Triple atrioventricular nodal pathways can be masked.

In summary, CL modulates the dispersion in refractoriness of triple nodal pathways by causing greater changes in refractoriness in the slower pathways and thus determines the feasibility of manifestation.

Autonomic nervous system activity in idiopathic dilated cardiomyopathy and in hypertrophic cardiomyopathy.

To assess autonomic nervous activity in patients with cardiomyopathies, analysis of heart rate variability was performed using 24-hour ambulatory electrocardiograms in 14 patients with idiopathic dilated cardiomyopathy (IDC), 15 with hypertrophic cardiomyopathy (HC) and 18 healthy subjects. Heart rate variability during the night and daytime was calculated using fast-Fourier transform, and power spectra were quantified in 2 frequency bandwidths: 0.00 to 0.15 Hz (low-frequency power [LF]) and 0.15 to 0.50 Hz (high-frequency power [HF]). Log(HF) was used as an index of parasympathetic nervous activity, and log(LF/HF), of sympathetic nervous activity. Log(HF) was significantly lower and log(LF/HF) was significantly higher in IDC. These changes were related to ejection fraction. In HC, lower log(HF) and higher log(LF/HF) were recognized only during the night, and these changes were independent of the degree of myocardial hypertrophy. Our results indicated attenuation of parasympathetic activity and enhanced sympathetic activity in HC during the night, and also in IDC. Assessment of autonomic imbalance by analysis of heart rate variability may be useful for understanding the pathophysiology of cardiomyopathies.

Immunohistochemical localization of calbindin D-28k in the migratory pathway from the rat olfactory placode.

The spatiotemporal localization of calbindin D-28k (Calb), a calcium-binding protein, was examined immunohistochemically in the developing rat olfactory system with special reference to cell migration from the olfactory placode. Calb immunoreactivity was first detected at embryonic day 12 (E12) in a few cells just outside the olfactory epithelium, and at E13, Calb-immunoreactive cells were found scattered in the laminin-rich mesenchyme. By E14, Calb-immunoreactive cells had increased in number and were seen along the entire migratory route between the vomeronasal organ, a derivative of the medial olfactory pit, and the ventromedial surface of the telencephalic vesicle. Calb neurones were not seen in the olfactory epithelium, a derivative of the lateral olfactory pit. Although the distribution pattern of Calb-immunoreactive cells was similar to that of luteinizing hormone releasing hormone (LHRH)-producing neurones, which are known to originate in the vomeronasal organ and migrate into the forebrain, Calb and LHRH immunoreactivities were contained in separate neuronal populations. Calb-immunoreactive cells were localized along the vomeronasal nerves, identified by labelling the vomeronasal organ with the lipophilic dye, DiI, and strongly immunoreactive for neural cell adhesion molecule (NCAM). These data strongly suggest that, in addition to LHRH neurones, the rat vomeronasal organ generates Calb-immunoreactive neurones which migrate along the vomeronasal nerves to enter the forebrain. The final fate and functional importance of these cells remains to be determined.

Localization of two cholinergic markers, choline acetyltransferase and vesicular acetylcholine transporter in the central nervous system of the rat: in situ hybridization histochemistry and immunohistochemistry.

Choline acetyltransferase (ChAT) and vesicular acetylcholine transporter (VAChT) are proteins that are required for cholinergic neurotransmission. Present knowledge concerning the organization of cholinergic structures has been derived primarily from immunohistochemistry for ChAT. In the present study, we investigated the distribution of mRNAs and the corresponding proteins for ChAT and VAChT by in situ hybridization histochemistry and immunohistochemistry. The patterns of distribution of perikarya containing ChAT mRNA. ChAT protein, VAChT mRNA and VAChT protein were similar in most regions, and co-localization in the same neuron of mRNAs for ChAT and VAChT, that of ChAT mRNA and ChAT protein, and that of VAChT mRNA and VAChT protein were demonstrated. However, in the cerebral cortex and hypothalamus, ChAT-immunoreactive perikarya were present, but they did not contain mRNAs for ChAT and VAChT, and VAChT protein. On the other hand, in the cerebellum, Purkinje cell bodies contained VAChT mRNA and VAChT protein, but they did not contain either ChAT mRNA or ChAT protein. Axon bundles were clearly revealed by immunohistochemistry for ChAT, but they were not detected by that for VAChT. Both ChAT and VAChT antibodies revealed preterminal axons and terminal-like structures. In the forebrain, they were present in the olfactory bulb, nucleus of the lateral olfactory tract, olfactory tubercle, lateral septal nucleus, amygdala, hippocampus, neocortex, caudate-putamen, thalamus and median eminence of the hypothalamus. In the brainstem, they were localized in the superior colliculus, interpeduncular nucleus and some cranial nerve motor nuclei, and further in the ventral horn of the spinal cord. These results indicate strongly that ChAT and VAChT are expressed in most of the cholinergic neurons, and that immunohistochemistry for VAChT is as useful to detect cholinergic terminal fields as that for ChAT.

