1
|
Camps J, Berg LA, Wang ZJ, Sebastian R, Riebel LL, Doste R, Zhou X, Sachetto R, Coleman J, Lawson B, Grau V, Burrage K, Bueno-Orovio A, Weber Dos Santos R, Rodriguez B. Digital twinning of the human ventricular activation sequence to Clinical 12-lead ECGs and magnetic resonance imaging using realistic Purkinje networks for in silico clinical trials. Med Image Anal 2024; 94:103108. [PMID: 38447244 DOI: 10.1016/j.media.2024.103108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 02/06/2024] [Accepted: 02/13/2024] [Indexed: 03/08/2024]
Abstract
Cardiac in silico clinical trials can virtually assess the safety and efficacy of therapies using human-based modelling and simulation. These technologies can provide mechanistic explanations for clinically observed pathological behaviour. Designing virtual cohorts for in silico trials requires exploiting clinical data to capture the physiological variability in the human population. The clinical characterisation of ventricular activation and the Purkinje network is challenging, especially non-invasively. Our study aims to present a novel digital twinning pipeline that can efficiently generate and integrate Purkinje networks into human multiscale biventricular models based on subject-specific clinical 12-lead electrocardiogram and magnetic resonance recordings. Essential novel features of the pipeline are the human-based Purkinje network generation method, personalisation considering ECG R wave progression as well as QRS morphology, and translation from reduced-order Eikonal models to equivalent biophysically-detailed monodomain ones. We demonstrate ECG simulations in line with clinical data with clinical image-based multiscale models with Purkinje in four control subjects and two hypertrophic cardiomyopathy patients (simulated and clinical QRS complexes with Pearson's correlation coefficients > 0.7). Our methods also considered possible differences in the density of Purkinje myocardial junctions in the Eikonal-based inference as regional conduction velocities. These differences translated into regional coupling effects between Purkinje and myocardial models in the monodomain formulation. In summary, we demonstrate a digital twin pipeline enabling simulations yielding clinically consistent ECGs with clinical CMR image-based biventricular multiscale models, including personalised Purkinje in healthy and cardiac disease conditions.
Collapse
Affiliation(s)
- Julia Camps
- University of Oxford, Oxford, United Kingdom.
| | | | | | | | | | - Ruben Doste
- University of Oxford, Oxford, United Kingdom
| | - Xin Zhou
- University of Oxford, Oxford, United Kingdom
| | - Rafael Sachetto
- Universidade Federal de São João del Rei, São João del Rei, MG, Brazil
| | | | - Brodie Lawson
- Queensland University of Technology, Brisbane, Australia
| | | | - Kevin Burrage
- University of Oxford, Oxford, United Kingdom; Queensland University of Technology, Brisbane, Australia
| | | | | | | |
Collapse
|
2
|
O' Brien S, Holmes AP, Johnson DM, Kabir SN, O' Shea C, O' Reilly M, Avezzu A, Reyat JS, Hall AW, Apicella C, Ellinor PT, Niederer S, Tucker NR, Fabritz L, Kirchhof P, Pavlovic D. Increased atrial effectiveness of flecainide conferred by altered biophysical properties of sodium channels. J Mol Cell Cardiol 2022; 166:23-35. [PMID: 35114252 DOI: 10.1016/j.yjmcc.2022.01.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 01/13/2022] [Accepted: 01/26/2022] [Indexed: 11/25/2022]
Abstract
Atrial fibrillation (AF) affects over 1% of the population and is a leading cause of stroke and heart failure in the elderly. A feared side effect of sodium channel blocker therapy, ventricular pro-arrhythmia, appears to be relatively rare in patients with AF. The biophysical reasons for this relative safety of sodium blockers are not known. Our data demonstrates intrinsic differences between atrial and ventricular cardiac voltage-gated sodium currents (INa), leading to reduced maximum upstroke velocity of action potential and slower conduction, in left atria compared to ventricle. Reduced atrial INa is only detected at physiological membrane potentials and is driven by alterations in sodium channel biophysical properties and not by NaV1.5 protein expression. Flecainide displayed greater inhibition of atrial INa, greater reduction of maximum upstroke velocity of action potential, and slowed conduction in atrial cells and tissue. Our work highlights differences in biophysical properties of sodium channels in left atria and ventricles and their response to flecainide. These differences can explain the relative safety of sodium channel blocker therapy in patients with atrial fibrillation.
