Is the denervation or hyperinnervation of the cardiac sympathetic nerve in the subepicardium related to unexpected cardiac death?

BACKGROUND

Past studies have reported that abnormal innervation of cardiac sympathetic nerve can cause sudden cardiac death through the arrythmogenesis; however, the severe cardiac sympathetic degeneration does not necessarily cause clinical problems. This study aimed to examine whether denervation or hyperinnervation of cardiac sympathetic nerves in the subepicardium is associated with unexpected cardiac death (UCD).

METHODS

Cardiac tissues of 278 forensic autopsy cases within 48 h after death were analyzed by double-staining immunohistochemistry for tyrosine hydroxylase and neurofilament. The density of nerve fascicles and the degeneration rate in the subepicardium of the left ventricular anterior wall were compared between the UCD group and the non-UCD group.

RESULTS

The density of nerve fascicles was lower in the SCD group (median: 51.9/cm(2)) than in the non-SCD group (median: 58.9/cm(2)); however, the difference was not significant (P = .08). The degeneration rate was higher in the SCD group (median: 0.19) than in the non-SCD group (median: 0.17), but again, the difference was not significant (P = .43). The multiple logistic regression model did not show a significant association between the incidence of UCD and the density of nerve fascicles or the degeneration rate.

CONCLUSIONS

It cannot be concluded that the denervation or hyperinnervation of cardiac sympathetic nerves in the subepicardium is related to UCD. Abnormal innervation of cardiac sympathetic nerves in the subepicardium may not have a substantial effect on UCD, compared to other arrhythmogenic factors.

Distribution and morphology of calcitonin gene-related peptide and substance P immunoreactive axons in the whole-mount atria of mice

The murine model has been used to investigate the role of cardiac sensory axons in various disease states. However, the distribution and morphological structures of cardiac nociceptive axons in normal murine tissues have not yet been well characterized. In this study, whole-mount atria from FVB mice were processed with calcitonin gene-related peptide (CGRP) and substance P (SP) primary antibodies followed by secondary antibodies, and then examined using confocal microscopy. We found: 1) Large CGRP-IR axon bundles entered the atria with the major veins, and these large bundles bifurcated into small bundles and single axons that formed terminal end-nets and free endings in the epicardium. Varicose CGRP-IR axons had close contacts with muscle fibers, and some CGRP-IR axons formed varicosities around principle neurons (PNs) within intrinsic cardiac ganglia (ICGs). 2) SP-IR axons also were found in the same regions of the atria, attached to veins, and within cardiac ganglia. Similar to CGRP-IR axons, these SP-IR axons formed terminal end-nets and free endings in the atrial epicardium and myocardium. Within ICGs, SP-IR axons formed varicose endings around PNs. However, SP-IR nerve fibers were less abundant than CGRP-IR fibers in the atria. 3) None of the PNs were CGRP-IR or SP-IR. 4) CGRP-IR and SP-IR often colocalized in terminal varicosities around PNs. Collectively, our data document the distribution pattern and morphology of CGRP-IR and SP-IR axons and terminals in different regions of the atria. This knowledge provides useful information for CGRP-IR and SP-IR axons that can be referred to in future studies of pathological remodeling.

Coronary veins determine the pattern of sympathetic innervation in the developing heart

Anatomical congruence of peripheral nerves and blood vessels is well recognized in a variety of tissues. Their physical proximity and similar branching patterns suggest that the development of these networks might be a coordinated process. Here we show that large diameter coronary veins serve as an intermediate template for distal sympathetic axon extension in the subepicardial layer of the dorsal ventricular wall of the developing mouse heart. Vascular smooth muscle cells (VSMCs) associate with large diameter veins during angiogenesis. In vivo and in vitro experiments demonstrate that these cells mediate extension of sympathetic axons via nerve growth factor (NGF). This association enables topological targeting of axons to final targets such as large diameter coronary arteries in the deeper myocardial layer. As axons extend along veins, arterial VSMCs begin to secrete NGF, which allows axons to reach target cells. We propose a sequential mechanism in which initial axon extension in the subepicardium is governed by transient NGF expression by VSMCs as they are recruited to coronary veins; subsequently, VSMCs in the myocardium begin to express NGF as they are recruited by remodeling arteries, attracting axons toward their final targets. The proposed mechanism underlies a distinct, stereotypical pattern of autonomic innervation that is adapted to the complex tissue structure and physiology of the heart.

The neuronal control of cardiac functions in Molluscs

In this manuscript, I review the current and relevant classical studies on properties of the Mollusca heart and their central nervous system including ganglia, neurons, and nerves involved in cardiomodulation. Similar to mammalian brain hemispheres, these invertebrates possess symmetrical pairs of ganglia albeit visceral (only one) ganglion and the parietal ganglia (the right ganglion is bigger than the left one). Furthermore, there are two major regulatory drives into the compartments (pericard, auricle, and ventricle) and cardiomyocytes of the heart. These are the excitatory and inhibitory signals that originate from a few designated neurons and their putative neurotransmitters. Many of these neurons are well-identified, their specific locations within the corresponding ganglion are mapped, and some are termed as either heart excitatory (HE) or inhibitory (HI) cells. The remaining neurons are classified as cardio-regulatory, and their direct and indirect actions on the heart's function have been documented. The cardiovascular anatomy of frequently used experimental animals, Achatina, Aplysia, Helix, and Lymnaea is relatively simple. However, as in humans, it possesses all major components including even trabeculae and atrio-ventricular valves. Since the myocardial cells are enzymatically dispersible, multiple voltage dependent cationic currents in isolated cardiomyocytes are described. The latter include at least the A-type K(+), delayed rectifier K(+), TTX-sensitive Na(+), and L-type Ca(2+) channels.

[Successful surgical ablation of an epicardial accessory pathway on the right coronary artery]

We present a case of successful surgical ablation of an oblique epicardial accessory pathway on the right coronary artery in a 56-year-old female patient with Wolff-Parkinson-White (WPW) syndrome, for which the radio-frequency (RF) catheter ablation had not been effective 3 times. The heart was exposed via a T-shaped sternotomy, and positioned for adequate exposure using a suction device. Epicardial mapping was performed with a multi-electrode catheter fixed on the atrioventricular sulcus. The epicardium just above the right coronary was dissected with an ultrasonic scalpel and we confirmed complete electrophysiological block of the accessory pathway. For 3 years since the surgery, there has been no recurrence of arrhythmia in the patient. Although an RF ablation through a transcutaneous intrapericardial approach can be an alternative, surgical ablation seems to be a safer and more curative approach to failed RF catheter ablation of accessory pathway. Such surgical skills should be maintained.

Effects of acupuncture at Neiguan (PC 6) of the pericardial meridian on blood pressure and heart rate variability

The aims of this study were to investigate (i) if and when the blood pressure would rise or fall and (ii) the associated changes of human heart rate variability (HRV) by manual stimulation of the Neiguan (PC 6) acupuncture site. In this paper, two groups of six healthy male volunteers with ranges of ages 20-56 and 20-55 and with no neurological diseases participated in this study. In order to minimize artefacts, the electrocardiogram (ECG) and radial arterial pulse pressure wave were collected with the subjects alert but eyes closed before, during, and after sham/manual acupuncture. No statistically significant changes (P > 0.05) were found in the sham acupuncture group. As for the manual acupuncture group, the needle was inserted into the PC 6 acupoint and manually stimulated about 15 to 30 seconds to achieve De Qi sensation. Needles were left in place for 30 min and then removed. Analysis of the data due to acupuncture was then compared with the baseline values. Results indicate that the blood pressures of different subject can either rise (P < 0.01) or fall (P < 0.01). To further determine the indicator for one subject who exhibited both rise and fall of blood pressures, 7 more trials were given conducted with the same protocol until statistically significant results were obtained (P < 0.01). We found that his change of blood pressure was highly correlated (p = -0.94 and -0.99 for rise and fall, respectively) with the ratio of the magnitude of pulse pressure to that of the dicrotic notch in the local radial pulse wave (P < 0.01). As to the heart rate variability (HRV) spectra, significant changes in the low frequency (LF) and very low frequency (VLF) ranges were also detected. These results indicate that the autonomic innervations of heart have been modified. However, the information on the power of LF, high frequency (HF), and LF/HF of HRV are not conclusive to statistically differentiate the sympathetic contribution from that of the parasympathetic nervous systems at present stage.

Gastric Hypomotility Following Epicardial Vagal Denervation Ablation to Treat Atrial Fibrillation

We report a case of a 55-year-old man with vagal paroxysmal atrial fibrillation (AF) who was submitted to selective epicardial and endocardial atrial vagal denervation with the objective of treating AF. Radiofrequency pulses were applied on epicardial and endocardial surface of the left atrium close to right pulmonary veins (PVs) and also on epicardial surface close to left inferior PV. Following the procedure, patient presented with symptoms of gastroparesis, which was documented on CT scan and gastric emptying scintigraphy. Symptoms were transient and the patient recovered completely.

