Models of Parasystole and Reflection. In: Rosenbaum MB, Elizari MV, editors. Frontiers of Cardiac Electrophysiology. Dordrecht: Springer Netherlands; 1983. pp. 217-38. [DOI: 10.1007/978-94-009-6781-6_11]

Flecainide-induced arrhythmia in canine ventricular epicardium. Phase 2 reentry?

BACKGROUND

We recently reported that sodium channel block can produce opposite effects on action potential duration (APD) and refractoriness in epicardial versus endocardial tissues of the canine ventricle. In addition, strong sodium channel current inhibition was found to cause loss of the action potential dome in epicardium but not endocardium, thus inducing a marked dispersion of repolarization and refractoriness between epicardium and endocardium as well as among neighboring epicardial sites. The marked heterogeneity that evolves under these conditions provides a substrate for the development of arrhythmias. Flecainide was found to induce extrasystolic activity more readily than other sodium blockers. The present study contrasts the electrophysiological actions of flecainide in canine ventricular epicardium and endocardium and examines the characteristics of flecainide-induced arrhythmias in epicardial sheets of canine ventricle.

METHODS AND RESULTS

Standard microelectrode techniques were used. Flecainide (10-20 microM) produced either prolongation or marked abbreviation of APD in epicardium but only minor changes in the APD of endocardium. Marked abbreviation of APD in epicardium was due to loss of the action potential dome (plateau phase). Arrhythmias displaying characteristics of reentry could be readily induced in flecainide-treated preparations either by increasing the stimulation rate or by introduction of extrastimuli. Flecainide-induced slowing of conduction, more accentuated at the faster stimulation rates, appeared to act synergistically with the drug-induced dispersion of repolarization to generate reentry in these relatively small sheets of epicardium. 4-Aminopyridine, a transient outward current (Ito) blocker, reversed the flecainide-induced marked abbreviation of APD in epicardium and abolished reentrant activity in all cases. Flecainide failed to induce reentry in preparations pretreated with 4-aminopyridine.

CONCLUSIONS

Our data suggest that the presence of a prominent Ito in epicardium contributes the development of marked electrical heterogeneity in the ventricle after exposure to flecainide. Flecainide-induced dispersion of repolarization, especially when accompanied by prominent conduction delays, results in extrasystolic activity via a mechanism that we have termed "phase 2 reentry." Our results also suggest a role for Ito blockers in the treatment of reentrant arrhythmias.

Reflection after delayed excitation in a computer model of a single fiber

Reflection (reflected reentry) is a case of reentry in a one-dimensional structure, divided into proximal and distal segments, in which tissue excited by a wave front propagating in a forward direction is reexcited by electrical activity coming backward from the original direction of propagation. Cases of reflection have been demonstrated in Purkinje fibers and in ventricular muscle preparations containing multiple fibers. Several mechanisms possibly responsible for reflected reentry have been proposed. However, the difficulty in the interpretation of the experimental results, as well as the limited number of different conditions in which reflection was obtained, has kept open the question about conditions and mechanisms for reflection. We have developed a computer model in which reflection occurs. The model involves a single fiber and uses the DiFrancesco-Noble equations for the Purkinje fiber to model the ionic currents. The results show that reflection is possible in a single fiber and that diastolic depolarization (automaticity) is not a requirement for reflection. Active membrane responses to a just-above-threshold stimulus were important for achieving the necessary time delay. Systematic simulations showed further that reflection occurred only when the right coupling conditions linked a short or long proximal fiber to a short distal segment.