Role of early afterdepolarization in familial long QTU syndrome and torsade de pointes

Frequency-dependent acceleration of cardiac repolarization by progesterone underlying its cardiac protection against drug-induced proarrhythmic effects in female rabbits

Concurrent supplement of estradiol and progesterone has been shown to reduce the cardiac sensitivity to class III antiarrhythmic agent-induced arrhythmias in ovariectomized rabbits. To understand the underlying cardiac electrophysiological mechanisms of the hormones, present study explored the modulation of progesterone and estradiol on repolarization and its frequency dependence in papillary muscles of female rabbit right ventricles by glass microelectrode technique. Results showed that progesterone shortened action potential duration for 90% repolarization (APD(90)) whereas estradiol prolonged APD(90) and those actions on APD(90) were concentration-dependent for both hormones at 1.0-30 μM (P<0.05 or P<0.01). Further, the action of both hormones on APD(90) was found to be dependent on stimulation frequencies (0.2-3.3Hz). The shortening of APD(90) by progesterone (10 μM) was enhanced with the increase in frequencies reaching a statistic significance at frequencies ≥1.0 Hz, whereas the prolongation of APD(90) by estradiol (3 μM) was weakened with the increase in frequencies and the significant change was observed at frequencies ≤2.0 Hz (P<0.05 or P<0.01). More interestingly, the relative change of APD(90) and the incidence of early afterdepolarization induced after by dofetilide (0.1 μM), a class III antiarrhythmic agent, were significantly less or lower in the papillary muscles pretreated with progesterone than in those pretreated with estradiol (P<0.01 or P<0.05). In conclusion, progesterone has a reverse modulating affect on cardiac repolarization to that of estradiol. By acceleration of ventricular repolarization, progesterone may reduce the susceptibility of females to class III antiarrhythmic agents-induced proarrhythmic affection.

Concurrent supplement of estradiol and progesterone reduces the cardiac sensitivity to D,L-sotalol-induced arrhythmias in ovariectomized rabbits

BACKGROUND

Although the difference in the modulation of estradiol and dihydrotesterone on ventricular repolarization has been intensively studied, little information is available concerning the role of the different ovarian hormones in the modulation of repolarization in the female.

METHODS

The chronic modulation of female hormones, estradiol, and progesterone, on cardiac repolarization and the susceptibility to d,l-sotalol, a class III antiarrhythmic agent, were studied in female rabbits by ovariectomy and hormone replacement therapy (HRT) through recording and analyzing of electrocardiograms.

RESULTS

The corrected QT interval (QTc) measured 2 weeks after ovariectomy was not significantly different from that in the time-matched control rabbits. After 2 weeks of HRT, the QTc in the ovariectomized rabbits treated with estradiol alone (group E) was not significantly different from that in the control (group C); whereas in the ovariectomized rabbits treated with estradiol plus progesterone (group E + P), it was significantly shorter than those in groups E (P < .05) and C (P < .01), respectively. The corrected Tpeak-end interval (Tpec), an indicator of global dispersion of ventricular repolarization, was also significantly reduced in group E + P compared with that of group C (P < .01). In group E, d,l-sotalol-induced prolongation of QTc and the rate and the severity of arrhythmias were significantly higher, while the dose of sotalol to initiate arrhythmias was significantly lower than those in groups C or E + P, respectively (P < .05 or P < .01).

CONCLUSION

Estradiol potentiates QTc prolonging effects of d,l-sotalol and increases the susceptibility to d,l-sotalol-induced arrhythmias without significantly altering QTc itself, whereas progesterone may accelerate the process of repolarization and protect the females from drug-induced arrhythmias, thus counteracting the effect of estradiol.