Collapse
Affiliation(s)
- Sian O' Brien
- Institute of Cardiovascular Science, University of Birmingham, Birmingham, UK
| | - Andrew P Holmes
- Institute of Cardiovascular Science, University of Birmingham, Birmingham, UK; School of Biomedical Sciences, Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Daniel M Johnson
- Institute of Cardiovascular Science, University of Birmingham, Birmingham, UK; School of Life, Health and Chemical Sciences, The Open University, Walton Hall, Milton Keynes, UK
| | - S Nashitha Kabir
- Institute of Cardiovascular Science, University of Birmingham, Birmingham, UK
| | - Christopher O' Shea
- Institute of Cardiovascular Science, University of Birmingham, Birmingham, UK
| | - Molly O' Reilly
- Institute of Cardiovascular Science, University of Birmingham, Birmingham, UK
| | - Adelisa Avezzu
- School of Biomedical Engineering & Imaging Sciences, Kings' College London, London, UK
| | - Jasmeet S Reyat
- Institute of Cardiovascular Science, University of Birmingham, Birmingham, UK
| | - Amelia W Hall
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA 02129, USA; Cardiovascular Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Clara Apicella
- Institute of Cardiovascular Science, University of Birmingham, Birmingham, UK
| | - Patrick T Ellinor
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA 02129, USA; Cardiovascular Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Steven Niederer
- School of Biomedical Engineering & Imaging Sciences, Kings' College London, London, UK
| | - Nathan R Tucker
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA 02129, USA; Cardiovascular Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; Masonic Medical Research Institute, Utica, NY, 13501, USA
| | - Larissa Fabritz
- Institute of Cardiovascular Science, University of Birmingham, Birmingham, UK; University Center of Cardiovascular Science, University Heart and Vascular Center UKE, Hamburg, Germany; Department of Cardiology, University Heart and Vascular Center UKE, Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Germany
| | - Paulus Kirchhof
- Institute of Cardiovascular Science, University of Birmingham, Birmingham, UK; Department of Cardiology, University Heart and Vascular Center UKE, Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Germany
| | - Davor Pavlovic
- Institute of Cardiovascular Science, University of Birmingham, Birmingham, UK.
| |
Collapse
|
3
|
Jian K, Li C, Hancox JC, Zhang H. Pro-Arrhythmic Effects of Discontinuous Conduction at the Purkinje Fiber-Ventricle Junction Arising From Heart Failure-Induced Ionic Remodeling - Insights From Computational Modelling. Front Physiol 2022; 13:877428. [PMID: 35547576 PMCID: PMC9081695 DOI: 10.3389/fphys.2022.877428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 03/18/2022] [Indexed: 11/18/2022] Open
Abstract
Heart failure is associated with electrical remodeling of the electrical properties and kinetics of the ion channels and transporters that are responsible for cardiac action potentials. However, it is still unclear whether heart failure-induced ionic remodeling can affect the conduction of excitation waves at the Purkinje fiber-ventricle junction contributing to pro-arrhythmic effects of heart failure, as the complexity of the heart impedes a detailed experimental analysis. The aim of this study was to employ computational models to investigate the pro-arrhythmic effects of heart failure-induced ionic remodeling on the cardiac action potentials and excitation wave conduction at the Purkinje fiber-ventricle junction. Single cell models of canine Purkinje fiber and ventricular myocytes were developed for control and heart failure. These single cell models were then incorporated into one-dimensional strand and three-dimensional wedge models to investigate the effects of heart failure-induced remodeling on propagation of action potentials in Purkinje fiber and ventricular tissue and at the Purkinje fiber-ventricle junction. This revealed that heart failure-induced ionic remodeling of Purkinje fiber and ventricular tissue reduced conduction safety and increased tissue vulnerability to the genesis of the unidirectional conduction block. This was marked at the Purkinje fiber-ventricle junction, forming a potential substrate for the genesis of conduction failure that led to re-entry. This study provides new insights into proarrhythmic consequences of heart failure-induced ionic remodeling.