Changes of expression levels of choline acetyltransferase and vesicular acetylcholine transporter mRNAs after transection of the hypoglossal nerve in adult rats.

Acetylcholine, synthesized in the cytoplasm of cholinergic neurons by choline acetyltransferase (ChAT), is packaged in synaptic vesicles by vesicular acetylcholine transporter (VAChT). The entire VAChT gene has been reported to be located within the first intron of the ChAT gene. In order to examine whether or not ChAT and VAChT transcription may be coordinately regulated, the levels of ChAT and VAChT mRNAs in hypoglossal neurons were analyzed by in situ hybridization following transection of the hypoglossal nerve in adult rats. After unilateral transection, the levels of expression of ChAT and VAChT mRNAs were dramatically reduced in the ipsilateral hypoglossal nucleus 1 week after the surgery. However the expression of both mRNAs gradually recovered thereafter. These results suggest that the transcription of the two cholinergic genes is tightly linked in motor neurons.

Right ventricular cardiomyopathy showing right bundle branch block and right precordial ST segment elevation.

A 73-year-old man who had a family history of sudden death, experienced syncope. His electrocardiogram (ECG) presented right bundle branch block and right precordial ST segment elevation which are findings identical with those in Brugada syndrome. The cardiac MRI showed right ventricular mild dilatation, and endomyocardial biopsy revealed fatty replacement of myocardial fibers. Though no ventricular tachyarrhythmias were induced during an electrophysiologic test, the effects on ECG of antiarrhythmic agents and autonomic modulations were similar to those in Brugada syndrome. This case may suggest the relationship between Brugada syndrome and right ventricular cardiomyopathy.

Ultrastructural evidence of kisspeptin-gonadotrophin-releasing hormone (GnRH) interaction in the median eminence of female rats: implication of axo-axonal regulation of GnRH release.

The present study was conducted to determine the morphological and functional interaction between kisspeptin and gonadotrophin-releasing hormone (GnRH) neuronal elements at the median eminence in female rats to clarify a possibility that kisspeptin directly stimulates GnRH release at the nerve end. A dual immunoelectron microscopic study of kisspeptin and GnRH showed that the kisspeptin-immunoreactive nerve element directly abutted the GnRH-immunoreactive nerve element, although no obvious synaptic structure was found between kisspeptin and GnRH neurones in the median eminence. The current retrograde tracing study with FluoroGold (FG) indicates that kisspeptin neurones are not in contact with fenestrated capillaries because no FG signal was found in kisspeptin neurones when the FG was injected peripherally. This peripheral FG injection revealed the neuroendocrine neurones projecting to the median eminence because FG-positive GnRH neuronal cell bodies were found in the preoptic area. Synthetic rat kisspeptin (1-52)-amide stimulated GnRH release from the median eminence tissues in a dose-dependent manner. Thus, the present results suggest that kisspeptin at least partly exerts stimulatory effects on GnRH release from the neuronal terminals of GnRH neurones by axo-axonal nonsynaptic interaction in the median eminence.

His-bundle parasystole masquerading as exercise-induced 2:1 atrioventricular block.

We describe a case of symptomatic pseudo-AV block due to His-bundle parasystole masquerading as exercise-induced 2:1 AV block. Electrophysiologic study revealed the presence of His-bundle parasystole, and the fluctuation of parasystolic cycle length could be explained by the concept of modulated parasystole. Modulated parasystole is a possible explanation for maintenance of stable 2:1 AV conduction at an atrial rate of specific range during exercise.