Detection, properties, and frequency of local calcium release from the sarcoplasmic reticulum in teleost cardiomyocytes

Calcium release from the sarcoplasmic reticulum (SR) plays a central role in the regulation of cardiac contraction and rhythm in mammals and humans but its role is controversial in teleosts. Since the zebrafish is an emerging model for studies of cardiovascular function and regeneration we here sought to determine if basic features of SR calcium release are phylogenetically conserved. Confocal calcium imaging was used to detect spontaneous calcium release (calcium sparks and waves) from the SR. Calcium sparks were detected in 16 of 38 trout atrial myocytes and 6 of 15 ventricular cells. The spark amplitude was 1.45±0.03 times the baseline fluorescence and the time to half maximal decay of sparks was 27±3 ms. Spark frequency was 0.88 sparks µm(-1) min(-1) while calcium waves were 8.5 times less frequent. Inhibition of SR calcium uptake reduced the calcium transient (F/F(0)) from 1.77±0.17 to 1.12±0.18 (p = 0.002) and abolished calcium sparks and waves. Moreover, elevation of extracellular calcium from 2 to 10 mM promoted early and delayed afterdepolarizations (from 0.6±0.3 min(-1) to 8.1±2.0 min(-1), p = 0.001), demonstrating the ability of SR calcium release to induce afterdepolarizations in the trout heart. Calcium sparks of similar width and duration were also observed in zebrafish ventricular myocytes. In conclusion, this is the first study to consistently report calcium sparks in teleosts and demonstrate that the basic features of calcium release through the ryanodine receptor are conserved, suggesting that teleost cardiac myocytes is a relevant model to study the functional impact of abnormal SR function.

Diverse modulating effects of estradiol and progesterone on the monophasic action potential duration in Langendorff-perfused female rabbit hearts

This study aimed to comparatively investigate the acute modulating effects of oestrogen and progesterone on the repolarization and the susceptibility of female rabbits to class III anti-arrhythmic agents. The acute influence of estradiol and progesterone on the cardiac repolarization and the drug sensitivity of the rapidly activating delayed rectifier K(+) channel to sotalol was comparatively studied in Langendorff-perfused rabbit hearts at pharmacological concentrations through recording of epicardial monophasic action potentials. In Langendorff-perfused rabbit hearts, estradiol (1-30 μm) concentration-dependently prolonged the monophasic action potential durations (MAPD(30) and MAPD(90) ) (P < 0.05); while the effects of progesterone on MAPD were biphasic: it prolonged MAPD(30) and MAPD(90) at lower concentrations (1-3 μm) but shortened MAPD(30) and MAPD(90) at higher concentrations (10-30 μm). Sotalol-induced prolongation of MAPD(90) was significantly less in the hearts pretreated with progesterone than those treated with estradiol (P < 0.05). The incidence of the pro-arrhythmic events induced by sotalol in the hearts pretreated with progesterone was also significantly lower than those pretreated with estradiol (P < 0.05). In conclusion, estradiol and progesterone have different modulating effects on cardiac repolarization: estradiol can concentration-dependently prolong the cardiac repolarization time and thus may reduce the repolarization reserve and increase the susceptibility of female rabbits to sotalol-induced arrhythmias, whereas progesterone may shorten the cardiac repolarization time at concentrations above 10 μm, thus protecting the heart from drug-induced arrhythmias.

Quinidine revisited

One of the earliest antiarrhythmic drugs developed, quinidine had a significant role in the treatment of many arrhythmias. After concerns for increased risk of ventricular arrhythmia and death with quinidine emerged, the use of quinidine fell dramatically in favor of newer antiarrhythmic medications. However, recent trials have generated renewed interest in the use of quinidine. In particular, quinidine appears to be safe and efficacious in combination with verapamil for the treatment of atrial fibrillation. Quinidine has also been used successfully to treat idiopathic ventricular fibrillation, Brugada syndrome, and Short QT syndrome. Although it is one of the oldest drugs in our armamentarium, quinidine continues to have a role in modern cardiology.