Collapse
Affiliation(s)
- Kun Jian
- Biological Physics Group, Department of Physics and Astronomy, The University of Manchester, Manchester, United Kingdom
| | - Chen Li
- Biological Physics Group, Department of Physics and Astronomy, The University of Manchester, Manchester, United Kingdom
| | - Jules C. Hancox
- Biological Physics Group, Department of Physics and Astronomy, The University of Manchester, Manchester, United Kingdom
- School of Physiology, Pharmacology and Neuroscience, Medical Sciences Building, University Walk, Bristol, United Kingdom
| | - Henggui Zhang
- Biological Physics Group, Department of Physics and Astronomy, The University of Manchester, Manchester, United Kingdom
- Key Laboratory of Medical Electrophysiology of Ministry of Education and Medical Electrophysiological Key Laboratory of Sichuan Province, Institute of Cardiovascular Research, Southwest Medical University, Luzhou, China
| |
Collapse
|
4
|
Barber F, Langfield P, Lozano M, Garcia-Fernandez I, Duchateau J, Hocini M, Haissaguerre M, Vigmond E, Sebastian R. Estimation of Personalized Minimal Purkinje Systems From Human Electro-Anatomical Maps. IEEE TRANSACTIONS ON MEDICAL IMAGING 2021; 40:2182-2194. [PMID: 33856987 DOI: 10.1109/tmi.2021.3073499] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The Purkinje system is a heart structure responsible for transmitting electrical impulses through the ventricles in a fast and coordinated way to trigger mechanical contraction. Estimating a patient-specific compatible Purkinje Network from an electro-anatomical map is a challenging task, that could help to improve models for electrophysiology simulations or provide aid in therapy planning, such as radiofrequency ablation. In this study, we present a methodology to inversely estimate a Purkinje network from a patient's electro-anatomical map. First, we carry out a simulation study to assess the accuracy of the method for different synthetic Purkinje network morphologies and myocardial junction densities. Second, we estimate the Purkinje network from a set of 28 electro-anatomical maps from patients, obtaining an optimal conduction velocity in the Purkinje network of 1.95 ± 0.25 m/s, together with the location of their Purkinje-myocardial junctions, and Purkinje network structure. Our results showed an average local activation time error of 6.8±2.2 ms in the endocardium. Finally, using the personalized Purkinje network, we obtained correlations higher than 0.85 between simulated and clinical 12-lead ECGs.
Collapse
|
5
|
Doki K. Use of Pharmacogenetic Information for Therapeutic Drug Monitoring of an Antiarrhythmic Drug. YAKUGAKU ZASSHI 2018; 138:1145-1150. [DOI: 10.1248/yakushi.18-00114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Kosuke Doki
- Department of Pharmaceutical Sciences, Faculty of Medicine, University of Tsukuba
| |
Collapse
|
6
|
β1-Adrenergic receptor Arg389Gly polymorphism affects the antiarrhythmic efficacy of flecainide in patients with coadministration of β-blockers. Pharmacogenet Genomics 2017; 26:481-5. [PMID: 27500822 DOI: 10.1097/fpc.0000000000000239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE β1-Adrenergic receptor (β1-AR) stimulation modulates the antiarrhythmic activities of sodium channel blockers. The β1-AR Gly389 variant shows a marked decrease in agonist-stimulated cyclic AMP production compared with that of the wild-type Arg389 in vitro. We investigated whether the Arg389Gly polymorphism affects the efficacy of flecainide, a typical sodium channel blocker, in patients with or without coadministration of β-blockers. METHODS The effects of the β1-AR Arg389Gly polymorphism on the antiarrhythmic efficacy of flecainide were compared between with and without coadministered β-blockers in 159 patients with supraventricular tachyarrhythmia. The antiarrhythmic efficacy of flecainide was assessed for at least 2 months by evaluating symptomatology, 12-lead ECGs, and Holter monitoring results. RESULTS Genetic differences in the antiarrhythmic efficacy of flecainide were observed in patients with coadministration of β-blockers. Tachyarrhythmia was well controlled in 60% of Arg389-homozygotes, 30% of Gly389-heterozygotes, and 0% of Gly389-homozygotes (P=0.001). In contrast, no difference in the antiarrhythmic efficacy was observed among the three genotypes in the patients without coadministration of β-blockers (64, 70, and 60%, respectively). Heart rate in tachyarrhythmia in patients treated with flecainide was significantly higher in Gly389 carriers than in Arg389-homozygotes (P=0.013). CONCLUSION The Gly389 polymorphism decreased the antiarrhythmic efficacy of flecainide when coadministered with β-blockers. The results indicate that the Arg389Gly polymorphism may play an important role in predicting the efficacy of flecainide in patients with coadministration of β-blockers.
