In silico study of calcium handling in the human failing heart

Tesis por compendio[EN] Heart failure, a cardiomyopathy that produces mechanical dysfunction and sudden cardiac death following fatal arrhythmias, is one of the main causes of mortality worldwide that also causes elevated morbidity rates. Current clinical therapies are challenged by the complexity of this cardiac pathology, in which many factors are involved in the electrical instabilities that lead to an altered function. The electrical activity of the heart comprises a wide range of spatial and temporal scales. Ion transport across transmembrane proteins initiate the cellular depolarization that is propagated cell to cell through the myocardium depolarizing and then repolarizing the entire heart in an orchestrated manner. The electrical excitation of cardiomyocytes triggers the cellular contraction, a process in which Ca2+ ions are the main mediators. Ca2+ dynamics plays a relevant role in controlling excitation-contraction coupling and consequently, investigations have focused on Ca2+-handling proteins and the regulation of Ca2+ homeostasis to elucidate the causes of impaired contractility and pro-arrhythmic conditions in cardiac diseases. This thesis takes advantage of the existence of mathematical models with detailed representation of the subcellular processes to perform computational simulations of cardiac electrophysiology and understand the altered mechanisms that govern heart failure, especially those related with intracellular Ca2+ cycling. It is known that failing myocytes undergo a specific remodeling of ion channels and Ca2+-handling proteins that lead to an impaired excitation-contraction coupling. Initially, it was analyzed, in the human action potential model of ventricular myocytes selected for the whole study, the effects of modulating ionic mechanisms on the electrical activity and Ca2+ dynamics. In tissue, heart failure induces additional changes affecting cellular coupling. The development of fibroblasts and impact on myocyte electrophysiology was investigated, including the vulnerability to generate alternans, a common precursor to arrhythmogenesis. Finally, the beta-adrenergic signaling model was integrated with the action potential model because of the electrophysiological modulation exerted by the sympathetic nervous system, which is aggravated under heart failure conditions. Results highlighted the need of studying heart failure therapies on failing cells because of the different response of ion channels and membrane proteins to drugs. Functional Ca2+ proteins were important to maintain Ca2+ homeostasis and to avoid malignant electrical consequences, being SERCA pump the most critical factor. Apart from the electrophysiological remodeling, fibroblast interaction contributed to alter Ca2+ dynamics in myocytes and, when analyzing Ca2+ alternans, spatial electrical discordances predominated in failing tissues. The inclusion of beta-adrenergic stimulation showed that the inotropic response was diminished in heart failure as well as the antiarrhythmic benefits provided by catecholamines in the normal heart. These findings contribute to gain insight into the pathophysiology of heart failure and the development of new pharmacological agents targeted to restore Ca2+ dynamics. The control of intracellular Ca2+ cycling is crucial to ensure both the mechanical force and the electrical activity that lead to a rhythmic contraction of the heart.[ES] La insuficiencia cardíaca, una cardiomiopatía que provoca disfunción mecánica y muerte súbita tras arritmias cardíacas letales, es una de las principales causas de mortalidad en todo el mundo que además causa tasas de morbilidad elevadas. Las terapias usadas actualmente en la clínica están comprometidas por la complejidad de esta patología cardíaca, ya que son muchos los factores que están implicados en las inestabilidades eléctricas que conllevan a alteraciones funcionales. La actividad eléctrica del corazón abarca un amplio rango escalas espaciales y temporales. El transporte de iones a través de las proteínas transmembrana inicia la despolarización celular que se propaga de célula en célula a través del miocardio, despolarizando y luego repolarizando todo el corazón de manera sincronizada. La excitación eléctrica de los cardiomiocitos desencadena la contracción celular, un proceso en el que los iones de Ca2+ son los principales intermediarios. La dinámica de Ca2+ tiene un papel relevante en el control del acoplamiento excitación-contracción y, como consecuencia, las investigaciones se han centrado en las proteínas que controlan el ciclo del Ca2+ y la regulación homeostática para encontrar las causas que empeoran la contractilidad y conducen a condiciones proarrítmicas en casos de insuficiencia cardíaca. Esta tesis hace uso de la existencia de modelos matemáticos con una representación detallada de los procesos subcelulares para realizar simulaciones computacionales de electrofisiología cardíaca y comprender los mecanismos que están alterados y predominan en insuficiencia cardíaca, especialmente aquellos relacionados con el ciclo intracelular de Ca2+ . Se sabe que los miocitos dañados por insuficiencia cardíaca experimentan un remodelado específico en los canales iónicos y en las proteínas partícipes en el ciclo de Ca2+, ocasionando fallos en el acoplamiento excitación-contracción. Inicialmente, se analizaron, en el modelo de potencial de acción humano de miocitos ventriculares seleccionado para todo el estudio, los efectos de la modulación de los mecanismos iónicos sobre la actividad eléctrica y la dinámica de Ca2+. En los tejidos, la insuficiencia cardíaca induce cambios adicionales que afectan el acoplamiento celular. Se ha investigado la presencia de fibroblastos y