Voltage noise influences action potential duration in cardiac myocytes

Stochastic gating of ion channels introduces noise to membrane currents in cardiac muscle cells (myocytes). Since membrane currents drive membrane potential, noise thereby influences action potential duration (APD) in myocytes. To assess the influence of noise on APD, membrane potential is in this study formulated as a stochastic process known as a diffusion process, which describes both the current-voltage relationship and voltage noise. In this framework, the response of APD voltage noise and the dependence of response on the shape of the current-voltage relationship can be characterized analytically. We find that in response to an increase in noise level, action potential in a canine ventricular myocytes is typically prolonged and that distribution of APDs becomes more skewed towards long APDs, which may lead to an increased frequency of early after-depolarization formation. This is a novel mechanism by which voltage noise may influence APD. The results are in good agreement with those obtained from more biophysically-detailed mathematical models, and increased voltage noise (due to gating noise) may partially underlie an increased incidence of early after-depolarizations in heart failure.

Influence of Menstrual Cycle on QT Interval Dynamics

OBJECTIVES

The aim of this study was to investigate the effects of the menstrual cycle on QT interval dynamics and the autonomic tone in healthy women.

METHODS

Holter ECGs were recorded in 11 healthy women aged 18-32 years during the follicular and luteal phases of their regular menstrual cycle. The interval from QRS onset to the apex (QaT) and to the end of the T-wave (QeT), the interval between the apex and the end of the T-wave (Ta-e), and RR intervals were measured automatically in the course of 24 hours by Holter ECGs. The QeT/RR, QaT/RR, and Ta-e/RR relationships were evaluated in each subject. The autonomic tone was assessed by the serum catecholamine level at rest and heart rate variability was measured by Holter ECGs.

RESULTS

(1) The follicular and luteal phases did not differ significantly with respect to the slopes of the QeT/RR, QaT/RR, and Ta-e/RR relationships. However, QeT and QaT intervals were significantly shorter for all RR intervals in the luteal than in the follicular phase (P < 0.0001). (2) The serum progesterone concentration was significantly higher in the luteal than in the follicular phase (P < 0.001). (3) Noradrenaline was significantly higher in the luteal than in the follicular phase (P < 0.05). There was no significant difference in the follicular and luteal phases with respect to heart rate variability measurements.

CONCLUSIONS

Our results suggest that the menstrual cycle affects the QT intervals. The observed shorter QT interval during the luteal than the follicular phase may be attributable to the increase in serum progesterone and sympathetic tone.

The role of stochastic and modal gating of cardiac L-type Ca2+ channels on early after-depolarizations

Certain signaling events that promote L-type Ca2+ channel (LCC) phosphorylation, such as beta-adrenergic stimulation or an increased expression of Ca(2+)/calmodulin-dependent protein kinase II, promote mode 2 gating of LCCs. Experimental data suggest the hypothesis that these events increase the likelihood of early after-depolarizations (EADs). We test this hypothesis using an ionic model of the canine ventricular myocyte incorporating stochastic gating of LCCs and ryanodine-sensitive calcium release channels. The model is extended to describe myocyte responses to the beta-adrenergic agonist isoproterenol. Results demonstrate that in the presence of isoproterenol the random opening of a small number of LCCs gating in mode 2 during the plateau phase of the action potential (AP) can trigger EADs. EADs occur randomly, where the likelihood of these events increases as a function of the fraction of LCCs gating in mode 2. Fluctuations of the L-type Ca2+ current during the AP plateau lead to variability in AP duration. Consequently, prolonged APs are occasionally observed and exhibit an increased likelihood of EAD formation. These results suggest a novel stochastic mechanism, whereby phosphorylation-induced changes in LCC gating properties contribute to EAD generation.

A patient with LQTS in whom verapamil administration and permanent pacemaker implantation were useful for preventing torsade de pointes

A 21-year-old woman with long QT syndrome and missense mutation in HERG (T613M), suffered from repeated attacks of pause dependent torsade de pointes, even though she was given beta-blockers and underwent stellate ganglion block twice at the age of eight. After she received permanent pacemaker implantation and administration of verapamil, no premature beats or pause dependent torsade de pointes was observed.