Collapse
|
7
|
Nia AM, Caglayan E, Gassanov N, Zimmermann T, Aslan O, Hellmich M, Duru F, Erdmann E, Rosenkranz S, Er F. Beta1-adrenoceptor polymorphism predicts flecainide action in patients with atrial fibrillation. PLoS One 2010; 5:e11421. [PMID: 20625396 PMCID: PMC2896398 DOI: 10.1371/journal.pone.0011421] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Accepted: 06/11/2010] [Indexed: 01/08/2023] Open
Abstract
Background Antiarrhythmic action of flecainide is based on sodium channel blockade. Beta1-adrenoceptor (β1AR) activation induces sodium channel inhibition, too. The aim of the present study was to evaluate the impact of different β1AR genotypes on antiarrhythmic action of flecainide in patients with structural heart disease and atrial fibrillation. Methodology/Principal Findings In 145 subjects, 87 with atrial fibrillation, genotyping was performed to identify the individual β1AR Arg389Gly and Ser49Gly polymorphism. Resting heart rate during atrial fibrillation and success of flecainide-induced cardioversion were correlated with β1AR genotype. The overall cardioversion rate with flecainide was 39%. The Arg389Arg genotype was associated with the highest cardioversion rate (55.5%; OR 3.30; 95% CI; 1.34–8.13; p = 0.003) compared to patients with Arg389Gly (29.5%; OR 0.44; 95% CI; 0.18–1.06; p = 0.066) and Gly389Gly (14%; OR 0.24; 95% CI 0.03–2.07; p = 0.17) variants. The single Ser49Gly polymorphism did not influence the conversion rate. In combination, patients with Arg389Gly-Ser49Gly genotype displayed the lowest conversion rate with 20.8% (OR 0.31; 95% CI; 0.10–0.93; p = 0.03). In patients with Arg389Arg variants the heart rate during atrial fibrillation was significantly higher (110±2.7 bpm; p = 0.03 vs. other variants) compared to Arg389Gly (104.8±2.4 bpm) and Gly389Gly (96.9±5.8 bpm) carriers. The Arg389Gly-Ser49Gly genotype was more common in patients with atrial fibrillation compared to patients without atrial fibrillation (27.6% vs. 5.2%; HR 6.98; 95% CI; 1.99–24.46; p<0.001). Conclusions The β1AR Arg389Arg genotype is associated with increased flecainide potency and higher heart rate during atrial fibrillation. The Arg389Gly-Ser49Gly genotype might be of predictive value for atrial fibrillation.
Collapse
Affiliation(s)
- Amir M. Nia
- Department of Internal Medicine III, University of Cologne, Cologne, Germany
| | - Evren Caglayan
- Department of Internal Medicine III, University of Cologne, Cologne, Germany
| | - Natig Gassanov
- Department of Internal Medicine III, University of Cologne, Cologne, Germany
| | - Tom Zimmermann
- Department of Internal Medicine III, University of Cologne, Cologne, Germany
| | - Orhan Aslan
- Department of Internal Medicine III, University of Cologne, Cologne, Germany
| | - Martin Hellmich
- Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Cologne, Germany
| | - Firat Duru
- Clinic for Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Erland Erdmann
- Department of Internal Medicine III, University of Cologne, Cologne, Germany
| | - Stephan Rosenkranz
- Department of Internal Medicine III, University of Cologne, Cologne, Germany
| | - Fikret Er
- Department of Internal Medicine III, University of Cologne, Cologne, Germany
- * E-mail:
| |
Collapse
|
8
|
Clements-Jewery H, Kanaganayagam GS, Kabra R, Curtis MJ. Actions of flecainide on susceptibility to phase-2 ventricular arrhythmias during infarct evolution in rat isolated perfused hearts. Br J Pharmacol 2006; 147:468-75. [PMID: 16415912 PMCID: PMC1616984 DOI: 10.1038/sj.bjp.0706633] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The mechanism of flecainide-induced unexpected death remains uncertain. Phase-2 ventricular arrhythmias occur during infarct evolution. We examined whether flecainide (0.74 and 1.48 microM, representing the peak unbound plasma and total blood concentrations, respectively, at 'therapeutic' dosage) has proarrhythmic activity on phase-2 arrhythmia susceptibility during infarct evolution. To achieve this, we used the Langendorff-perfused rat heart preparation (n=8 per group) in which baseline phase-2 arrhythmia susceptibility is low. Left main coronary occlusion evoked phase-1 (acute ischaemia-induced) ventricular arrhythmias including fibrillation (VF) in all hearts. By 90 min, hearts were relatively arrhythmia-free. Randomized and blinded switch of perfusion to flecainide at 90 min caused no increase over baseline in the incidence of VF, tachycardia (VT) or premature beats (VPB) during the following 150 min of ischaemia, or during reperfusion (begun 240 min after the onset of ischaemia). In separate hearts, catecholamines (313 nM norepinephrine and 75 nM epinephrine) were co-perfused with flecainide from 90 min of ischaemia. Catecholamine perfusion increased heart rate, coronary flow and QT interval, and shortened PR interval (all P<0.05), actions that were not altered by flecainide. Catecholamine perfusion caused a weak nonsignificant increase in phase-2 VPB, VT and VF incidence, but there was no proarrhythmic interaction with flecainide. In conclusion, the present findings suggest that the increased risk of death associated with clinical use of flecainide is not due to facilitation of phase-2 ventricular arrhythmias.
