Direct-current cardioversion of atrial tachyarrhythmias under oral flecainide therapy

Results of direct-current cardioversion of 48 patients with atrial arrhythmia taking oral flecainide were compared with those of 96 control-matched patients. After completion of 3 shocks, 98% of flecainide patients were converted versus 78% of control patients (p <0.01). Thus, despite an experimental increase in defibrillation threshold, flecainide given before cardioversion seems to have a beneficial effect.

Selective enhancement of the slow component of delayed rectifier K+ current in guinea-pig atrial cells by external ATP

1. The effects of external ATP on the rapidly and slowly activating components (IKr and IKs, respectively) of the delayed rectifier K+ current (IK) in guinea-pig atrial myocytes were determined using the whole-cell configuration of the patch-clamp technique. 2. An envelope of tails test was conducted by applying depolarizing pulses to +40 mV from a holding potential of -40 mV for various durations between 50 ms and 2 s under control conditions and during exposure to 50 microM ATP. The ATP-induced IK, obtained by digital subtraction, exhibited a constant ratio (0.37) of the tail current to time-dependent current, regardless of the pulse duration. This current ratio was compatible with the predicted ratio of the driving force at +40 and -40 mV for a non-rectifying K+ conductance, suggesting that the ATP-induced IK is due primarily to IKs. 3. The amplitude of IKr isolated from the IK enhanced by ATP, determined as an E-4031 (5 microM)-sensitive current, was similar to the control magnitude of IKr, thus showing that external ATP did not cause an increase in IKr. 4. The voltage-dependent activation of the ATP-induced IK during 500 ms depolarizing test pulses could be described by a Boltzmann equation with a half-activation voltage (V1/2) of 11.5 mV and slope factor (k) of 12.0 mV, which were close to those of IKs (V1/2 of 12.1 mV and k of 12.3 mV), determined as an E-4031-resistant IK, under the same isochronal (500 ms) activation conditions. 5. These results provide evidence to suggest that extracellular ATP selectively potentiates the slow component of IK (IKs), with no measurable effects on IKr, in guinea-pig atrial myocytes.

Allosteric effects of permeating cations on gating currents during K+ channel deactivation

K+ channel gating currents are usually measured in the absence of permeating ions, when a common feature of channel closing is a rising phase of off-gating current and slow subsequent decay. Current models of gating invoke a concerted rearrangement of subunits just before the open state to explain this very slow charge return from opening potentials. We have measured gating currents from the voltage-gated K+ channel, Kv1.5, highly overexpressed in human embryonic kidney cells. In the presence of permeating K+ or Cs+, we show, by comparison with data obtained in the absence of permeant ions, that there is a rapid return of charge after depolarizations. Measurement of off-gating currents on repolarization before and after K+ dialysis from cells allowed a comparison of off-gating current amplitudes and time course in the same cells. Parallel experiments utilizing the low permeability of Cs+ through Kv1.5 revealed similar rapid charge return during measurements of off-gating currents at ECs. Such effects could not be reproduced in a nonconducting mutant (W472F) of Kv1.5, in which, by definition, ion permeation was macroscopically absent. This preservation of a fast kinetic structure of off-gating currents on return from potentials at which channels open suggests an allosteric modulation by permeant cations. This may arise from a direct action on a slow step late in the activation pathway, or via a retardation in the rate of C-type inactivation. The activation energy barrier for K+ channel closing is reduced, which may be important during repetitive action potential spiking where ion channels characteristically undergo continuous cyclical activation and deactivation.

Changes to biological activity following acetylation of dendrotoxin I from Dendroaspis polylepis (black mamba)

The potassium channel blocker dendrotoxin I was acetylated with acetic anhydride. Mono-acetyl derivatives of all seven lysine residues (N-terminus blocked) and a di-derivative were isolated by chromatography on the cation-exchanger Bio-Rex 70 and reversed-phase high-performance liquid chromatography. The derivative acetyl-Lys 29 and the di-derivative of Tyr 24 and Lys 28 had more than 1000 times lower affinity than the native toxin as determined by inhibition of the 125I-dendrotoxin binding to synaptosomal membranes from rat brain. Lys 29 is part of the triplet Lys-Lys-Lys (28-30) which also occurs in the homologous alpha-dendrotoxin where the triplet is not in the functional site, as shown by site-directed mutagenesis. Acetylation of Lys 29 may have produced large structural perturbations that inactivated the toxin. Acetylation of Lys 28 alone had little effect, but the toxin became almost inactive when both Lys 28 and Tyr 24 were modified. Ten experiments were conducted under similar conditions, but a derivative of Tyr 24 was obtained only three times. In these cases the toxin apparently had a different structure, with Tyr 24 accessible to the reagent. This may depend on freeze-drying, which can alter the structure of proteins. The third derivative with low activity was acetyl-Lys 5, with affinity decreased 20-fold. Lys 5 has a protruding side-chain that does not interact with any other group in the toxin molecule. Therefore, Lys 5 is probably part of the functional site for dendrotoxin's binding to the voltage-dependent K+ channels.

Interactions of the nonsedating antihistamine loratadine with a Kv1.5-type potassium channel cloned from human heart

The use of nonsedating antihistamines may, on rare occasions, be associated with cardiac arrhythmias. This could be due to blockade of voltage-dependent K+ channels in the heart, leading to a prolongation in repolarization in the human myocardium. For this reason, we examined the effects of the nonsedating antihistamine loratadine on a rapidly activating delayed-rectifier K+ channel (Kv1.5) cloned from human heart and stably expressed in HEK 293 cells or mouse Ltk- cells. Using patch-clamp electrophysiology, we found that loratadine blocked Kv1.5 current measured from inside-out membrane patches at concentrations of > or = 100 nM, resulting in an IC50 value of 808 nM at +50 mV. The drug enhanced the rate of Kv1.5 current decay, and block was enhanced at membrane potentials near threshold relative to higher potentials. Loratadine did not alter the kinetics of Kv1.5 current activation or deactivation. Unitary Kv1.5 currents were recorded in cell-attached patches. At the single-channel level, the main effect of loratadine was to reduce the mean probability of opening of Kv1.5. This effect of loratadine was achieved by a reduced number of openings in bursts and burst duration. Finally, loratadine (10 microM) failed to inhibit HERG K+ channel currents expressed in Xenopus laevis oocytes. It is concluded that loratadine is an effective blocker of Kv1.5 that interacts with an activated state or states of the channel. This interaction suggests a potential for loratadine to alter cardiac excitability in vivo.

Block of human cardiac Kv1.5 channels by loratadine: voltage-, time- and use-dependent block at concentrations above therapeutic levels

OBJECTIVE

The aim of this study was to analyze the effects of loratadine on a human cardiac K+ channel (hKv1.5) cloned from human ventricle and stably expressed in a mouse cell line.

METHODS

Currents were studied using the whole-cell configuration of the patch-clamp technique in Ltk- cells transfected with the gene encoding hKv1.5 channels.

RESULTS

Loratadine inhibited in a concentration-dependent manner the hKv1.5 current, the apparent affinity being 1.2 +/- 0.2 microM. The blockade increased steeply between -30 and 0 mV which corresponded with the voltage range for channel opening, thus suggesting that the drug binds preferentially to the open state of the channel. The apparent association and dissociation rate constants were (3.6 +/- 0.5) x 10(6).M-1.s-1 and 3.7 +/- 1.6.s-1, respectively. Loratadine, 1 microM, increased the time constant of deactivation of tail currents elicited on return to -40 mV after 500 ms depolarizing pulses to +60 mV from 36.2 +/- 3.4 to 64.9 +/- 3.6 ms (n = 6, P < 0.01), thus inducing a 'crossover' phenomenon. Application of trains of pulses at 1 Hz lead to a progressive increase in the blockade reaching a final value of 48.6 +/- 4.3%. Recovery from loratadine-induced block at -80 mV exhibited a time constant of 743.0 +/- 78.0 ms. Finally, the results of a mathematical stimulation of the effects of loratadine, based on an open-channel block model, reproduced fairly well the main effects of the drug.

CONCLUSIONS

The present results demonstrated that loratadine blocked hKv1.5 channels in a concentration-, voltage-, time- and use-dependent manner but only at concentrations much higher than therapeutic plasma levels in man.

Effect of phenylephrine infusion on atrial electrophysiological properties

OBJECTIVE

To determine the effect of changes in autonomic tone induced by phenylephrine infusion on atrial refractoriness and conduction.

DESIGN

Left and right atrial electrophysiological properties were measured before and after a constant phenylephrine infusion designed to increase sinus cycle length by 25%.

SUBJECTS

20 patients, aged 53 (SD 6) years, undergoing electrophysiological study for investigation of idiopathic paroxysmal atrial fibrillation (seven patients) or for routine follow up after successful catheter ablation of supraventricular tachycardia (13 patients).

