Dynamical anchoring of distant Arrhythmia Sources by Fibrotic Regions via Restructuring of the Activation Pattern

Rotors are functional reentry sources identified in clinically relevant cardiac arrhythmias, such as ventricular and atrial fibrillation. Ablation targeting rotor sites has resulted in arrhythmia termination. Recent clinical, experimental and modelling studies demonstrate that rotors are often anchored around fibrotic scars or regions with increased fibrosis. However the mechanisms leading to abundance of rotors at these locations are not clear. The current study explores the hypothesis whether fibrotic scars just serve as anchoring sites for the rotors or whether there are other active processes which drive the rotors to these fibrotic regions. Rotors were induced at different distances from fibrotic scars of various sizes and degree of fibrosis. Simulations were performed in a 2D model of human ventricular tissue and in a patient-specific model of the left ventricle of a patient with remote myocardial infarction. In both the 2D and the patient-specific model we found that without fibrotic scars, the rotors were stable at the site of their initiation. However, in the presence of a scar, rotors were eventually dynamically anchored from large distances by the fibrotic scar via a process of dynamical reorganization of the excitation pattern. This process coalesces with a change from polymorphic to monomorphic ventricular tachycardia.Comment: 16 pages, 7 figure

Nonlinear physics of electrical wave propagation in the heart: a review

The beating of the heart is a synchronized contraction of muscle cells (myocytes) that are triggered by a periodic sequence of electrical waves (action potentials) originating in the sino-atrial node and propagating over the atria and the ventricles. Cardiac arrhythmias like atrial and ventricular fibrillation (AF,VF) or ventricular tachycardia (VT) are caused by disruptions and instabilities of these electrical excitations, that lead to the emergence of rotating waves (VT) and turbulent wave patterns (AF,VF). Numerous simulation and experimental studies during the last 20 years have addressed these topics. In this review we focus on the nonlinear dynamics of wave propagation in the heart with an emphasis on the theory of pulses, spirals and scroll waves and their instabilities in excitable media and their application to cardiac modeling. After an introduction into electrophysiological models for action potential propagation, the modeling and analysis of spatiotemporal alternans, spiral and scroll meandering, spiral breakup and scroll wave instabilities like negative line tension and sproing are reviewed in depth and discussed with emphasis on their impact in cardiac arrhythmias.Peer ReviewedPreprin

Multiple mechanisms of spiral wave breakup in a model of cardiac electrical activity

It has become widely accepted that the most dangerous cardiac arrhythmias are due to re- entrant waves, i.e., electrical wave(s) that re-circulate repeatedly throughout the tissue at a higher frequency than the waves produced by the heart's natural pacemaker (sinoatrial node). However, the complicated structure of cardiac tissue, as well as the complex ionic currents in the cell, has made it extremely difficult to pinpoint the detailed mechanisms of these life-threatening reentrant arrhythmias. A simplified ionic model of the cardiac action potential (AP), which can be fitted to a wide variety of experimentally and numerically obtained mesoscopic characteristics of cardiac tissue such as AP shape and restitution of AP duration and conduction velocity, is used to explain many different mechanisms of spiral wave breakup which in principle can occur in cardiac tissue. Some, but not all, of these mechanisms have been observed before using other models; therefore, the purpose of this paper is to demonstrate them using just one framework model and to explain the different parameter regimes or physiological properties necessary for each mechanism (such as high or low excitability, corresponding to normal or ischemic tissue, spiral tip trajectory types, and tissue structures such as rotational anisotropy and periodic boundary conditions). Each mechanism is compared with data from other ionic models or experiments to illustrate that they are not model-specific phenomena. The fact that many different breakup mechanisms exist has important implications for antiarrhythmic drug design and for comparisons of fibrillation experiments using different species, electromechanical uncoupling drugs, and initiation protocols.Comment: 128 pages, 42 figures (29 color, 13 b&w

Modeling and simulation of the electric activity of the heart using graphic processing units