Collapse
Affiliation(s)
- Hugh Clements-Jewery
- Cardiovascular Division, Kings College London, The Rayne Institute, St Thomas' Hospital, London, SE1 7EH
| | | | - Ruchi Kabra
- Cardiovascular Division, Kings College London, The Rayne Institute, St Thomas' Hospital, London, SE1 7EH
| | - Michael J Curtis
- Cardiovascular Division, Kings College London, The Rayne Institute, St Thomas' Hospital, London, SE1 7EH
- Author for correspondence:
| |
Collapse
|
9
|
Abstract
The Cardiac Arrhythmia Suppression Trial has shown that treatment with flecainide is associated with an increased incidence of cardiac death in patients following myocardial infarction. It is believed that there is a complex mechanism involving an interaction between flecainide, sympathetic activation, and acute ischemia that is responsible for the increased risk of sudden death. The purpose of this study was to determine the effects of flecainide on muscle sympathetic nerve activity (MSNA) in humans. We measured MSNA using microneurography and cardiac output using the dye dilution method in 30 healthy individuals. Measurements were made at rest and after the oral administration of flecainide (200mg, n=12) or placebo (n=9), or intravenous administration of propranolol (0.2 mg/kg, n=9). Flecainide significantly increased heart rate and decreased the cardiac index (both p<0.01). Flecainide increased the burst rate from 16.7 +/- 3.5 to 23.3 +/- 4.1 bursts/min and the burst incidence from 26.6 +/- 5.1 to 34.7 +/ -5.6bursts/100 heartbeats (both p<0.01). For all of the hemodynamic parameters except heart rate, the effects of propranolol were similar to those of flecainide. Propranolol also increased the burst rate by 52 +/- 34% and the burst incidence by 106 +/- 39%. These results suggest that flecainide suppresses myocardial contractility and produces reflex-mediated increases in sympathetic nerve firing in humans.
Collapse
Affiliation(s)
- Yoshiki Nagata
- Department of Cancer Gene Regulation, Gastroenterology and Nephrology, Graduate School of Medical Science, Kanazawa University, Japan.
| |
Collapse
|
10
|
Nakamura W, Segawa K, Ito H, Tanaka S, Yoshimoto N. Class IC antiarrhythmic drugs, flecainide and pilsicainide, produce ST segment elevation simulating inferior myocardial ischemia. J Cardiovasc Electrophysiol 1998; 9:855-8. [PMID: 9727664 DOI: 10.1111/j.1540-8167.1998.tb00125.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Flecainide and pilsicainide, Class IC antiarrhythmic drugs with slow kinetics, were administered to a 64-year-old man experiencing ventricular tachycardia. Both drugs suppressed the arrhythmia, but caused ST segment elevation in leads II, III, and aVF. No evidence of ischemic heart disease was detected. Withdrawal of the drugs eliminated the ST change. Because these drugs frequently are used to treat tachyarrhythmias in patients who may present with chest pain, this rare ECG manifestation of Class IC drugs should be recognized to avoid misdiagnosis of acute inferior myocardial infarction.
Collapse
Affiliation(s)
- W Nakamura
- The Third Department of Internal Medicine, Saitama Medical Center, Saitama Medical School, Kamoda, Kawagoe, Japan
| | | | | | | | | |
Collapse
|