MAIN OUTCOME MEASURES

Changes in left and right atrial effective refractory periods, atrial activation times, and frequency of induction of atrial fibrillation.

RESULTS

Phenylephrine (mean dose 69 (SD 18) mg/min) increased mean blood pressure by 22 (12) mm Hg (range 7 to 44) and lengthened sinus cycle length by 223 (94) ms (20 to 430). Left atrial effective refractory period lengthened following phenylephrine infusion from 250 (25) to 264 (21) ms (P < 0.001) but there was no significant change in right atrial effective refractory period: 200 (20) v 206 (29), P = 0.11. There was a significant relation between the effect of phenylephrine on sinus cycle length and on right atrial refractoriness (r = 0.6, P = 0.005) with shortening of right atrial refractoriness in patients with the greatest prolongation in sinus cycle length. During phenylephrine infusion, the right atrial stimulus to left atrial activation time at the basic pacing cycle length of 600 ms was unchanged, at 130 (18) v 131 (17) ms, but activation delay with a premature extrastimulus increased: 212 (28) v 227 (38) ms, P = 0.002. Atrial fibrillation was induced by two of 58 refractory period measurements at baseline and by 12 of 61 measurements during phenylephrine infusion (P < 0.01). Phenylephrine increased the difference between left and right atrial refractory periods by 22.8 (19.4) ms in the five patients with induced atrial fibrillation after phenylephrine compared to 0.9 (16.2) ms in the 13 patients without induced atrial fibrillation after phenylephrine infusion (P = 0.02).

CONCLUSIONS

Phenylephrine infusion increased left atrial refractoriness and intra-atrial conduction delay following a premature right atrial extrastimulus. Induction of atrial fibrillation during phenylephrine infusion was associated with non-uniform changes in atrial refractoriness. These data support the concept that changes in autonomic tone may precipitate atrial fibrillation in susceptible individuals.

Subunit combinations defined for K+ channel Kv1 subtypes in synaptic membranes from bovine brain

Voltage-dependent Shaker-related (Kv1) K+ channels are composed of transmembrane alpha subunits and peripheral Kv beta proteins that exist as octomers with (alpha)4(beta)4 stoichiometry. Although several alpha (designated Kv1.X) and three Kv beta subunits are known to be expressed in brain, their oligomeric combinations in neurons have yet to be deciphered. Herein, the subunits comprising a number of neuronal K+ channels from bovine brain cortex were deduced by immunoprecipitation and Western blotting, using antibodies specific for Kv1.X and Kv beta subtypes. Only a subset of the theoretically possible oligomers was detected, showing that the synthesis and/or assembly of these multisubunit K+ proteins is controlled to yield a limited variety of K+ channels. Except for a small population of Kv1.4 containing K+ channels, all the recognizable species contained Kv1.2 and beta2 subunits. Furthermore, several subpopulations were identified including a fully defined complex of Kv1.2/1.3/1.4/1.6 and Kv beta2, plus oligomers containing three or two assigned alpha subunits. Kv1.2 was also shown to occur in the absence of these other subunits as a putative homo-oligomer. Thus, for the first time, the complete subunit combination of an authentic K+ channel has been elucidated; also, the strategy employed to establish this can now be applied to closely related members of other K+ channel families.

Lymphocyte-specific inducible expression of potassium channel beta subunits

Many studies have shown that voltage-gated potassium (Kv) channel activity is essential for T-lymphocyte proliferation. The IL-2-inducible neuroimmune gene, I2rf5 is the mouse homologue of the rat Kv beta 2 subunit. In this study we show that in addition to constitutive expression in adult murine brain, expression of Kv channel subunits beta 1.1 and beta 2.1 is inducible in a cloned T-helper cell line stimulated with IL-2 and in normal murine splenocytes stimulated with Con A or LPS. This expression pattern appears to be lymphocyte specific, because stimulated fibroblasts and vascular smooth muscle cells do not express Kv beta channel subunit mRNA. These observations suggest that Kv beta subunit expression is tissue specific and inducible in stimulated lymphocytes. Because Kv beta subunits modulate K+ channel activity, the inducible and variable expression of these subunits in lymphocytes may represent an additional regulatory mechanism for lymphocyte proliferation.

A quantitative analysis of the activation and inactivation kinetics of HERG expressed in Xenopus oocytes

1. The human ether à-go-go-related gene (HERG) encodes a K+ channel that is believed to be the basis of the delayed rectified current, IKr, in cardiac muscle. We studied HERG expressed in Xenopus oocytes using a two-electrode and cut-open oocyte clamp technique with [K+]0 of 2 and 98 mM. 2. The time course of activation of the channel was measured using an envelope of tails protocol and demonstrated that activation of the heterologously expressed HERG current (IHERG) was sigmoidal in onset. At least three closed states were required to reproduce the sigmoid time course. 3. The voltage dependence of the activation process and its saturation at positive voltages suggested the existence of at least one relatively voltage-insensitive step. A three closed state activation model with a single voltage-insensitive intermediate closed state was able to reproduce the time and voltage dependence of activation, deactivation and steady-state activation. Activation was insensitive to changes in [K+]0. 4. Both inactivation and recovery time constants increased with a change of [K+]0 from 2 to 98 mM. Steady-state inactivation shifted by approximately 30 mV in the depolarized direction with a change from 2 to 98 mM K+0. 5. Simulations showed that modulation of inactivation is a minimal component of the increase of this current by [K+]0, and that a large increase in total conductance must also occur.

Electrophysiologic Effects of the New Class III Antiarrhythmic Drug Dofetilide in an Experimental Canine Model of Pacing-induced Atrial Fibrillation

BACKGROUND: Dofetilide is a new class III antiarrhythmic drug currently under investigation for the treatment of supraventricular arrhythmias in humans. Dofetilide have been previously shown to be highly effective in terminating and suppressing reentrant atrial flutter in the experimental canine crush-injury model, in which its antiarrhythmic efficacy was correlated with prolongation of wavelength and reduction in dispersion of refractoriness, effects not produced by the class IA antiarrhythmic drug quinidine. The purpose of this study was to evaluate the antiarrhythmic efficacy and mechanisms of action of dofetilide in an experimental model of atrial fibrillation. METHODS AND RESULTS: Dofetilide was administered intravenously to seven open-chest dogs with acute sustained atrial fibrillation induced by rapid atrial pacing for up to 4 hours. Mean atrial effective refractory period (ERP), dispersion of ERP, conduction velocity and wave-length were determined by multipoint right atrial programmed stimulation and activation mappin gusing a 56-electrode mapping plaque on the right atrial free wall. Dofetilide prolonged average ERP by 22% from 104 +/- 13 to 127 +/- 15 ms (P <.001), prolonged maximum ERP by 11% from 129 +/- 7 to 143 +/- 10 (P <.003), had no effect on conduction velocity at 200 ms pacing cycle length, slowed conduction velocity by 16% from 0.89 +/- 12 to 0.75 +/-.17 ms at 150 ms pacing cycle length, slowed conduction velocity by 16% from 0.89 +/- 12 to 0.75 +/-.17 ms at 150 ms pacing cycle length (P <.001), increased wavelength by 20% from 93 +/- 7 to 112 +/- 9 mm (P <.01), reduced dispersion of ERP by 24% from 11.4 +/- 2.9 to 8.7 +/- 2.3 (P =.016), and reduced the number of adjacent electrodes with ERP difference >/=20 ms by 67% from 18.4 +/- 7.1 to 6.1 +/- 4.2 (P <.001). Dofetilide reduced the number of excitation wavelets (total over three beats) entering the region of the mapping plaque by 38% from 5.0 +/-.8 to 3.1 +/-.4 (P <.002). Dofetilide terminated atrial fibrillation in all seven dogs at a mean of 3.4 +/- 2.2 minutes into the loading infusion and prevented reinduction of atrial fibrillation in all seven dogs after completion of the loading infusion, while on maintenance infusion. Time to termination of atrial fibrillation correlated closely with change in ERP (r = 0.78, P =.036). CONCLUSIONS: Dofetilide was highly effective in terminating and suppressing sustained pacing induced atrial fibrillation in this canine model. Time to termination of atrial fibrillation correlated with the degree of change in ERP produced by dofetilide. The mechanism of termination of atrial fibrillation by dofetilide appeared to be a progressive reduction and eventual extinction of re-entrant wavelets. The predominant electrophysiologic effects of dofetilide were prolongation of ERP and wavelength and a reduction in dispersion of refractoriness. Dofetilide had little effect on conduction velocity in this model, except at very short pacing cycle lengths.

