Chronic myocardial infarction promotes atrial action potential alternans, afterdepolarisations and fibrillation

Aims: Atrial fibrillation (AF) is increased in patients with heart failure resulting from myocardial infarction (MI). We aimed to determine the effects of chronic ventricular MI in rabbits on the susceptibility to AF, and underlying atrial electrophysiological and Ca2+-handling mechanisms. Methods and results: In Langendorff-perfused rabbit hearts, under beta-adrenergic-stimulation with isoproterenol (1 µM; ISO), 8 weeks MI decreased AF threshold, indicating increased AF-susceptibility. This was associated with increased atrial action potential duration-alternans at 90% repolarisation, by 147%, and no significant change in mean APD or atrial global conduction velocity (n=6-13 non-MI hearts, 5-12 MI). In atrial isolated myocytes, also under beta-stimulation, L-type Ca2+ current (ICaL) density and intracellular Ca2+-transient amplitude were decreased by MI, by 35% and 41%, respectively, and the frequency of spontaneous depolarisations (SDs) was substantially increased. MI increased atrial myocyte size and capacity, and markedly decreased transverse-tubule density. In non-MI hearts perfused with ISO, the ICaL-blocker nifedipine, at a concentration (0.02 µM) causing an equivalent ICaL-reduction (35%) to that from the MI, did not affect AF-susceptibility, and decreased APD. Conclusion: chronic MI in rabbits remodels atrial structure, electrophysiology and intracellular Ca2+-handling. Increased susceptibility to AF by MI, under beta-adrenergic-stimulation, may result from associated production of atrial APD-alternans and SDs, since steady-state APD and global conduction velocity were unchanged under these conditions, and may be unrelated to the associated reduction in whole-cell ICaL. Future studies may clarify potential contributions of local conduction changes, and cellular and sub-cellular mechanisms of alternans, to the increased AF-susceptibility

Calcium Handling Defects and Cardiac Arrhythmia Syndromes

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Calcium Handling Defects and Cardiac Arrhythmia Syndromes

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Cardiac Remodeling Of Conduction, Repolarization and Excitation-Contraction Coupling: From Animal Model to Failing Human Heart

Heart failure is one of the leading causes of death worldwide, with rising impact with the increasing ageing population. This is in sharp contrast with the limited and non-ideal therapies available. Approximately 50% of deaths from heart failure are sudden and unexpected, and presumably the consequence of lethal ventricular arrhythmias. Despite significant reduction of mortality from sudden cardiac death achieved by ICDs and drugs such as beta-blockers, there remains a large room for improving the survivability of heart failure patients by advancing our understanding of arrhythmogenesis from molecular level to multi-cellular tissue level. Another important aspect of heart failure is abnormal excitation-contraction: EC) coupling and calcium handling, functional changes of which exert great impact on both arrhythmia vulnerability and pump failure. Advancing the understanding the remodeling of EC coupling and calcium handling might provide potential molecular and anatomical targets for clinical intervention. In this dissertation, I first developed two optical imaging systems: both hardware and software) for quantifying the conduction, repolarization and excitation-contraction coupling. The first one is the panoramic imaging system for mapping the entire ventricular epicardium of a rabbit heart. The second one is the dual imaging system for simultaneous measurement of action potential and calcium transient. Using the systems I developed, I conducted two rabbit studies to investigate the role electrical instability and structural heterogeneity in the induction and maintenance of arrhythmias. We first identified the importance of both dynamic instability and effective tissue size in the spontaneous termination of arrhythmia in the normal rabbit heart. We then identified novel mechanism of how healed myocardial infarction promotes the induction of ventricular arrhythmia. Finally, guided by the knowledge from the animal studies, I studied the failing human heart with the aim to advance our understanding of cardiac electrophysiology in human heart failure. We first demonstrated the transmural heterogeneity of EC coupling in nonfailing heart and identified potential mechanisms of electrical and mechanical dysfunction by quantifying the remodeling of EC coupling. We then studied the remodeling of conduction and repolarization with the aim to determine of the role of dispersion of repolarization and electrical instability in the induction of arrhythmia in human heart failure