su impacto en la electrofisiología de los miocitos, incluida la vulnerabilidad para generar alternantes, un precursor común de la arritmogénesis. Finalmente, se ha incluido el modelo de señalización -adrenérgica integrado con el modelo de potencial de acción debido a la modulación electrofisiológica ejercida por el sistema nervioso simpático, que se agrava en condiciones de insuficiencia cardíaca. Los resultados han destacado la necesidad de estudiar las terapias de insuficiencia cardíaca en células de estos corazones debido a la diferente respuesta de los canales iónicos y las proteínas de membrana a los medicamentos. El buen funcionamiento de las proteínas reguladoras del Ca2+ es importantes para mantener la homeostasis del Ca2+ y evitar consecuencias eléctricas malignas, siendo la bomba SERCA el factor más crítico. Además del remodelado electrofisiológico, la interacción con fibroblastos contribuye a alterar la dinámica de Ca2+ en los miocitos y, al analizar los alternantes de Ca2+, predominan las discordancias eléctricas espaciales en los tejidos de corazones con insuficiencia cardíaca. La inclusión de la estimulación -adrenérgica ha mostrado que la respuesta inotrópica disminuye en insuficiencia cardíaca, así como los beneficios antiarrítmicos proporcionados por las catecolaminas en un corazón normal. Estos hallazgos contribuyen a obtener información sobre la fisiopatología de la insuficiencia cardíaca y el desarrollo de nuevos agentes farmacológicos destinados a restaurar la dinámica de Ca 2+. El control del ciclo de Ca2+ intracelular es crítico para garantizar tanto la fuerza mecánica como la actividad eléctrica que conducen a una contracción rítmica del corazón.[CA] La insuficiència cardíaca, una cardiomiopatia que provoca disfunció mecànica i mort sobtada després d'arrítmies cardíaques letals, és una de les principals causes de mortalitat a tot el món que a més causa taxes de morbiditat elevades. Les teràpies utilitzades actualment en la clínica estan compromeses per la complexitat d'aquesta patologia cardíaca, ja que són molts els factors que estan implicats en les inestabilitats elèctriques que comporten a alteracions funcionals. L'activitat elèctrica del cor abasta un ampli rang d'escales espacials i temporals. El transport d'ions a través de les proteïnes transmembrana inicia la despolarització cel·lular que es propaga de cèl·lula en cèl·lula a través del miocardi, despolaritzant i després repolaritzant tot el cor de manera sincronitzada. L'excitació elèctrica dels cardiomiòcits desencadena la contracció cel·lular, un procés en el qual els ions de Ca2+ són els principals intermediaris. La dinàmica de Ca2+ té un paper rellevant en el control de l'acoblament excitació-contracció i, com a conseqüència, les investigacions s'han centrat en les proteïnes que controlen el cicle del Ca2+ i la regulació homeostàtica per a trobar les causes que empitjoren la contractilitat i condueixen a condicions proarrítmiques en casos d'insuficiència cardíaca. Aquesta tesi fa ús de l'existència de models matemàtics amb una representació detallada dels processos subcel·lulars per a realitzar simulacions computacionals de l'electrofisiologia cardíaca i comprendre els mecanismes que estan alterats i predominen en insuficiència cardíaca, especialment aquells relacionats amb el cicle intracel·lular de Ca2+. Se sap que els miòcits danyats per insuficiència cardíaca experimenten un remodelat específic en els canals iònics i en les proteïnes partícips en el cicle de Ca2+, ocasionant fallades en l'acoblament excitació-contracció. Inicialment, es van analitzar, en el model de potencial d'acció humà de miòcits ventriculars seleccionat per a tot l'estudi, els efectes de la modulació dels mecanismes iònics sobre l'activitat elèctrica i la dinàmica de Ca2+. En els teixits, la insuficiència cardíaca indueix canvis addicionals que afecten l'acoblament cel·lular. S'ha investigat la presència de fibroblasts i el seu impacte en l'electrofisiologia dels miòcits, inclosa la vulnerabilitat per a generar alternants, un precursor comú de l'arritmogènesi. Finalment, s'ha inclòs el model de senyalització beta-adrenèrgica integrat amb el model de potencial d'acció a causa de la modulació electrofisiològica exercida pel sistema nerviós simpàtic, que s'agreuja en condicions d'insuficiència cardíaca. Els resultats han destacat la necessitat d'estudiar les teràpies d'insuficiència cardíaca en cèl·lules d'aquests cors a causa de la diferent resposta dels canals iònics i les proteïnes de membrana als medicaments. El bon funcionament de les proteïnes reguladores del Ca2+ és importants per a mantindre l'homeòstasi del Ca2+ i evitar conseqüències elèctriques malignes, sent la bomba SERCA el factor més crític. A més del remodelat electrofisiològic, la interacció amb fibroblasts contribueix a alterar la dinàmica de Ca2+ en els miòcits i, en analitzar els alternants de Ca2+, predominen les discordances elèctriques espacials en els teixits de cors amb insuficiència cardíaca. La inclusió de l'estimulació beta-adrenèrgica ha mostrat que la resposta inotròpica disminueix en insuficiència cardíaca, així com els beneficis antiarrítmics proporcionats per les catecolamines en un cor normal. Aquestes troballes contribueixen a obtindre informació sobre la fisiopatologia de la insuficiència cardíaca i el desenvolupament de nous agents farmacològics destinats a restaurar la dinàmica de Ca2+. El control del cicle de Ca2+ intracel·lular és crític per a garantir tant la força mecànica com l'activitat elèctrica per a una contracció rítmica del cor.Mora Fenoll, MT. (2020). In silico study of calcium handling in the human failing heart [Tesis doctoral no publicada]. Universitat Politècnica de València. https://doi.org/10.4995/Thesis/10251/153143TESISCompendi