Regional localization of ERG, the channel protein responsible for the rapid component of the delayed rectifier, K+ current in the ferret heart

Repolarization of the cardiac action potential varies widely throughout the heart. This could be due to the differential distribution of ion channels responsible for repolarization, especially the K+ channels. We have therefore studied the cardiac localization of ERG, a channel protein known to play an important role in generation of the rapid component of the delayed rectifier K+ current (IKr), an important determinant of the repolarization waveform, Cryosections of the ferret atrium and ventricle were prepared to determine the localization of ERG by fluorescence in situ hybridization (FISH) and immunofluorescence. We found that in the ferret, ERG transcript and protein expression was most abundant in the epicardial cell layers throughout most of the ventricle, except at the base. In the atrium, we found that ERG is most abundant in the medial right atrium, especially in the trabeculae and the crista terminalis of the right atrial appendage. It also is present in areas within the sinoatrial node. In all regions studied, FISH and immunofluorescence showed concordant localization patterns. These data suggest that repolarization mediated by IKr is not uniform throughout the ferret heart and provide a molecular explanation for heterogeneity in action potential repolarization throughout the mammalian heart.

Stable expression and characterization of the human brain potassium channel Kv2.1: blockade by antipsychotic agents

We have cloned the cDNA encoding the voltage-dependent K+ channel Kv2.1 from human brain (hKv2.1). RNase protection and RT-PCR (reverse transcriptase-PCR) experiments reveal abundant Kv2.1 transcripts in human brain with virtually no expression detectable in human heart. hKv2.1 has been stably transfected into a human glioblastoma cell line, and transformed cells display large, slowly activating outward currents. The kinetics, steady-state activation and inactivation parameters, and external tetraethylammonium sensitivity were all similar to those described previously for hKv2.1 channels transiently expressed in Xenopus oocytes or other mammalian cell lines. A number of dopamine receptor antagonist/antipsychotic agents were shown to block hKv2.1. Trifluoperizine, trifluperidol and pimozide produced time-dependent blockade of hKv2.1 with IC50 values of approx. 1-2 microM. The diphenylbutylpiperidine fluspirilene was shown to be 4-5-fold more potent than the other agents tested inhibiting hKv2.1 current with an IC50 value of 297 nM. The block produced by fluspirilene was both time- and frequency-dependent. Furthermore, fluspirilene (1 microM) shifted the midpotential of the hKv2.1 steady-state inactivation curve by approx. 15 mV in the hyperpolarizing direction. These results demonstrate the usefulness of this transfection system for the pharmacological characterization of hKv2. 1. Fluspirilene proved to be a relatively potent blocker of hKv2.1 and may provide a useful starting point for the development of more potent and selective agents active against this brain K+ channel.

Purification, characterization, and synthesis of an inward-rectifier K+ channel inhibitor from scorpion venom

We have purified a protein inhibitor of an inward-rectifier K+ channel, ROMK1, from the venom of the scorpion Leiurus quinquestriatus var. hebraeus. The inhibitor is Lq2, a previously discovered blocker of voltage- and Ca2+-activated K+ channels. Mutations were made on the channel and the inhibitor, and the resulting effects were examined using an electrophysiological assay. The data show that Lq2 blocks the pore of ROMK1, and that the interaction surface on Lq2 is the same for binding to inward-rectifier, voltage-activated, or Ca2+-activated K+ channels. These findings support the notion that different classes of K+ channels have different gates but a similar K+-selective pore structure.

Rapid inactivation determines the rectification and [K+]o dependence of the rapid component of the delayed rectifier K+ current in cardiac cells

Two characteristic features of the rapid component of the cardiac delayed rectifier current (IKr) are prominent inward rectification and an unexpected reduction in activating current with decreased [K+]o. Similar features are observed with heterologous expression of HERG, the gene thought to encode the channel carrying IKr, moreover, recent studies indicate that the mechanism underlying rectification of HERG current is the inactivation that channels rapidly undergo during depolarizing pulses. The present studies were designed to determine the mechanism of IKr rectification and [K+]o sensitivity in the mouse atrial myocyte cell line, AT-1 cells. Reducing [Mg2+]i to 0, which reverses inward rectification of some K+ channels, did not alter IKr current-voltage relationships, although it did decrease sensitivity to the IKr blockers dofetilide and quinidine 2- to 5-fold. To determine the presence and extent of fast inactivation of IKr in AT-1 cells, a brief hyperpolarizing pulse (20 ms to -120 mV) was applied during long depolarizations. Immediately after this pulse, a very large outward current that decayed rapidly to the previous activating current baseline was observed. This outward current component was blocked by the IKr-specific inhibitor dofetilide, indicating that it represented recovery from fast inactivation during the hyperpolarizing step, with fast reinactivation during the return to depolarized potential. With removal of inactivation using this approach, current-voltage relationships for IKr ([K+]o, 1 to 20 mmol/L) were linar and reversed close to the predicted Nernst potential for K+. In addition, decreased [K+]o decreased the time constants for open-->inactivated and inactivated-->open transitions. Thus, in these cardiac myocytes, as with heterologously expressed HERG, IKr undergoes fast inactivation that determines its characteristic inward rectification. These studies demonstrate that the mechanism underlying decreased activating current observed at low [K+]o is more extensive fast inactivation.

Comparative effects of nonsedating histamine H1 receptor antagonists, ebastine and terfenadine, on human Kv1.5 channels

The effects of ebastine and terfenadine, long-acting nonsedating histamine H1 receptor antagonists, were studied on hKv1.5 channels using the whole-cell voltage-clamp configuration of the patch-clamp technique in Ltk- cells transfected with the gene encoding the hKv1.5 channel. Upon depolarization to +60 mV, terfenadine, 1 microM and 3 microM, inhibited the hKv1.5 current by 42.4 +/- 6.4% and 69.3 +/- 4.2% (P < 0.01). In contrast, at the same range of concentrations, ebastine-induced inhibition of this K+ current averaged 6.5 +/- 2.0% and 13.0 +/- 2.0 (P < 0.05). At the highest concentration tested (3 microM) neither terfenadine carboxylate nor carebastine significantly modified hKv1.5 current. All these results suggest that ebastine could represent a safer alternative to terfenadine in the clinical practice.

Kvbeta2 inhibits the Kvbeta1-mediated inactivation of K+ channels in transfected mammalian cells

Cloned auxiliary beta-subunits (e.g. Kvbeta1) modulate the kinetic properties of the pore-forming alpha-subunits of a subset of Shaker-like potassium channels. Coexpression of the alpha-subunit and Kvbeta2, however, induces little change in channel properties. Since more than one beta-subunit has been found in individual K+ channel complexes and expression patterns of different beta-subunits overlap in vivo, it is important to test the possible physical and/or functional interaction(s) between different beta-subunits. In this report, we show that both Kvbeta2 and Kvbeta1 recognize the same region on the pore-forming alpha-subunits of the Kv1 Shaker-like potassium channels. In the absence of alpha-subunits the Kvbeta2 polypeptide interacts with additional beta-subunit(s) to form either a homomultimer with Kvbeta2 or a heteromultimer with Kvbeta1. When coexpressing alpha-subunits and Kvbeta1 in the presence of Kvbeta2, we find that Kvbeta2 is capable of inhibiting the Kvbeta1-mediated inactivation. Using deletion analysis, we have localized the minimal interaction region that is sufficient for Kvbeta2 to associate with both alpha-subunits and Kvbeta1. This mapped minimal interaction region is necessary and sufficient for inhibiting the Kvbeta1-mediated inactivation, consistent with the notion that the inhibitory activity of Kvbeta2 results from the coassembly of Kvbeta2 with compatible alpha-subunits and possibly with Kvbeta1. Together, these results provide biochemical evidence that Kvbeta2 may profoundly alter the inactivation activity of another beta-subunit by either differential subunit assembly or by competing for binding sites on alpha-subunits, which indicates that Kvbeta2 is capable of serving as an important determinant in regulating the kinetic properties of K+ currents.

KvLQT1, a voltage-gated potassium channel responsible for human cardiac arrhythmias

The clinical features of long QT syndrome result from episodic life-threatening cardiac arrhythmias, specifically the polymorphic ventricular tachycardia torsades de pointes. KVLQT1 has been established as the human chromosome 11-linked gene responsible for more than 50% of inherited long QT syndrome. Here we describe the cloning of a full-length KVLQT1 cDNA and its functional expression. KVLQT1 encodes a 676-amino acid polypeptide with structural characteristics similar to voltage-gated potassium channels. Expression of KvLQT1 in Xenopus oocytes and in human embryonic kidney cells elicits a rapidly activating, K+-selective outward current. The I(Kr)-specific blockers, E-4031 and dofetilide, do not inhibit KvLQT1, whereas clofilium, a class III antiarrhythmic agent with the propensity to induce torsades de pointes, substantially inhibits the current. Elevation of cAMP levels in oocytes nearly doubles the amplitude of KvLQT1 currents. Coexpression of minK with KvLQT1 results in a conductance with pharmacological and biophysical properties more similar to I(Ks) than other known delayed rectifier K+ currents in the heart.

