(1): 98 - 107. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
X. Zhang, I. Ramachandra, Z. Liu, B. Muneer, S. M. Pogwizd, and B. He Noninvasive three-dimensional electrocardiographic imaging of ventricular activation sequence Am J Physiol Heart Circ Physiol, December 1, 2005; 289(6): H2724 - H2732. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
W. Xiong, Y. Tian, D. DiSilvestre, and G. F. Tomaselli Transmural Heterogeneity of Na+-Ca2+ Exchange: Evidence for Differential Expression in Normal and Failing Hearts Circ. Res., August 5, 2005; 97(3): 207 - 209. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. R. Abraham, C. A. Henrikson, L. Tung, M. G. Chang, M. Aon, T. Xue, R. A. Li, B. O' Rourke, and E. Marban Antiarrhythmic Engineering of Skeletal Myoblasts for Cardiac Transplantation Circ. Res., July 22, 2005; 97(2): 159 - 167. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. P. Katra and K. R. Laurita Cellular Mechanism of Calcium-Mediated Triggered Activity in the Heart Circ. Res., March 18, 2005; 96(5): 535 - 542. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M T Kearney, K A A Fox, A J Lee, W P Brooksby, A M Shah, A Flapan, R J Prescott, R Andrews, P D Batin, D L Eckberg, et al. Predicting sudden death in patients with mild to moderate chronic heart failure Heart, October 1, 2004; 90(10): 1137 - 1143. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. Moriwaki, A. Stempien-Otero, M. Kremen, A. E. Cozen, and D. A. Dichek Overexpression of Urokinase by Macrophages or Deficiency of Plasminogen Activator Inhibitor Type 1 Causes Cardiac Fibrosis in Mice Circ. Res., September 17, 2004; 95(6): 637 - 644. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. J Janse Electrophysiological changes in heart failure and their relationship to arrhythmogenesis Cardiovasc Res, February 1, 2004; 61(2): 208 - 217. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. H. Hsia, D. J. Callans, and F. E. Marchlinski Characterization of Endocardial Electrophysiological Substrate in Patients With Nonischemic Cardiomyopathy and Monomorphic Ventricular Tachycardia Circulation, August 12, 2003; 108(6): 704 - 710. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. C. Saumarez, L. Chojnowska, R. Derksen, M. Pytkowski, M. Sterlinski, C. L.-H. Huang, N. Sadoul, R. N.W. Hauer, W. Ruzyllo, and A. A. Grace Sudden Death in Noncoronary Heart Disease Is Associated With Delayed Paced Ventricular Activation Circulation, May 27, 2003; 107(20): 2595 - 2600. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M Scoote, P A Poole-Wilson, and A J Williams The therapeutic potential of new insights into myocardial excitation-contraction coupling Heart, April 1, 2003; 89(4): 371 - 376. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. J. Ciaccio Premature excitation and onset of reentrant ventricular tachycardia Am J Physiol Heart Circ Physiol, October 1, 2002; 283(4): H1703 - H1712. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Y. Wu, J. Temple, R. Zhang, I. Dzhura, W. Zhang, R. Trimble, D. M. Roden, R. Passier, E. N. Olson, R. J. Colbran, et al. Calmodulin Kinase II and Arrhythmias in a Mouse Model of Cardiac Hypertrophy Circulation, September 3, 2002; 106(10): 1288 - 1293. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Kadish Primary prevention ofsudden death using ICD therapy: incremental steps J. Am. Coll. Cardiol., March 6, 2002; 39(5): 788 - 789. [Full Text] [PDF]
|
|
|
|
|
|
