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Rate and rhythm dependent vulnerability of the human ventricular myocardium

Rhythmus- und frequenzabhängige Vulnerabilität der menschlichen Herzkammer nach vorzeitiger Stimulation

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Summary

The effects of premature ventricular stimulation on intracardiac conduction and ventricular vulnerability were compared during a ventricular versus a supraventricular rhythm in 52 patients. Using the extrastimulus technique, premature right ventricular (RV) stimuli of double diastolic threshold and 1 ms duration were induced with increasing prematurity after every tenth basic beat until the effective refractory period of the RV myocardium was reached.

There was a striking difference in the frequency of ventricular vulnerability when both stimulation techniques were compared in the individual case. Ventricular vulnerability which was defined as repetitive ventricular response to one single test impulse occurred with a decreasing frequency of 61%, 50% and 31% of all patients studied at the rates of 80, 100 and 120/min during the RV drive rhythm; repetitive ventricular firing, however, was not observed in a single case after premature RV stimulation during a right atrial (RA) drive rhythm. The vulnerability of the RV myocardium was restricted to mainly one spontaneous extrasystole revealing no tendency to an, acceleration of the arrhythmia. Concomitantly, there was a strong correlation between the occurrence of repetitive firing and a prolonged, critical conduction delay of the premature RV test impulse during the RV drive. In contrast, measurably prolonged intraventricular conduction times during the RA drive rhythm could rarely be demonstrated never reaching the critical delay to exhibit vulnerability.

The difference in conduction time of the premature RV test impulse during both drive rhythms is interpreted as a strong argument to confine the main conduction delay of the test impulse in the distal RV Purkinje system. Therefore, local re-entry mechanisms in the distal RV Purkinje system occurring simultaneously with critical conduction delays after premature RV stimuli most likely lead, to the spontaneous extrasystoles. The rate and rhythm dependent repetitive firing is valued as a physiologic phenomenon helping to explain certain clinically observed pacemaker induced arrhythmias and to elucidate the multiform face of ventricular vulnerability.

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References

  1. Wiggers, C. J.: The mechanism and nature of ventricular fibrillation, Amer. Heart J.20, 399 (1940).

    Google Scholar 

  2. Brooks, C. McC., B. F. Hoffman, E. E. Suckling, O. Orias: Excitability of the heart, (New York 1955).

  3. Surawicz, B.: Ventricular fibrillation, Amer. J. Cardiol.28, 268 (1971).

    PubMed  Google Scholar 

  4. Antoni, H.: Elektrophysiologische Äquivalente bei Herzrhythmusstörungen. Verh. Dtsch. Ges. Innere Med.81, 69 (1975).

    Google Scholar 

  5. El-Sherif, M., B. J. Scherlag, R. Lazzara, R. R. Hope: Re-entrant ventricular arrhythmias in the late infarction period: 1. Conduction characteristics in the infarction zone. Circulation55, 686 (1977).

    PubMed  Google Scholar 

  6. Durrer, D., L. Schoo, R. M. Schuilenburg, H. J. J. Wellens:The role of premature beats in the initiation and termination of supraventricular tachycardia in the Wolff-Parkinson-White syndrome.Circulation 36, 644 (1967).

    PubMed  Google Scholar 

  7. Wellens, H. J. J.: Electrical stimulation of the heart in the study and treatment of tachycardias (Leiden 1971).

  8. Scherlag, B. J., S. H. Lau, R. H. Helfant, W. D. Berkowitz, E. Stein, A. N. Damato: Catheter technique for recordingHis bundle activity in man. Circulation39, 13 (1969).

    PubMed  Google Scholar 

  9. Frommer, P. L.: Studies on coupled pacing technique and some comments on paired electrical stimulation. Bull. N. Y. Acad. Med.41, 670 (1965).

    PubMed  Google Scholar 

  10. Avenhaus, H., H. Grohmann, K. Seibel: Refraktärzeitbestimmungen des Herzens beim Menschen. Untersuchungen mit elektrischer Stimulation. Klin. Wschr.46, 1267 (1968).

    PubMed  Google Scholar 

  11. Heinz, N.: Untersuchungen der refraktären, supernormalen und vulnerablen Phase des Herzens an Patienten mit bradykarden Rhythmusstörungen. Arch. Kreislaufforschg.67, 201 (1972).

    Google Scholar 

  12. Akhtar, M., A. N. Damato, W. P. Batsford, J. N. Ruskin, J. B. Ogunkulu, G. Vargas: Demonstration of reentry within the His-Purkinje system in man. Circulation50, 1150 (1974).

    PubMed  Google Scholar 

  13. Fleischmann, D. W., T. Pop, J. M. T. De Bakker: Zur Frage der Entstehung ventrikulärer Extrasystolen. Kreiserregung im intraventrikulären Leitungssystem. Herz/Kreisl.7, 82 (1975).