Restoring Sinus Rhythm in Patients With Atrial Flutter and Fibrillation: Pharmacologic or Electrical Cardioversion?

Atrial fibrillation and atrial flutter, the most frequently encountered tachyarrhythmias requiring treatment, have become a major focus for clinical and basic research in recent years. Restoration and maintenance of sinus rhythmn, having been shown to improve exercise capacity, alleviate symptoms, and reduce the incidence of thromboembolic events, may be the optimal management strategy. Identification of the safest, most efficacious and cost-effective means of restoring sinus rhythm is necessary prior to the institution of optimal antiarrhythmic therapy to maintain sinus rhythm. Potential advantages of pharmacologic compared with electrical cardioversion include lack of need for general anesthesia and likely lower cost. Pharmacologic conversion include lack of need for general anesthesia and likely lower cost. Pharmacologic conversion has been accomplished with drugs that prolong atrial refractorinerss, including class Ia (quinidine, procainamide, disopyramide), class Ic (flecainide, propafenone), and class II (sotalol, amiodarone) compounds. The so-called pure class III agents were created to overcome the blocker side effects of sotalol and the complex pharmacodynamic profile of amiodarone. Two such agents are dofetilide, which selectively blocks the rapid component of the delayed rectifier current (Ikr) and ibutilide, which augments the slow inward sodium current, with a smaller component of action mediated by the block of Ikr. Reported overall conversion rates for recent onset atrial fibrillation and atrial flutter were 31% and 54% for difetilide, respectively, and 29-31% and 38-63%, respectively, for ibutilide. Proarrhythmia, manifested as polymorphic ventricular tachycardia requiring cardioversion, was a significant early side effect of both agents. Data from clinical trtials with these new agents, combined with increasing nowledge of the electrophysiologic substrate for these arrhythmias, has renewed initerest in the development of safer, more efficacious class IIIdrugs for atrial fibrillation and atrial flutter conversion.

Insights into mechanisms of antiarrhythmic drug action from experimental models of atrial fibrillation

Atrial fibrillation (AF) remains a challenge to medical therapy. Over the past several years, a variety of experimental models of AF have been developed. These have provided insights into mechanisms underlying AF and antiarrhythmic drug action against the arrhythmia. A variety of drugs effective against clinical AF, including flecainide, propafenone, procainamide, and sotalol, have been found to terminate experimental AF. All of these agents appear to act by prolonging the wavelength for atrial reentry at rapid rates, thereby increasing the size and decreasing the number of functional circuits maintaining the arrhythmia. While the ability to terminate AF is determined by refractoriness prolongation at rapid rates, refractoriness prolongation at slow rates (e.g., sinus rhythm) can prevent AF induction by premature beats. Thus, drugs with strong reverse use-dependence (like sotalol) may be much more effective in preventing than in terminating AF. Spacial heterogeneity in refractoriness is an important contributor to AF occurrence in some models, particularly vagal AF, and is reduced by some (but not all) drugs that terminate AF. New insights are being gained into mechanisms of electrical remodeling, which promotes AF maintenance when rapid atrial rates are maintained, such as during AF. This electrical remodeling may be an interesting novel target for therapy of AF. Insights into AF mechanisms obtained in experimental models of AF should help in the development of new and improved therapeutic approaches.

Comparisons of oral propafenone and sotalol as an initial treatment in patients with symptomatic paroxysmal atrial fibrillation

The main goal of this study is to evaluate the safety and efficacy of propafenone versus sotalol as an initial choice of treatment in patients with symptomatic paroxysmal atrial fibrillation (AF), according to a double-blind randomized system. In the oral propafenone group (n = 41), 2 patients (5%) discontinued therapy because of gastrointestinal discomfort in 1 and dizziness in the other. Thirty-one (79%) of the 39 patients who continued the treatment had effective response to oral propafenone (>75% reduction of symptomatic arrhythmic attacks) on a mean dose of 663 +/- 99 mg/day with a decrease in attack frequency from 10 +/- 3 to 2 +/- 1 times per week. In the oral sotalol group (n = 38), 4 patients (11%) discontinued treatment because of dizziness in 2 and symptomatic bradycardia in 2. Twenty-six of the 34 patients (76%) who continued the treatment had effective response to oral sotalol on a mean dose of 200 +/- 57 mg/day with a decrease in attack frequency from 11 +/- 3 to 2 +/- 1 times per week. Comparisons of the results between propafenone and sotalol groups showed a similar incidence of intolerable (2 of 41 vs 4 of 38, p = 0.42) and tolerable side effects (10 of 39 vs 8 of 34, p = 1.0). The attack frequency at baseline (11 +/- 3 vs 10 +/- 4 times per week, p = 0.23) and after treatment (3 +/- 1 vs 3 +/- 2 times per week, p = 0.85) did not differ significantly between the 2 groups. The incidence of effective response to drugs was also similar (31 of 39 vs 26 of 34, p = 0.78). Furthermore, the decrease of symptom scores (-32 +/- 8% vs -29 +/- 7%, p = 0.18) and percentage decrease of ventricular rate (-15 +/- 4% vs -18 +/- 4%, p = 0.10) during AF were also similar between the 2 groups. In conclusion, oral propafenone and sotalol are equally effective and safe in preventing attacks and alleviating symptoms of paroxysmal AF.

Antisense oligodeoxynucleotides directed against Kv1.5 mRNA specifically inhibit ultrarapid delayed rectifier K+ current in cultured adult human atrial myocytes

Several cloned K+ channel subunits are candidates to underlie macroscopic currents in the human heart, but direct evidence bearing on their role is lacking. The Kv1.5 K+ channel subunit has been suggested to play a potential role in human cardiac ultrarapid delayed rectifier (IKur) and transient outward (Ito) currents. To evaluate the role of proteins encoded by the Kv1.5 gene, we incubated cultured human atrial myocytes for 48 hours in medium containing antisense phosphorothioate oligodeoxynucleotides directed against octodecameric segments of the Kv1.5 mRNA coding sequence, the same concentration of homologous oligodeoxynucleotides with four mismatch mutations, or vehicle (control group). Cells exposed to antisense showed a highly significant (approximately 50%) reduction in IKur whether measured by step current at the end of a 400-millisecond depolarizing pulse, tail current at -20 mV, or current sensitive to a concentration of 4-aminopyridine (50 mumol/L) that is highly selective for IKur compared with control cells or cells exposed to mismatch oligodeoxynucleotides. In contrast, Ito was not different among the three experimental groups. When cultured human ventricular myocytes were exposed to Kv1.5 antisense oligodeoxynucleotides with the same controls, no changes occurred in either Ito or the sustained current at the end of a depolarizing pulse. We conclude that Kv1.5 channel subunits are essential to the expression of IKur and do not play a role in Ito in cultured human atrial myocytes. These studies provide the first direct evidence with an antisense approach for the equivalence between a macroscopic cardiac K+ current and a cloned K+ channel subunit and offer insights into the molecular electrophysiology of the human heart.

Gating charge and ionic currents associated with quinidine block of human Kv1.5 delayed rectifier channels

1. The mechanism of quinidine-induced ionic and gating current inhibition was studied in human Kv1.5 (hKv1.5) delayed rectifier channels expressed in human embryonic kidney cells. In the steady state, quinidine produced a voltage-dependent block between +30 and +120 mV (Kd at +60 mV = 7.2 microM) with an equivalent electrical distance, delta, of 0.29 +/- 0.06 and 0.26 +/- 0.05 at 10 and 50 microM quinidine, respectively. The apparent affinity at 0 mV (Kd) was 25 microM at 10 microM quinidine and 38 microM at 50 microM quinidine. The data suggested a quinidine binding site that sensed 20-30% of the transmembrane electrical field, from the inside. Non-steady-state measurements indicated rapid open channel block with mean time constants of 2.1 +/- 0.9 and 1.2 +/- 0.2 ms at 10 and 50 microM quinidine, respectively. 2. 'On' gating current (on-Ig) was unaffected over a wide range of potentials and between 10 and 100 microM quinidine. On-gating charge (Qon) was similarly conserved in the steady state between -100 and +50 mV. On return to -100 mV, quinidine slowed the off-gating current (off-Ig) after depolarizations more positive than -25 mV. After depolarizations to +50 mV, only 59 +/- 3.4% (10 microM quinidine) and 6.6 +/- 9.5% (100 microM quinidine) of the charge returned within 25 ms, compared with 100% in control. Due to the conservation of Qon in subsequent pulses, the remaining charge must have returned during the subsequent 10 s interpulse interval. 3. A threshold for quinidine action on off-Ig was established positive to -25 mV. The voltage dependence of Qoff immobilization at more positive potentials than +20 mV had an equivalent electrical distance of 0.32 +/- 0.04 (10 microM quinidine) and 0.20 +/- 0.32 (100 microM quinidine) with calculated Kd values of 21.6 +/- 4.6 and 16.2 +/- 8.4 microM at 10 and 100 microM quinidine, respectively. These characteristics of block are in good agreement with values obtained from ionic data. 4. Simultaneous measurements of ionic and gating currents confirmed, after subtraction, an ionic current threshold at -21.8 +/- 1.8 mV. The gating current data confirm directly that ionic current block by quinidine occurs by binding at a site on the hKv1.5 channel that becomes accessible when the channel opens. There was no evidence for action of quinidine on kinetic states prior to the open state at concentrations of quinidine up to 100 microM.