D. M. Bers Calcium and Cardiac Rhythms: Physiological and Pathophysiological Circ. Res., January 11, 2002; 90(1): 14 - 17. [Full Text] [PDF]
|
|
|
|
 |
|
 X.H.T. WEHRENS and A.R. MARKS Myocardial Disease in Failing Hearts: Defective Excitation-Contraction Coupling Cold Spring Harb Symp Quant Biol, January 1, 2002; 67(0): 533 - 542. [Abstract] [PDF]
|
|
|
|
|
|
A. O. Verkerk, M. W. Veldkamp, A. Baartscheer, C. A. Schumacher, C. Klopping, A. C.G. van Ginneken, and J. H. Ravesloot Ionic Mechanism of Delayed Afterdepolarizations in Ventricular Cells Isolated From Human End-Stage Failing Hearts Circulation, November 27, 2001; 104(22): 2728 - 2733. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Roberts and U. Sigwart New Concepts in Hypertrophic Cardiomyopathies, Part II Circulation, October 30, 2001; 104(18): 2249 - 2252. [Full Text] [PDF]
|
|
|
|
 |
|
 X. Jouven and P. Ducimetiere Exercise testing: do frequent premature ventricular depolarizations represent a new criterion of positivity? Eur. Heart J., October 1, 2001; 22(19): 1759 - 1761. [PDF]
|
|
|
|
 |
|
 S. Capomolla, O. Febo, C. Opasich, G. Guazzotti, A. Caporotondi, M. T. La Rovere, M. Gnemmi, A. Mortara, M. Vona, G. D. Pinna, et al. Chronic infusion of dobutamine and nitroprusside in patients with end-stage heart failure awaiting heart transplantation: safety and clinical outcome Eur J Heart Fail, October 1, 2001; 3(5): 601 - 610. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Adachi-Akahane and Y. Kurachi New Era for Translational Research in Cardiac Arrhythmias Circ. Res., June 8, 2001; 88(11): 1095 - 1096. [Full Text] [PDF]
|
|
|
|
|
|
S. M. Pogwizd Increased Na+-Ca2+ Exchanger in the Failing Heart Circ. Res., October 13, 2000; 87(8): 641 - 643. [Full Text] [PDF]
|
|
|
|
 |
|
 X. Jouven, M. Zureik, M. Desnos, D. Courbon, and P. Ducimetiere Long-Term Outcome in Asymptomatic Men with Exercise-Induced Premature Ventricular Depolarizations N. Engl. J. Med., September 21, 2000; 343(12): 826 - 833. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Zhuang, K. A. Yamada, J. E. Saffitz, and A. G. Kleber Pulsatile Stretch Remodels Cell-to-Cell Communication in Cultured Myocytes Circ. Res., August 18, 2000; 87(4): 316 - 322. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Becker and W. Schoels Re: 'Ventricular arrhythmias induced by endothelin-1 or by acute ischemia: a comparative analysis using three-dimensional mapping' (Cardiovasc Res 2000;45:310-320) Cardiovasc Res, June 1, 2000; 46(3): 606 - 607. [Full Text] [PDF]
|
|
|
|
|
|
P. C. Viswanathan and Y. Rudy Cellular Arrhythmogenic Effects of Congenital and Acquired Long-QT Syndrome in the Heterogeneous Myocardium Circulation, March 14, 2000; 101(10): 1192 - 1198. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. I. Goldhaber Sodium-Calcium Exchange : The Phantom Menace Circ. Res., November 26, 1999; 85(11): 982 - 984. [Full Text] [PDF]
|
|
|
|
|
|
S. M. Pogwizd, M. Qi, W. Yuan, A. M. Samarel, and D. M. Bers Upregulation of Na+/Ca2+ Exchanger Expression and Function in an Arrhythmogenic Rabbit Model of Heart Failure Circ. Res., November 26, 1999; 85(11): 1009 - 1019. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. M. Pogwizd, K. Schlotthauer, L. Li, W. Yuan, and D. M. Bers Arrhythmogenesis and Contractile Dysfunction in Heart Failure : Roles of Sodium-Calcium Exchange, Inward Rectifier Potassium Current, and Residual {beta}-Adrenergic Responsiveness Circ. Res., June 8, 2001; 88(11): 1159 - 1167. [Abstract] [Full Text] [PDF]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||