Population of human ventricular cell models calibrated with in vivo measurements unravels ionic mechanisms of cardiac alternans

Cardiac alternansis an important risk factor in cardiac physiology, and is related to the initiation of many pathophysiological conditions. However, the mechanisms underlying the generation of alternans remain unclear. In this study, we used a population of computational human ventricle models based onthe O’Hara model [1] to explore the effect of 11 key factors experimentally reported to be related to alternans. In vivo experimental datasets coming from patients undergoing cardiac surgery were used in the calibration of our in silico population of models. The calibrated models in the population were divided into two groups (Normal and Alternans) depending on alternans occurrence. Our results showed that there were significant differences in the following 5 ionic currents between the two groups: fast sodium current, sodium calcium exchanger current, sodium potassium pump current, sarcoplasmic reticulum (SR) calcium release flux and SR calcium reuptake flux. Further analysis indicated that fast sodium current and SR calcium uptake were the two most significant currents that contributed to voltage and calcium alternans generation, respectively

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

MECHANISM UNDERLYING BRADYCARDIA AND LONG QT 2 RELATED ARRHYTHMIAS: INTERPLAY BETWEEN Ca2+ OVERLOAD AND ELECTRICAL DYSFUNCTION

In numerous pathologies, spontaneous Ca2+ release (SCR) emanating from the sarcoplasmic reticulum and occurring during the action potential (AP) plateau can drive voltage instability that initiates arrhythmias, but the direct interplay between SCRs and arrhythmogeneis has not been fully understood in bradycardia and in long QT type 2 (LQT2) models. Simultaneous optical measurement of intracellular Ca2+ transient (CaiT) and AP were performed in Langendorff-perfused rabbit hearts following AV node ablation. Bradycardia and/or LQT2 was/were induced and the spatial heterogeneity of intracellular Ca2+ handling and its link to voltage dispersion were investigated. Upon switching from 120 to 50 beats/min, AP duration (APD) increased gradually with increasing occurrence of SCRs during the AP plateau (p<0.01, n=7). SCR was a) regionally heterogeneous, b) spatially correlated with APD prolongation, c) associated with enhanced dispersion of repolarization (DOR), d) reversed by pacing at 120 beats/min and e) suppressed with K201 (1µM) or flecainide (5µM), inhibitors of cardiac ryanodine receptors (RyR2) which reduced APD (p<0.01, n=5) and DOR (p<0.02, n=5). Western blots of Ca2+ channels/transporters revealed intrinsic spatial distributions of Cav1.2α and NCX (but not RyR2, and SERCA2a) that correlate with the distribution of SCR and underlie the molecular mechanism responsible for SCRs. In LQT2, lability of Cai, voltage, and ECG signals increased during paced rhythm, before the appearance of early afterdepolarizations (EADs). When EADs appeared, Cai occasionally rose before voltage upstrokes at the origins of propagating EADs. Localized, areas of SCRs appeared in LQT2 and corresponded to areas of prolonged CaiT and APD. Triggered activity appeared after 3-5 min of LQT2 and emanated only at sites with steep membrane potential (Vm) gradients (ΔVm gradient percentile: 94.9 ± 3.2%, n=6). Pre- or post-treatment with K201 suppressed SCRs and decreased DOR, ΔVm and ΔCai. The reduction of ΔVm suppressed triggered activity (n=8/9 hearts). The results show that bradycardia and LQT2 elicit spatially discordant SCR, which is tightly correlated with AP instability. The SCR mediated-enhancement of repolarization gradients and AP prolongation can promote arrhythmogenesis. These findings underscore the importance of a detailed understanding of Ca2+-dependent arrhythmogenic mechanisms for the development of rational treatment strategies

