Background-Identification of patients at risk for drug-induced torsades de pointes arrhythmia (TdP) is difficult. Increased temporal lability of repolarization has been suggested as being valuable to predict proarrhythmia. The predictive value of different repolarization parameters, including beat-to-beat variability of repolarization (BVR), was compared in this serial investigation in dogs with chronic AV block. Methods and Results-In anesthetized dogs with electrically remodeled hearts, the dose-dependent difference in drug-induced TdP (d-sotalol, 2 and 4 mg/kg IV over 5 minutes, 25% and 75% TdP, respectively) could not be accounted for by prolongation of QT c (410Ϯ37 to 475Ϯ60 versus 415Ϯ47 to 484Ϯ52 ms, respectively). BVR was quantified by Poincaré plots at baseline and immediately before onset of d-sotalol-induced extrasystolic activity. TdP occurrence was associated with an increase in short-term variability (STV) of the left ventricular monophasic action potential duration (3.5Ϯ1.5 to 5.5Ϯ1.6 versus 3.0Ϯ0.7 to 8.6Ϯ3.8 ms, respectively), which was reversible when TdP was abolished by I K,ATP activation. The absence of TdP despite QT c prolongation after chronic amiodarone treatment could also be explained by an unchanged STV. In experiments with isolated ventricular myocytes, STV increased after I Kr block and was highest in cells that subsequently showed early afterdepolarizations. Conclusions-Proarrhythmia is not related to differences in prolongation of repolarization but corresponds to BVR, here quantified as STV of the left ventricle. STV could be a new parameter to predict drug-induced TdP in patients.

Deletion of amino-acid residues 1505-1507 (KPQ) in the cardiac SCN5A Na(+) channel causes autosomal dominant prolongation of the electrocardiographic QT interval (long-QT syndrome type 3 or LQT3). Excessive prolongation of the action potential at low heart rates predisposes individuals with LQT3 to fatal arrhythmias, typically at rest or during sleep. Here we report that mice heterozygous for a knock-in KPQ-deletion (SCN5A(Delta/+)) show the essential LQT3 features and spontaneously develop life-threatening polymorphous ventricular arrhythmias. Unexpectedly, sudden accelerations in heart rate or premature beats caused lengthening of the action potential with early afterdepolarization and triggered arrhythmias in Scn5a(Delta/+) mice. Adrenergic agonists normalized the response to rate acceleration in vitro and suppressed arrhythmias upon premature stimulation in vivo. These results show the possible risk of sudden heart-rate accelerations. The Scn5a(Delta/+) mouse with its predisposition for pacing-induced arrhythmia might be useful for the development of new treatments for the LQT3 syndrome.

Despite down-regulation of I(NaL) in remodeled cAVB hearts, ranolazine is antiarrhythmic against drug-induced TdP. The antiarrhythmic effects are reflected in concomitant changes of BVR.

The effect of removing extracellular divalent cations on resting potential (Vrest) and background conductance of rat cardiac muscle was studied. Vrest was measured with 3 M KCl‐filled microelectrodes in papillary muscles, or with a patch electrode in ventricular myocytes. Whole‐cell membrane currents were measured in myocytes using step or ramp voltage commands. In both muscles and single cells, decrease or removal of Ca2+o and Mg2+o caused a nifedipine‐resistant depolarization, which was reversed upon readmission of Ca2+o or Mg2+o (half‐maximal effect at 0.8 mM Ca2+o or 3 mM Mg2+o in muscles). In single myocytes, removal of Ca2+o and Mg2+o had no effect on the seal resistance in non‐ruptured cell‐attached recordings, but reversibly induced a current with a reversal potential (Vrev) of −8 ± 3.4 mV (with internal Cs+; mean. s.e.m., n= 23) during whole‐cell recordings. The current was insensitive to nifedipine (3–100 μM) or amiloride (1 mM). Vrev was insensitive to changes in the equilibrium potential for chloride ions (Ecl. The current induced in the absence of extracellular divalent cations was blocked in a concentration‐dependent manner by Ca2+o. (At −80 mV, the affinity constant Kca was 60 μM with a Hill coefficient of 0.9.) KCa was voltage dependent at positive but not negative potentials. Mg2+o, Ni2+o, Sr2+o, Ba2+o, Cd2+o and Gd3+o also blocked the current. In 0 mM Na+ (145 mM NMDG+), the inward component of the divalent cation‐sensitive current was decreased and Vrev shifted to more negative potentials. These results suggest that a novel conductance pathway, permeable to monovalent cations but not to OF and blocked by divalent cations, exists in ventricular myocytes.