Topography of the porcine epicardiac nerve plexus as revealed by histochemistry for acetylcholinesterase

The aim of the present study was to map the topography of the porcine epicardiac nerve plexus (ENP) and to re-examine the total number and distribution of the porcine intracardiac ganglia and neurons. Eleven juvenile pigs (Sus scrofa domestica, 3-4 weeks of age) were examined employing histochemistry for acetylcholinesterase to reveal the ENP on total hearts. The nerves entered porcine epicardium at five sites: (1) ventro-medially to the origin of the superior vena cava, (2) dorsally to the origin of the superior vena cava, (3) among the pulmonary veins, (4) dorso-medially to the origin of the left azygos vein, and (5) ventrally to the left pulmonary vein. Within the porcine epicardium, the nerves connected to the groups of the intrinsic ganglia and proceeded into the discrete atrial and ventricular regions via five topographical pathways (subplexuses). In general, the porcine left atrium received nerves by four subplexuses, left ventricle by three subplexuses, right atrium and right ventricle each by two subplexuses. The estimated total number of the intrinsic ganglia per porcine heart was 362+/-52. About 55% of ganglia per porcine heart were accumulated on the left atrium while 36% on the right atrium. The percentage of ganglia within porcine ventricular and para-aortic regions was 7.6% and 1.6%, respectively. On average, porcine heart contained about 12,000 intrinsic neurons. In summary, the results of the present study imply that (1) the porcine epicardiac nerves are grouped into distinct topographical pathways, and (2) the porcine atria contain significantly more intrinsic ganglia and neurons compared to the ventricles.

The ligament of Marshall as a parasympathetic conduit

The objective of the study was to investigate the morphology, distribution, and electrophysiological profile of the autonomic fibers that innervate the ligament of Marshall (LOM). Gross anatomical dissections were performed in 10 dogs. Sections of the left vagus nerve, left stellate ganglion, and the LOM were immunostained to identify adrenergic and cholinergic nerves. Hearts were also stained for acetylcholinesterase to identify epicardial cholinergic nerves. In vivo electrophysiological studies were performed in another 10 dogs before and after LOM ablation. The anatomical examination revealed that the LOM is innervated by a branch of the left vagus. Immunohistochemistry confirmed that these nerve bundles are predominantly cholinergic (cholinergic-to-adrenergic ratio of 12.6 +/- 3.9:1). Cholinergic nerves originating in the LOM were found to innervate surrounding left atrial structures, including the pulmonary veins, left atrial appendage, coronary sinus, and posterior left atrial fat pad. Ablation of the LOM significantly attenuated effective refractory period shortening at distant sites, such as pulmonary veins and left atrial appendage, in response to vagal stimulation (vagal-induced ERP decrease in the left atrium: baseline vs. postablation = 17 vs. 4%; P = 0.0056). In conclusion, the LOM contains a predominance of cholinergic nerve fibers. Cholinergic fibers arising from the LOM innervate surrounding structures and contribute to the electrophysiological profile of the left atrium. These findings may provide a basis for the role of the LOM in the genesis and maintenance of atrial fibrillation.

Intraoperative epicardial electrophysiologic mapping and isolation of autonomic ganglionic plexi

BACKGROUND

Autonomic ganglionic plexi (GPs) have been implicated as triggers in lone atrial fibrillation (AF). The purpose of this study was to describe the technique and results of epicardial electrophysiologic mapping and the early effects of GP isolation.

METHODS

Intraoperative epicardial electrophysiologic mapping was performed on 41 consecutive patients during a stand-alone minimally invasive operation for AF. A map labeling anatomic locations was developed to describe the findings. Intraoperative high-frequency stimulation (800/minute, 12 to 16 mA, pulse duration 9.9 ms) was performed using a standard quadripolar catheter placed directly on the epicardium. Locations where stimulation resulted in ventricular slowing with doubling of the electrocardiographic R-R interval were defined as active GPs. These areas were mapped and described. After dry bipolar radiofrequency isolation, the sites were again stimulated to assess isolation.

RESULTS

Forty-one patients (mean age of 60.2 years, 31 males) underwent operation for AF (28 intermittent AF, 13 chronic). Active GPs were identified in all patients (24 bilateral, 17 unilateral). There was a mean of 5.0 GPs on the right and 2.7 on the left. More than 50% of patients had active GPs along the interatrial groove on the right and along the ligament of Marshall. All sites were inactive after radiofrequency isolation. Six-month follow-up is available for 15 patients, with 14 patients free of AF.

CONCLUSIONS

Autonomic GPs can be routinely identified during AF surgery utilizing high-frequency stimulation. The GPs are clustered around the interatrial groove and the ligament of Marshall, and the cardiac response to GP stimulation can be eliminated with bipolar radiofrequency isolation. The addition of GP isolation to bilateral pulmonary vein isolation may increase freedom from AF.

Impact of Epicardial Anterior Fat Pad Retention on Postcardiothoracic Surgery Atrial Fibrillation Incidence

OBJECTIVES

We conducted a randomized, blinded, controlled study evaluating the impact of anterior fat pad (AFP) maintenance on postoperative atrial fibrillation (POAF) incidence.

BACKGROUND

Drugs with antiadrenergic effects reduce POAF. Because the epicardial AFP is parasympathetically innervated, its routine excision during coronary artery bypass grafting (CABG) might precipitate autonomic imbalance and induce POAF.

METHODS

Patients (n = 180, mean age = 66 +/- 10 years, 80% men, 5% with previous atrial fibrillation) undergoing CABG surgery were randomized to either AFP maintenance or AFP removal. Routine prophylaxis against POAF with beta-blockers (85%) and amiodarone (28%) was allowed on the basis of caregivers' discretion. The development of POAF, total hospital costs, and heart rate variability was compared between groups.

RESULTS

Anterior fat pad maintenance did not reduce POAF incidence (34.8% vs. 35.2%, p = 0.950) or total hospital costs (data as medians with 25%, 75% percentiles: 22,940 dollars [17,629 dollars, 29,274 dollars] vs. 23,866 dollars [18,602 dollars, 30,370 dollars], p = 0.647) but was associated with higher heart rate variability (SD of normal-to-normal RR intervals [SDNN]: 31.7 +/- 24.6 vs. 22.7 +/- 8.3, p = 0.05 and SD of all 5-min mean RR intervals [SDANN 5]: 17.1 +/- 11.9 vs. 10.1 +/- 5.5, p = 0.003) than AFP removal.

CONCLUSIONS

Maintaining the AFP prevents attenuation of parasympathetic tone after CABG but does not reduce POAF or total hospital costs in any appreciable way.

Vagal denervation and atrial fibrillation inducibility: Epicardial fat pad ablation does not have long-term effects

BACKGROUND

Major epicardial fat pads contain cardiac ganglionated plexi of the autonomic, predominantly vagal nerves. Vagal denervation may improve the success rate of atrial fibrillation (AF) treatment.

OBJECTIVES

The purpose of this study was to elucidate the long-term effects of fat pad ablation on the electrophysiologic characteristics of the atrium and AF inducibility.

METHODS

Six mongrel dogs were studied. Cervical vagal stimulation was applied to determine effects on the sinus node, AV node, atrial effective refractory period (AERP), and AF inducibility. AERP and AF inducibility were evaluated at both the right atrial and left atrial appendages and at the right atrial and left atrial free walls. Radiofrequency energy was delivered epicardially to the entire areas of two major fat pads: right pulmonary vein fat pad and inferior vena cava-left atrium fat pad. Cervical vagal stimulation then was applied to confirm the acute effects of fat pad ablation. The same evaluation was repeated 4 weeks later.

RESULTS

The effects of vagal stimulation on the sinus node, AV node, and AERP were significantly eliminated immediately after fat pad ablation. However, these denervation effects disappeared after 4 weeks. At baseline, AF inducibility was increased by vagal stimulation (right atrial appendage: 72% +/- 31% vs 4.8% +/- 12%; right atrial free wall: 75% +/- 31% vs 0.0% +/- 0.0%; left atrial appendage: 60% +/- 29% vs 0.0% +/- 0.0%; left atrial free wall: 65% +/- 42% vs 0.0% +/- 0.0%). Fat pad ablation significantly reduced this vagal stimulation effect (8.3% +/- 20%, 10% +/- 22%, 17% +/- 29%, and 25% +/- 29%, respectively). However, similar to baseline, AF inducibility was strongly augmented by vagal stimulation 4 weeks after fat pad ablation (96% +/- 10%, 100% +/- 0.0%, 100% +/- 0.0%, and 95% +/- 11%, respectively).