4-aminopyridine activates potassium currents by activation of a muscarinic receptor in feline atrial myocytes

1. The effects of 4-aminopyridine (4-AP) on action potentials, macroscopic membrane currents and single-channel recording from cardiac left atrial myocytes of the adult cat were studied using the whole-cell and cell-attached configurations of the patch-clamp technique. 2. 4-AP (1 mM) produced a hyperpolarization of the resting membrane potential and a shortening of action potential duration. Under voltage-clamp conditions, we have found that 4-AP increased a background current and a delayed rectifier outward current. These effects were antagonized by atropine. In addition, both effects seemed to be mediated through a pertussis toxin-sensitive G protein. 3. The background current induced by 4-AP displayed properties that are highly similar to those of the inwardly rectifying potassium current activated by acetylcholine (IK(ACh)). The time-dependent potassium current activated by 4-AP has kinetic and pharmacological properties different from those of the delayed rectifier potassium current previously identified in cardiac myocytes. 4. The activation of the delayed rectifier-like potassium current could be explained by the activation of a novel muscarinic receptor subtype in which acetylcholine acts as the antagonist. Another possibility is that 4-AP activates IK(ACh) in a time- and voltage-dependent manner.

Azimilide (NE-10064) can prolong or shorten the action potential duration in canine ventricular myocytes: dependence on blockade of K, Ca, and Na channels

INTRODUCTION

Azimilide (NE-10064) has antiarrhythmic and antifibrillatory effects in canine models of ventricular arrhythmia. The goal of the present study was to examine the effects of azimilide on action potential and membrane currents of canine ventricular myocytes.

METHODS AND RESULTS

Membrane voltage and current were recorded using the whole cell, patch clamp method. Azimilide at 1 microM induced a consistent prolongation of action potential duration (APD): on average APD90 was prolonged by 25% and 17% at stimulation rates of 0.33 and 1 Hz, respectively. Elevating the drug concentration to 5 microM induced APD prolongation in some cells but APD shortening in the others at 0.33 Hz, and a consistent APD shortening at 1 Hz. Azimilide suppressed the following currents (Kd in parenthesis): IKr (< 1 microM at -20 mV), IKs (1.8 microM at +30 mV), L-type Ca current (17.8 microM at +10 mV), and Na current (19 microM at -40 mV). Azimilide was a weak blocker of the transient outward and inward rectifier currents (Kd > or = 50 microM at +50 and -140 mV, respectively). Azimilide blocked IKr, IKs, and INa in a use-dependent manner. Furthermore, azimilide reduced a slowly inactivating component of Na current that might be important for maintaining the action potential plateau in canine ventricular myocytes.

CONCLUSION

Azimilide has variable effects on APD in canine ventricular myocytes due to its blocking effects on multiple currents with different potencies. Its Class III antiarrhythmic action is most likely seen at low concentrations (< 5 microM).

Heterogeneity in K+ channel transcript expression detected in isolated ferret cardiac myocytes

The molecular basis of the potassium ion (K+) channels that generate repolarization in heart tissue remains uncertain, in part because of the molecular diversity of the voltage-gated K+ channel family. In our investigation, we used fluorescent labeled oligonucleotide probes to perform in situ hybridization studies on enzymatically isolated myocytes to determine the identity, regional distribution, and cellular distribution of voltage-gated K+ channel, alpha-subunit mRNA expressed in ferret heart. The regions studied were from the sinoatrial node (SA), right and left atrium, right and left ventricle, and interatrial and interventricular septa. Kv1.5 and Kv1.4 were the most widely distributed K+ channel transcripts in the ferret heart (present in approximately 70%-86% and approximately 46%-95% of tested myocytes, respectively), followed by Kv1.2, Kv2.1, and Kv4.2. In addition, many myocytes contain transcripts for Kv1.3, Kv2.2, Kv4.1, Kv5.1, and members of the Kv3 family. Kv1.1, Kv1.6, and Kv6.1 were rarely expressed in working myocytes, but were more commonly expressed in SA nodal cells. Two other transcripts whose genes have been implicated in the long QT syndrome, erg and KvLQT1, were common in all regions (approximately 41%-58% and 52%-72%, respectively). These results show that both the diversity and heterogeneity of K+ channel mRNA in heart tissue is greater than previously suspected.

The inhibitory effect of the antipsychotic drug haloperidol on HERG potassium channels expressed in Xenopus oocytes

1. The antipsychotic drug haloperidol can induce a marked QT prolongation and polymorphic ventricular arrhythmias. In this study, we expressed several cloned cardiac K+ channels, including the human ether-a-go-go related gene (HERG) channels, in Xenopus oocytes and tested them for their haloperidol sensitivity. 2. Haloperidol had only little effects on the delayed rectifier channels Kv1.1, Kv1.2, Kv1.5 and IsK, the A-type channel Kv1.4 and the inward rectifier channel Kir2.1 (inhibition < 6% at 3 microM haloperidol). 3. In contrast, haloperidol blocked HERG channels potently with an IC50 value of approximately 1 microM. Reduced haloperidol, the primary metabolite of haloperidol, produced a block with an IC50 value of 2.6 microM. 4. Haloperidol block was use- and voltage-dependent, suggesting that it binds preferentially to either open or inactivated HERG channels. As haloperidol increased the degree and rate of HERG inactivation, binding to inactivated HERG channels is suggested. 5. The channel mutant HERG S631A has been shown to exhibit greatly reduced C-type inactivation which occurs only at potentials greater than 0 mV. Haloperidol block of HERG S631A at 0 mV was four fold weaker than for HERG wild-type channels. Haloperidol affinity for HERG S631A was increased four fold at +40 mV compared to 0 mV. 6. In summary, the data suggest that HERG channel blockade is involved in the arrhythmogenic side effects of haloperidol. The mechanism of haloperidol block involves binding to inactivated HERG channels.

Evidence that outwardly rectifying Cl- channels underlie volume-regulated Cl- currents in heart

Swelling-induced Cl- current (ICl.swell) is present in most cardiac tissues, but the unitary channel underlying ICls.well is unknown. We used the cell-attached patch-clamp technique to assess the properties of single channels underlying ICls.well and the basally active Cl- current (ICl.b) in rabbit atrial myocytes. Under isotonic conditions, single outwardly rectifying Cl- channels (ORCCs) with a slope conductance of 28 +/- 1 pS at the reversal potential were observed in 21 (5.7%) of 367 patches. Unconditional kinetic analysis revealed at least three open and four closed-channel states. Hypotonic superfusion-induced swelling resulted in the appearance of active channels in 41 (15.5%) of 265 patches without channel activity under isotonic conditions and caused a second active channel to appear in 3 of 14 patches showing a single channel under isotonic conditions. Overall, channels were seen in 54 of 336 patches under hypotonic conditions (16.1%, P < .001 versus isotonic conditions). The current-voltage relations, reversal potential-[Cl-]o relations, open probability, and kinetics of swelling-induced channels were indistinguishable from those of ORCCs under isotonic conditions. Unitary ORCCs, ICl.b, and ICl.swell were strongly and similarly inhibited by tamoxifen. Swelling-induced increases in macroscopic Cl- current were attributable to an increase in the number of active ORCCs with no significant effects on single-channel amplitude or open probability. Estimated macroscopic currents based on cell surface area, patch dimensions, single-channel ORCC current amplitude, open probability, and density were consistent with measured values of ICl.b and ICl.swell. We conclude that ORCCs underlie volume-regulated basal and swelling-induced Cl- currents in isolated rabbit atrial myocytes.

Cloned potassium channels from eukaryotes and prokaryotes

Potassium channels contribute to the excitability of neurons and signaling in the nervous system. They arise from multiple gene families including one for voltage-gated potassium channels and one for inwardly rectifying potassium channels. Features of potassium permeation, channel gating and regulation, and subunit interaction have been analyzed. Potassium channels of similar design have been found in animals ranging from jellyfish to humans, as well as in plants, yeast, and bacteria. Structural similarities are evident for the pore-forming alpha subunits and for the beta subunits, which could potentially regulate channel activity according to the level of energy and/or reducing power of the cell.