Incidence of induced atrial fibrillation/flutter in complete atrioventricular block. A concept of 'atrial-malfunctioning' atrio-hisian block.

BACKGROUND: Atrial fibrillation/flutter (Af) has been considered to occur coincidentally with atrioventricular (AV) block. However, a case with complete AV block was reported to histologically show fibrotic changes solely in the atrial muscles but neither in the AV node nor in the His bundle, indicating a possible relation between AV block and atrial tachyarrhythmias. To test a hypothesis that AV block and Af are causally interrelated, we investigated the incidence and electrophysiological characteristics of Af in complete AV block. METHODS AND RESULTS: Forty-two patients with persistent complete AV block underwent the electrophysiological study. Patients with spontaneous/electrically induced Af were compared with the other patients with respect to their electrophysiological variables. Of the 42 patients, Af was transiently induced by electrical stimulation in 5 patients (11.9%), while persistent Af was observed in 2 patients (4.8%, AH and HV block). AV block in the 5 patients with induced Af was invariably due to AH block. AH block complicated by persistent/induced Af was marked by relatively short RR intervals, significantly short junctional recovery time, and impaired intra-atrial conduction. CONCLUSIONS: Electrically induced Af in complete AV block was associated frequently with complete AH block. These patients were characterized differently from the commonly recognized AV block and therefore may stand as a unique subgroup of AH block.

Parasympathetic activity is a major modulator of the circadian variability of heart rate in healthy subjects and in patients with coronary artery disease or diabetes mellitus.

Autonomic heart rate control was assessed by power spectral analysis of heart rate variability in 24-hour ambulatory electrocardiographic recordings from 23 healthy subjects, 14 patients with coronary artery disease without cardiac dysfunction, and 14 patients with diabetes mellitus. The log value of the ratio of the low-frequency component (LF = 0.04 to 0.15 Hz) to the high-frequency component (HF = 0.15 to 0.5 Hz) and logHF were employed as indexes of sympathetic and parasympathetic activity, respectively. Diurnal and nocturnal logLF, logHF, and log(LF/HF) values were calculated for heart rates of 60, 70, and 80 beats/min. Intergroup differences among these three variables were not significant at any heart rate. Although a heart rate-related decrease in logHF was generally observed, the relationship between log(LF/HF) and heart rate was not consistent. The correlation between diurnal and nocturnal logHF values was significant at all three heart rates (r = 0.63, 0.87, and 0.59), whereas the diurnal log(LF/HF) was correlated with the nocturnal value only at 70 beats/min (r = 0.77). These results suggest that the heart rate during normal daily activities is a reliable indicator of parasympathetic tone, if not sympathetic tone, in healthy subjects and patients with coronary artery disease or diabetes mellitus.

Effects of a class III antiarrhythmic drug and biphasic shocks on the postdefibrillation refractory period of relatively refractory myocardium.

INTRODUCTION: This study was designed to test whether the refractory state of nondepolarized myocardium is a major determinant of electrical defibrillation. METHODS AND RESULTS: Postshock recovery interval (PSRI) was estimated by measuring the residual refractory period after an appropriately timed field stimulus (1 to 16 V). The PSRI and transcardiac defibrillation threshold (DFT) were compared before and during the administration of E-4031, a new Class III antiarrhythmic drug (group 1, n = 10), or between monophasic and biphasic shocks (group 2, n = 14) in anesthetized open chest dogs. Group 1: E-4031 reduced the DFT from 2.6 +/- 0.6 J to 1.8 +/- 0.6 J (P < 0.01). The PSRI increased with the increase of the applied voltage and was almost always greater during E-4031 infusion than at baseline. There was an inverse correlation between the changes of DFT and PSRI measured with a 14-V stimulus (r = -0.80, P < 0.01) and a 16-V stimulus (r = -0.80, P < 0.01). Group 2: Mean DFTs were not statistically different between the two waveforms (3.3 +/- 1.0 J vs 2.9 +/- 1.4 J). However, there also was an inverse correlation between the differences in individual PSRIs and DFTs of the two waveforms (10-V stimulus: r = -0.62, P < 0.05; 16-V stimulus: r = -0.75, P < 0.01). CONCLUSIONS: Modulation of defibrillation efficiency by E-4031 infusion or by changes of the shock waveform was related to the effect of these interventions on PSRI. These results suggest an independent role for the refractoriness of nondepolarized myocardium in the mechanism of defibrillation.