Mathematical modelling and simulation of the electric activity of the heart (cardiac electrophysiology) offers and ideal framework to combine clinical and experimental data in order to help understanding the underlying mechanisms behind the observed respond under physiological and pathological conditions. In this regard, solving the electric activity of the heart possess a big challenge, not only because of the structural complexities inherent to the heart tissue, but also because of the complex electric behaviour of the cardiac cells. The multi- scale nature of the electrophysiology problem makes difficult its numerical solution, requiring temporal and spatial resolutions of 0.1 ms and 0.2 mm respectively for accurate simulations, leading to models with millions degrees of freedom that need to be solved for thousand time steps. Solution of this problem requires the use of algorithms with higher level of parallelism in multi-core platforms. In this regard the newer programmable graphic processing units (GPU) has become a valid alternative due to their tremendous computational horsepower. This thesis develops around the implementation of an electrophysiology simulation software entirely developed in Compute Unified Device Architecture (CUDA) for GPU computing. The software implements fully explicit and semi-implicit solvers for the monodomain model, using operator splitting and the finite element method for space discretization. Performance is compared with classical multi-core MPI based solvers operating on dedicated high-performance computer clusters. Results obtained with the GPU based solver show enormous potential for this technology with accelerations over 50× for three-dimensional problems when using an implicit scheme for the parabolic equation, whereas accelerations reach values up to 100× for the explicit implementation. The implemented solver has been applied to study pro-arrhythmic mechanisms during acute ischemia. In particular, we investigate on how hyperkalemia affects the vulnerability window to reentry and the reentry patterns in the heterogeneous substrate caused by acute regional ischemia using an anatomically and biophysically detailed human biventricular model. A three dimensional geometrically and anatomically accurate regionally ischemic human heart model was created. The ischemic region was located in the inferolateral and posterior side of the left ventricle mimicking the occlusion of the circumflex artery, and the presence of a washed-out zone not affected by ischemia at the endocardium has been incorporated. Realistic heterogeneity and fi er anisotropy has also been considered in the model. A highly electrophysiological detailed action potential model for human has been adapted to make it suitable for modeling ischemic conditions (hyperkalemia, hipoxia, and acidic conditions) by introducing a formulation of the ATP-sensitive K+ current. The model predicts the generation of sustained re-entrant activity in the form single and double circus around a blocked area within the ischemic zone for K+ concentrations bellow 9mM, with the reentrant activity associated with ventricular tachycardia in all cases. Results suggest the washed-out zone as a potential pro-arrhythmic substrate factor helping on establishing sustained ventricular tachycardia.Colli-Franzone P, Pavarino L. A parallel solver for reaction-diffusion systems in computational electrocardiology, Math. Models Methods Appl. Sci. 14 (06):883-911, 2004.Colli-Franzone P, Deu hard P, Erdmann B, Lang J, Pavarino L F. Adaptivity in space and time for reaction-diffusion systems in electrocardiology, SIAM J. Sci. Comput. 28 (3):942-962, 2006.Ferrero J M(Jr), Saiz J, Ferrero J M, Thakor N V. Simulation of action potentials from metabolically impaired cardiac myocytes: Role of atp-sensitive K+ current. Circ Res, 79(2):208-221, 1996.Ferrero J M (Jr), Trenor B. Rodriguez B, Saiz J. Electrical acticvity and reentry during acute regional myocardial ischemia: Insights from simulations.Int J Bif Chaos, 13:3703-3715, 2003.Heidenreich E, Ferrero J M, Doblare M, Rodriguez J F. Adaptive macro finite elements for the numerical solution of monodomain equations in cardiac electrophysiology, Ann. Biomed. Eng. 38 (7):2331-2345, 2010.Janse M J, Kleber A G. Electrophysiological changes and ventricular arrhythmias in the early phase of regional myocardial ischemia. Circ. Res. 49:1069-1081, 1981.ten Tusscher K HWJ, Panlov A V. Alternans and spiral breakup in a human ventricular tissue model. Am. J.Physiol. Heart Circ. Physiol. 291(3):1088-1100, 2006.<br /