CONCLUSION

Radiofrequency fat pad ablation may not achieve long-term suppression of AF induction in this canine model.

Differential expression of vesicular glutamate transporters by vagal afferent terminals in rat nucleus of the solitary tract: projections from the heart preferentially express vesicular glutamate transporter 1

The central projections and neurochemistry of vagal afferent neurones supplying the heart in the rat were investigated by injecting cholera toxin B-subunit into the pericardium. Transganglionically transported cholera toxin B-subunit was visualized in the medulla oblongata in axons and varicosities that were predominantly aggregated in the dorsomedial, dorsolateral, ventrolateral and commissural subnuclei of the caudal nucleus of the solitary tract. Unilateral vagal section in control rats prevented cholera toxin B-subunit labeling on the ipsilateral side of the nucleus of the solitary tract. Fluorescent and electron microscopic dual labeling showed colocalization of immunoreactivity for vesicular glutamate transporter 1, but only rarely vesicular glutamate transporters 2 or 3 with cholera toxin B-subunit in terminals in nucleus of the solitary tract, suggesting that cardiac vagal axons release glutamate as a neurotransmitter. In contrast, populations of vagal afferent fibers labeled by injection of cholera toxin B-subunit, tetra-methylrhodamine dextran or biotin dextran amine into the aortic nerve, stomach or nodose ganglion colocalized vesicular glutamate transporter 2 more frequently than vesicular glutamate transporter 1. The presence of other neurochemical markers of primary afferent neurones was examined in nucleus of the solitary tract axons and nodose ganglion cells labeled by pericardial cholera toxin B-subunit injections. Immunoreactivity for a 200-kDa neurofilament protein in many large, cholera toxin B-subunit-labeled nodose ganglion cells indicated that the cardiac afferent fibers labeled are mostly myelinated, whereas binding of Griffonia simplicifolia isolectin B4 to fewer small cholera toxin B-subunit-labeled ganglion cells suggested that tracer was also taken up by some non-myelinated axons. A few labeled nucleus of the solitary tract axons and ganglion cells were positive for substance P and calcitonin gene-related peptide, which are considered as peptide markers of nociceptive afferent neurones. These data suggest that the population of cardiac vagal afferents labeled by pericardial cholera toxin B-subunit injection is neurochemically varied, which may be related to a functional heterogeneity of baroreceptive, chemoreceptive and nociceptive afferent fibers. A high proportion of cardiac neurones appear to be glutamatergic, but differ from other vagal afferents in expressing vesicular glutamate transporter 1.

[Changes of heart electrophysiological parameters after destruction of epicardial subplexuses that innervate sinoatrial node]

The aims of present study were to verify the topography of the intracardiac nerve subplexuses (INS) by using electrophysiological methods, its relations with sinoatrial (SA) node function and to investigate possibility of selective surgical SA node denervation. Fifteen mongrel dogs of either sex weighing 8 to 15 kg were used for electrophysiological studies. Both cervical vagosympathetic trunks were isolated and crushed by tight ligatures. Nervus subplexuses destructions were performed by cryocoagulation in three zones located around the right superior vena cava: ventral, lateral and dorsal. The sinus rhythm, SA node function recovery time, AV node conductivity, AV node and atrial effective refractory period were measured. Five experiments in each of three zones were performed. Experimental data show that destruction of the epicardial nerves has different effect on electrophysiological parameters. After destruction of the anterior zone of the right atrium the sinus rhythm decreased on an average by 11.6%; SA node function recovery time prolonged by 7.2%; AV node conductivity decreased by 13.1%; AV node effective refractory period prolonged by 12.9% and atrial effective refractory period, by 10.9 %. Measurements of electrophysiological parameters after intravenous injection of atropine sulphate show that sinus rhythm decreased on an average by 23.4%; SA node function recovery time increased by 9.1%; the conductivity of AV node decreased by 10.2%; AV node effective refractory period prolonged by 15.4% and atrial effective refractory period, by 13.2%. After destruction of the intracardiac nerves of the lateral zone, the sinus rhythm decreased by 15.7%; SA node function recovery time increased by 16.3%; AV node conductivity decreased by 8.3%; AV node effective refractory period and atrial effective refractory period prolonged by 11.9% and 10.0%, respectively. After the atropine sulphate intravenous injection, the sinus rhythm decreased on an average by 7.1%, SA node function recovery time prolonged by 7.1%, AV conductivity decreased by 9.1%, AV node effective refractory period increased by 12.4%, and atrial effective refractory period prolonged by 12.5%. After destruction of the nerves in the dorsal zone the changes of electrophysiological parameters were opposite to those obtained after destruction of the nerve tracts in the anterior or lateral zones: the sinus rhythm increased on an average by 4.3%; SA node function recovery time shortened by 8.8%; AV conductivity increased by 9.7%; AV node and atrial effective refractory period decreased by 12.3% and 12.1%, respectively. After intravenous atropine sulphate infusion, sinus rhythm decreased on an average by 8.3%; SA node function recovery time prolonged by 9.6%; AV node conductivity decreased by 5%; AV node and atrial effective refractory period prolonged by 4.2% and 5.2%, respectively. The average changes of electrophysiological parameters before and after INS destruction shows that cryocoagulation of ventral and lateral zones eliminates the effects of sympathetic tone to SA and AV nodal activity. Cryocoagulation of dorsal zone eliminates the effects of nervus vagus to both nodal structures. These findings shows the possibility alter or correct SA node function by making selective surgical SA node denervation.

Sensing tissue ischemia: another new function for capsaicin receptors?

BACKGROUND

Chest pain is a hallmark of myocardial ischemia, but its underlying signaling mechanisms remain poorly understood. The capsaicin receptor, vanilloid receptor-1 (VR1), is an important cation channel present on primary nociceptive neurons. We have shown that the VR1 is expressed on sensory nerve endings of the heart. In the present study, we determined the role of VR1s in activation of cardiac spinal afferent nerves caused by myocardial ischemia.

METHODS AND RESULTS

Single-unit activity of cardiac afferents was recorded from the sympathetic chain of anesthetized ferrets. Cardiac afferents responded to 5 minutes of regional myocardial ischemia and topical application of 10 microg/mL bradykinin in a reproducible manner. Topical application of a specific VR1 antagonist, iodoresiniferatoxin (50 micromol/L), to the receptive field of afferents produced a large attenuation of the firing activity of cardiac afferents caused by myocardial ischemia. Iodoresiniferatoxin also significantly reduced the afferent response to bradykinin applied to the receptive field. Furthermore, treatment with a VR1 channel blocker, ruthenium red (200 micromol/L), had a similar inhibitory effect on the afferent responses to myocardial ischemia and bradykinin.

CONCLUSIONS

This study provides the first functional evidence that ischemic stimulation of cardiac spinal afferent nerves is mediated through VR1s. The VR1 on the cardiac sensory nerve may function as a molecular sensor to detect tissue ischemia and activate cardiac nociceptors.

Atrial fibrillation: mechanistic insights from biatrial (and triatrial) mapping

Percutaneous radiofrequency ablation of pulmonary vein potentials has been shown to eliminate atrial fibrillation in a subset of patients characterized by frequent and repetitive paroxysms of atrial fibrillation. However, pulmonary vein disconnection has had only limited success at curing patients with persistent atrial fibrillation. In those patients, left atrial substrate modification and linear ablation strategies have had substantially higher success rates. Furthermore, in other patients, elimination of right atrial triggers (superior vena cava) or modification of right atrial substrate has been required for elimination of atrial fibrillation. Finally, the realization that the coronary sinus is a third atrial chamber that can both initiate and maintain atrial fibrillation has provided new understanding to the pathogenesis of atrial fibrillation. From a clinical perspective, only careful anatomic and mapping strategies specifically aimed at each subset of patients with atrial fibrillation will allow for pattern recognition and establish which mechanisms are responsible for initiation and maintenance of atrial fibrillation. Only the latter will allow for increased long-term success rates of ablation of atrial fibrillation.