Electrophysiological background of individual variability in electrical defibrillation efficacy.

This study was performed to test whether heart-to-heart variability of defibrillation efficacy is attributable to differences in postshock refractory state of nondepolarized myocardium. In 30 anesthetized dogs, a localized potential gradient was created using 1-16 V of stimulus across a pair of platinum plate electrodes on the right ventricle (5-mm interelectrode distance). The postshock recovery interval (PSRI) of the relatively refractory myocardium directly adjacent to the excited area was estimated by measuring the recovery interval after an appropriately timed field stimulus. The transcardiac defibrillation threshold (DFT) was also determined. The results showed that DFT normalized by the weight of the heart was inversely correlated with the PSRI measured with a field stimulus of 6 V (local shock intensity approximately 5 V/cm) or more (6 V: r = -0.502, P < 0.005; 16 V: r = -0.635, P < 0.0005). This observation suggests that variability of defibrillation efficacy in intact hearts is largely due to differences in the postshock refractory state of the nondepolarized myocardium.

Lysosomal storage results in impaired survival but normal neurite outgrowth in dorsal root ganglion neurones from a mouse model of Sandhoff disease.

Sandhoff disease is a heritable lysosomal storage disease resulting from impaired degradation of GM2 ganglioside and related substrates. A mouse model of Sandhoff disease created by gene targeting displays progressive neurological manifestations, similar to patients with the disease. In the present in vivo and in vitro studies, we examined morphological and functional abnormalities of dorsal root ganglion (DRG) neurones in Sandhoff disease mice at an asymptomatic stage (approximately 1 month of age). Light microscopic studies with Nissl staining and immunocytochemistry suggested extensive intracytoplasmic storage of GM2 ganglioside in the Sandhoff mouse DRG neurones. These findings were consistent with the results of electron microscopy, in which a huge number of pleomorphic inclusion bodies immunoreactive for GM2 ganglioside were present in the cytoplasm of the neurones. The inclusion bodies were also identified in satellite cells and Schwann cells in the Sandhoff mouse DRG. The survival ratios of DRG neurones after 1, 2, 4 and 6 days in culture were significantly lower in the Sandhoff mice than in the age-matched heterozygous mice. The ratio of neurite-bearing cells on poly-l-lysine-coated dishes after 2 days in culture was also lower by approximately 10% in the Sandhoff mice compared to the heterozygotes, but additional coating of laminin onto poly-l-lysine dramatically enhanced the neurite extension from the neurones in both groups of mice. These results indicate that accumulation of GM2 ganglioside in DRG neurones impairs the capability of the neurones to survive in vitro, although viable neurones from the Sandhoff mice in culture can regenerate neurites nearly as well as unaffected neurones.

Ostensible day-night difference of QT prolongation during long-term treatment with antiarrhythmic drugs: reappraisal of the law of "regression to the mean".

This study was designed to test whether the law of regression to the mean explains the diurnal variation in the modulation of electrocardiographic variables during the treatment with antiarrhythmic agents. In part 1, in 34 subjects, ambulatory ECG monitorings were repeated twice, and the corrected QT interval (QTc) at a heart rate of 60 beats/min was calculated separately for the daytime and night. The individual diurnal QTc variation (day-night difference) of the first recording (4.4 +/- 3.3%) was significantly correlated with that of the second recording (5.0 +/- 3.1%; r = 0.61; p < 0.0001), and naturally, the second measurement tended to be lower than the first value in those with relatively greater baseline diurnal QTc variation and vice versa (p < 0.005). In part 2, 30 subjects undertook ambulatory ECG recordings before and during treatment with class Ia antiarrhythmic drugs. Mean QTc changes in the daytime and in the night with the drugs were comparable (18 +/- 17 ms and 19 +/- 15 ms). However, the day-night difference of postdrug QTc changes in each subject was inversely correlated with baseline diurnal QTc variation (r = -0.64; p < 0.0001). These observations in part 2 were comparable with those in part 1, and individual day-night difference in QT prolongation with antiarrhythmic drugs seemed to be a chance occurrence. It was suggested that the law of regression to the mean is appreciably reflected in the ostensible intraday variation of pharmacologic modulation of electrocardiographic variables.