The relationship between repolarisation alternans and the production of ventricular arrhythmia in heart failure

Microvolt T-wave alternans is thought to predict the risk of ventricular arrhythmias in patients with heart disease, although recent clinical studies have conflicting results. Understanding the cellular basis for alternans may not only inform more effective utilisation of the clinical test, but also provide new insights into the causes of lethal arrhythmias in man. Cellular repolarisation alternans is thought to underlie T-wave alternans and in recent years, the concept of discordant repolarisation alternans has emerged as a new paradigm for the induction of re-entrant ventricular arrhythmia. This experimental observation has not been examined in clinically relevant models of pathology and so the aim of this study was to investigate whether increased transmural heterogeneity of repolarisation as a result of heart failure following myocardial infarction in the rabbit would predispose to the development of arrhythmogenic discordant alternans. A rabbit ventricular wedge preparation was developed and the transmural electrophysiology of intact rabbit ventricle was characterised using optical imaging techniques. This revealed transmural gradients of repolarisation in intact rabbit myocardium, which appeared to be influenced by electrotonic load, rather than purely being a reflection of intrinsic cellular differences. Interestingly, repolarisation alternans also appeared in transmural patterns, which were also modified by activation sequence, underlining the role of conduction and electrotonic influences in dictating the spatial patterns of alternans, which may be crucial in determining spatially discordant alternans. In this study, similar baseline electrophysiological characteristics were apparent in the remodelled myocardium of failing hearts compared with normal hearts, underlining the possible importance of dynamic factors in producing the increased vulnerability to re-entrant arrhythmias observed in failing hearts. Repolarisation alternans, elicited by low temperature and rapid pacing, occurred at lower heart rates in failing hearts. At physiological temperature, repolarisation alternans was also more common in failing hearts. Spatially discordant alternans was not consistently observed on the transmural surface and did not appear to be directly related to the development of arrhythmia. Failing hearts displayed an increased vulnerability to ventricular arrhythmia. Although heart failure was associated with both alternans and ventricular arrhythmia, there was no demonstrable mechanistic link between alternans and ventricular arrhythmias in failing hearts. These data establish the occurrence of repolarisation alternans in a clinically relevant pathology, and so constitute an important step forward in our understanding of the experimental paradigm. However, a definitive mechanistic link between alternans and arrhythmia in heart failure is yet to be shown

INVESTIGATION OF CARDIAC ELECTROPHYSIOLOGY IN HUMAN VENTRICULAR TISSUE

Individuals with cardiomyopathy are at higher risk to die from sudden cardiac arrest than those with non-failing (NF) hearts. This study examined the differences in electrical properties of failing and NF human hearts in terms of cardiac memory through explicit control of diastolic intervals in a sinusoidal fashion, restitution of action potential duration (APD) through standard and dynamic pacing protocols, maximum rate of depolarization and APD alternans. Recordings of transmembrane potentials were made in tissues extracted from patients with heart failure and one donor NF heart. Computational simulations were performed using the O’Hara Rudy model for generating surrogates of control data. Significant differences were seen between left ventricular (LV) tissue and NF LV tissue in tilt, and measures of memory in terms of area and thickness during the sinusoidal 400ms protocol. Minimum delay was also significantly higher in the failing LV during the sinusoidal 150ms protocol. Failing tissues showed a higher restitution slope and prolonged AP which is consistent with previous studies and is hypothesized to contribute to the increased susceptibility to unstable alternans. This study further explored how disease alters the electrical functioning of the heart and why these patients are at a higher risk of ventricular arrhythmia

