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Atrial fibrillation (AF) is the most common cardiac arrhythmia in the United States today. However, treatment options remain limited despite the enormous magnitude of both AF prevalence and the associated economic cost. Of those treatment options that are available, ablation-based interventional methods have demonstrated the highest rates of long-term cure. Unfortunately, these methods have substantially lower efficacy in patients with heavier burdens of disease, thus leaving the most affected individuals with the least hope for successful treatment. The focus of this research is to develop a mechanistically guided approach towards the treatment of multi-wavelet reentry (MWR), one of the primary drivers of AF. For this purpose, we use a computational model of electrical propagation in cardiac tissue to simulate both episodes of fibrillatory activity and the ablative treatment thereof. We demonstrate that the probability of forming the reentrant circuits necessary for continuous electrical activity is a function of the shape and size of a tissue as well as its underlying cellular properties. Ablation at tissue sites with high probability of circuit formation more efficiently reduces the overall duration of fibrillatory episodes than ablation at sites with low probability. We then propose and validate in silico a parameter-based metric for predicting the propensity of an individual tissue to support fibrillation, which we term the fibrillogenicity index. Using this metric, we develop an algorithm for prospectively determining optimized, tissue-specific ablation patterns. Finally, we examine the relationship between multi-wavelet reentry and focal drivers, and demonstrate that MWR and fibrillatory conduction exist along a continuum. We examine the complex interplay between functional and structural substrates within fibrillating tissue and define the mechanisms by which they promote the perpetuation of AF. These findings present a novel theoretical framework for understanding treatment of multi-wavelet reentry driven AF and provide a set of testable predictions that can serve to guide the design of future experimental studies aimed at advancing the rational design of patient-specific ablation sets for treating AF.

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal.

Real time spectrum analysis of signals obtained through lasso catheter during radiofrequency ablation of pulmonary vein was performed to determine the channel with dominant frequency. Threshold algorithm was used for signals which could be classified as type I and type II AF. Type III AF Signals which were highly fractionated or differentiated were evaluated for frequency content by performing Fast Fourier Transform. Data from Seven patients was collected and an episode of 180 ± 40 seconds was recorded and analyzed for each pulmonary vein that showed electrical activation. Frequency spectra for one second segment of signal for each channel were determined. The frequencies of channels were then compared to determine the channel with highest or dominant frequency. In most cases the frequency of a single channel varied erratically between 1 to 10 Hz for every subsequent one second segment which made DF detection among the channels unreliable and a single channel with dominant frequency could not be determined. A five second averaging for each channel did not produce a stable DF output and improvement was minimal. The erratic frequency behavior could be attributed to the spatial shift of micro- reentrant circuits or temporal variation in waveform over lap at the point of detection. To determine the DF more precisely either an increase in number of electrode or increase in time segment block for DF calculation is warranted. Increasing the time segment block will defeat the purpose of real time analysis thus an increase in number of electrode mapping the area of interest would be appropriate to resolve the issue.

Divorce is a stressor associated with long-term health risk, though the mechanisms of this effect are poorly understood. Cardiovascular reactivity is one biological pathway implicated as a predictor of poor long-term health after divorce. A sample of recently separated and divorced adults (N = 138) was assessed over an average of 7.5 months to explore whether individual differences in heart rate variability—assessed by respiratory sinus arrhythmia—operate in combination with subjective reports of separation-related distress to predict prospective changes in cardiovascular reactivity, as indexed by blood pressure reactivity. Participants with low resting respiratory sinus arrhythmia at baseline showed no association between divorce-related distress and later blood pressure reactivity, whereas participants with high respiratory sinus arrhythmia showed a positive association. In addition, within-person variation in respiratory sinus arrhythmia and between-persons variation in separation-related distress interacted to predict blood pressure reactivity at each laboratory visit. Individual differences in heart rate variability and subjective distress operate together to predict cardiovascular reactivity and may explain some of the long-term health risk associated with divorce.