Effect of autonomic nervous system on the transmural dispersion of ventricular repolarization in intact canine

The effect of the autonomic nerves on the transmural dispersion of ventricular repolarization in intact canine was investigated. By using the monophasic action potential (MAP) recording technique, monophasic action potentials (MAPs) of the epicardium (Epi), midmyocardium (Mid) and endocardium (Endo) were recorded simultaneously by specially designed plunge-needle electrodes at the left ventricular free wall in 12 open-chest dogs. MAPD90 and transmural dispersion of repolarization among three myocardial layers as well as the incidence of the EAD before autonomic nervous stimulation and during autonomic nervous stimulation were compared. The results showed that the MAPD90 of Epi, Mid and Endo before autonomic nervous stimulation were 278 +/- 11 ms, 316 +/- 16 ms and 270 +/- 12 ms respectively, the MAPD90 of Mid was significantly longer than that of Epi or Endo (P<0.01). MAPD90 of Epi, Mid and Endo were shortened by 19 +/- 4 ms, 45 +/- 6 ms, 18 +/- 3 ms respectively during sympathetic stimulation. Compared with that of the control, the transmural dispersion of repolarization during sympathetic stimulation was shortened from 44 +/- 4 ms to 15 +/- 3 ms (P<0.01), but early afterdepolarizations were elicited in the Mid of 5 dogs (41%) during sympathetic stimulation. Parasympathetic stimulation did not significantly affect the MAPD90 in the three layers. It is concluded that there is the transmural dispersion of ventricular repolarization in intact canine. Sympathetic stimulation can reduce transmural dispersion of repolarization, but it can produce early afterdepolarizations in the Mid. Parasympathetic stimulation does not significantly affect the transmural dispersion of ventricular repolarization.

Noninvasive electrocardiographic imaging (ECGI): application of the generalized minimal residual (GMRes) method

Electrocardiographic imaging (ECGI) is a developing imaging modality for cardiac electrophysiology and arrhythmias. It reconstructs epicardial potentials, electrograms, and isochrones from electrocardiographic body-surface potentials noninvasively. Current ECGI methodology employs Tikhonov regularization, which imposes constraints on the reconstructed potentials or their derivatives. This approach can sometimes reduce spatial resolution by smoothing the solution. Accuracy depends on a priori knowledge of solution characteristics and determination of an optimal regularization parameter. These properties led us to implement an independent, iterative approach for ECGI--the generalized minimal residual (GMRes) method--which does not apply constraints. GMRes was applied to experimental data during activation/repolarization of normal and infarcted hearts. GMRes reconstructions were compared to Tikhonov reconstructions and to measured "gold standards" in isolated hearts. Overall, the accuracy of GMRes solutions was similar to Tikhonov regularization. However, in certain cases GMRes recovered localized potential features (e.g., multiple potential minima), which were lost in the Tikhonov solution. Simultaneous use of these two complementary methods in clinical ECGI will ensure reliability and maximal extraction of diagnostic information in the absence of a priori information about a patient's condition.

Identification and characterization of atrioventricular parasympathetic innervation in humans

INTRODUCTION

We hypothesized that in humans there is an epicardial fat pad from which parasympathetic ganglia supply the AV node. We also hypothesized that the parasympathetic nerves innervating the AV node also innervate the right atrium, and the greatest density of innervation is near the AV nodal fat pad.

METHODS AND RESULTS

An epicardial fat pad near the junction of the left atrium and right inferior pulmonary vein was identified during cardiac surgery in seven patients. A ring electrode was used to stimulate this fat pad intraoperatively during sinus rhythm to produce transient complete heart block. Subsequently, temporary epicardial wire electrodes were sutured in pairs on this epicardial fat pad, the high right atrium, and the right ventricle by direct visualization during coronary artery bypass surgery in seven patients. Experiments were performed in the electrophysiology laboratory 1 to 5 days after surgery. Programmed atrial stimulation was performed via an endocardial electrode catheter advanced to the right atrium. The catheter tip electrode was moved in 1-cm concentric zones around the epicardial wires by fluoroscopic guidance. Atrial refractoriness at each catheter site was determined in the presence and absence of parasympathetic nerve stimulation (via the epicardial wires). In all seven patients, an AV nodal fat pad was identified. Fat pad stimulation during and after surgery caused complete heart block but no change in sinus rate. Fat pad stimulation decreased the right atrial effective refractory period at 1 cm (280 +/- 42 msec to 242 +/- 39 msec) and 2 cm (235 +/- 21 msec to 201 +/- 11 msec) from the fat pad (P = 0.04, compared with baseline). No significant change in atrial refractoriness occurred at distances >2 cm. The response to stimulation decreased as the distance from the fat pad increased.

CONCLUSION

For the first time in humans, an epicardial fat pad was identified from which parasympathetic nerve fibers selectively innervate the AV node but not the sinoatrial node. Nerves in this fat pad also innervate the surrounding right atrium.

Comparison of the effects of racemic bupivacaine, levobupivacaine, and ropivacaine on ventricular conduction, refractoriness, and wavelength: an epicardial mapping study

BACKGROUND

The study was designed to compare the effects of equimolar concentrations of racemic bupivacaine, levobupivacaine, and ropivacaine on ventricular conduction, anisotropy, duration and homogeneity of refractoriness, and wavelengths, and to provide a potency ratio for effects on conduction velocity.

METHODS

Isolated frozen rabbit hearts (which leave a thin layer of surviving epicardial muscle) were treated with 0.1, 1, and 10 mum racemic bupivacaine, levobupivacaine, or ropivacaine. Left ventricular longitudinal and transverse conduction velocities, anisotropic ratio, minimum pacing cycle length, use dependency, duration and dispersion of ventricular effective refractory period, and wavelengths were studied. A high-resolution mapping system was used for data acquisition. In addition to two-way analysis of variance for repeated measures, data for conduction velocities were fitted simultaneously using a nonlinear mixed-effect modeling program to allow intergroup comparison.

RESULTS

Each agent induced a concentration- and use-dependent slowing of conduction velocities, with no change of the anisotropic ratio. The use-dependent effect of levobupivacaine is similar to that of racemic bupivacaine concerning longitudinal conduction velocity. Fitting of conduction velocities provided a racemic bupivacaine to levobupivacaine and to ropivacaine ratio of 1:1.38 for concentration effect at 1,000-ms pacing cycle length, and 1:0.74 for use-dependent effect at 600-ms pacing cycle length. Racemic bupivacaine and levobupivacaine prolonged the ventricular effective refractory period, whereas ropivacaine did not. No dispersion in ventricular effective refractory period values occurred. All three agents induced significant decreases in wavelengths. This effect was not different among groups.

CONCLUSIONS

Differences among racemic bupivacaine, levobupivacaine, and ropivacaine at equimolar concentrations are mainly caused by the use-dependent effects on conduction velocities and the concentration-dependent effects on ventricular effective refractory period. Therefore, one must take into account the corresponding pacing rates when comparing the potency ratios of local anesthetics.

Activity of cardiorespiratory networks revealed by transsynaptic virus expressing GFP

A fluorescent transneuronal marker capable of labeling individual neurons in a central network while maintaining their normal physiology would permit functional studies of neurons within entire networks responsible for complex behaviors such as cardiorespiratory reflexes. The Bartha strain of pseudorabies virus (PRV), an attenuated swine alpha herpesvirus, can be used as a transsynaptic marker of neural circuits. Bartha PRV invades neuronal networks in the CNS through peripherally projecting axons, replicates in these parent neurons, and then travels transsynaptically to continue labeling the second- and higher-order neurons in a time-dependent manner. A Bartha PRV mutant that expresses green fluorescent protein (GFP) was used to visualize and record from neurons that determine the vagal motor outflow to the heart. Here we show that Bartha PRV-GFP-labeled neurons retain their normal electrophysiological properties and that the labeled baroreflex pathways that control heart rate are unaltered by the virus. This novel transynaptic virus permits in vitro studies of identified neurons within functionally defined neuronal systems including networks that mediate cardiovascular and respiratory function and interactions. We also demonstrate superior laryngeal motorneurons fire spontaneously and synapse on cardiac vagal neurons in the nucleus ambiguus. This cardiorespiratory pathway provides a neural basis of respiratory sinus arrhythmias.

Distension of urinary bladder induces exaggerated coronary constriction in smokers with early atherosclerosis

Distension of the urinary bladder causes an increase in efferent sympathetic activity, which can precipitate myocardial ischemia. Smoking has been shown to modulate activities of afferent nerves from the distended urinary bladder and to impair endothelial function in response to sympathetic activation. To assess the effect of bladder distension on coronary dynamics in smokers, we measured epicardial and microvascular responses in 24 patients with early atherosclerosis (< 50% diameter stenosis). Patients were classified into habitual smokers (group 1, n = 14) and nonsmokers (group 2, n = 10). Habitual smokers were randomized into two subgroups on the basis of the use of doxazosin, as follows: subgroup 1A (n = 7), without administration of doxazosin before catheterization; subgroup 1B (n = 7), with dosing doxazosin. In response to bladder distension (mean intravesical pressure 21.5 mmHg), bladder distension significantly decreased coronary diameter at the stenotic segments, coronary blood flow, and increased coronary resistance compared with baseline values, in subgroup 1A patients. In subgroup 1B patients during bladder distension, coronary diameter, coronary blood flow, and coronary resistance did not show significant changes compared with baseline values. There were significant differences of coronary diameter at the stenotic segments, coronary blood flow, and of changes of coronary vascular resistance between subgroup 1A and group 2 during bladder distension, despite similar changes in rate-pressure product. The present study showed that urinary bladder distension caused an abnormal vasomotor response of epicardial vasoconstriction and a concomitant increased coronary resistance, which leads to reduction in coronary blood flow in patients with early atherosclerosis. Smoking may further impair the response, implying that smoking has exaggerated response to sympathetic stimulation of conduit and resistance vessels. The abnormal response was abolished by pretreated administration of doxazosin, suggesting that the involved mechanisms are related to alpha(1)-adrenoceptors.