The cardiac ryanodine receptor, but not sarcoplasmic reticulum Ca2-ATPase, is a major determinant of Ca2 alternans in intact mouse hearts

Sarcoplasmic reticulum (SR) Ca2+ cycling is governed by the cardiac ryanodine receptor (RyR2) and SR Ca2+-ATPase (SERCA2a). Abnormal SR Ca2+ cycling is thought to be the primary cause of Ca2+ alternans that can elicit ventricular arrhythmias and sudden cardiac arrest. Although alterations in either RyR2 or SERCA2a function are expected to affect SR Ca2+ cycling, whether and to what extent altered RyR2 or SERCA2a function affects Ca2+ alternans is unclear. Here we employed a gain-of-function RyR2 variant (R4496C) and the phospholamban-knockout (PLB-KO) mouse model to assess the effect of genetically enhanced RyR2 or SERCA2a function on Ca2+ alternans. Confocal Ca2+ imaging revealed that RyR2-R4496C shortened SR Ca2+ release refractoriness and markedly suppressed rapid pacing-induced Ca2+ alternans. Interestingly, despite enhancing RyR2 function, intact RyR2-R4496C hearts exhibited no detectable spontaneous SR Ca2+ release events during pacing. Unlike for RyR2, enhancing SERCA2a function by ablating PLB exerted a relatively minor effect on Ca2+ alternans in intact hearts expressing RyR2 wildtype or a loss-of-function RyR2 variant, E4872Q, that promotes Ca2+ alternans. Furthermore, partial SERCA2a inhibition with 3 µM 2,5-di-tert-butylhydroquinone (tBHQ) also had little impact on Ca2+ alternans, while strong SERCA2a inhibition with 10 µM tBHQ markedly reduced the amplitude of Ca2+ transients and suppressed Ca2+ alternans in intact hearts. Our results demonstrate that enhanced RyR2 function suppresses Ca2+ alternans in the absence of spontaneous Ca2+ release and that RyR2, but not SERCA2a, is a key determinant of Ca2+ alternans in intact working hearts, making RyR2 an important therapeutic target for cardiac alternans.Peer ReviewedPostprint (published version

Blockade of sodium‑calcium exchanger via ORM-10962 attenuates cardiac alternans

Repolarization alternans, a periodic oscillation of long-short action potential duration, is an important source of arrhythmogenic substrate, although the mechanisms driving it are insufficiently understood. Despite its relevance as an arrhythmia precursor, there are no successful therapies able to target it specifically. We hypothesized that blockade of the sodium‑calcium exchanger (NCX) could inhibit alternans. The effects of the selective NCX blocker ORM-10962 were evaluated on action potentials measured with microelectrodes from canine papillary muscle preparations, and calcium transients measured using Fluo4-AM from isolated ventricular myocytes paced to evoke alternans. Computer simulations were used to obtain insight into the drug's mechanisms of action. ORM-10962 attenuated cardiac alternans, both in action potential duration and calcium transient amplitude. Three morphological types of alternans were observed, with differential response to ORM-10962 with regards to APD alternans attenuation. Analysis of APD restitution indicates that calcium oscillations underlie alternans formation. Furthermore, ORM-10962 did not markedly alter APD restitution, but increased post-repolarization refractoriness, which may be mediated by indirectly reduced L-type calcium current. Computer simulations reproduced alternans attenuation via ORM-10962, suggesting that it is acts by reducing sarcoplasmic reticulum release refractoriness. This results from the ORM-10962-induced sodium‑calcium exchanger block accompanied by an indirect reduction in L-type calcium current. Using a computer model of a heart failure cell, we furthermore demonstrate that the anti-alternans effect holds also for this disease, in which the risk of alternans is elevated. Targeting NCX may therefore be a useful anti-arrhythmic strategy to specifically prevent calcium driven alternans