Altered excitation-contraction coupling in human chronic atrial fibrillation

This review focuses on the (mal)adaptive processes in atrial excitation-contraction coupling occurring in patients with chronic atrial fibrillation. Cellular remodeling includes shortening of the atrial action potential duration and effective refractory period, depressed intracellular Ca<sup>2+</sup> transient, and reduced myocyte contractility. Here we summarize the current knowledge of the ionic bases underlying these changes. Understanding the molecular mechanisms of excitation-contraction-coupling remodeling in the fibrillating human atria is important to identify new potential targets for AF therapy

Minimally invasive system to reliably characterize ventricular electrophysiology from living donors

Cardiac tissue slices preserve the heterogeneous structure and multicellularity of the myocardium and allow its functional characterization. However, access to human ventricular samples is scarce. We aim to demonstrate that slices from small transmural core biopsies collected from living donors during routine cardiac surgery preserve structural and functional properties of larger myocardial specimens, allowing accurate electrophysiological characterization. In pigs, we compared left ventricular transmural core biopsies with transmural tissue blocks from the same ventricular region. In humans, we analyzed transmural biopsies and papillary muscles from living donors. All tissues were vibratomesliced. By histological analysis of the transmural biopsies, we showed that tissue architecture and cellular organization were preserved. Enzymatic and vital staining methods verifed viability. Optically mapped transmembrane potentials confrmed that action potential duration and morphology were similar in pig biopsies and tissue blocks. Action potential morphology and duration in human biopsies and papillary muscles agreed with published ranges. In both pigs and humans, responses to increasing pacing frequencies and β-adrenergic stimulation were similar in transmural biopsies and larger tissues. We show that it is possible to successfully collect and characterize tissue slices from human myocardial biopsies routinely extracted from living donors, whose behavior mimics that of larger myocardial preparations both structurally and electrophysiologically.Fil: Oliván Viguera, Aida. Universidad de Zaragoza; EspañaFil: Pérez Zabalza, María. Universidad de Zaragoza; EspañaFil: García Mendívil, Laura. Universidad de Zaragoza; EspañaFil: Mountris, Konstantinos A.. Universidad de Zaragoza; EspañaFil: Orós Rodrigo, Sofía. Universidad de Zaragoza; EspañaFil: Ramos Marquès, Estel. Universidad de Zaragoza; EspañaFil: Vallejo Gil, José María. University Hospital Miguel Servet; EspañaFil: Fresneda Roldán, Pedro Carlos. University Hospital Miguel Servet; EspañaFil: Fañanás Mastral, Javier. University Hospital Miguel Servet; EspañaFil: Vázquez Sancho, Manuel. University Hospital Miguel Servet; EspañaFil: Matamala Adell, Marta. University Hospital Miguel Servet; EspañaFil: Sorribas Berjón, Fernando. University Hospital Miguel Servet; EspañaFil: Bellido Morales, Javier André. University Hospital Miguel Servet; EspañaFil: Mancebón Sierra, Francisco Javier. University Hospital Miguel Servet; EspañaFil: Vaca Núñez, Alexánder Sebastián. University Hospital Miguel Servet; EspañaFil: Ballester Cuenca, Carlos. University Hospital Miguel Servet; EspañaFil: Marigil, Miguel Ángel. Hospital San Jorge; EspañaFil: Pastor, Cristina. Aragón Institute of Health Sciences; EspañaFil: Ordovás, Laura. Aragón Agency for Research and Development; España. Universidad de Zaragoza; EspañaFil: Köhler, Ralf. Aragón Institute of Health Sciences; España. Aragón Agency for Research and Development; EspañaFil: Diez, Emiliano Raúl. Universidad Nacional de Cuyo. Facultad de Ciencias Médicas. Cátedra de Fisiología Humana Normal; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Mendoza. Instituto de Medicina y Biología Experimental de Cuyo; ArgentinaFil: Pueyo, Esther. Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina; España. Universidad de Zaragoza; Españ