    Google Scholar 

  14. Fleischmann, D., D. Mathey, W. Bleifeld, W. Irnich, S. Effert:His Bündel Elektrographie bei Patienten mit intraventrikulären Leitungsstörungen. Klin. Wschr.51, 1066 (1973).

    Google Scholar 

  15. Langendorf, R.: Concealed A-V conduction: The effect, of blocked impulses on the formation and conduction of subsequent impulses. Amer. Heart J.35, 542 (1948).

    Google Scholar 

  16. Fleischmann, D. W.: Untersuchungen zur recht- und rückläufigen Vorhofkammerleitung des menschlichen Herzens. Habilitationsschrift pp. 56, 94, 95 (Aachen 1977).

  17. Wiggers, C. J., R. Wegria: Ventricular fibrillation due to single localized induction and condenser shocks applied during the vulnerable phase of ventricular systole. Amer. J. Physiol.128, 500 (1939).

    Google Scholar 

  18. Antoni, H., K. Younossi, H. J. Rüdiger, K. P. Haap: Elektrophysiologische Untersuchungen über die Flimmerschwelle des isolierten Meerschweinchenherzens für Gleich- und Wechselstrom. In:Hauf, R. (ed.): Beiträge zur Ersten Hilfe und Behandlung von Unfällen durch elektrischen Strom, p. 85 (Freiburg 1976).

  19. Fleischmann, D., T. Pop, J. M. T. De Bakker: Reentry mechanism within the His-Purkinje-system in man during extrasystolic stimulation of the right ventricle. InLüderitz, B. (ed.): Cardiac pacing. p. 194 (Berlin 1976).

  20. Fleischmann, D. W., T. Pop, J. M. T. De Bakker: Evidence for re-entry within the His-Purkinje system in man during extrasystolic stimulation of the right ventricle: Macro-versus micro-re-entry. In:Kulbertus, H. E. (ed.), Re-entrant Arrhythmias. p. 256 (Lancaster 1977).

  21. Fleischmann, D. W., T. Pop: Assessment of refractoriness of the human Purkinje system. Cardiovasc. Res., in press.

  22. Hoffman, B. F., C. Y. Kao, E. E. Suckling: Refractoriness in cardiac muscle. Amer. J. Physiol.190; 473, (1957).

    PubMed  Google Scholar 

  23. Kao, C. Y., B. F. Hoffmann: Graded and decremental response in heart muscle fibers. Amer. J. Physiol.194, 187 (1958).

    PubMed  Google Scholar 

  24. Van Dam, R. F., E. N. Moore, B. F. Hoffman: Initiation and conduction of impulses in partially depolarized cardiac fibers. Amer. J. Physiol.204, 1133 (1963).

    PubMed  Google Scholar 

  25. Mendez, C., W. F. Müller, J. Merideth, G. K. Moe: Interaction of transmembrane potentials in canine Purkinje fibers and at Purkinje fiber-muscle junctions. Circul. Res.24, 361 (1969).

    Google Scholar 

  26. Myerburg, R. J., J. W. Stewart, B. F. Hoffman: Electrophysiological properties of the canine peripheral A-V conducting system. Circul. Res.26, 361 (1970).

    Google Scholar 

  27. Hoffman, B. F., P. F. Cranefield: Electrophysiology of the heart. (New York 1960).

  28. Abildskov, J. A.: Effects of activation sequence on the local recovery of ventricular excitability in the dog. Circul. Res.38, 240 (1976).

    Google Scholar 

  29. Sasyniuk, B. J., C. Mendez: A mechanism for reentry in canine ventricular tissue. Circul. Res.28, 3 (1971).

    Google Scholar 

  30. Wit, A. C., B. F. Hoffman, P. F. Cranefield: Slow conduction and reentry in the ventricular conducting system. I. Return extrasystole in canine Purkinje fibers. Circul. Res.30, 1 (1972).

    Google Scholar 

  31. Wit, A. C., P. F. Cranefield, B. F. Hoffman: Slow conduction and reentry in the ventricular conduction system. II. Single and sustained circus movement in networks of canine and bovine Purkinje fibers. Circul. Res.30, 11 (1972).

    Google Scholar 

  32. Chardack, W. M., H. Ishikawa, F. J. Fochler, S. Souther, A. A. Gage: Pacing and ventricular fibrillation Ann. M. Y. Acad. Scienc.167, 919 (1969).

    Google Scholar 

  33. Zoll, P. M., A. Linenthal: External electrical stimulation of the heart. Ann. M. Y. Acad. Scienc.111, 932 (1964).

    Google Scholar 

  34. Zucker, J. R., E. L. Rothfeld, V. Parsonnet, L. Gilbert, A. Bernstein: Competitive idiacardiac and extrinsic pacemaker stimuli in heart block. Amer. Heart J.69, 62 (1965).