Inotropic, chronotropic, and dromotropic effects mediated via parasympathetic ganglia in the dog heart

Some parasympathetic ganglionic cells are located in the epicardial fat pad between the medial superior vena cava and the aortic root (SVC-Ao fat pad) of the dog. We investigated whether the ganglionic cells in the SVC-Ao fat pad control the right atrial contractile force, sinus cycle length (SCL), and atrioventricular (AV) conduction in the autonomically decentralized heart of the anesthetized dog. Stimulation of both sides of the cervical vagal complexes (CVS) decreased right atrial contractile force, increased SCL, and prolonged AV interval. Stimulation of the rate-related parasympathetic nerves to the sinoatrial (SA) node (SAPS) increased SCL and decreased atrial contractile force. Stimulation of the AV conduction-related parasympathetic nerves to the AV node prolonged AV interval. Trimethaphan, a ganglionic nicotinic receptor blocker, injected into the SVC-Ao fat pad attenuated the negative inotropic, chronotropic, and dromotropic responses to CVS by 33 approximately 37%. On the other hand, lidocaine, a sodium channel blocker, injected into the SVC-Ao fat pad almost totally inhibited the inotropic and chronotropic responses to CVS and partly inhibited the dromotropic one. Lidocaine or trimethaphan injected into the SAPS locus abolished the inotropic responses to SAPS, but it partly attenuated those to CVS, although these treatments abolished the chronotropic responses to SAPS or CVS. These results suggest that parasympathetic ganglionic cells in the SVC-Ao fat pad, differing from those in SA and AV fat pads, nonselectively control the atrial contractile force, SCL, and AV conduction partially in the dog heart.

Ventricular rate control during atrial fibrillation by cardiac parasympathetic nerve stimulation: a transvenous approach

OBJECTIVES

To identify intravascular sites for continuous, stable parasympathetic stimulation (PS) in order to control the ventricular rate during atrial fibrillation (AF).

BACKGROUND

Ventricular rate control during AF in patients with congestive heart failure is a significant clinical problem because many drugs that slow the ventricular rate may depress ventricular function and cause hypotension. Parasympathetic stimulation can exert negative dromotropic effects without significantly affecting the ventricles.

METHODS

In 22 dogs, PS was performed using rectangular stimuli (0.05 ms duration, 20 Hz) delivered through a catheter with an expandable electrode-basket at its end. The catheter was positioned either in the superior vena cava (SVC, n = 6), coronary sinus (CS, n = 10) or right pulmonary artery (RPA, n = 6). The basket was then expanded to obtain long-term catheter stability. Atrial fibrillation was induced and maintained by rapid atrial pacing.

RESULTS

Nonfluoroscopic (SVC) and fluoroscopic (CS/RPA) identification of effective intravascular PS sites was achieved within 3 to 10 min. The ventricular rate slowing effect during AF started and ceased immediately after on-offset of PS, respectively, and could be maintained over 20 h. In the SVC, at least a 50% increase of ventricular rate (R-R) intervals occurred at 22 +/- 11 V (331 +/- 139 ms to 653 +/- 286 ms, p < 0.001), in the CS at 16 +/- 10 V (312 +/- 102 ms vs. 561 +/- 172 ms, p < 0.001) and in the RPA at 18 +/- 7 V (307 +/- 62 ms to 681 +/- 151 ms, p < 0.001). Parasympathetic stimulation did not change ventricular refractory periods.

CONCLUSIONS

Intravascular PS results in a significant ventricular rate slowing during AF in dogs. This may be beneficial in patients with AF and rapid ventricular response since many drugs that decrease atrioventricular conduction have negative inotropic effects which could worsen concomitant congestive heart failure.

Localisation and quantitation of autonomic innervation in the porcine heart II: endocardium, myocardium and epicardium

The immunological problems of pig hearts supporting life in human recipients have potentially been solved by transgenic technology. Nevertheless, other problems still remain. Autonomic innervation is important for the control of cardiac dynamics and there is evidence suggesting that some neurons remain intact after transplantation. Previous studies in the human heart have established regional differences in both general autonomic innervation and in its component neural subpopulations. Such studies are lacking in the pig heart. Quantitative immunohistochemical and histochemical techniques were used to demonstrate the pattern of innervation in pig hearts (Sus scrofa). Gradients of immunoreactivity for the general neural marker protein gene product 9.5 were observed both within and between the endocardial, myocardial and epicardial plexuses throughout the 4 cardiac chambers. An extensive ganglionated plexus was observed in the epicardial tissues and, to a lesser extent, in the myocardial tissues. The predominant neural subpopulation displayed acetylcholinesterase activity, throughout the endocardium, myocardium and epicardium. These nerves showed a right to left gradient in density in the endocardial plexus, which was not observed in either the myocardial or epicardial plexuses. A large proportion of nerves in the ganglionated plexus of the atrial epicardial tissues displayed AChE activity, together with their cell bodies. Tyrosine hydroxylase (TH)-immunoreactive nerves were the next most prominent subpopulation throughout the heart. TH-immunoreactive cell bodies were observed in the atrial ganglionated plexuses. Endocardial TH- and NPY-immunoreactive nerves also displayed a right to left gradient in density, whereas in the epicardial tissues they showed a ventricular to atrial gradient. Calcitonin gene-related peptide (CGRP)-immunoreactive nerves were the most abundant peptide-containing subpopulation after those possessing NPY immunoreactivity. They were most abundant in the epicardial tissues of the ventricles. Several important differences were observed between the innervation of the pig heart compared with the human heart. These differences may have implications for the function of donor transgenic pig hearts within human recipients.

The autonomic control of the transmural dispersion of ventricular repolarization in anesthetized dogs

INTRODUCTION

The initiation of ventricular arrhythmias is in part associated with autonomic nervous tone. We investigated the effects of sympathetic and parasympathetic stimulation on the monophasic action potentials (MAPs) of the epicardium (EPi), mid-myocardial (M) region, and endocardium (Endo) in vivo.

METHODS AND RESULTS

In 12 mongrel open chest anesthetized dogs, both sides of the cervical vagus nerves and stellate ganglia were crushed with a tight ligature. Right atrial pacing at 600 msec cycle length was begun after the sinus nodal area had been crushed. MAPs from the M region were measured by two needle electrodes that were supported by a W-shaped plastic frame. The epicardial, M region, and endocardial MAP durations at 90% repolarization (MAPD90) were 287+/-7, 315+/-7, and 290+/-8 msec, respectively. The MAPD90 from M cells was longer than that from Epi or Endo. Sympathetic stimulation shortened MAPD90 more in the M region (53+/-4 msec) than that in the Epi (27+/-3 msec) or Endo (26+/-4 msec). The transmural dispersion of repolarization during sympathetic stimulation was shorter than that of the control. Parasympathetic stimulation did not significantly affect any of the MAPD90 values. Simultaneous sympathetic and parasympathetic stimulation produced changes not significantly to those produced by sympathetic stimulation alone.

CONCLUSION

Our results suggest that sympathetic activity can reduce transmural dispersion of repolarization under autonomic control in the canine heart under baseline conditions.