A case of a pseudomalfunction of a DDD pacemaker.

DDD pacemaker pseudomalfunction occurred in a 65-year-old man. This was due to premature ventricular contraction (PVC) response option and cross-talk detection window, which are designed to protect against pacemaker related tachycardia or cross-talk. Pseudomalfunction disappeared by eliminating PVC response option.

Shock-induced refractory period extension and pharmacologic modulation of defibrillation threshold.

Shock-induced refractory period extension (RPE) has been suggested as a mechanism of electrical defibrillation. We measured RPE caused by localized field stimulation measured before and during infusion of disopyramide (n = 5), flecainide (n = 5), or E-4031 (n = 5) in anesthetized dogs and determined the effect of the drugs on the internal defibrillation threshold (DFT). In the baseline state (n = 15), 16 V/cm S2 field stimulation prolonged the effective RP by 36 +/- 15 ms (22 +/- 12% of RP without S2), whereas 4 and 8 V/cm S2 stimuli did not cause marked RPE. The RPE normalized by the RP without S2 was not significantly influenced by any drug (16 V/cm: disopyramide 30 +/- 11 vs. 27 +/- 11, flecainide 25 +/- 5 vs. 19 +/- 12, and E-4031 18 +/- 13 vs. 22 +/- 14%). Disopyramide did not alter the defibrillation threshold (4.2 +/- 0.6-4.4 +/- 0.6 J). In 2 dogs given flecainide, ventricular fibrillation became refractory to defibrillation. In contrast, E-4031 lowered the threshold from 4.5 +/- 2.4 to 2.2 +/- 1.2 J (p < 0.01). The results suggest that flecainide and E-4031 do not modulate defibrillation efficiency through their effects on RPE.

Is the QT interval an indicator of autonomic state?

Prolonged QT interval is suggested to indicate an increased risk of sudden cardiac death in certain clinical conditions such as diabetes mellitus. We investigated whether the individual QT interval is an indicator of an autonomic state. An ambulatory 24-hour ECG was recorded in 53 subjects from different clinical backgrounds. Power spectral components of heart rate variability (HRV) and the QT interval were regressively obtained at a heart rate of 60, 70, 80, 90, or 100 beats per minutes (bpm). Log values of the high-frequency component of HRV (HF: 0.15-0.50 Hz, a scale of cardiac parasympathetic tone) failed to show a relationship with the QT interval. In contrast, the QT interval at a heart rate of 90 bpm and 100 bpm showed a significant correlation with the log values of the low-frequency component (LF: 0.04-0.15 Hz) and the log[LF/HF], i.e., a putative scale of sympathetic tone (100 bpm: QT vs logLF: r = 0.414, p < 0.005, QT vs log[LF/HF]: 0.416, p < 0.002). Also, attenuated rate-dependent QT shortening was associated with greater logLF and log[LF / HF] values at a heart rate of 80, 90, or 100 bpm. These results suggest that the QT interval at a moderate heart rate (approximately 90-100 / min) and the degree of rate-dependent QT shortening are related to individual sympathetic tone.

Nonreentrant supraventricular tachycardia due to double ventricular response via dual atrioventricular nodal pathways.

Narrow and wide QRS tachycardias associated with various rhythm disturbances were recognized during 24-hour ambulatory eletrocardiographic monitoring in a 65-year-old man with coronary artery disease. Laddergram analysis revealed the presence of dual atrioventricular nodal pathways. Non-reentrant supraventricular tachycardia due to simultaneous fast and slow conduction through the dual atrioventricular nodal pathways was confirmed by electrophysiologic study. The atrial rate determined the occurrence of simultaneous conduction, and extrastimulation failed to induce a double ventricular response. Enhanced vagal activity was thought to play a critical role in provoking this phenomenon. Radiofrequency catheter ablation of the slow pathway eliminated the arrhythmias.