The N-terminal domain of a K+ channel beta subunit increases the rate of C-type inactivation from the cytoplasmic side of the channel

Voltage-gated K+ channels are complexes of membrane-bound, ion-conducting alpha and cytoplasmic ancillary (beta) subunits. The primary physiologic effect of coexpression of alpha and beta subunits is to increase the intrinsic rate of inactivation of the alpha subunit. For one beta subunit, Kv beta 1.1, inactivation is enhanced through an N-type mechanism. A second beta subunit, Kv beta 1.2, has been shown to increase inactivation, but through a distinct mechanism. Here we show that the degree of enhancement of Kv beta 1.2 inactivation is dependent on the amino acid composition in the pore mouth of the alpha subunit and the concentration of extracellular K+. Experimental conditions that promote C-type inactivation also enhance the stimulation of inactivation by Kv beta 1.2, showing that this beta subunit directly stimulates C-type inactivation. Chimeric constructs containing just the nonconserved N-terminal region of Kv beta 1.2 fused with an alpha subunit behave in a similar fashion to coexpressed Kv beta 1.2 and alpha subunit. This shows that it is the N-terminal domain of Kv beta 1.2 that mediates the increase in C-type inactivation from the cytoplasmic side of the pore. We propose a model whereby the N terminus of Kv beta 1.2 acts as a weakly binding "ball" domain that associates with the intracellular vestibule of the alpha subunit to effect a conformational change leading to enhancement of C-type inactivation.

Voltage-gated K+ channel beta subunits: expression and distribution of Kv beta 1 and Kv beta 2 in adult rat brain

Recent cloning of K+ channel beta subunits revealed that these cytoplasmic polypeptides can dramatically alter the kinetics of current inactivation and promote efficient glycosylation and surface expression of the channel-forming alpha subunits. Here, we examined the expression, distribution, and association of two of these beta subunits, Kv beta 1 and Kv beta 2, in adult rat brain. In situ hybridization using cRNA probes revealed that these beta-subunit genes are heterogeneously expressed, with high densities of Kv beta 1 mRNA in the striatum, CA1 subfield of the hippocampus, and cerebellar Purkinje cells, and high densities of Kv beta 2 mRNA in the cerebral cortex, cerebellum, and brainstem. Immunohistochemical staining using subunit-specific monoclonal and affinity-purified polyclonal antibodies revealed that the Kv beta 1 and Kv beta 2 polypeptides frequently co-localize and are concentrated in neuronal perikarya, dendrites, and terminal fields, and in the juxtaparanodal region of myelinated axons. Immunoblot and reciprocal co-immunoprecipitation analyses indicated that Kv beta 2 is the major beta subunit present in rat brain membranes, and that most K+ channel complexes containing Kv beta 1 also contain Kv beta 2. Taken together, these data suggest that Kv beta 2 is a component of almost all K+ channel complexes containing Kv 1 alpha subunits, and that individual channels may contain two or more biochemically and functionally distinct beta-subunit polypeptides.

Right and left atrial radiofrequency catheter therapy of paroxysmal atrial fibrillation

INTRODUCTION

Atrial fibrillation (AF), the most common arrhythmia, is due to multiple simultaneous wavelets of reentry in the atria. The only available curative treatment is surgical, using atriotomies to compartmentalize the atria. Therefore, we investigated a staged anatomical approach using radiofrequency catheter ablation lines to prevent paroxysmal AF.

METHODS AND RESULTS

Forty-five patients with frequent symptomatic drug-refractory episodes of paroxysmal AF were studied. Progressively complex linear lesions were created by sequential applications of radiofrequency current in the right atrium and then in the left atrium if required. The outcome of the procedure was considered a success when the episodes of AF were either eliminated or recurred at a rate of no more than one episode (lasting < 6 hours) in 3 months. Patients who had no more than one episode per month were considered "improved." Right atrial ablation organized local electrical activity and led to stable sinus rhythm during the procedure in 18 (40%) of the 45 patients. However, sustained AF remained inducible in 40 of 45 patients, and the lesions failed to produce evidence of a significant linear conduction block/delay in all but four patients. There were no significant complications except for two transient sinus node dysfunctions. The procedure duration and fluoroscopic time were 248 +/- 79 and 53 +/- 22 min, respectively. Additional sessions were required in 19 patients to treat sustained right atrial flutter or arrhythmias linked to ectopic right or left atrial foci. During a mean follow-up of 11 +/- 4 months, right atrial ablation was successful in 15 (33%) patients, 6 without medication and 9 with a previously ineffective drug. Nine (20%) additional patients were improved. Ten patients with an unsuccessful outcome then underwent linear ablation in the left atrium. The procedure duration and fluoroscopy time were 292 +/- 94 and 66 +/- 24 min. A hemopericardium occurred in one patient. Two patients required reablation to treat ectopic atrial foci. Left atrial ablation terminated AF during the procedure in 8 patients, and sustained AF could not be induced in 5. Subsequent success was achieved in 6 (60%) patients, including 4 without medication, and 1 additional patient was improved.

CONCLUSIONS

Successful radiofrequency catheter ablation of drug-refractory daily paroxysmal AF is feasible using linear atrial lesions complemented by focal ablation targeted at arrhythmogenic foci. Ablation only in the right atrium is a safe technique providing limited success, whereas linear lesions in the left atrium significantly increase the incidence of stable restoration of sinus rhythm, the inability to induce sustained AF, and the final success rate. The described technique is promising but must be considered preliminary because significant improvements are required to optimize lesion characteristics and shorten total procedure duration.

Human epithelial cystic fibrosis transmembrane conductance regulator without exon 5 maintains partial chloride channel function in intracellular membranes

The cardiac isoform of the cystic fibrosis transmembrane conductance regulator (CFTR) is a splice variant of the epithelial CFTR, with lacks 30 amino acids encoded by exon 5 in the first intracellular loop. For examination of the role of exon 5 in CFTR channel function, a CFTR deletion mutant, in which exon 5 was removed from the human epithelial CFTR, was constructed. The wild type and delta exon5 CFTR were expressed in a human embryonic kidney cell line (293 HEK). Fully mature glycosylated CFTR (approximately 170 kDa) was immunoprecipitated from cells transfected with wild type CFTR cDNA, whereas cells transfected with delta exon5 CFTR express only a core-glycosylated from (approximately 140 kDa). The Western blot test performed on subcellular membrane fractions showed that delta exon5 CFTR was located in the intracellular membranes. Neither incubation at lower temperature (26 degrees C) nor stimulation of 293 HEK cells with forskolin or CPT-cAMP caused improvement in glycosylation and processing of delta exon5 CFTR proteins, indicating that the human epithelial CFTR lacking exon5 did not process properly in 293 HEK cells. On incorporation of intracellular membrane vesicles containing the delta exon5 CFTR proteins into the lipid bilayer membrane, functional phosphorylation- and ATP-dependent chloride channels were identified. CFTR channels with an 8-pS full-conductance state were observed in 14% of the experiments. The channel had an average open probability (Po) of 0.098 +/- 0.022, significantly less than that of the wild type CFTR (Po = 0.318 +/- 0.028). More frequently, the delta exon5 CFTR formed chloride channels with lower conductance states of approximately 2-3 and approximately 4-6 pS. These subconductance states were also observed with wild type CFTR but to a much lesser extent. Average Po for the 2-3-pS subconductance state, estimated from the area under the curve on an amplitude histogram, was 0.461 +/- 0.194 for delta exon5 CFTR and 0.332 +/- 0.142 for wild type (p = 0.073). The data obtained indicate that deleting 30 amino acids from the first intracellular loop of CFTR affects both processing and function of the CFTR chloride channel.

Flecainide and the electrophysiologic matrix: the effects of flecainide acetate on the determinants of cardiac excitability in sheep Purkinje fibers

Flecainide was associated with excess mortality distributed virtually equally throughout the period of the Cardiac Arrhythmia Suppression Trial, suggesting the intersection of two events, drug effect and perhaps ischemia. Flecainide's effect on active properties has been studied extensively, but nothing is known of its effects on passive properties or on the balance among active and passive cellular properties that determines cardiac excitability. The multiple microelectrode method of intracellular current application and transmembrane voltage recording was used in sheep Purkinje fibers to determines strength- and charge-duration as well as constant current-voltage relationships and to estimate active properties, liminal length, and cable properties at a normal [K+]o and in a setting of hyperkalemia analogous to that of ischemia. A computer tracked in time the alterations in the active and passive properties relevant to excitability. Flecainide slightly decreased excitability at a normal [K+]o, primarily by depressing the sodium system with some contributory effect of passive properties. At high [K+]o, flecainide caused a frequency-dependent decrease in excitability and conduction, the latter best interpreted as a failure of the fiber to attain the liminal length requirements to produce a local action potential due primarily to an effect on sodium conductance. Together, the observations suggest that the action potential is the local phenomenon and that the propagated event is the sequential fulfillment of liminal length requirements. The data were interpreted in terms of the electrophysiologic matrix first proposed in detail in this Journal, which indicated that the electrophysiologic universe moved as a system in response to the drug and a change in [K+]o, the presumed antiarrhythmic and proarrhythmic electrophysiologic matrices for flecainide were quite similar, and the matrical configuration shared characteristics with the matrices of other drugs with known proarrhythmic potential.

