Abstract
In the chronic complete atrioventricular (AV) block dog (CAVB) model, both bradycardia and altered ventricular activation due to the uncontrolled idioventricular rhythm contribute to ventricular remodeling and the enhanced susceptibility to Torsade de Pointes (TdP) arrhythmias. We investigated the effect of permanent bradycardic right ventricular apex (RVA) pacing on mechanical and electrical remodeling and TdP. In 23 anesthetized dogs, serial experiments were performed at sinus rhythm (SR), acutely after AV block (AAVB) and 3 weeks of remodeling CAVB at a fixed pacing rate of 60/min. ECG, and left (LV) and right ventricular (RV) monophasic action potentials durations (MAPD) were recorded; activation time (AT) and activation recovery interval (ARI) were determined from ten distinct LV electrograms; interventricular mechanical delay (IVMD) and time-to-peak strain (TTP) of the LV septal and lateral wall (ΔTTP: lateral wall minus septal wall) were obtained echocardiographically. Dofetilide (25 μg/kg/5 min) was infused to study TdP inducibility. In baseline AAVB, in comparison to SR, RVA bradypacing acutely increased QT interval, LV, and RVMAPD. Echocardiographic IVMD and ΔTTP were initially increased, which was partially corrected after 3 weeks of RVA pacing (IVMD: 22 ± 13 vs. 42 ± 11 vs. 31 ± 6 ms; ΔTTP: −2 ± 47 vs. −114 ± 38 vs. −36 ± 22 ms). QT interval (362 ± 23 vs. 373 ± 29 ms), LVMAPD (245 ± 18 vs. 253 ± 22 ms), RVMAPD (226 ± 26 vs. 238 ± 31 ms), and mean LV-ARI (268 ± 5 vs. 267 ± 6 ms) were not significantly changed after 3 weeks of RVA pacing. During AAVB, dofetilide increased mean LV-ARI (381 ± 11 ms) with largest increases in the later activated basal areas (slope AT-ARI: +0.96). In contrast with acute RVA pacing, 3 week pacing increased TdP inducibility (0/13 vs. 11/21) and mean LV-ARI (484 ± 18 ms), while the slope of AT-ARI responded differently on dofetilide (−2.37), with larger APD increases in the early region. The latter was supported at the molecular level: reduced RNA expressions of three repolarization-related ion channel genes in early (KCNQ1, KCNH2, and KCNJ2) versus two in late regions (KNCQ1 and KCNJ2). In conclusion, bradycardic RVA pacing acutely induced LV intra- and interventricular mechanical dyssynchrony, which was partially reversed after 3 weeks of pacing (remodeling). The latter occurred without apparent baseline electrical effects. However, dofetilide clearly unmasked (region-specific) arrhythmic consequences of remodeling.
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References
Aiba T, Tomaselli G (2012) Electrical remodeling in dyssynchrony and resynchronization. J Cardiovasc Transl Res 5:170–179. doi:10.1007/s12265-012-9348-9
Akerstrom F, Pachon M, Puchol A, Jimenez-Lopez J, Segovia D, Rodriguez-Padial L, Arias MA (2014) Chronic right ventricular apical pacing: adverse effects and current therapeutic strategies to minimize them. Int J Cardiol 173:351–360. doi:10.1016/j.ijcard.2014.03.079
Antzelevitch C (2004) Arrhythmogenic mechanisms of QT prolonging drugs: is QT prolongation really the problem? J Electrocardiol 37(Suppl):15–24
Birati EY, Belhassen B, Bardai A, Wilde AA, Viskin S (2011) The site of origin of torsade de pointes. Heart 97:1650–1654. doi:10.1136/hrt.2010.212381
Coronel R, de Bakker JM, Wilms-Schopman FJ, Opthof T, Linnenbank AC, Belterman CN, Janse MJ (2006) Monophasic action potentials and activation recovery intervals as measures of ventricular action potential duration: experimental evidence to resolve some controversies. Heart Rhythm 3:1043–1050. doi:10.1016/j.hrthm.2006.05.027
Delgado V, Tops LF, Trines SA, Zeppenfeld K, Marsan NA, Bertini M, Holman ER, Schalij MJ, Bax JJ (2009) Acute effects of right ventricular apical pacing on left ventricular synchrony and mechanics. Circ Arrhythm Electrophysiol 2:135–145. doi:10.1161/CIRCEP.108.814608
Delhaas T, Arts T, Prinzen FW, Reneman RS (1994) Regional fibre stress-fibre strain area as an estimate of regional blood flow and oxygen demand in the canine heart. J Physiol 477(Pt 3):481–496. doi:10.1113/jphysiol.1994.sp020209
Dunnink A, Stams TRG, Bossu A, Meijborg VMF, Beekman JDM, Wijers SC, De Bakker JMT, Vos MA (2017) Torsade de pointes arrhythmias arise at the site of maximal heterogeneity of repolarization in the chronic complete atrioventricular block dog. Europace 19:858–865. doi:10.1093/europace/euw087