Les mutations du gène SCN5A, codant la sous-unité ? du canal Na+ cardiaque Nav1.5, sont responsables d'arythmies cardiaques héréditaires. La pénétrance incomplète observée dans ces maladies suggère l'existence d'autres facteurs modulant le phénotype associé à ces mutations. Dans ce travail de thèse, nous avons caractérisé deux mutations identifiées dans SCN5A. Le mutant R104W, identifié chez un patient atteint du syndrome de Brugada, est retenu dans le réticulum endoplasmique (RE), dégradé par le protéasome et abolit le courant Na+. Co-exprimé avec le canal sauvage, R104W conduit à la rétention de celui-ci dans le RE, résultant en un effet dominant négatif sur les canaux sauvages. Nous avons démontré que ce nouveau mécanisme mettait en jeu une interaction entre les sous-unités ? de Nav1.5. La mutation R1860Gfs*12 a été identifiée dans une famille présentant des arythmies auriculaires. Dans un système d'expression hétérologue, ce mutant induit à la fois une perte et un gain de fonction de Nav1.5. La modélisation informatique nous a permis de montrer que la perte de fonction était plus prononcée dans les cellules auriculaires que ventriculaires. De plus, nous avons montré que la présence de polymorphismes en amont du gène PITX2 dans cette famille pouvait expliquer la variabilité des phénotypes observés. En conclusion, l'interaction entre les sous-unités ? de Nav1.5, les propriétés électriques différentes entre oreillette et ventricule et la présence de polymorphismes chez les patients porteurs de mutations SCN5A sont des facteurs importants dans l'interprétation des effets fonctionnels de ces mutations, contribuant à la variabilité phénotypique des canalopathies Na+. / Mutations in the SCN5A gene, which encodes the α-subunit of the cardiac sodium channel Nav1.5, are implicated in different inherited cardiac arrhythmias. The incomplete penetrance observed in these diseases suggests the existence of other factors modulating the phenotype of these mutations. In this thesis work, we characterized two mutations identified in SCN5A. The R104W mutant identified in a patient with Brugada syndrome is retained in the endoplasmic reticulum (ER), degraded by the proteasome and abolishes the sodium current. Co-expressed with wild type (WT) channels, R104W leads to WT channels ER retention, causing a dominant-negative effect. We demonstrated that interaction between Nav1.5 α-subunits is responsible for the retention and the dominant-negative effect. The R1860Gfs*12 mutation was identified in a family with atrial arrhythmias. In a heterologous system, this mutant induces both loss- and gain-of-function effects on Nav1.5. Computer-model simulation showed that the loss-of-function was more pronounced in atrial than in ventricular cells. In addition, we showed that the presence of polymorphisms upstream of the PITX2 gene could explain the observed phenotypic variability in this family. In conclusion, the interaction between the α-subunits of Nav1.5, the different electrical properties between atria and ventricles and the presence of polymorphisms in patients with SCN5A mutations, are important factors in the interpretation of the functional effects of these mutations, which could explain the phenotypic variability of sodium channelopathies.