Torsades de pointes (TdP) ventricular tachycardia typically occurs in the setting of early afterdepolarizations; it contributes to arrhythmias and sudden death in congenital and acquired heart disease. Window L-type Ca 2+ current (I CaL ) has a central role in the arrhythmogenesis and may be particularly important under β-adrenergic stimulation. We studied the properties of I CaL in myocytes from the dog with chronic atrioventricular block (cAVB) that has cardiac hypertrophy and an increased susceptibility to TdP. Peak I CaL densities at baseline (K + -and Na + -free solutions, 10 mmol l −1 [EGTA] pip ) in cAVB were comparable to control, but inactivation was shifted to the right, resulting in a larger window current area in cAVB. Under β-adrenergic stimulation, the window current area was increased and shifted to the left, but less so in cAVB (maximum at −27 mV, versus −32 mV in control). I CaL during a step to −35 mV showed a transient reduction immediately after the peak. Test steps to 0 mV, simultaneous recording of [Ca 2+ ] i and manipulation of sarcoplasmic reticulum (SR) Ca 2+ release showed that this resulted from inhibition and fast recovery of I CaL with SR Ca 2+ release. The extent of this dynamic modulation was larger in cAVB than in control (23 ± 2% of the initially available current, versus 13 ± 3%; P < 0.05). Early afterdepolarizations (EADs) in cAVB myocytes under β-adrenergic stimulation typically occurred in the window current voltage range and after decline of [Ca 2+ ] i . In conclusion, in cAVB, the larger window current, its rightward shift and enhanced dynamic modulation by SR Ca 2+ release may contribute to an increased incidence of EADs in cAVB under β-adrenergic stimulation.

IntroductionHypercapnic acidosis (HCA) that accompanies lung-protective ventilation may be considered permissive (a tolerable side effect), or it may be therapeutic by itself. Cardiovascular effects may contribute to, or limit, the potential therapeutic impact of HCA; therefore, a complex physiological study was performed in healthy pigs to evaluate the systemic and organ-specific circulatory effects of HCA, and to compare them with those of metabolic (eucapnic) acidosis (MAC).MethodsIn anesthetized, mechanically ventilated and instrumented pigs, HCA was induced by increasing the inspired fraction of CO2 (n = 8) and MAC (n = 8) by the infusion of HCl, to reach an arterial plasma pH of 7.1. In the control group (n = 8), the normal plasma pH was maintained throughout the experiment. Hemodynamic parameters, including regional organ hemodynamics, blood gases, and electrocardiograms, were measured in vivo. Subsequently, isometric contractions and membrane potentials were recorded in vitro in the right ventricular trabeculae.ResultsHCA affected both the pulmonary (increase in mean pulmonary arterial pressure (MPAP) and pulmonary vascular resistance (PVR)) and systemic (increase in mean arterial pressure (MAP), decrease in systemic vascular resistance (SVR)) circulations. Although the renal perfusion remained unaffected by any type of acidosis, HCA increased carotid, portal, and, hence, total liver blood flow. MAC influenced the pulmonary circulation only (increase in MPAP and PVR). Both MAC and HCA reduced the stroke volume, which was compensated for by an increase in heart rate to maintain (MAC), or even increase (HCA), the cardiac output. The right ventricular stroke work per minute was increased by both MAC and HCA; however, the left ventricular stroke work was increased by HCA only. In vitro, the trabeculae from the control pigs and pigs with acidosis showed similar contraction force and action-potential duration (APD). Perfusion with an acidic solution decreased the contraction force, whereas APD was not influenced.ConclusionsMAC preferentially affects the pulmonary circulation, whereas HCA affects the pulmonary, systemic, and regional circulations. The cardiac contractile function was reduced, but the cardiac output was maintained (MAC), or even increased (HCA). The increased ventricular stroke work per minute revealed an increased work demand placed by acidosis on the heart.

In guinea-pig ventricular myocytes, in which the deactivation of slowly activating delayed rectifier potassium current (IKs) is slow, IKs can be increased by rapid pacing as a result of incomplete deactivation and subsequent current accumulation. Whether accumulation of IKs occurs in dogs, in which the deactivation is much faster, is still unclear. In this study the conditions under which accumulation occurs in canine ventricular myocytes were studied with regard to its physiological relevance in controlling action potential duration (APD). At baseline, square pulse voltage clamp experiments revealed that the accumulation of canine IKs could occur, but only at rather short interpulse intervals (< 100 ms). With action potential (AP) clamp commands of constant duration (originally recorded at rate of 2 Hz), an accumulation was only found at interpulse intervals close to 0 ms. Transmembrane potential recordings with high-resistance microelectrodes revealed, however, that at the fastest stimulation rates with normally captured APs (5 Hz) the interpulse interval exceeded 50 ms. This suggested that no IKs accumulation occurs, which was supported by the lack of effect of an IKs blocker, HMR 1556 (500 nM), on APD. In the presence of the beta-adrenergic receptor agonist isoproterenol (isoprenaline, 100 nM) the accumulation with AP clamp commands of constant duration was much more pronounced and a significant accumulating current was found at a relevant interpulse interval of 100 ms. HMR 1556 prolonged APD, but this lengthening was reverse rate dependent. AP clamp experiments in a physiologically relevant setting (short, high rate APs delivered at a corresponding rate) revealed a limited accumulation of IKs in the presence of isoproterenol. In conclusion, a physiologically relevant accumulation of IKs was only observed in the presence of isoproterenol. Block of IKs, however, led to a reverse rate-dependent prolongation of APD indicating that IKs does not have a dominant role at short cycle lengths.

Background-In large mammals and humans, the contribution of I Ks to ventricular repolarization is still incompletely understood. Methods and Results-In