    PubMed  Google Scholar 

  35. Fleischmann, D. W., T. Pop: unpublished observation.

  36. Castellanos, A., O. Maytin, L. Lemberg, B. V. Berkovits: Pacemaker induced cardiac disturbances. Ann. N. Y. Acad. Scienc.167, 903 (1969).

    Google Scholar 

  37. Siddons, H., E. Sowton: Cardiac pacing, p. 109 (Springfield 1967).

  38. Katz, L. M.: Effects of artificially induced paired and, coupled beats. Bull. N. Y. Acad. Med.41, 428 (1965).

    PubMed  Google Scholar 

  39. Resnekov, L., E. Sowton, P. Lord, J. Norman: Hemodynamic and clinical effects of paired stimulation of the heart. Brit. Heart J.28, 622 (1966).

    PubMed  Google Scholar 

  40. Castellanos, A., L. Lemberg, J. R. Jude, B. V. Berkovits: Repetitive firing occurring during synchronized electrical stimulation of the heart. J. thoracic cardiovasc. surg.51, 334 (1966).

    Google Scholar 

  41. Sowton, E.: Artificial pacemaking and sinus rhythm. Brit. Heart J.27, 311 (1965).

    PubMed  Google Scholar 

  42. Effert, S., J. Sykosch: Emergency pacing techniques, Ann. N. Y. Acad. Scienc.167, 614 (1969).

    Google Scholar 

  43. Robinson, D. S., H. L. Falsetti, D. H. Wheeler, D. B. Miller, E. L. Amidon: Ventricular fibrillation associated with two functioning implanted cardiac pacemakers. Amer. J. Cardiol.15, 397 (1965).

    PubMed  Google Scholar 

  44. Dressler, W., S. Jonas, R. Rubin; Observations in patients with inplanted cardiac pacemakers. IV Repetitive responses to electrical stimuli. Amer. J. Cardiol.15, 391 (1965).

    PubMed  Google Scholar 

  45. Harris, A., D. Redwood, M. Davies, G. Davies: Causes of death in patients with complete heart block and artificial pacemakers. Brit. Heart J.30, 14 (1968).

    PubMed  Google Scholar 

  46. Richter-v. Arnauld, H. P., E. Theim, K. W. Westermann: Interferenzprobleme bei Schrittmacherbehandlung. Med. Klin.69, 1500 (1974).

    PubMed  Google Scholar 

  47. Seipel, L., E. Bub, S. Driwas; Kammerflimmern bei Funktionsprüfung eines Demand-Schrittmachers. Dtsch. med. Wschr.100, 2439 (1975).

    PubMed  Google Scholar 

  48. Bilitch, M.: Ventricular fibrillation and pacing. Ann. N. Y. Acad. Scienc.167, 934 (1969).

    Google Scholar 

  49. Arcebal, A. G., A. Castellanos, L. Salhanick, L. Lemberg: Pacemaker induced repetitive firing in acute myocardial infarction. Clin. Res.27, 14 (1969).

    Google Scholar 

  50. Wellens, H. J. J., D. R. Duren, K. I. Lie: Observations of mechanisms of ventricular tachycardia in man. Circulation54, 237 (1976).

    PubMed  Google Scholar 

  51. Fleischmann, D. W., T. Pop:His bundle electrography and programmed electrical stimulation of the heart in patients with ventricular tachycardia. Z. Kardiol.67, 405 (1978).

    PubMed  Google Scholar 

  52. Jahrmärker, H., K. Theisen: Kammerflattern und Kammerflimmern. In:H. Antoni, S. Effert (ed.): Herzrhythmusstörungen, p. 299 (Stuttgart 1974).

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  1. D. W. Fleischmann

    Present address: Abteilung Innere Medizin I Medizinischen Fakultät und Helmholtz-Institut für biomedizinische Technik, Rehin.-Westf. Technische Hochschule Aachen, Goethestraße 27-29, D-5100, Aachen, Germany

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  1. Abteilung Innere Medizin I Medizinischen Fakultät und Helmholtz-Institut für biomedizinische Technik, Rehin.-Westf. Technische Hochschule Aachen, Goethestraße 27-29, D-5100, Aachen, Germany

    H. U. Marschall & J. M. T. De Bakker

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  2. H. U. Marschall
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With 6 figures and 2 tables

Supported by Deutsche Forschungsgemeinschaft SFB 109

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Fleischmann, D.W., Marschall, H.U. & De Bakker, J.M.T. Rate and rhythm dependent vulnerability of the human ventricular myocardium. Basic Res Cardiol 74, 203–223 (1979). https://doi.org/10.1007/BF01907821

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  • DOI: https://doi.org/10.1007/BF01907821

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