Myocardial slices as an in vitro platform to study cardiac disease

In vitro models are the pillars of fundamental research and drug discovery, offering reductionist methods to better understand cellular responses in isolation. Often these methods are oversimplified, which makes their relevance to human biology and clinical translation ambiguous. Living myocardial slices (LMSLMSs) are viable thin (200-400μm) cardiac tissue slices, with preserved native multicellularity, architecture, mechanical and electrophysiological responses. Recent development in their culture, by us and others, paved the way for long-term preservation of adult mammalian heart tissue in vitro, without significant changes in its function and structure. This model has been extensively used in healthy tissue; however, to date, there are no established pathological models to study disease progression in vitro. Here we hypothesised that LMSLMSs can be used as an informative in vitro disease model to study temporal and spatial changes in cardiac function/structure in response to local cardiac damage. Before inducing cardiac damage, we further improved and characterised the cultured LMS model by designing robust tissue holders, optimising the oxygenation of the media, and establishing the best slice thickness (300μ) for oxygen diffusion and tissue stability in culture. We found that the LMSLMSs were adequately oxygenated in the inner layers and responded to mechanical stimuli with an increase in their contraction and hyperpolarisation of the mitochondrial membrane. We then developed a cryoinjury model, by applying a cooled probe on the LMSLMSs. We found that injury created a distinct necrotic area, surrounded by a border zone (BZ). The injury resulted in preserved force but electrical instability, with the presence of spontaneous contractions. Microscopic analysis of the BZ showed the presence of high numbers of spontaneous Ca2+ sparks, which could be affected by inhibiting the activation of Ca2+/calmodulin-dependent protein kinase II (CamKII). The inhibitory effect was more pronounced in endocardial LMSLMSs, showing transmural differences of CamKII under pathological conditions. Structural analysis of the BZ also showed an acute increase of the sarcomere length and loss of t-tubule density upon culture, that could also account for the arrhythmogenicity of the injured LMSLMSs. One application of therapeutic interventions on the model, by using extracellular vesicles (EVs), did not show any functional or molecular improvements. This thesis demonstrates the significance of using diseased LMSLMSs to study the way that local injury affects tissue stability, function, and structure. Further work is required to better understand the link between spontaneous Ca2+ and contraction events, as well as finding successful therapeutic interventions.Open Acces

Fractional diffusion models of cardiac electrical propagation: role of structural heterogeneity in dispersion of repolarization

Structural heterogeneity constitutes one of the main substrates influencing impulse propagation in living tissues. In cardiac muscle, improved understanding on its role is key to advancing our interpretation of cell-to-cell coupling, and how tissue structure modulates electrical propagation and arrhythmogenesis in the intact and diseased heart. We propose fractional diffusion models as a novel mathematical description of structurally heterogeneous excitable media, as a mean of representing the modulation of the total electric field by the secondary electrical sources associated with tissue inhomogeneities. Our results, validated against in-vivo human recordings and experimental data of different animal species, indicate that structural heterogeneity underlies many relevant characteristics of cardiac propagation, including the shortening of action potential duration along the activation pathway, and the progressive modulation by premature beats of spatial patterns of dispersion of repolarization. The proposed approach may also have important implications in other research fields involving excitable complex media

Load-dependent electrophysiological and structural cardiac remodelling studied in ultrathin myocardial slices.

Introduction: Myocardial slices are becoming an established system to study cardiac electrophysiology and pharmacological research and development. Unlike other preparations, cardiac slices are a multicellular preparation that has an intermediate, adequate complexity required for this research. Previous studies have successfully obtained slices from human biopsies and animal models, where the electrical and structural parameters could be maintained for several hours – a process which is comparable to other preparation types. Therefore, we aimed to use left ventricular myocardial slices obtained from rat models of mechanical unloading (HAHLT) and from two models of overload (TAC and SHR), to investigate electrophysiological and structural alterations in these models. Methods: Mechanical unloading was achieved by heterotopic abdominal heart and lung transplantation (HAHLT, 8 weeks) and overload was induced by thoracic aortic constriction (TAC, 10 and 20 weeks) in male Lewis rats. Spontaneous hypertensive rats (SHR) were also used as a second model of overload and were primarily induced by hypertension (3, 12 and 20 months). Brown Norway and Wistar Kyoto rats were used as the control groups for SHR. Myocardial slices from the left ventricle (LV) free wall were cut (300-350 µm thick) tangentially to the epicardial surface using a high-precision slow-advancing Vibratome and were point-stimulated using a multi-electrode array system (MEA), therefore, acquiring field potentials (FPs). Field potential duration (FPD) and conduction velocity (CV) were analysed locally and transmurally across the LV free wall. In addition, FPD heterogeneity within each slice was calculated. For the SHR group, the same slices used for the MEA recording were preserved and used subsequently to measure Cx43, Nav1.5 protein levels and fibrosis. Results: Slices obtained from normal rat hearts that are chronically unloaded were found to develop atrophy at a whole heart level. They showed an increase in FPD and its heterogeneity with preserved conduction properties when compared to controls. In TACs, an in vivo whole heart function assessment confirmed hypertrophy with no signs of cardiac dysfunction. Slices from TAC rats showed an increase in FPD at both 10 and 20 weeks after banding. FPD heterogeneity was increased at 10 weeks but normalised at 20 weeks. Changes in CV properties were observed in this group, showing a faster CV and longitudinal conduction velocity (CVL) at 10 weeks and no change at 20 weeks. Transverse conduction velocity (CVT) was unchanged in the TAC group. In SHRs, however, hypertrophy was confirmed and signs of dysfunction in the aged group (20 months) were observed due to the decrease in EF by 18%, especially when compared to the 12 months group. FPD and its heterogeneity was unchanged in SHR when compared to controls. Disease and age-related abnormalities in CV properties were observed in SHR and these were associated with changes in Cx43, Nav1.5 protein level and fibrosis. Conclusion: Myocardial slices are a suitable multicellular preparation to study electrophysiological remodelling obtained from different rat models of cardiovascular disease. In addition, it was possible to investigate the changes in CV and FPD transmurally in rats using this type of preparation method. Thus, this study supports the use of this multicellular preparation in understanding the mechanisms of cardiac disease and the testing of new treatments and therapeutic targets.Open Acces