Au cours du couplage excitation-contraction (CEC) cardiaque, une partie du calcium (Ca2+) libéré par le réticulum sarcoplasmique (RS) via les récepteurs de la ryanodine de type (RyR2) est captée par la mitochondrie. Une fois dans la matrice mitochondriale, le Ca2+ module l’activité de plusieurs enzymes du métabolisme oxydatif ainsi que la production d’ATP. Une altération de la libération de Ca2+ du RS et une dysfonction mitochondriale ont été décrites dans plusieurs pathologies cardiovasculaires associées à des troubles métaboliques comme la cardiomyopathie diabétique (CMD). Cependant, les mécanismes qui sous-tendent le remodelage du métabolisme et de l’homéostasie calcique au stade précoce de la CMD demeurent méconnus. Afin de déterminer dans quelle mesure la dynamique calcique et le couplage excitation métabolisme oxydatif sont altérés au stade précoce de la CMD, des souris C57Bl/6 ont été soumises à un régime enrichi en graisses et en sucres (HFS) pendant deux semaines. Au terme du régime, les souris HFS présentent un hyperinsulinisme, une euglycémie et une dyslipidémie. En plus de ce statut pré-diabétique, le flux mitral (E/A) évalué par échocardiographie, est significativement diminué chez les animaux HFS par rapport aux animaux Ctrl, suggérant une dysfonction diastolique précoce du ventricule gauche. A l’échelle du cardiomyocyte, une diminution du raccourcissement cellulaire sans modification de l’amplitude des transitoires calciques induits par stimulation électrique est responsable d’une diminution de l’efficacité du CEC en condition HFS. De plus, l’entrée dynamique de Ca2+ dans la mitochondrie, évaluée à l’aide de la technique de patch-clamp en configuration cellule entière, est également significativement diminuée. Bien que l’expression du canal anionique dépendant du voltage (VDAC) et de l’unipore calcique (MCU) demeure inchangée, l’expression de la protéine MICU1 augmente. Cette altération de l’entrée de Ca2+ dans la mitochondrie est responsable d’une diminution de l’activité de la pyruvate déshydrogénase via sa phosphorylation sur le résidu ser232, réduisant ainsi l’utilisation des glucides comme substrats énergétiques. Enfin, bien que les paramètres de base de l’ECG soient comparables entre les deux groupes, les souris HFS déclenchent spontanément des troubles du rythme et présentent une altération de la modulation de la fonction cardiaque par le système nerveux autonome.Ces travaux suggèrent que MICU1, en modulant l’homéostatisie calcique, le couplage excitation-métabolisme oxydatif et la flexibilité métabolique, pourrait jouer un rôle de senseur métabolique au sein des cardiomyocytes initiant ainsi la cardiomyopathie diabétique. / During cardiac excitation-contraction coupling (ECC) a fraction of the calcium (Ca2+) released by the sarcoplasmic reticulum (SR) through type 2 Ryanodine Receptor (RyR2) is taken up by mitochondria. Once in the matrix, Ca2+ modulates several enzymes of oxidative metabolism and ATP production. SR Ca2+ release alteration and mitochondrial dysfunction have been reported in several cardiovascular diseases associated with metabolic disorders such as diabetic cardiomyopathy (DCM). However, the mechanisms that govern the metabolic remodeling and Ca2+ handling at the early stage of DCM are currently unknown. To determine whether mitochondrial Ca2+ dynamics and excitation oxidative metabolism coupling are affected at the early stage of DCM, C57Bl/6 mice were fed a standard or high fat sucrose (HFS) diet for two weeks. At the end of the diet, HFS mice display hyperinsulinemia, euglycemia and dyslipidemia. In addition to this prediabetic state, the transmitral inflow (E/A), assessed by echocardiography, is significantly reduced in HFS mice compared to their control (Ctrl) littermates suggesting an early left ventricle diastolic dysfunction. At the single cardiomyocyte level, a decrease in peak cell shortening without any change regarding the amplitude of electrically evoked Ca2+ transients leads to reduced ECC efficiency under HFS conditions. Moreover, dynamic mitochondrial Ca2+ uptake measured using the whole cell patch-clamp technique is significantly decreased. While the expression of voltage-dependent anionic channel (VDAC) and mitochondrial uniporter (MCU) is unchanged, expression of mitochondrial Ca2+ uptake protein 1 (MICU1) increases. Impaired mitochondrial Ca2+ uptake leads to reduced pyruvate dehydrogenase activity through the phosphorylation of ser232, thus decreasing the use of carbohydrates as energetic substrate. Finally, although ECG basal parameters are comparable between the two groups, HFS mice trigger spontaneous arrhythmia and impaired autonomic modulation of cardiovascular function.This study suggests that MICU1 could act as a metabolic sensor by modulating mitochondrial Ca2+ handling, excitation–oxidative metabolic coupling and the metabolic flexibility paving the way to the DCM.

Thesis (Ph.D.)--Massachusetts Institute of Technology, Dept. of Electrical Engineering and Computer Science, 1981. / MICROFICHE COPY AVAILABLE IN ARCHIVES AND ENGINEERING. / Vita. / Bibliography: leaves 410-424. / by Paul Scott Schluter. / Ph.D.

Cardiac diseases and conduction disorders are associated with stroke, heart failure and sudden cardiac death and are a major health concern worldwide. In the US alone, more than 14 million people suffer from heart rhythm disorders. Current mapping and characterization techniques in the clinic involve invasive procedures, which are time-consuming, costly, and may involve ionizing radiation. In this dissertation, we introduce Electromechanical Wave Imaging (EWI) as a non-invasive, ultrasound-based treatment planning tool for pre-procedure characterization and assessment of arrhythmia in the clinic. In particular, standard EWI processing methods for mapping the electromechanical wave (EW), i.e. the onset of the mechanical activity following the depolarization of the heart, are described and detailed. Next, validation of EWI is performed with 3D electromechanical mapping and the EW propagation is shown to follow the electrical activation in all four chambers of the heart. Demonstration of the value of EWI for the characterization of cardiac arrhythmia is accomplished in vivo in a large animal model. First, EWI is shown capable of localizing the earliest region of activation in the ventricles during pacing from a standard pacemaker lead, as well as during pacing from a novel biological pacemaker. Repeatability is also demonstrated between consecutive cardiac cycle during normal sinus rhythm and during pacing. Then, in the atria, we demonstrate that EWI is capable of accurately identifying focal sources while pacing from several locations in both the left and right atria. In addition to being capable of localizing the focal source, EWI is also shown capable of differentiating between endocardial and epicardial focal sources. Finally, it is shown that EWI can correctly identify regions of infarction and monitor formation of infarcts over several days, after ligation of the left anterior descending coronary artery of canine hearts. Novel processing techniques aimed at extracting quantitative parameters from EWI estimates are then developed and implemented. Details of the implementation of processing methods for estimating the velocity of the EW propagation are presented, and a study of the EW velocity values in a canine heart before and after infarct formation is conducted. Electromechanical cycle length mapping (ECLM), which is aimed at extracting local rates of electromechanical activation in the heart, is then introduced and its implementation detailed. ECLM is subsequently validated in a paced canine heart in vivo. Finally, initial clinical feasibility is demonstrated. First, in the study of treatment of chaotic arrhythmia such as in the case of atrial fibrillation patients undergoing direct current cardioversion, ECLM is shown to be able to confirm acute treatment success. Then, the clinical value of EWI in the electrophysiology lab as a treatment planning tool for the characterization of focal arrhythmia is shown in ventricular tachycardia and Wolff-Parkinson-White patients. EWI is currently only a step away from real-world clinical application. As a non-invasive, ultrasound-based imaging modality, EWI is capable of providing relevant insights into the origins of an arrhythmia and has the potential to position itself in the clinic as a uniquely valuable pre-procedure planning tool for the non-invasive characterization of focal arrhythmias.