Anatomical study of the neural ganglionated plexus in the canine right atrium: implications for selective denervation and electrophysiology of the sinoatrial node in dog

The aim of the present study was to elucidate the topography and architecture of the intrinsic neural plexus (INP) in the canine right atrium because of its importance for selective denervation of the sinoatrial node (SAN). The morphology of the intrinsic INP was revealed by a histochemical method for acetylcholinesterase in whole hearts of 36 mongrel dogs and examined by stereoscopic, contact, and electron microscopes. At the hilum of the heart, nerves forming a right atrial INP were detected in five sites adjacent to the right superior pulmonary veins and superior vena cava (SVC). Nerves entered the epicardium and formed a INP, the ganglia of which, as a wide ganglionated field, were continuously distributed on the sides of the root of the SVC (RSVC). The epicardiac ganglia located on the RSVC were differentially involved in the innervation of the sinoatrial node, as revealed by epicardiac nerves emanating from its lower ganglia that proceed also into the atrial walls and right auricle. The INP on the RSVC (INP-RSVC) varied from animal to animal and in relation to the age of the animal. The INP-RSVC of juvenile dogs contained more small ganglia than that of adult animals. Generally, the canine INP-RSVC included 434+/-29 small, 17+/-4 medium-sized, and 3+/-1 large epicardiac ganglia that contained an estimated 44,700, 6,400, and 2,800 neurons, respectively. Therefore, the canine right atrium, including the SAN, may be innervated by more than 54,000 intracardiac neurons residing mostly in the INP-RSVC. In conclusion, the present study indicates that epicardiac ganglia that project to the SA-node are distributed more widely and are more abundant than was previously thought. Therefore, both selective and total denervation of the canine SAN should involve the whole region of the RSVC containing the INP-RSVC.

Vagal innervation of the gastrointestinal tract arises from dorsal motor nucleus while that of the heart largely from nucleus ambiguus in the cat

The origin of medullary cells that form the cardiac vagal branch and the vagal branches in the lower thorax innervating the gastrointestinal (GI) tract was studied using horseradish peroxidase (HRP), a retrograde transport tracer in the cat. The distributions of parasympathetic postganglionic neurons of the heart were studied with acetylcholinesterase histochemistry. Intracardiac ganglionic neurons were found mainly in the connective tissue surrounding the base of the pulmonary arteries and in an area in and dorsal to the interatrial septum. Following injection of HRP into the subepicardum where most of the cardiac postganglionic neurons reside, 91% of the labelled neurons were found bilaterally distributed in the nucleus ambiguus (NA). A small population of labelled neurons was found in the dorsal motor nucleus of the vagus (DMV) and an intermediate zone (IZ) between the two nuclei. When HRP was injected into the left or right cardiopulmonary vagus branch, labelled neurons were found exclusively in the ipsilateral NA, DMV and IZ with a predominance in the NA. In the thorax, after they course around the heart, the left and right thoracic vagus nerves divides into a left and a right branch, respectively. The left branch of the left thoracic vagus joins the left branch of the right thoracic vagus to form the anterior vagus nerve at 3 cm above the diaphragm. The right branch of the right thoracic vagus nerve joins the right branch of the left thoracic vagus to form the posterior vagus nerve. After application of HRP into the right or the left branch of the left thoracic vagus, HRP labelled cells were found in the left DMV. Similarly, after application of HRP into the left or the right branch of the right thoracic vagus, labelled cells were found in the right DMV. On the other hand, when HRP was injected into the anterior vagus, labelled neurons were found bilaterally in the DMV. This suggests that all rostral branches of the thoracic vagus have their origin in the ipsilateral DMV, and intermixing occurs only at the caudal level near the diaphragm. Findings of the present experiments suggest that parasympathetic preganglionic neurons innervating the GI tract are located exclusively in the DMV while those of the heart are located mainly in the NA. Within the DMV, GI vagal neurons were found medially from the level 0-2.5 mm rostral to the obex. In contrast, cardiac vagal neurons were found in the lateral edge of the DMV at the level 0-1 mm rostral to the obex.

Estimation of conduction velocity vector fields from epicardial mapping data

An automated method to estimate vector fields of propagation velocity from observed epicardial extracellular potentials is introduced. The method relies on fitting polynomial surfaces T(x, y) to the space-time (x, y, t) coordinates of activity. Both speed and direction of propagation are computed from the gradient of the local polynomial surface. The components of velocity, which are total derivatives, are expressed in terms of the partial derivatives which comprise the gradient of T. The method was validated on two-dimensional (2-D) simulations of propagation and then applied to cardiac mapping data. Conduction velocity was estimated at multiple epicardial locations during sinus rhythm, pacing, and ventricular fibrillation (VF) in pigs. Data were obtained via a 528-channel mapping system from 23 x 22 and 24 x 21 arrays of unipolar electrodes sutured to the right ventricular epicardium. Velocity estimates are displayed as vector fields and are used to characterize propagation qualitatively and quantitatively during both simple and complex rhythms.

Thoracic spinal neuron responses to repeated myocardial ischemia and epicardial bradykinin

Bradykinin has been strongly implicated as a mediator of cardiac nociception. During coronary artery occlusion, the content of bradykinin in coronary sinus blood increases. In non-cardiac tissues nociception to bradykinin exhibits tachyphylaxis, however, this phenomenon has not been rigorously studied in the heart. This raises the question that repeated coronary occlusions may also result in tachyphylaxis, thereby reducing cardiac sensation on subsequent ischemic stimulation. We therefore examined the hypothesis that repetitive episodes of myocardial ischemia and of epicardial application of bradykinin demonstrate tachyphylaxis. Mongrel cats were anesthetized with alpha-chloralose and heart rate, arterial pressure, and thoracic spinal neuron firing rate were recorded during 60 s of anterior descending coronary occlusion or local epicardial application of bradykinin (10 microM). Neurons were identified by cutaneous receptive fields in the left shoulder area. Sixty-one of 93 neurons tested responded with an increase in firing rate to coronary artery occlusion only (n=24), bradykinin only (n=19) or to both (n=18). On repetitive coronary occlusion, 14 of 25 neurons demonstrated tachyphylaxis compared to 12 of 15 tested with bradykinin (p<0.05). Similar responses were observed in thoracic spinal neurons that projected to the brain. In neurons demonstrating tachyphylaxis, dorsal cervical cold block partially restored the neuronal activation to coronary occlusion but not to bradykinin. We conclude, based on neuronal responses to repetitive stimuli, that afferent spinal responses to coronary occlusion and bradykinin are different. These data suggest that bradykinin is not the sole mediator of myocardial ischemic pain. The tachyphylaxis to repeated coronary artery occlusions may contribute to the clinical phenomenon of silent myocardial ischemia.

Restoration of the transient outward potassium current by noradrenaline in chagasic canine epicardium

1. The transient outward potassium current (Ito) is reduced in canine epicardial myocytes during the acute stage of infection with Trypanosoma cruzi (Chagas' disease). Sympathetic nerve terminals are also destroyed during the acute stage of this disease. To test whether the reduction of Ito is related to the absence of sympathetic innervation, acutely infected isolated epicardial myocytes were exposed in vitro to the sympathetic neurotransmitter noradrenaline (NA) and the effects of NA exposure on Ito were determined. 2. Continuous exposure to NA (1.0 microM) for 0-6 h had no effect on Ito density, whereas exposure to NA for 24 h significantly increased Ito density. Ito was also restored 24 h after a 1 h exposure to NA. Cell capacitance was not significantly affected by NA. 3. The alpha1-adrenergic receptor antagonist prazosin (0.1 microM) blocked the effects of NA on Ito, but the beta-adrenergic receptor antagonist propranolol (20 microM) did not. The beta-adrenergic receptor agonist isoprenaline (1 microM) had no effect on Ito. 4. Restoration of Ito by NA was prevented by pretreatment with neomycin (100 microM), a phospholipase C inhibitor, but not by pretreatment with 100-400 ng ml(-1) pertussis toxin (PTX). 5. The protein kinase C (PKC) activator phorbol 12-myristate 13-acetate (0.1 microM) mimicked the effect of NA on Ito, whereas the inactive analogue 4alpha-phorbol (20 microM) had no effect on Ito. Pretreatment with bisindolylmaleimide (0.1 microM), a specific PKC inhibitor, completely blocked the effect of NA on Ito. 6. Thus, NA restores Ito in chagasic canine epicardial myocytes. The induction of Ito by NA appears to result from alpha1-adrenergic stimulation of PKC via a PTX-insensitive signalling cascade. These results suggest that the reduction of Ito in chagasic myocytes during the acute stage of Chagas' disease may reflect the lack of the trophic effects of sympathetic innervation.

Muscarinic effects on action potential duration and its rate dependence in canine Purkinje fibers

Studies of the autonomic influence on action potential duration (APD) in the ventricles show direct effects of muscarinic stimulation on epicardial, but not endocardial, APD and conflicting results regarding direct vagal effects on the conduction system. In canine Purkinje fibers, we analyzed the action of the M2 agonist oxotremorine (OXO, 0.1 microM) on APD and on its cycle length (CL) dependence. Fibers were impaled with glass microelectrodes and superfused with Tyrode's solution. APD90 was measured after 3 minutes of drive at CL between 0.3 and 5 seconds. The best fit for the APD/CL relationship at steady state was a hyperbole: APD = APDmax*CL/(CL+CL50), where APDmax (APD at infinite CL) is a rate independent measure of APD, and CL50 (CL at which 50% APDmax is reached) is an index of the rate dependence of APD. In five fibers, OXO reduced APD at all CL (P < 0.05), APDmax was also reduced to 377 +/- 41 ms from 447 +/- 34 ms (P < 0.05), while CL50 was unchanged (405 +/- 46 ms from 437 +/- 28 ms). No effects of OXO on APD and APDmax were seen in two fibers obtained from dogs pretreated with pertussis toxin (PTX). In conclusion, stimulation of M2 receptors in intact, and not PTX treated, Purkinje fibers affects APD but not its CL dependence. This may reflect the activation of a rate independent, background current through a GTP binding protein-linked pathway, such as, IK,ACh. These data differ from those obtained in endocardial and epicardial muscle, stressing the regional differences in vagal modulation of ventricular electrophysiological properties.