Modélisation d'arythmies auriculaires modulées par le système nerveux autonome

La fibrillation auriculaire (FA) est la forme d’arythmie la plus fréquente et représente environ un tiers des hospitalisations attribuables aux troubles du rythme cardiaque. Les mécanismes d’initiation et de maintenance de la FA sont complexes et multiples. Parmi ceux-ci, une contribution du système nerveux autonome a été identifiée mais son rôle exact demeure mal compris. Ce travail cible l’étude de la modulation induite par l’acétylcholine (ACh) sur l’initiation et le maintien de la FA, en utilisant un modèle de tissu bidimensionnel. La propagation de l’influx électrique sur ce tissu est décrite par une équation réaction-diffusion non-linéaire résolue sur un maillage rectangulaire avec une méthode de différences finies, et la cinétique d'ACh suit une évolution temporelle prédéfinie qui correspond à l’activation du système parasympathique. Plus de 4400 simulations ont été réalisées sur la base de 4 épisodes d’arythmies, 5 tailles différentes de région modulée par l’ACh, 10 concentrations d’ACh et 22 constantes de temps de libération et de dégradation d’ACh. La complexité de la dynamique des réentrées est décrite en fonction de la constante de temps qui représente le taux de variation d’ACh. Les résultats obtenus suggèrent que la stimulation vagale peut mener soit à une dynamique plus complexe des réentrées soit à l’arrêt de la FA en fonction des quatre paramètres étudiés. Ils démontrent qu’une décharge vagale rapide, représentée par des constantes de temps faibles combinées à une quantité suffisamment grande d’ACh, a une forte probabilité de briser la réentrée primaire provoquant une activité fibrillatoire. Cette activité est caractérisée par la création de plusieurs ondelettes à partir d’un rotor primaire sous l’effet de l’hétérogénéité du gradient de repolarisation causé par l’activité autonomique.Atrial fibrillation (AF) is the most frequent arrhythmia and accounts for about one-third of hospitalizations for cardiac rhythm disturbances. The mechanisms of initiation and maintenance of atrial fibrillation are complex and multifaceted. Among them, a contribution of the autonomic nervous system has been identified but its exact role remains poorly understood. This work targets the study of the effect of autonomic modulation induced by acetylcholine (ACh) on the initiation and maintenance of AF, using a two-dimensional tissue model. Electrical impulse propagation in the tissue was described by as a non-linear reaction-diffusion equation solved on a rectangular mesh with finite difference methods, and ACh kinetics followed a predefined time evolution corresponding to parasympathetic activation. More than 4400 simulations were performed based on 4 fibrillatory initial conditions, 5 sizes of ACh patch, 10 ACh concentrations and 22 time constants representing ACh release and degradation speed. Our results suggest that vagal stimulation can sustain or terminate AF depending on the 4 parameters studied. Results demonstrate that rapid vagal discharge, represented by low time constants combined with sufficient quantities of ACh, has a high probability of breaking the primary reentry and causing fibrillatory activity. This activity is characterized by the generation of several wavelets from a primary rotor under the heterogeneity of repolarization gradient due to autonomic modulation

Mapping and Ablation of Idiopathic Ventricular Fibrillation

Idiopathic ventricular fibrillation (IVF) is the main cause of unexplained sudden cardiac death, particularly in young patients under the age of 35. IVF is a diagnosis of exclusion in patients who have survived a VF episode without any identifiable structural or metabolic causes despite extensive diagnostic testing. Genetic testing allows identification of a likely causative mutation in up to 27% of unexplained sudden deaths in children and young adults. In the majority of cases, VF is triggered by PVCs that originate from the Purkinje network. Ablation of VF triggers in this setting is associated with high rates of acute success and long-term freedom from VF recurrence. Recent studies demonstrate that a significant subset of IVF defined by negative comprehensive investigations, demonstrate in fact subclinical structural alterations. These localized myocardial alterations are identified by high density electrogram mapping, are of small size and are mainly located in the epicardium. As reentrant VF drivers are often colocated with regions of abnormal electrograms, this localized substrate can be shown to be mechanistically linked with VF. Such areas may represent an important target for ablation

Tissue engineering of the human atrium : approaching mechanisms of genesis and control of atrial fibrillation