Long QT syndrome

In conclusion, much has been learned in the past several years regarding the molecular biology of LQTS, and this information has been directly applicable to the clinical care of patients with this syndrome. The knowledge also has been of considerable importance for understanding the molecular basis of arrhythmias in general and is providing insights into potential molecular-based therapies for arrhythmias.

Deletion of protein kinase A phosphorylation sites in the HERG potassium channel inhibits activation shift by protein kinase A

We investigated the role of protein kinase A (PKA) in regulation of the human ether-a-go-go-related gene (HERG) potassium channel activation. HERG clones with single mutations destroying one of four consensus PKA phosphorylation sites (S283A, S890A, T895A, S1137A), as well as one clone carrying all mutations with no PKA phosphorylation sites (HERG 4M) were constructed. These clones were expressed heterologously in Xenopus oocytes, and HERG potassium currents were measured with the two microelectrode voltage clamp technique. Application of the cAMP-specific phosphodiesterase (PDE IV) inhibitor Ro-20-1724 (100 microM), which results in an increased cAMP level and PKA stimulation, induced a reduction of HERG wild type outward currents by 19.1% due to a shift in the activation curve of 12.4 mV. When 100 microM Ro-20-1724 was applied to the HERG 4M channel, missing all PKA sites, there was no significant shift in the activation curve, and the current amplitude was not reduced. Furthermore, the adenylate cyclase activator forskolin that leads to PKA activation (400 microM, 60 min), shifted HERG wild type channel activation by 14.1 mV and reduced currents by 39.9%, whereas HERG 4M channels showed only a small shift of 4.3 mV and a weaker current reduction of 22.3%. We conclude that PKA regulates HERG channel activation, and direct phosphorylation of the HERG channel protein has a functional role that may be important in regulation of cardiac repolarization.

The long QT syndrome: ion channel diseases of the heart

Once limited to discussions of the Jervell and Lange-Nielsen syndrome and Romano-Ward syndrome, the long QT syndrome (LQTS) is now understood to be a collection of genetically distinct arrhythmogenic cardiovascular disorders resulting from mutations in fundamental cardiac ion channels that orchestrate the action potential of the human heart. Our understanding of this genetic "channelopathy" has increased dramatically from electrocardiographic depictions of marked QT interval prolongation and torsades de pointes and clinical descriptions of people experiencing syncope and sudden death to molecular revelations in the 1990s of perturbed ion channel genes. More than 35 mutations in four cardiac ion channel genes--KVLQT1 (voltage-gated K channel gene causing one of the autosomal dominant forms of LQTS) (LQT1), HERG (human ether-a-go-go related gene.) (LQT2), SCN5A (LQT3), and KCNE1 (minK, LQT5)--have been identified in LQTS. These genes encode ion channels responsible for three of the fundamental ionic currents in the cardiac action potential. These exciting molecular break-throughs have provided new opportunities for translational research with investigations into genotype-phenotype correlations and gene-targeted therapies.

Electrophysiologic features of torsades de pointes: insights from a new isolated rabbit heart model

INTRODUCTION

The exact electrophysiologic mechanism of torsades de pointes (TdP) is under intense investigation. No isolated animal heart model of this particular arrhythmia exists.

METHODS AND RESULTS

In isolated rabbit hearts, TdP was induced by means of bradycardia in the presence of a high concentration of d-sotalol (10(-4) M) and shortly after lowering the concentration of potassium and magnesium in the perfusate. Multiple simultaneous epicardial and endocardial monophasic action potentials (MAPs) and volume-conducted 12-lead ECGs were recorded. d-Sotalol prolonged repolarization and increased dispersion of ventricular repolarization compared to baseline recordings. With the onset of low potassium and magnesium concentrations, repolarization was further prolonged and dispersion of repolarization was further increased followed by the occurrence of early afterdepolarizations (EADs) in the majority of MAP recordings, i.e., at both endocardial and epicardial locations of both ventricles. Upon increase of EAD amplitude, triggered arrhythmias with TdP of up to 42 beats ensued in 10 of 11 hearts studied. MAP duration at 90% repolarization (APD90), dispersion of APD90, and the incidence of EADs as well as dispersion of the QT interval and T wave area were significantly higher in beats triggering bigemini, couplets, or runs of TdP.