Fornwalt BK, Cummings RM, Arita T, Delfino JG, Fyfe DA, Campbell RM, Strieper MJ, Oshinski JN, Frias PA (2008) Acute pacing-induced dyssynchronous activation of the left ventricle creates systolic dyssynchrony with preserved diastolic synchrony. J Cardiovasc Electrophysiol 19:483–488. doi:10.1111/j.1540-8167.2007.01079.x
Heusch G (2008) Heart rate in the pathophysiology of coronary blood flow and myocardial ischaemia: benefit from selective bradycardic agents. Br J Pharmacol 153:1589–1601. doi:10.1038/sj.bjp.0707673
Jeyaraj D, Wan X, Ficker E, Stelzer JE, Deschenes I, Liu H, Wilson LD, Decker KF, Said TH, Jain MK, Rudy Y, Rosenbaum DS (2013) Ionic bases for electrical remodeling of the canine cardiac ventricle. Am J Physiol Heart Circ Physiol 305:H410–H419. doi:10.1152/ajpheart.00213.2013
Jeyaraj D, Wilson LD, Zhong J, Flask C, Saffitz JE, Deschenes I, Yu X, Rosenbaum DS (2007) Mechanoelectrical feedback as novel mechanism of cardiac electrical remodeling. Circulation 115:3145–3155. doi:10.1161/CIRCULATIONAHA.107.688317
Kiehl EL, Makki T, Kumar R, Gumber D, Kwon DH, Rickard JW, Kanj M, Wazni OM, Saliba WI, Varma N, Wilkoff BL, Cantillon DJ (2016) Incidence and predictors of right ventricular pacing-induced cardiomyopathy in patients with complete atrioventricular block and preserved left ventricular systolic function. Heart Rhythm 13:2272–2278. doi:10.1016/j.hrthm.2016.09.027
Liu WH, Chen MC, Chen YL, Guo BF, Pan KL, Yang CH, Chang HW (2008) Right ventricular apical pacing acutely impairs left ventricular function and induces mechanical dyssynchrony in patients with sick sinus syndrome: a real-time three-dimensional echocardiographic study. J Am Soc Echocardiogr 21:224–229. doi:10.1016/j.echo.2007.08.045
Livak KJ, Schmittgen TD (2001) Analysis of relative gene expression data using real-time quantitative PCR and the 2(-Delta Delta C(T)) method. Methods 25:402–408. doi:10.1006/meth.2001.1262
Mills RW, Cornelussen RN, Mulligan LJ, Strik M, Rademakers LM, Skadsberg ND, van Hunnik A, Kuiper M, Lampert A, Delhaas T, Prinzen FW (2009) Left ventricular septal and left ventricular apical pacing chronically maintain cardiac contractile coordination, pump function and efficiency. Circ Arrhythm Electrophysiol 2:571–579. doi:10.1161/CIRCEP.109.882910
Mond HG, Proclemer A (2011) The 11th world survey of cardiac pacing and implantable cardioverter-defibrillators: calendar year 2009—a World Society of Arrhythmia’s project. Pacing Clin Electrophysiol 34:1013–1027. doi:10.1111/j.1540-8159.2011.03150.x
Ono S, Nohara R, Kambara H, Okuda K, Kawai C (1992) Regional myocardial perfusion and glucose metabolism in experimental left bundle branch block. Circulation 85:1125–1131. doi:10.1161/01.CIR.85.3.1125
Oros A, Beekman JD, Vos MA (2008) The canine model with chronic, complete atrio-ventricular block. Pharmacol Ther 119:168–178. doi:10.1016/j.pharmthera.2008.03.006
Prinzen FW, Augustijn CH, Arts T, Allessie MA, Reneman RS (1990) Redistribution of myocardial fiber strain and blood flow by asynchronous activation. Am J Physiol 259:H300–H308
Prinzen FW, Hunter WC, Wyman BT, McVeigh ER (1999) Mapping of regional myocardial strain and work during ventricular pacing: experimental study using magnetic resonance imaging tagging. J Am Coll Cardiol 33:1735–1742. doi:10.1016/S0735-1097(99)00068-6
Ramakers C, Vos MA, Doevendans PA, Schoenmakers M, Wu YS, Scicchitano S, Iodice A, Thomas GP, Antzelevitch C, Dumaine R (2003) Coordinated down-regulation of KCNQ1 and KCNE1 expression contributes to reduction of I(Ks) in canine hypertrophied hearts. Cardiovasc Res 57:486–496
Ruijter JM, Ruiz Villalba A, Hellemans J, Untergasser A, van den Hoff MJ (2015) Removal of between-run variation in a multi-plate qPCR experiment. Biomol Detect Quantif 5:10–14. doi:10.1016/j.bdq.2015.07.001
Spragg DD, Akar FG, Helm RH, Tunin RS, Tomaselli GF, Kass DA (2005) Abnormal conduction and repolarization in late-activated myocardium of dyssynchronously contracting hearts. Cardiovasc Res 67:77–86. doi:10.1016/j.cardiores.2005.03.008
Sweeney MO, Hellkamp AS, Ellenbogen KA, Greenspon AJ, Freedman RA, Lee KL, Lamas GA, Investigators MOST (2003) Adverse effect of ventricular pacing on heart failure and atrial fibrillation among patients with normal baseline QRS duration in a clinical trial of pacemaker therapy for sinus node dysfunction. Circulation 107:2932–2937. doi:10.1161/01.CIR.0000072769.17295.B1