In vivo functional role of the Drosophila hyperkinetic beta subunit in gating and inactivation of Shaker K+ channels

The physiological roles of the beta, or auxiliary, subunits of voltage-gated ion channels, including Na+, Ca2+, and K+ channels, have not been demonstrated directly in vivo. Drosophila Hyperkinetic (Hk) mutations alter a gene encoding a homolog of the mammalian K+ channel beta subunit, providing a unique opportunity to delineate the in vivo function of auxiliary subunits in K+ channels. We found that the Hk beta subunit modulates a wide range of the Shaker (Sh) K+ current properties, including its amplitude, activation and inactivation, temperature dependence, and drug sensitivity. Characterizations of the existing mutants in identified muscle cells enabled an analysis of potential mechanisms of subunit interactions and their functional consequences. The results are consistent with the idea that via hydrophobic interaction, Hk beta subunits modulate Sh channel conformation in the cytoplasmic pore region. The modulatory effects of the Hk beta subunit appeared to be specific to the Sh alpha subunit because other voltage- and Ca(2+)-activated K+ currents were not affected by Hk mutations. The mutant effects were especially pronounced near the voltage threshold of IA activation, which can disrupt the maintenance of the quiescent state and lead to the striking neuromuscular and behavioral hyperexcitability previously reported.

Molecular physiology and pharmacology of HERG. Single-channel currents and block by dofetilide

BACKGROUND

The human ether-a-go-go-related gene (HERG) is one locus for the hereditary long-QT syndrome. A hypothesis is that HERG produces the repolarizing cardiac potassium current IKr with the consequence that mutations in HERG prolong the QT interval by reducing IKr. The elementary properties of HERG are unknown, and as a test of the hypothesis that HERG produces IKr, we compared their elementary properties.

METHODS AND RESULTS

We injected HERG cRNA into Xenopus oocytes and measured currents from single channels or current variance from the noise produced by ensembles of channels recorded from macro patches. Single-channel conductance was dependent on the extracellular potassium concentration ([K]o). At physiological [K]o, it was 2 picosiemens (pS), and at 100 mmol/L [K]o, it was 10 pS. Openings occurred in bursts with a mean duration of 26 ms at -100 mV. Mean open time was 3.2 ms and closed times were 1.0 and 26 ms. In excised macro patches, HERG currents were blocked by the class III antiarrhythmic drug dofetilide, with an IC50 of 35 nmol/L. Dofetilide block was slow and greatly attenuated at positive potentials at which HERG rectifies.

CONCLUSIONS

The microscopic physiology of HERG and IKr is similar, consistent with HERG being an important component of IKr. The pharmacology is also similar; dofetilide appears to primarily block activated channels and has a much lower affinity for closed and inactivated channels.

Comparison of binding and block produced by alternatively spliced Kvbeta1 subunits

Voltage-gated K+ (Kv) channels consist of alpha subunits complexed with cytoplasmic Kvbeta subunits. Kvbeta1 subunits enhance the inactivation of currents expressed by the Kv1 alpha subunit subfamily. Binding has been demonstrated between the C terminus of Kvbeta1.1 and a conserved segment of the N terminus of Kv1.4, Kv1.5, and Shaker alpha subunits. Here we have examined the interaction and functional properties of two alternatively spliced human Kvbeta subunits, 1.2 and 1.3, with Kvalpha subunits 1.1, 1.2, 1.4, and 1.5. In the yeast two-hybrid assay, we found that both Kvbeta subunits interact specifically through their conserved C-terminal domains with the N termini of each Kvalpha subunit. In functional experiments, we found differences in modulation of Kv1alpha subunit currents that we attribute to the unique N-terminal domains of the two Kvbeta subunits. Both Kvbeta subunits act as open channel blockers at physiological membrane potentials, but hKvbeta1.2 is a more potent blocker than hKvbeta1.3 of Kv1.1, Kv1.2, Kv1.4, and Kv1. 5. Moreover, hKvbeta1.2 is sensitive to redox conditions, whereas hKvbeta1.3 is not. We suggest that different Kvbeta subunits extend the range over which distinct Kv1alpha subunits are modulated and may provide a variable mechanism for adjusting K+ currents in response to alterations in cellular conditions.

Primary ablation of atrial flutter and atrial fibrillation

Direct treatment of atrial flutter and atrial fibrillation--that is, attempting to prevent arrhythmia recurrences by ablating atrial tissue--has been a challenge because of uncertainty about the location of optimal target tissues as well as the amount of atrial tissue requiring destruction to effect cure. Advances have yielded success rates for ablation of the common form of atrial flutter comparable to those for other types of supraventricular tachycardia and provide reason for optimism about the use of catheter techniques, to treat atrial fibrillation definitively. This article discusses some of these advances as well as the current status of catheter ablation for atrial flutter and atrial fibrillation and, finally, what the future may bring.

Developmental analysis reveals mismatches in the expression of K+ channel alpha subunits and voltage-gated K+ channel currents in rat ventricular myocytes

In the experiments here, the developmental expression of the functional Ca(2+)-independent, depolarization-activated K+ channel currents, Ito and IK, and of the voltage-gated K+ channel (Kv) alpha subunits, Kv1.2, Kv1.4, Kv1.5, Kv2.1, and Kv4.2 in rat ventricular myocytes were examined quantitatively. Using the whole-cell patch clamp recording method, the properties and the densities of Ito and IK in ventricular myocytes isolated from postnatal day 5 (P5), 10 (P10), 15 (P15), 20 (P20), 25 (P25), 30 (P30), and adult (8-12 wk) rats were characterized and compared. These experiments revealed that mean Ito densities increase fourfold between birth and P30, whereas IK densities vary only slightly. Neither the time- nor the voltage-dependent properties of the currents vary measurably, suggesting that the subunits underlying functional Ito and IK channels are the same throughout postnatal development. In parallel experiments, the developmental expression of each of the voltage-gated K+ channel alpha subunits, Kv1.2, Kv1.4, Kv1.5, Kv2.1, and Kv4.2, was examined quantitatively at the mRNA and protein levels using subunit-specific probes. RNase protection assays revealed that Kv1.4 message levels are high at birth, increase between P0 and P10, and subsequently decrease to very low levels in adult rat ventricles. The decrease in message is accompanied by a marked reduction in Kv1.4 protein, consistent with our previous suggestion that Kv1.4 does not contribute to the formation of functional K+ channels in adult rat ventricular myocytes. In contrast to Kv1.4, the mRNA levels of Kv1.2, Kv1.5, Kv2.1, and Kv4.2 increase (three- to five-fold) between birth and adult. Western analyses, however, revealed that the expression patterns of these subunits proteins vary in distinct ways: Kv1.2 and Kv4.2, for example, increase between P5 and adult, whereas Kv1.5 remains constant and Kv2.1 decreases. Throughout development, therefore, there is a mismatch between the numbers of Kv alpha subunits expressed and the functional voltage-gated K+ channel currents distinguished electrophysiologically in rat ventricular myocytes. Alternative experimental approaches will be required to define directly the Kv alpha subunits that underlie functional voltage-gated K+ channels in these (and other) cells. In addition, the finding that Kv alpha subunit protein expression levels do not necessarily mirror mRNA levels suggests that caution should be exercised in attempting functional interpretations of observed changes in mRNA levels alone.