Cardiovascular disease is prevalent across the western world and is a major cause of morbidity and mortality, accounting for approximately a third of all fatalities. Investigating the heart by simulating its electrophysiology via the aid of mathematical models has advanced significantly over the past 60 years and is now a well established field. While much of the research focus is placed on the ventricles, the study of the atria is in comparison neglected. Therefore this Thesis is focused on the genesis and maintenance of atrial fibrillation (AF). A series of case studies are performed whereby established biophysically detailed mathematical models are implemented and modified to incorporate electrophysical alterations of atrial cells resulting from a variety of external conditions. The opening section of this Thesis is dedicated to developing a background to the field, including a discussion into the clinical aspect of the diagnosis and management of AF. The suitability of two atrial cell models is discussed and the development of single cell, 1D, 2D, and 3D multi-scale simulation protocols are described in detail. In addition measurements taken to quantify the arrhythmogenic properties of the cells susceptibility to AF are outlined. The second section is focused on the incorporation of conditions thought to enhance atrial tissues ability to initiate and maintain the genesis of AF. Included is a case study into the missence S140G gene mutation, and elevated physiological levels of the hormone Homocystein. The third section investigates the effectiveness of well established and widely used pharmacological treatments such as Beta-Blockers. In addition possible avenues of investigations for the development of atrial specific drugs are explored. These include blocking of the ultra rapid potassium channel and a more novel target for therapy via the targeting of 5HT4 receptors; which is transcribed solely in the atria and alters the electrophysical properties of the L-type Calcium current. The final part of this Thesis is dedicated to the development of a 2D atrial sheet model which includes electrical and spatial heterogeneities via the inclusion of multiple cell types and basic fiber orientation respectively. This allows for an investigation into the role that heterogeneities play in role genesis and maintenance of AF. The main finding of this Thesis is that alterations to the electrophysiology of atrial cells, due to external factors, can be successfully simulated via the implementation of mathematically detailed atrial cell models. It is concluded that simulations of the KENQ1 mutation and elevated levels of Homocystein successfully reproduce conditions which increase the onset of AF. Established treatments such as Beta-Blockers are found to have limited effectiveness. Possible theoretical treatments, such as the blocking of IKur, are found to provide a small amount of therapeutic benefit. In contrast, investigations into the effects of Serotonin were inconclusive. The study into the 2D atria indicated the importance that heterogeneities play in atria. The conclusions show that models provide a powerful tool when investigating how changes to electrophysiology of cells are manifested at a multi-scale level. The models also have their limitations and require further advancement to improve their accuracy.EThOS - Electronic Theses Online ServiceEPSRCGBUnited Kingdo

Simulating the Effect of Global Cardiac Ischaemia on the Dynamics of Ventricular Arrhythmias in the Human Heart

Cardiac arrhythmias are significant causes of death in the world, and ventricular fibrillation is a very dangerous type of cardiac arrhythmia. Global myocardial ischemia is a consequence of ventricular fibrillation (VF) and has been shown to change the dynamic behaviour of activation waves on the heart. The aim of this thesis is to use computational models to study the behaviour of re-entry in the human ventricles when the heart becomes globally ischaemic. The effects of two ischaemic components (hyperkalaemia and hypoxia) on spiral wave re-entry behaviour in two dimensional (2D) ventricular tissue using two ventricular action potential (AP) models were simulated (Ten Tusscher et al. 2006 (TP06) and O’Hara et al. 2011 (ORd)). A three dimensional (3D) model of the human ventricles is used to examine the influence of each ischaemic component on the stability of ventricular fibrillation. Firstly, the main ventricular AP models relevant to this thesis are reviewed. Then, the current-voltage properties of four different IK(ATP) formulations are examined to assess which formulation was more appropriate to simulate hypoxia/ischaemia. Secondly, how the formulation of IK(ATP) influences cell excitability and AP duration (APD) in models of human ventricular myocytes is studied. Finally, mechanisms underlying ventricular arrhythmia generation under the conditions of ischaemia are investigated

The contact electrogram and its architectural determinants in atrial fibrillation

The electrogram is the sine qua non of excitable tissues, yet classification in atrial fibrillation (AF) remains poorly related to substrate factors. The objective of this thesis was to establish the relationship between electrograms and two commonly implicated substrate factors, connexin 43 and fibrosis in AF. The substrates and methods chosen to achieve this ranged from human acutely induced AF using open chest surgical mapping (Chapter 6), ex vivo whole heart Langendorff (Chapter 7) with in vivo telemetry confirming spontaneous AF in a new species of rat, the Brown Norway and finally isolated atrial preparations from an older cohort of rats using orthogonal pacing and novel co-localisation methods at sub-millimetre resolution and in some atria, optical mapping (Chapter 8). In rodents, electrode size and spacing was varied (Chapters 5, 10) to study its effects on structure function correlations (Chapter 9). Novel indices of AF organisation and automated electrogram morphology were used to quantify function (Chapter 4). Key results include the discoveries that humans without any history of prior AF have sinus rhythm electrograms with high spectral frequency content, that wavefront propagation velocities correlated with fibrosis and connexin phosphorylation ratios, that AF heterogeneity of conduction correlates to fibrosis and that orthogonal pacing in heavily fibrosed atria causes anisotropy in electrogram-fibrosis correlations. Furthermore, fibrosis and connexin 43 have differing and distinct spatial resolutions in their relationship with AF organisational indices. In conclusion a new model of AF has been found, and structure function correlations shown on an unprecedented scale, but with caveats of electrode size and direction dependence. These findings impact structure function methods and prove the effect of substrate on AF organisation.Open Acces