Novel ventricular tachyarrhythmia detection enhancement detects undertreated life-threatening arrhythmias.

BACKGROUND: Ventricular tachyarrhythmias (VTA) with low and varying signal amplitudes and morphologies may not be successfully identified utilizing traditional implantable cardioverter-defibrillator algorithms. OBJECTIVE: Develop and validate a novel algorithm (VF Therapy Assurance, VFTA) to improve detection and timely delivery of high-voltage therapy (HVT) for these arrhythmias. METHODS: Arrhythmia detection was simulated on recorded VTA electrograms (EGMs) utilizing Abbott's Merlin.net database. EGMs where an HVT occurred only when VFTA was enabled, or where VFTA provided an HVT >30 seconds earlier than without VFTA, were readjudicated with physician review. As VFTA never prevents detection or therapy, EGMs where VFTA did not activate or alter HVT were not adjudicated. RESULTS: Among 564,353 recorded VTA EGMs from 20,000 devices, VFTA altered HVT in 105 EGMs from 67 devices. Physician adjudication determined that 81.9% (86/105) of these EGMs were true undertreated VTA episodes and would have received appropriate HVT with VFTA enabled. Furthermore, 65% of the episodes (56/86) were ventricular fibrillation, were polymorphic, did not self-terminate during the recording window, or were not amenable antitachycardia pacing. Of those, 87.5% (49/56) would not have elicited HVT without VFTA. Overall, VFTA provided new or earlier appropriate HVT in 0.27% (53/20,000) of devices with an increase in inappropriate HVT in 0.07% (14/20,000) devices. CONCLUSION: The VFTA algorithm successfully identifies VTA missed by traditional detection algorithms, owing to undersensed ventricular signals resulting in the rate falling below the programmed detection rate. The use of VFTA increases the likelihood of delivering life-saving HVT.

Long-term in vivo performance of novel ultrasound powered implantable devices.

Neuromodulation devices have been approved for the treatment of epilepsy and seizures, with many other applications currently under research investigation. These devices rely on implanted battery powered pulse generators, that require replacement over time. Miniaturized ultrasound powered implantable devices have the potential to eliminate the need for batteries in neuromodulation devices. While these devices have been assessed in vitro, long-term in vivo assessment is required to determine device safety and performance. In this study, we developed a multi-stage long-term test platform to assess the performance of miniaturized ultrasound powered implantable devices.

Arrhythmogenic remodeling of ß2 versus ß1 adrenergic signaling in the human failing heart.

BACKGROUND: Arrhythmia is the major cause of death in patients with heart failure, for which ß-adrenergic receptor blockers are a mainstay therapy. But the role of ß-adrenergic signaling in electrophysiology and arrhythmias has never been studied in human ventricles. METHODS AND RESULTS: We used optical imaging of action potentials and [Ca(2+)]i transients to compare the ß1- and ß2-adrenergic responses in left ventricular wedge preparations of human donor and failing hearts. ß1-Stimulation significantly increased conduction velocity, shortened action potential duration, and [Ca(2+)]i transients duration (CaD) in donor but not in failing hearts, because of desensitization of ß1-adrenergic receptor in heart failure. In contrast, ß2-stimulation increased conduction velocity in both donor and failing hearts but shortened action potential duration only in failing hearts. ß2-Stimulation also affected transmural heterogeneity in action potential duration but not in [Ca(2+)]i transients duration. Both ß1- and ß2-stimulation augmented the vulnerability and frequency of ectopic activity and enhanced substrates for ventricular tachycardia in failing, but not in donor, hearts. Both ß1- and ß2-stimulation enhanced Purkinje fiber automaticity, whereas only ß2-stimulation promoted Ca-mediated premature ventricular contractions in heart failure. CONCLUSIONS: During end-stage heart failure, ß2-stimulation creates arrhythmogenic substrates via conduction velocity regulation and transmurally heterogeneous repolarization. ß2-Stimulation is, therefore, more arrhythmogenic than ß1-stimulation. In particular, ß2-stimulation increases the transmural difference between [Ca(2+)]i transients duration and action potential duration, which facilitates the formation of delayed afterdepolarizations.