Noradrenergic hyperinnervation in the heart of stroke-prone spontaneously hypertensive rats (SHRSP)

Noradrenergic (NA) nerve fiber density was investigated in the subepicardium and myocardium of ventricles in stroke-prone spontaneously hypertensive rats (SHRSP) and was compared with that of normotensive Wistar Kyoto (WKY) rats. Fluorescent NA nerve fibers in the subepicardium of the right and left ventricles of both strains at the ages of 10, 30, 60, 90, and 180 days were examined by the glyoxylic acid method. NA nerve fibers in the myocardium of the right and left ventricles and the ventricular septum of both strains at the ages of 30, 90, and 180 days were also examined in a similar manner. The density of NA nerve fibers was measured by quantitative image analysis. The distribution pattern of NA nerve fibers in the entire subepicardium of ventricles of both strains showed a meshwork pattern throughout the examination period. In sections of the myocardium, NA nerve fibers were distributed between heart muscle cells and around blood vessels in both strains at all ages examined. The densities of NA nerve fibers in the subepicardium of the ventricles of SHRSP were significantly higher than those of WKY rats at all ages examined except for the subepicardium of the left ventricle at 90 days of age. The densities in the myocardium of the right ventricle in 30- and 90-day-old SHRSP were significantly higher than those in WKY rats. The ratios of NA nerve fiber density of SHRSP to that of WKY rats were greater in the subepicardium of the right and left ventricles, except at 90 days of age, and in the myocardium of the right ventricle of younger animals as compared with older ones. NA hyperinnervation in the subepicardium and myocardium of the ventricles of SHRSP may be a primary change of the heart before the onset of hypertension and may be caused by hyperfunction of the stellate ganglia.

Phrenic afferent input excites C1-C2 spinal neurons in rats

Effects of electrical stimulation of the ipsilateral phrenic nerve above the heart were determined on cells in the C1-C2 spinal cord segments of 27 rats anesthetized with pentobarbital. Forty-five cells that responded to this stimulus were included in this study. These cells then were examined at the same stimulus parameters for effects of stimulating the ipsilateral phrenic nerve below the heart, the contralateral phrenic nerve above the heart, and/or the left (ipsilateral) cervical vagus nerve. Ipsilateral phrenic nerve stimulation below the heart had no effect on 20 of 20 cells tested. Seven of 16 cells tested for effects of contralateral phrenic nerve stimulation above the heart were excited and activity of 9 cells was unaffected. Activity changes and activation latencies were not significantly different in the 7 cells excited by both ipsilateral and contralateral phrenic nerve stimulation. Thirty-seven of 45 cells excited by ipsilateral phrenic nerve stimulation also were excited by stimulation of the left cervical (ipsilateral) vagus nerve. The mean increase in cell activity was significantly greater following vagal nerve stimulation compared to phrenic nerve stimulation, and mean activation latency was significantly longer for vagal stimulation. Excitatory receptive somatic fields were classified for 35 cells. Somatic field locations for most cells (80%) included the ipsilateral neck and jaw. Activity of 26 cells was increased by both noxious pinch and brushing the hair, activity of 6 cells was increased only by noxious pinch, and activity of 3 cells was increased only by brushing the hair. Results of this study indicate that there are afferent fibers in the phrenic nerve above the heart, but not below the heart, that excite cells in the C1-C2 segments of the spinal cord. Most cells also were excited by noxious stimuli applied to their somatic receptive fields. Thus, the phrenic nerve may provide a pathway for referral of pain to the neck and jaw from thoracic structures.

Ventricular sensory neurons in canine dorsal root ganglia: effects of adenosine and substance P

Effects elicited by adenosine and substance P on ventricular sensory endings of 14 dorsal root ganglion afferent neurons were studied in situ in anesthetized dogs. Sensory-field application of adenosine (1 microM) increased the activity of these neurons by 179%. Application of a nonspecific adenosine antagonist to epicardial sensory fields suppressed ongoing activity in all 14 neurons by 39%. Application of an A1- or A2-adenosine-receptor antagonist suppressed activity generated by 10 of these neurons by 44 and 59%, respectively. Adenosine applied after A1- or A2-receptor blockade increased activity in 10 neurons by 131 and 145%, respectively, indicating that A1- and A2-receptor effects were not additive. Application of substance P (1 microM) to identified sensory fields increased activity in 12 of these neurons by 169%, whereas application of a substance P-receptor antagonist reduced activity generated by these neurons by 75%. Myocardial ischemia increased activity of nine neurons associated with left ventricular sensory fields by 320%, an effect that was counteracted by the nonspecific adenosine-receptor antagonist. It is concluded that A1- and A2-adenosine receptors, as well as substance P receptors, are present on ventricular epicardial sensory nerve endings of dorsal root ganglion neurons that are tonically active during normal states, becoming further activated during ischemia.

Characteristics of the beta-adrenergic receptor complex in the epicardial border zone of the 5-day infarcted canine heart

BACKGROUND

The effect of isoproterenol on increasing the peak amplitude of the L-type calcium current is reduced in myocytes dispersed from the epicardial border zone (EBZ) of the 5-day infarcted canine heart when compared with control cells from noninfarcted hearts. This suggests that specific alterations in the beta-adrenergic receptor complex develop in this setting. The present study is an examination of individual components of the beta-adrenergic receptor complex with the aim of elucidating the biochemical defect(s) that might be responsible for the diminished beta-adrenergic receptor responsiveness in the myocytes that survive in the infarcted heart.

METHODS AND RESULTS

We compared components of the beta-adrenergic receptor signaling pathway in membranes prepared from the EBZ of the 5-day infarcted heart and a remote, noninfarcted region (RZ) of the same ventricle as well as the corresponding regions of noninfarcted ventricles. Defects in multiple components of the beta-adrenergic receptor complex were confined to the EBZ of the 5-day infarcted heart. These include a decrease in beta-adrenergic receptor density; diminished basal, guanine nucleotide-, isoproterenol-, forskolin-, and manganese-dependent adenylyl cyclase activities; an increase in the EC50 for isoproterenol-dependent activation of adenylyl cyclase; a diminished level of the alpha-subunit of the Gs protein. and an elevated level of the alpha-subunit of the Gi protein.

CONCLUSIONS

Defects in multiple components of the membrane beta-adrenergic receptor complex were identified in the EBZ of the 5-day infarcted canine heart. This constellation of abnormalities would be predicted to impair functional beta-adrenergic responsiveness and contribute to the defect in isoproterenol-dependent stimulation of the L-type calcium current in myocytes isolated from this tissue.

Intrapericardial denervation: responses to water immersion in rhesus monkeys

Eleven anesthetized rhesus monkeys were used to study cardiovascular, renal, and endocrine alterations associated with 120 min of head-out water immersion. Five animals underwent complete intrapericardial denervation using the Randall technique, while the remaining six monkeys served as intact controls. Each animal was chronically instrumented with an electromagnetic flow probe on the ascending aorta, a strain gauge pressure transducer implanted in the apex of the left ventricle (LV), and electrocardiogram leads anchored to the chest wall and LV. During immersion, LV end-diastolic pressure, urine flow, glomerular filtration rate, sodium excretion, and circulating atrial natriuretic peptide (ANP) each increased (P < 0.05) for intact and denervated monkeys. There were no alterations in free water clearance in either group during immersion, yet fractional excretion of free water increased (P < 0.05) in the intact monkeys. Plasma renin activity (PRA) decreased (P < 0.05) during immersion in intact monkeys but not the denervated animals. Plasma vasopressin (PVP) concentration decreased (P < 0.05) during the first 30 min of immersion in both groups but was not distinguishable from control by 60 min of immersion in denervated monkeys. These data demonstrate that complete cardiac denervation does not block the rise in plasma ANP or prevent the natriuresis associated with head-out water immersion. The suppression of PVP during the first minutes of immersion after complete cardiac denervation suggests that extracardiac sensing mechanisms associated with the induced fluid shifts may be responsible for the findings.