CONCLUSION

TdP observed in this new isolated heart model was associated with markedly increased dispersion of ventricular repolarization and the occurrence of EADs in multiple locations of the heart. TdP is initiated when the amplitude of an EAD reaches threshold for initiation of the first beat of an episode.

Mode of onset of torsade de pointes in congenital long QT syndrome

OBJECTIVES

We sought to describe the mode of onset of spontaneous torsade de pointes in the congenital long QT syndrome.

BACKGROUND

Contemporary classifications of the long QT syndrome (LQTS) refer to the congenital LQTS as "adrenergic dependent" and to the acquired LQTS as "pause dependent." Overlap between these two categories has been recognized, and a subgroup of patients with "idiopathic pause-dependent torsade" has been described. However, it is not known how commonly torsade is preceded by pauses in the congenital LQTS.

METHODS

We reviewed the electrocardiograms (ECGs) of all our patients with congenital LQTS evaluated for syncope or sudden death (30 patients). Documentation of the onset of torsade de pointes was available for 15 patients. All these patients had "definitive LQTS" by accepted clinical and ECG criteria.

RESULTS

Pause-dependent torsade de pointes was clearly documented in 14 of the 15 patients (95% confidence interval 68% to 100%). The cycle length of the pause leading to torsade was 1.3 +/- 0.2 times longer than the basic cycle length, and most pauses leading to torsade were unequivocally longer than the preceding basic cycle length (80% of pauses were > 80 ms longer than the preceding cycle length).

CONCLUSIONS

The "long-short" sequence, which has been recognized as a hallmark of torsade de pointes in the acquired LQTS, plays a major role in the genesis of torsade in the congenital LQTS as well. Our findings have important therapeutic implications regarding the use of pacemakers for prevention of torsade in the congenital LQTS.

Multiple mechanisms of Na+ channel--linked long-QT syndrome

Inheritable long-QT syndrome (LQTS) is a disease in which delayed ventricular repolarization leads to cardiac arrhythmias and the possibility of sudden death. In the chromosome 3-linked disease, one mutation of the cardiac Na+ channel gene results in a deletion of residues 1505 to 1507 (Delta KPQ), and two mutation result in substitutions (N1325S and R1644H). We compared all three mutant-channel phenotypes by heterologous expression in Xenopus oocytes. Each produced a late phase of inactivation-resistant, mexiletine- and tetrodotoxin-sensitive whole-cell currents, but the underlying mechanisms were different at the single-channel level. N1325S and R1644H showed dispersed reopenings after the initial transient, whereas Delta KPQ showed both dispersed reopenings and long-lasting bursts. Thus, two distinct biophysical defects underlie the in vitro phenotype of persistent current in Na+ channel-linked LQTS, and the additive effects of both are responsible for making the Delta KPQ phenotype the most severe.

Genetics and molecular biology of the inherited long QT syndrome

Two forms of the inherited long QT syndrome have been known for many years: the autosomal recessive Jervell and Lange-Nielsen form and the autosomal dominant Romano-Ward form. A gene marker at the 11p 15.5 locus has been identified for some, but not all, families with the autosomal dominant form, but as yet the gene has not been identified. It is apparent that mutations of at least four genes, and possibly more, can cause the syndrome. The molecular biology of the syndrome is not yet clarified, but abnormalities of ion channel function are likely, particularly the potassium delayed rectifier current. Proposals for the pathophysiology include an abnormality of a G protein which controls ion channel and adrenergic pathway function, as well as a disturbance of the sympathetic nervous system. The identification of the abnormal gene(s) and the gene products will provide precise information on the molecular physiology of the syndrome.