The mechanical contraction of the heart is tightly coupled to rapid and concerted electrical excitation of the cardiac muscle. This electrical activity is facilitated by a highly synchronized conduction system consisting of channels, pumps, and transporters that facilitate the flow of charged ions between cellular compartments, the cytoplasm, and the interstitial fluid between cells. The biophysical properties of these membrane proteins have been studied for many years, but their role in the generation of potentially lethal cardiac arrhythmias and their interactions with drugs remains an important field of research. The cardiac isoform of the voltage-gated Na+-channel, Nav1.5, has garnered widespread interest because of its role in the generation of electrical impulses in the cardiac myocyte, its association with congenital conduction disorders and acquired cardiac arrhythmias, and its unique pharmacological properties. The Congenital Long QT Syndrome Type 3 (LQT3) arises from heritable mutations in SCN5A - the gene encoding Nav1.5 - that disrupt the inactivation process responsible for imparting a refractory period and that often cause a sustained depolarizing late current (INaL). The gain of function depolarizing currents arising from LQT3 mutant channels cause a prolongation of the ventricular action potential and leave patients susceptible to asynchronous electrical activity, ventricular arrhythmias, and sudden cardiac death. The disruption of channel inactivation can arise through a wide range of modalities, including changes in inactivation voltage-dependence and kinetics, and has been shown to occur with varying degrees of severity. Because of this range of phenotypes there is heterogeneity in the risk factors for arrhythmia and sudden cardiac death and in the utility of Na+-channel blocking antiarrhythmic drugs. Moreover, INaL has been implicated as a proarrhythmic and potentiating factor in several acquired cardiac ailments including heart failure, ischemia, and hypertrophy. There is therefore a large unmet need for improved understanding of INaL and mechanisms of its selective inhibition, and LQT3 mutant channels provide a reliable experimental model for this class of cardiac arrhythmias. This study will employ a combination of electrophysiological and computational methods to unravel mechanisms by which mutant Nav1.5 produces pro-arrhythmic currents and the interactions of different disease-causing mutant channels with a set of clinically relevant antiarrhythmic drugs. Chapter 1 of this study presents a functional characterization of one LQT3 mutation, F1473C, that was discovered in a patient with severe QT prolongation, frequent ventricular arrhythmias, and a poor response to pharmacological intervention. This mutation gives rise to INaL by a mechanism that is functionally distinct from the mechanism discovered previously in the canonical LQT3 mutation, ΔKPQ (1505-1507del), and causes a unique response to channel inhibitors. In order to better understand the mechanisms of this divergent pharmacology, Chapter 2 presents the development of a series of computational models which explore the gating dysfunctions that cause INaL and how these pathological changes can influence the predicted safety and efficacy of pharmacological intervention. These models predict that the majority of mutation- specific drug effects can be attributed to differential mutant channel gating, but raise the possibility that mutations may directly alter the physical chemical interaction between drugs and channels. Finally, Chapter 3 presents an attempt to explore this possibility using an innovative chemical biology technique - the site-specific incorporation of unnatural amino acids - that allows for the measurement of precise chemical interactions hypothesized to vary in a mutation-dependent manner. The findings presented in this work promote the need for patient-specific screening of antiarrhythmic agents and lay the groundwork for the use of in silico systems analysis of cardiovascular pharmacology.