Effects of cardiac denervation on coronary and systemic circulation

The effects of cardiac denervation on coronary circulation and systemic hemodynamics were examined in patients who underwent coronary artery bypass grafting for a totally occluded left anterior descending coronary artery. The results in 14 patients who had undergone a combination of bypass grafting and intrapericardial denervation (group I) were compared with those in 19 patients who had undergone only bypass grafting (group II). The heart rate was 110 +/- 4.9 beats/min in group I and 104 +/- 3.7 beats/min in group II after denervation. Although the cardiac index was not significantly different between the two groups, the calculated systemic vascular resistance index of group I (1,358 +/- 111 dynes.s.cm-5.m2) was significantly lower (p < 0.02) than that in group II (1,713 +/- 75 dynes.s.cm-5.m2). The end-diastolic coronary resistance was significantly lower (p < 0.05) in group I (0.59 +/- 0.05 mm Hg.mL-1.min-1) than that in group II (1.04 +/- 0.14 mm Hg.mL-1.min-1), and the end-diastolic graft flow/mean graft flow ratio was 1.56 +/- 0.05 in group I and 1.28 +/- 0.04 in group II (p < 0.01). The plasma norepinephrine concentration in group I (223 +/- 52 pg/mL) was significantly low (p < 0.05) compared with that in group II (328 +/- 39 pg/mL) after denervation. Thus, cardiac denervation may have a beneficial effect on systemic hemodynamics and coronary circulation.

Effects of canine myocardial infarction on sympathetic efferent neuronal function: scintigraphic and electrophysiologic correlates

We studied the effects of nondecentralized left stellate ganglion stimulation on regional epicardial monophasic action potential duration at 50% (APD50) and 90% (APD90) repolarization from 104 sites in 10 surviving dogs with a chronic myocardial infarction model. These effects were correlated with thallium-201 and iodine-123 metiodobenzylguanidine (MIBG) imaging to identify areas of viable but denervated myocardium. Mean infarct size was 5.2% +/- 0.8% total heart weight, and the planimetered areas of denervation were always larger (18% +/- 4% total heart area). During constant ventricular pacing, stellate stimulation tended to shorten the APD90 only in normally innervated areas (364 +/- 5 to 358 +/- 5 msec) and to increase in denervated areas (358 +/- 5 to 362 +/- 5 msec), (p value not significant (NS) for prestellate and poststellate stimulation; p < 0.05 for difference between denervated vs innervated). The APD50 significantly shortened in innervated areas from 287 +/- 5 to 270 +/- 3 msec (p < 0.05) compared with denervated areas (283 +/- 4 to 274 +/- 5 msec, p = NS). We conclude that MIBG imaging demonstration of denervation identifies areas with impaired shortening of the epicardial APD50 in response to stellate stimulation and that nontransmural myocardial infarction produces areas of denervation larger than areas of necrosis.

Sympathetic denervation of the epicardial border zone in the genesis of dispersion of refractoriness and arrhythmogenesis in a 7-day-old canine myocardial infarction model

BACKGROUND

The purpose of this study was to clarify whether sympathetic denervation occurs in the infarcted heart and contributes to the dispersion of the effective refractory period (ERP) and arrhythmogenesis.

METHODS

ERP was measured at 47 epicardial sites in 13 dogs with 7-day-old infarctions after proximal ligation of the left anterior descending artery. To delineate the sympathetic innervation, the effects of ansae subclaviae stimulation (ASS), norepinephrine infusion, and prazosin infusion on ERP were tested.

RESULTS

The per cent change in ERP (delta ERP) induced by ASS was significantly lower at test sites where the surviving epicardial myocardial thickness (Th) was 2 mm or less than at those with a Th of more than 2 mm and the normal zone. Eleven out of 179 sites (6.1%) overlying the infarct showed no ERP change after ASS. ASS paradoxically prolonged ERP at 29 sites (16.2%). In contrast, norepinephrine infusion produced a greater delta ERP in the infarct zone than in the normal zone. Prazosin shortened ERP at sites where ASS prolonged it, but had no effect at sites where ASS shortened ERP. ASS increased both the degree of ERP dispersion and inducibility of ventricular tachycardias or ventricular fibrillation (VT/VF), whereas norepinephrine increased VT/VF inducibility despite a reduction in ERP dispersion.

CONCLUSIONS

We conclude that heterogeneous sympathetic denervation contributed to a prolongation and dispersion of ERP in the surviving epicardium overlying the infarct. Furthermore, a supersensitive response to norepinephrine with resultant ERP shortening and a paradoxical ERP prolongation during ASS caused by alpha-receptor mechanisms that may be related to increased electrical instability were observed.

Effects of acute ischemia on anisotropic conduction in canine ventricular muscle

The effects of acute ischemia on conduction velocities in the longitudinal (theta L) and transverse (theta T) fiber axis were determined from epicardial activation patterns, recorded with 48 bipolar electrodes (plaque electrode, 25 x 35 mm) on the left anterior ventricular wall of eight dogs and the posterior wall of seven dogs. During left ventricular stimulation (cycle length = 300 msec) in the center of the plaque electrode, theta L, theta T, and the ratio of longitudinal to transverse conduction velocities (theta L/T) were measured before and 2 to 5 minutes after occlusion of the left anterior descending coronary artery or the left circumflex coronary artery. During the control state theta L was greater than theta T demonstrating anisotropic properties of cardiac muscle, not only in the anterior but also in the posterior wall. During acute ischemia theta L and theta T were decreased from the control value and theta T was decreased by a greater extent than theta L resulting in an increase in theta L/T from 1.83 +/- 0.31 (mean +/- SD) to 2.19 +/- 0.36 in the anterior wall and from 1.58 +/- 0.17 to 1.92 +/- 0.28 in the posterior wall. During ventricular fibrillation some lines of conduction block were parallel to the long axis of epicardial muscle fiber bundle and the others were perpendicular. In conclusion, acute ischemia increased anisotropic conduction (theta L/T) in the epicardial ventricular muscle mainly due to greater reduction in theta T, in the anterior and the posterior wall. This augmented anisotropic ventricular conduction may have some relation to the initiation of ventricular fibrillation during acute ischemia.

[Morphofunctional bases of the choice of nerves for reinnervation of transplanted heart]

In two series of experiments on 61 dogs it was found that from all the nerves approaching the heart, the largest are on the ascending aorta, pulmonary trunk and pericardium transilicual tuck along which they cross the left pulmonary artery on the way to the dorsal surface of this organ. These nerves are able to provide the adequate heart activity under cardiovascular system loading. It is they that should be primarily used for transplanted heart reinnervation.

[Early results of surgical treatment of patients with Wolff-Parkinson-White syndrome]

Successful dissection of accessory pathways (AcP's) was performed in 19 of 20 patients. 15 pts had single, 4 double and 1 patient had 3 accessory pathways (AcP's). The patient with 3 AcP's was operated twice. During the first operation two AcP's were eliminated. The third one was revealed during the postoperative electrophysiologic study. Verapamil facilitated its manifestation and localisation. No patient had syncope or atrio-ventricular tachycardia after the operation. In 3 of 10 patients who had atrial fibrillation before the operation, episodes of AF occurred in the early postoperative period. Conduction to the ventricles was through the normal conduction system. Dissection of AcP's prevented extremely fast ventricular response and syncope. After discontinuation of amiodarone more frequent ventricular premature beats occurred in patients with long history of cardiac arrhythmias, on drugs for a long time and in patients who had heart dilatation. Several months after the operation VEB were less frequent, probably because tachycardias did not occur, left ventricle geometry improved, and cardiodepressant drugs were discontinued. Previously these patients had been treated usually with combination of 2-3 such drugs. After the successful dissection of AcP's the patients lost the feeling of illness and do not feel being imperilled. Children can attend schools normally and some adult patients resumed their professional activities.

[Emergency epicardial dissection of the accessory pathway in a patient with atrioventricular nodal reentrant tachycardia]

Diagnostic and therapeutic problems in 14 year old patient with concealed WPW syndrome were presented. Paroxysms of atrio-ventricular reentrant tachycardia 180-220/min were frequently recurring, usually with normal QRS pattern. Tachycardias often had to be terminated by intravenous administration of antiarrhythmic drugs. Long term treatment with various antiarrhythmic agents did not prevent recurrence of tachycardias but they became sustained and were recurring more often. Their other side effects manifested with sinus node disfunction and depression of the heart muscle. The electrophysiologic study revealed right anterior septal accessory pathway. Epicardial dissection of the accessory pathway was urgently performed. The control electrophysiologic study revealed no evidence of conduction through the accessory pathway. The patient did not require antiarrhythmic treatment. During the 12 months follow up no tachycardia occurred.