25 years of basic and translational science in EP Europace: novel insights into arrhythmia mechanisms and therapeutic strategies.

In the last 25 years, EP Europace has published more than 300 basic and translational science articles covering different arrhythmia types (ranging from atrial fibrillation to ventricular tachyarrhythmias), different diseases predisposing to arrhythmia formation (such as genetic arrhythmia disorders and heart failure), and different interventional and pharmacological anti-arrhythmic treatment strategies (ranging from pacing and defibrillation to different ablation approaches and novel drug-therapies). These studies have been conducted in cellular models, small and large animal models, and in the last couple of years increasingly in silico using computational approaches. In sum, these articles have contributed substantially to our pathophysiological understanding of arrhythmia mechanisms and treatment options; many of which have made their way into clinical applications. This review discusses a representative selection of EP Europace manuscripts covering the topics of pacing and ablation, atrial fibrillation, heart failure and pro-arrhythmic ventricular remodelling, ion channel (dys)function and pharmacology, inherited arrhythmia syndromes, and arrhythmogenic cardiomyopathies, highlighting some of the advances of the past 25 years. Given the increasingly recognized complexity and multidisciplinary nature of arrhythmogenesis and continued technological developments, basic and translational electrophysiological research is key advancing the field. EP Europace aims to further increase its contribution to the discovery of arrhythmia mechanisms and the implementation of mechanism-based precision therapy approaches in arrhythmia management

Contribution to the improvement of electrical therapies and to the comprehension of electrophysiological mechanisms in heart failure and acute ischemia using computational simulation