Thambo JB, Bordachar P, Garrigue S, Lafitte S, Sanders P, Reuter S, Girardot R, Crepin D, Reant P, Roudaut R, Jais P, Haissaguerre M, Clementy J, Jimenez M (2004) Detrimental ventricular remodeling in patients with congenital complete heart block and chronic right ventricular apical pacing. Circulation 110:3766–3772. doi:10.1161/01.CIR.0000150336.86033.8D
Thomsen MB, Oros A, Schoenmakers M, van Opstal JM, Maas JN, Beekman JD, Vos MA (2007) Proarrhythmic electrical remodelling is associated with increased beat-to-beat variability of repolarisation. Cardiovasc Res 73:521–530. doi:10.1016/j.cardiores.2006.11.025
Tops LF, Schalij MJ, Bax JJ (2009) The effects of right ventricular apical pacing on ventricular function and dyssynchrony implications for therapy. J Am Coll Cardiol 54:764–776. doi:10.1016/j.jacc.2009.06.006
van Oosterhout MF, Prinzen FW, Arts T, Schreuder JJ, Vanagt WY, Cleutjens JP, Reneman RS (1998) Asynchronous electrical activation induces asymmetrical hypertrophy of the left ventricular wall. Circulation 98:588–595. doi:10.1161/01.CIR.98.6.588
van Opstal JM, Schoenmakers M, Verduyn SC, de Groot SH, Leunissen JD, van Der Hulst FF, Molenschot MM, Wellens HJ, Vos MA (2001) Chronic amiodarone evokes no torsade de pointes arrhythmias despite QT lengthening in an animal model of acquired long-QT syndrome. Circulation 104:2722–2727
Vernooy K, Dijkman B, Cheriex EC, Prinzen FW, Crijns HJ (2006) Ventricular remodeling during long-term right ventricular pacing following His bundle ablation. Am J Cardiol 97:1223–1227. doi:10.1016/j.amjcard.2005.11.044
Vernooy K, Verbeek XA, Peschar M, Crijns HJ, Arts T, Cornelussen RN, Prinzen FW (2005) Left bundle branch block induces ventricular remodelling and functional septal hypoperfusion. Eur Heart J 26:91–98. doi:10.1093/eurheartj/ehi008
Volders PG, Sipido KR, Vos MA, Spatjens RL, Leunissen JD, Carmeliet E, Wellens HJ (1999) Downregulation of delayed rectifier K(+) currents in dogs with chronic complete atrioventricular block and acquired torsades de pointes. Circulation 100:2455–2461. doi:10.1161/01.CIR.100.24.2455
Vos MA, de Groot SH, Verduyn SC, van der Zande J, Leunissen HD, Cleutjens JP, van Bilsen M, Daemen MJ, Schreuder JJ, Allessie MA, Wellens HJ (1998) Enhanced susceptibility for acquired torsade de pointes arrhythmias in the dog with chronic, complete AV block is related to cardiac hypertrophy and electrical remodeling. Circulation 98:1125–1135. doi:10.1161/01.CIR.98.11.1125
Wilkoff BL, Cook JR, Epstein AE, Greene HL, Hallstrom AP, Hsia H, Kutalek SP, Sharma A, Dual C, Investigators VVIIDT (2002) Dual-chamber pacing or ventricular backup pacing in patients with an implantable defibrillator: the dual chamber and VVI implantable defibrillator (DAVID) trial. JAMA 288:3115–3123. doi:10.1001/jama.288.24.3115
Winckels SK, Thomsen MB, Oosterhoff P, Oros A, Beekman JD, Attevelt NJ, Kretzers L, Vos MA (2007) High-septal pacing reduces ventricular electrical remodeling and proarrhythmia in chronic atrioventricular block dogs. J Am Coll Cardiol 50:906–913. doi:10.1016/j.jacc.2007.05.019
Zaniboni M, Riva I, Cacciani F, Groppi M (2010) How different two almost identical action potentials can be: a model study on cardiac repolarization. Math Biosci 228:56–70. doi:10.1016/j.mbs.2010.08.007
Acknowledgements
The authors would like to thank Dr. P. Oosterhoff for the custom-written MATLAB software, Medtronic for providing the pacemakers, St. Jude Medical Netherlands for providing the duo-decapolar catheters, and Mrs. A. Gohar for language editing. This research was performed within the framework of CTMM, the Center for Translational Molecular Medicine (www.ctmm.nl), project COHFAR (Grant No. 01C-203), and supported by the Dutch Heart Foundation.
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Stams, T.R.G., Dunnink, A., van Everdingen, W.M. et al. Deleterious acute and chronic effects of bradycardic right ventricular apex pacing: consequences for arrhythmic outcome. Basic Res Cardiol 112, 46 (2017). https://doi.org/10.1007/s00395-017-0636-z
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DOI: https://doi.org/10.1007/s00395-017-0636-z