Rate-dependent effects of sematilide on ventricular monophasic action potential duration and delayed rectifier K+ current in rabbits

Our objective was to define the actions of sematilide in rabbits and to assess the contribution of the delayed rectifier (IK) to rate dependence of action potential duration (APD) in rabbit ventricular myocardium. In studies in vivo, New Zealand White rabbits were used to obtain dose/response curves of the effects of sematilide on APD from contact monophasic action potentials (MAP), ventricular effective refractory period (VERP), and ECG. Sematilide or placebo was administered as an i.v. bolus followed by a 45-min infusion in the following cumulative manner: infusion 1 (1 mg/kg bolus + 8 micrograms/kg/min); infusion 2 (2 mg/kg + 20 micrograms/kg/min); and infusion 3 (7 mg/kg + 68 micrograms/kg/min). At each infusion level, VERP and APD at 75% repolarization (APD75) were measured during cardiac pacing between 200- and 400-ms cycle length (CL). Serum sematilide levels were analyzed by high-performance liquid chromatography (HPLC). In studies in vitro, sematilide's effects on the delayed rectifier were assessed in isolated rabbit ventricular myocytes by using patch-clamp techniques. Sematilide infusion in vivo resulted in stable serum levels of 1.3 +/- 0.5, 3.7 +/- 1.4, and 13.4 +/- 1.8 micrograms/ml during infusions 1, 2, and 3, respectively. Maximal effects occurred at infusion 2, such that at 400 ms CL, sematilide widened predrug APD75 (145 +/- 5 ms) by 27 +/- 4% (p < 0.001 vs. placebo), and at 200-ms CL, sematilide prolonged predrug APD75 (115 +/- 10 ms) by only 18 +/- 4% (p < 0.001 vs. placebo; p < 0.05 vs. 400-ms CL). Similar effects were observed in VERP. Sematilide enhanced rate dependence of APD and produced the same degree of APD prolongation at a given CL, during accommodation to and recovery from rapid pacing. Rabbit ventricular myocytes appeared to have at least two types of delayed rectifier. Sematilide selectively blocked IKr, and block was not relieved by repetitive stimulation. In conclusion, the APD-widening effect of sematilide was independent of previous pacing history. Sematilide had little influence on background processes likely responsible for shortening APD because of rapid repetitive stimulation.

Characterization of an ultrarapid delayed rectifier potassium channel involved in canine atrial repolarization

1. Depolarizing pulses positive to 0 mV elicit a transient outward current (Ito) and a sustained 'pedestal' current in canine atrial myocytes. The pedestal current was highly sensitive to 4-aminopyridine (4-AP) and TEA, with 50% inhibitory concentrations (EC50) of 5.3 +/- 0.7 and 307 +/- 25 microM, respectively. When the pedestal current was separated from Ito with prepulses or by studying current sensitive to 10 mM TEA, it showed very rapid activation and deactivation. We therefore designated the current IKur,d, for 'ultrarapid delayed rectifier, dog'. IKur,d inactivation was bi-exponential, with mean time constants of 609 +/- 91 and 5563 +/- 676 ms during a 20 s pulse to +40 mV. 2. The reversal potential of IKur,d tail currents are dependent on extracellular potassium concentration ([K+]o; slope, 54.7 mV decade-1). The envelope of tails test was satisfied and the current inwardly rectified at > or = +40 mV. The current was insensitive to E-4031, dendrotoxin and chloride substitution, but was inhibited by barium, with an EC50 of 1.65 mM. Lanthanum ions caused a positive shift in voltage dependence without producing direct inhibition. 3. Single-channel activity was observed in cell-attached, inside-out and outside-out patches. Upon depolarization from -50 to +30 mV, single channels had similar time constants and [K+]o dependence to whole-cell current. Channel open probability (Po) increased with depolarization in a saturable fashion and the Po-voltage relation had a half-activation voltage and slope factor similar to whole-cell IKur,d. 4. Unitary channel current was linearly related to depolarization potential to +40 mV; at more positive potentials, inward rectification occurred. The unitary conductance was 20.3 and 35.5 pS for an [K+]o of 5.4 and 130 mM, respectively. Single-channel activity was strongly inhibited by 50 microM 4-AP or 10 mM TEA. Both 4-AP and TEA decreased open time, suggesting open-channel block. 5. Selective inhibition of IKur,d with 50 microM 4-AP or 0.3-5 mM TEA prolonged canine atrial action potentials, indicating that IKur,d contributes to canine atrial repolarization. The single-channel and macroscopic properties of IKur,d have many similarities to those of currents carried by Kv3.1 cloned channels and our findings thus suggest a possible role for Kv3.1 channels in cardiac repolarization.

Antiarrhythmic drug therapy in the treatment of atrial fibrillation

Treatment of atrial fibrillation is often unsatisfactory because no available drug has been shown to be clearly superior for maintaining patients in sinus rhythm, and all agents have significant potential for toxicity. Selection of an antiarrhythmic drug is more likely to be based on the drug's potential for toxicity, rather than its demonstrated superior efficacy in the treatment of atrial fibrillation. Careful assessment of each patient for contraindications to individual agents and the likelihood of treatment success needs to be done before initiating antiarrhythmic therapy.

Regional disparities of endocardial atrial activation in paroxysmal atrial fibrillation

Previous experimental data suggest that atrial activity is homogeneously distributed during paroxysmal atrial fibrillation (AFib). Little is known about this in human paroxysmal AFib.

METHODS

Twenty-five men and two women (mean age 49 +/- 11 years; five with structural heart disease) with paroxysmal AFib for a mean 5 +/- 6.2 years despite the use of a mean of 3.6 +/- 1.7 antiarrhythmic drugs underwent atrial mapping. The right atrium was divided into four regions: posterior (intercaval), lateral, anterior, and septal. A 14-pole catheter was positioned to assess complex electrical activity defined as the duration of continuous electrical activity or electrograms with FF intervals < 100 ms for 60 seconds (expressed as percentage of time). In addition, the left atrium (divided into three regions: posterior, anterior, and septal) was explored in 12 patients with a multipolar catheter.

RESULTS

The complex electrical activity time between all the regions explored was significantly different. In the right atrium, the septal (74% +/- 32%; P = 0.02) and the posterior (63% +/- 32%; P = 0.04) areas were significantly more disorganized than the lateral (22% +/-23%) and anterior (21% +/- 26%) regions. In the left atrium, complex electrical activity was predominant and widely distributed (posterior: 87% +/- 11%; septal: 65% +/- 27%) except in the appendage area (anterior region: 18% +/- 14%).

CONCLUSIONS

Quantitative assessment of complex electrical activity in both atria in humans shows heterogeneous temporal and spatial distribution. This may have implications for guiding catheter ablation of AFib.

Hemodynamic effects of cardiomyoplasty in an experimental model of acute heart failure and atrial fibrillation

The aim of our work was to study the hemodynamic effects of dynamic cardiomyoplasty on an acute animal model of atrial fibrillated heart failure. Eight anesthetized open chest dogs suffering from atrial fibrillation and heart failure, obtained by topic acetylcholine and propranolol, were treated by a cardiomyoplasty procedure performed with an electrostimulated latissimus dorsi muscle flap (LDMF). Values considered for analysis during LDMF stimulation were selected from cardiac cycles with R-R intervals similar to those when the LDMF was not stimulated (+/- 20 ms). Atrial fibrillated heart failure showed a significant increase of systemic vascular resistance, end diastolic left ventricular pressure (EDLVP) and right atrial pressure (p < 0.05), and a significant decrease in cardiac output, systolic left ventricular pressure (SLVP), and mean aortic pressure (p < 0.05) compared with control values. LDMF stimulation in atrial fibrillated heart failure resulted in a significant increase of SLVP, cardiac output, and mean aortic pressure (p < 0.05) and a significant decrease of systemic vascular resistance, EDLVP, and right atrial pressure (p < 0.05) compared with nonstimulated values. The highest LVP values were obtained with R-R intervals long enough to allow an adequate LV filling. We conclude that dynamic cardiomyoplasty provides an appropriate recovery in this animal model of atrial fibrillated heart failure. Cardiomyoplasty is an appropriate procedure for cardiac assist when R-R intervals allow an adequate LV filling.

A new K+ channel beta subunit to specifically enhance Kv2.2 (CDRK) expression

Cloned K+ channel beta subunits are hydrophilic proteins which associate to pore-forming alpha subunits of the Shaker subfamily. The resulting alphabeta heteromultimers K+ channels have inactivation kinetics significantly more rapid than those of the corresponding alpha homomultimers. This paper reports the cloning and the brain localization of mKvbeta4 (m for mouse), a new beta subunit. This new beta subunit is highly expressed in the nervous system but is also present in other tissues such as kidney. In contrast with other beta subunits, coexpression of the mKvbeta4 subunit with alpha subunits of Shaker-type K+ channel does not modify the kinetic properties or voltage-dependence of these channels in Xenopus oocytes. Instead, mKvbeta4 associates to Kv2.2 (CDRK), a Shab K+ channel, to specifically enhance (a factor of up to 6) its expression level without changing its elementary conductance or kinetics. It is without effect on another closely related Shab K+ channel Kv2.1 (DRK1). Chimeras between Kv2.1 and Kv2. 2 indicate that the COOH-terminal end of the Kv2.2 protein is essential for its mKvbeta4 sensitivity. The functional results associated with the observation of the co-localization of mKvbeta4 and Kv2.2 transcripts in most brain areas strongly suggest that both subunits interact in vivo to form a slowly-inactivating K+ channel. A chaperone-like effect of mKvbeta4 seems to permit the integration of a larger number of Kv2.2 channels at the plasma membrane.