[ES] Una mejor comprensión de los mecanismos subyacentes a las arritmias ventriculares, así como una mejora de las terapias eléctricas y farmacológicas asociadas, son un factor clave para prevenir la muerte súbita cardíaca en pacientes con cardiopatías estructurales y eléctricas. Una miocardiopatía importante que puede provocar arritmias ventriculares potencialmente mortales es la insuficiencia cardíaca (HF). Los pacientes con HF a menudo sufren también de bloqueo de rama izquierda (LBBB) que deteriora su condición. Actualmente, el tratamiento más eficaz para estos pacientes es la terapia de resincronización cardíaca (CRT). Sin embargo, no se alcanza una respuesta positiva en todos los casos, por lo que es necesario un mayor estudio para mejorar este tratamiento. Una segunda patología cardíaca que también produce arritmias letales es la isquemia miocárdica. Evidencia experimental ha demostrado que las alteraciones electrofisiológicas en el miocardio ventricular constituyen un sustrato para la generación de arritmias durante la fase aguda de isquemia. Estas alteraciones son inducidas por los tres componentes isquémicos principales: hipercalemia, hipoxia y acidosis. Sin embargo, la influencia de cada componente en los mecanismos de inicio y mantenimiento de las arritmias no se comprende aún con claridad. Una primera parte de esta tesis doctoral, se centra en la optimización de la CRT durante su aplicación en un corazón que padece HF y LBBB. Para esto, se modificó el modelo de potencial de acción (AP) de O'Hara para simular una velocidad de conducción realista tanto en condiciones sanas como patológicas. Además, se estimó e incorporó un sistema de His-Purkinje (HPS) dentro de un modelo biventricular/torso humano 3D para simular un LBBB realista. A continuación, se desarrolló un conjunto de simulaciones computacionales para diferentes configuraciones de la CRT a fin de determinar la posición y el instante de estimulación óptimo que conducen a la duración más corta del QRS. Posteriormente, los resultados se compararon con otros criterios de optimización. Los principales hallazgos de este estudio mostraron la necesidad de definir criterios de optimización mejores o complementarios, como un índice basado en el tiempo hasta alcanzar el 90% del área del QRS sugerido en este trabajo, para alcanzar la mejor sincronía eléctrica ventricular durante la aplicación de la CRT. Además, nuestros resultados también muestran que el septo superior cercano al tracto de salida es un sitio alternativo para la estimulación del ventrículo derecho, lo cual evita los problemas de perforación de la pared apical durante el procedimiento típico de la CRT. Por último, para obtener mejores resultados de la CRT se deben considerar protocolos de estimulación endocárdica en el ventrículo izquierdo. En la segunda parte de esta tesis se investigó los efectos de los tres componentes principales de la isquemia sobre la vulnerabilidad a una reentrada, así como el papel del HPS y sus mecanismos de acción en la generación y mantenimiento de arritmias ventriculares. Para lograr este objetivo, en primer lugar, se modificó el modelo AP ventricular para simular de forma realista las principales alteraciones provocadas por la isquemia miocárdica aguda. Las simulaciones se realizaron en un modelo biventricular humano 3D, acoplado en un torso virtual, que incluye una geometría realista de las zonas isquémicas central y de borde, así como un HPS detallado. Se simularon cuatro escenarios de severidad isquémica correspondientes a diferentes minutos de oclusión de la arteria coronaria para evaluar los efectos de la evolución de la isquemia en el tiempo. Luego, se evaluó la influencia individual de la hipercalemia, hipoxia y acidosis en el ancho de la ventana vulnerable (VW) a reentradas durante siete escenarios de isquemia aguda. Finalmente, se repitió este último conjunto de simulaciones isquémicas utilizando el modelo anatómico sin el HPS para evaluar el efecto de este último en la VW. Los resultados muestran que una condición isquémica moderada es el peor escenario para la generación de una reentrada. La hipoxia es el componente isquémico con el efecto más significativo en el ancho de la VW. Además, el flujo de corriente retrógrado desde el miocardio hacia el HPS en la región isquémica, los bloqueos de conducción en secciones discretas del HPS y el grado de hiperkalemia que afecta a las células de Purkinje, son sugeridos como mecanismos que podrían favorecer la aparición de arritmias ventriculares.[EN] A better understanding of the mechanisms underlying ventricular arrhythmias, as well as an improvement of the associated electrical and pharmacological therapies, are a key factor to prevent sudden cardiac death in patients with structural and electrical heart diseases. An important cardiomyopathy that can lead to life-threatening ventricular arrhythmias is heart failure (HF). Patients with HF also often suffer from left bundle branch block (LBBB), which worsens their condition. Currently, the most effective treatment to these patients is cardiac resynchronization therapy (CRT). However, many patients are non-responders, so further studies are needed to improve this treatment. A second cardiac pathology that also produces lethal arrhythmias is myocardial ischemia. Substantial experimental evidence has shown that electrophysiological alterations in the ventricular myocardium constitute a substrate for the generation of arrhythmias during the acute phase of ischemia. These alterations are induced by the three main ischemic components: hyperkalemia, hypoxia and acidosis. However, the influence of each component in the mechanisms of arrhythmia initiation and maintenance is still not completely understood. In the first section of this doctoral thesis, we focus on the optimization of CRT during its application in a heart suffering from HF and LBBB. For this purpose, we modified the O'Hara action potential (AP) model to simulate a realistic conduction velocity both in healthy and pathological conditions. In addition, a His-Purkinje system (HPS) was generated and incorporated into a 3D human biventricular/torso model to simulate realistic LBBB. A set of computational simulations were performed for different CRT configurations to determine the optimal pacing leads location and delay values leading to the shortest QRS duration. Subsequently, results were compared with other optimization criteria. The main findings of this study showed the need of better or complementary optimization criteria, such as an index based on the time to reach the 90% of the QRS area suggested in this work, to reach the best ventricular electrical synchrony during the CRT application. In addition, our