Local ß-adrenergic stimulation overcomes source-sink mismatch to generate focal arrhythmia.

RATIONALE: ß-Adrenergic receptor stimulation produces sarcoplasmic reticulum Ca(2+) overload and delayed afterdepolarizations in isolated ventricular myocytes. How delayed afterdepolarizations are synchronized to overcome the source-sink mismatch and produce focal arrhythmia in the intact heart remains unknown. OBJECTIVE: To determine whether local ß-adrenergic receptor stimulation produces spatiotemporal synchronization of delayed afterdepolarizations and to examine the effects of tissue geometry and cell-cell coupling on the induction of focal arrhythmia. METHODS AND RESULTS: Simultaneous optical mapping of transmembrane potential and Ca(2+) transients was performed in normal rabbit hearts during subepicardial injections (50 µL) of norepinephrine (NE) or control (normal Tyrode's solution). Local NE produced premature ventricular complexes (PVCs) from the injection site that were dose-dependent (low-dose [30-60 µmol/L], 0.45±0.62 PVCs per injection; high-dose [125-250 µmol/L], 1.33±1.46 PVCs per injection; P<0.0001) and were inhibited by propranolol. NE-induced PVCs exhibited abnormal voltage-Ca(2+) delay at the initiation site and were inhibited by either sarcoplasmic/endoplasmic reticulum Ca(2+)-ATPase inhibition or reduced perfusate [Ca(2+)], which indicates a Ca(2+)-mediated mechanism. NE-induced PVCs were more common at right ventricular than at left ventricular sites (1.48±1.50 versus 0.55±0.89, P<0.01), and this was unchanged after chemical ablation of endocardial Purkinje fibers, which suggests that source-sink interactions may contribute to the greater propensity to right ventricular PVCs. Partial gap junction uncoupling with carbenoxolone (25 µmol/L) increased focal activity (2.18±1.43 versus 1.33±1.46 PVCs per injection, P<0.05), which further supports source-sink balance as a critical mediator of Ca(2+)-induced PVCs. CONCLUSIONS: These data provide the first experimental demonstration that localized ß-adrenergic receptor stimulation produces spatiotemporal synchronization of sarcoplasmic reticulum Ca(2+) overload and release in the intact heart and highlight the critical nature of source-sink balance in initiating focal arrhythmias.

A computational model to predict the effects of class I anti-arrhythmic drugs on ventricular rhythms.

A long-sought, and thus far elusive, goal has been to develop drugs to manage diseases of excitability. One such disease that affects millions each year is cardiac arrhythmia, which occurs when electrical impulses in the heart become disordered, sometimes causing sudden death. Pharmacological management of cardiac arrhythmia has failed because it is not possible to predict how drugs that target cardiac ion channels, and have intrinsically complex dynamic interactions with ion channels, will alter the emergent electrical behavior generated in the heart. Here, we applied a computational model, which was informed and validated by experimental data, that defined key measurable parameters necessary to simulate the interaction kinetics of the anti-arrhythmic drugs flecainide and lidocaine with cardiac sodium channels. We then used the model to predict the effects of these drugs on normal human ventricular cellular and tissue electrical activity in the setting of a common arrhythmia trigger, spontaneous ventricular ectopy. The model forecasts the clinically relevant concentrations at which flecainide and lidocaine exacerbate, rather than ameliorate, arrhythmia. Experiments in rabbit hearts and simulations in human ventricles based on magnetic resonance images validated the model predictions. This computational framework initiates the first steps toward development of a virtual drug-screening system that models drug-channel interactions and predicts the effects of drugs on emergent electrical activity in the heart.