results also show that the upper septum close to the outflow tract is an alternative site for the right ventricle (RV) stimulation, which avoids the perforation problems of the RV apical wall during the typical CRT procedure. Finally, protocols of left ventricle endocardial pacing should be considered to obtain better CRT results. In the second section of this thesis, we investigated the effects of the three main components of ischemia on the vulnerability to reentry, as well as the role of the HPS and its mechanisms of action in the generation and maintenance of ventricular arrhythmias. In order to achieve our goal, we first modified the ventricular AP model to realistically simulate the major alterations caused by acute myocardial ischemia. Simulations were performed in a 3D human biventricular model, embedded in a virtual torso, which includes a realistic geometry of the central and border ischemic zones, as well as a detailed HPS. Four scenarios of ischemic severity corresponding to different minutes after coronary artery occlusion were simulated to evaluate the effects of the evolution of ischemia over time. Then, the individual influence of hyperkalemia, hypoxia and acidosis in the width of the vulnerable window (VW) for reentry was assessed during seven scenarios of acute ischemia. Finally, this last set of ischemic simulations was repeated using the anatomical model without the HPS to evaluate the effect of the latter in the VW. Results show that a moderate ischemic condition is the worst scenario for reentry generation. Hypoxia is the ischemic component with the most significant effect on the width of the VW. Furthermore, the retrograde current flow from the myocardium to the HPS in the ischemic region, conduction blocks in discrete sections of the HPS, and the degree of hyperkalemia affecting the Purkinje cells, are suggested as HPS mechanisms that could favor the triggering of ventricular arrhythmias.[CA] Una millor comprensió dels mecanismes subjacents a les arrítmies ventriculars, així com una millora de les teràpies elèctriques i farmacològiques associades, són un factor clau per a previndre la mort sobtada cardíaca en pacients amb cardiopaties estructurals i elèctriques. Una miocardiopatia important que pot provocar arrítmies ventriculars potencialment mortals és la insuficiència cardíaca (HF). Els pacients amb HF sovint pateixen també de bloqueig de branca esquerra (LBBB) que deteriora la seua condició. Actualment, el tractament més eficaç per a aquests pacients és la teràpia de resincronització cardíaca (CRT). No obstant això, no s'aconsegueix una resposta positiva en tots els casos, per la qual cosa és necessari un major estudi per a millorar aquest tractament. Una segona patologia cardíaca que també produeix arrítmies letals és la isquèmia miocàrdica. Evidència experimental ha demostrat que les alteracions electrofisiològiques en el miocardi ventricular constitueixen un substrat per a la generació d'arrítmies durant la fase aguda d'isquèmia. Aquestes alteracions són induïdes pels tres components isquèmics principals: hipercalèmia, hipòxia i acidosi. No obstant això, la influència de cada component en els mecanismes d'inici i manteniment de les arrítmies no es comprén encara amb claredat. Una primera part d'aquesta tesi doctoral, se centra en l'optimització de la CRT durant la seua aplicació en un cor que pateix HF i LBBB. Per a això, es va modificar el model de potencial d'acció (AP) de O'Hara per a simular una velocitat de conducció realista tant en condicions sanes com patològiques. A més, es va estimar i es va incorporar un sistema de His-Purkinje (HPS) dins d'un model biventricular/tors humà 3D per a simular un LBBB realista. A continuació, es va desenvolupar un conjunt de simulacions computacionals per a diferents configuracions de la CRT a fi de determinar la posició i l'instant d'estimulació òptim que condueixen a la duració més curta del QRS. Posteriorment, els resultats es van comparar amb altres criteris d'optimització. Les principals troballes d'aquest estudi van mostrar la necessitat de definir millors o complementaris criteris d'optimització, com un índex basat en el temps fins a aconseguir el 90% de l'àrea del QRS suggerida en aquest treball, per a aconseguir la millor sincronia elèctrica ventricular durant l'aplicació de la CRT. A més, els nostres resultats també mostren que el septe superior pròxim al tracte d'eixida és un lloc alternatiu per a l'estimulació del ventricle dret, la cual cosa evita els problemes de perforació de la paret apical durant el procediment típic de la CRT. Finalment, per a obtindre millors resultats de la CRT s'han de considerar protocols d'estimulació endocárdica en el ventricle esquerre. En la segona part d'aquesta tesi es va investigar els efectes dels tres components principals de la isquèmia sobre la vulnerabilitat a una reentrada, així com el paper del HPS i els seus mecanismes d'acció en la generació i manteniment d'arrítmies ventriculars. Per a aconseguir aquest objectiu, en primer lloc es va modificar el model AP ventricular per a simular de manera realista les principals alteracions provocades per la isquèmia miocàrdica aguda. Les simulacions es van realitzar en un model biventricular humà 3D, acoblat en un tors virtual, que inclou una geometria realista de les zones isquèmiques central i de vora, així com un HPS detallat. Es van simular quatre escenaris de severitat isquèmica corresponents a diferents minuts d'oclusió de l'artèria coronària per a avaluar els efectes de l'evolució de la isquèmia en el temps. Després, es va avaluar la influència individual de la hipercalèmia, hipòxia i acidosi en l'ample de la finestra vulnerable (VW) a reentradas durant set escenaris d'isquèmia aguda. Finalment, es va repetir aquest últim conjunt de simulacions isquèmiques utilitzant el model anatòmic sense el HPS per a avaluar l'efecte d'aquest últim en la VW. Els resultats mostren que una condició isquèmica moderada és el pitjor escenari per a la generació d'una reentrada. La hipòxia és el component isquèmic amb l'efecte més significatiu en l'ample de la VW. A més, el flux de corrent retrògrad des del miocardi cap al HPS a la regió isquèmica, els bloquejos de conducció en seccions discretes del HPS i el grau d'hiperkalèmia que afecta les cèl·lules de Purkinje, són suggerits com a mecanismes que podrien afavorir l'aparició d'arrítmies ventriculars.Carpio Garay, EF. (2021). Contribution to the improvement of electrical therapies and to the comprehension of electrophysiological mechanisms in heart failure and acute ischemia using computational simulation [Tesis doctoral]. Universitat Politècnica de València. https://doi.org/10.4995/Thesis/10251/163041TESI