atrial fibrillation; Editorials; inflammation; nervous system, autonomic
Bidirectional ventricular tachycardia; Andersen-Tawil Syndrome; Alternans
ablation; arrhythmia; electrophysiology; tachyarrhythmias; tachycardia
Recent evidence indicates that the voltage (cyclic activation and deactivation of membrane ion channels) and Ca2+ clocks (rhythmic spontaneous sarcoplasmic reticulum Ca2+ release) jointly regulate sinoatrial node (SAN) automaticity. Since the intact SAN is a heterogeneous structure that includes multiple different cell types interacting with each other, the relative importance of the voltage and Ca2+ clocks for pacemaking may be variable in different regions of the SAN. Recently, we performed optical mapping in isolated and Langendorff-perfused canine right atria. We mapped the intracellular calcium (Cai) and membrane potentials of the intact SAN simultaneously. Using previously described criteria of the timing of the late diastolic Cai elevation (LDCAE) relative to the action potential upstroke to detect Ca2+ clock activity, we demonstrated that the sinus rate increased and the leading pacemaker shifted to the superior SAN with the robust LDCAE during β-adrenergic stimulation. We also showed that the LDCAE was caused by spontaneous diastolic SR Ca2+ release and was closely related with heart rate changes. We conclude that the Ca2+ and voltage clocks work synergistically to generate SAN automaticity.
Calcium; Sinoatrial node; Sarcoplasmic reticulum; Sympathetic nervous system
This review focuses on the importance of autonomic nervous system (ANS) activity in the induction of paroxysmal atrial fibrillation (PAF). Clinical studies suggest that both sympathetic and parasympathetic nervous systems are important in mediating PAF. Consistent with that hypothesis, heart rate variability analyses showed that sympathovagal imbalance is present before the onset of PAF episodes. The importance of the ANS in PAF is further supported by animal experiments and recent clinical studies showing that vagal denervation enhances the efficacy of circumferential pulmonary vein ablation in preventing AF recurrence. In vitro studies show that ANS activation facilitates early afterdepolarization and triggered activity by simultaneously prolonging the intracellular calcium (Cai) transient (sympathetic effect) and shortening the action potential duration (parasympathetic effect). By simultaneously mapping the membrane potential and Cai transient in canine pulmonary vein during sympathetic stimulation, we demonstrated that spontaneous (voltage-independent) sarcoplasmic reticulum calcium release underlies the mechanisms of focal discharges. We developed and studied canine models of PAF induced by electrical, structural, and neural remodeling. We also have developed methods for long-term continuous recording of sympathetic and vagal nerve activity in ambulatory dogs. Preliminary results show that simultaneous sympathovagal discharges precede the onset of PAF in these dogs. ANS activity and Cai transient dynamics are important in the development of PAF. These studies suggest that new methods or drugs aimed at modification of cardiac ANS activity may lead to new opportunities for AF control.
Intracellular calcium current; Optical mapping; Triggered activity; Afterdepolarization
Protein complex of the cardiac junctional sarcoplasmic reticulum (SR) membrane formed by type 2 ryanodine receptor, junction, triadin, and calsequestrin is responsible for controlling SR calcium (Ca) release. Increased intracellular calcium (Cai) activates the electrogenic sodium–Ca exchanger current, which is known to be important in afterdepolarization and triggered activities (TAs). Using optical-mapping techniques, it is possible to simultaneously map membrane potential (Vm) and Cai transient in Langendorff-perfused rabbit ventricles to better define the mechanisms by which Vm and Cai interactions cause early afterdepolarizations (EADs). Phase 3 EAD is dependent on heterogeneously prolonged action potential duration (APD). Electrotonic currents that flow between a persistently depolarized region and its recovered neighbors underlies the mechanisms of phase 3 EADs and TAs. In contrast, “late phase-3 EAD” is induced by APD shortening, not APD prolongation. In failing ventricles, upregulation of apamin-sensitive Ca-activated potassium (K) channels (IKAS) causes APD shortening after fibrillation-defibrillation episodes. Shortened APD in the presence of large Cai transients generates late-phase 3 EADs and recurrent spontaneous ventricular fibrillation. The latter findings suggest that IKAS may be a novel antiarrhythmic targets in patients with heart failure and electrical storms.
Triggered activity; After depolarization; Ventricular fibrillation; Calcium dynamics; Optical mapping
Although the adult mammalian myocardium exhibits a limited ability to undergo regenerative growth, its intrinsic renewal rate is insufficient to compensate for myocyte loss during cardiac disease. Transplantation of donor cardiomyocytes or cardiomyogenic stem cells is considered a promising strategy to reconstitute cardiac mass, provided the engrafted cells functionally integrate with host myocardium and actively contribute to its contractile force. We have previously developed a two-photon fluorescence microscopy-based assay that allows in situ screening of donor cell function following their intracardiac delivery. Here we review the techniques and summarize its application for quantitation of the extent to which a variety of donor cell types stably and functionally couple with the recipient myocardium.
Cellular transplantation; myocardial regeneration; intracellular calcium regulation; two-photon fluorescence microscopy
Apamin sensitive potassium current (IKAS), carried by the type 2 small conductance Ca2+-activated potassium (SK2) channels, plays an important role in post-shock action potential duration (APD) shortening and recurrent spontaneous ventricular fibrillation (VF) in failing ventricles.
To test the hypothesis that amiodarone inhibits IKAS in human embryonic kidney 293 (HEK-293) cells.
We used the patch-clamp technique to study IKAS in HEK-293 cells transiently expressing human SK2 before and after amiodarone administration.
Amiodarone inhibited IKAS in a dose-dependent manner (IC50, 2.67±0.25 µM with 1 µM intrapipette Ca2+). Maximal inhibition was observed with 50 µM amiodarone which inhibited 85.6±3.1% of IKAS induced with 1 µM intrapipette Ca2+ (n = 3). IKAS inhibition by amiodarone was not voltage-dependent, but was Ca2+-dependent: 30 µM amiodarone inhibited 81.5±1.9% of IKAS induced with 1 µM Ca2+ (n = 4), and 16.4±4.9% with 250 nM Ca2+ (n = 5). Desethylamiodarone, a major metabolite of amiodarone, also exerts voltage-independent but Ca2+ dependent inhibition of IKAS.
Both amiodarone and desethylamiodarone inhibit IKAS at therapeutic concentrations. The inhibition is independent of time and voltage, but is dependent on the intracellular Ca2+ concentration. SK2 current inhibition may in part underlie amiodarone's effects in preventing electrical storm in failing ventricles.
Myocardial infarction (MI) results in cardiac nerve sprouting in the myocardium. Whether or not similar neural remodeling occurs in the stellate ganglia (SG) is unknown. We aimed to test the hypothesis that MI induces bilateral SG nerve sprouting.
Acute MI was created by coronary artery ligation in rabbits (n=12). Serum nerve growth factor (NGF) level was measured by enzyme-linked immunosorbent assay (ELISA). The hearts and bilateral SGs were harvested for immunohistochemistry after 1 week in 6 rabbits, and after 1 month in 6 rabbits. Immunostaining for tyrosine hydroxylase (TH), growth-associated protein 43 (GAP43), cholineacetyltransferase (ChAT) and synaptophysin (SYN) was performed to determine the magnitude of nerve sprouting. Tissues from 6 normal rabbits were used as controls. Nerve density was determined by computerized morphometry.
MI results in increased serum NGF levels at 1 week (1519.8±632.2 ng/ml) that persists to 1 month (1361.2±176.3 ng/ml) as compared to controls (89.6±34.9 ng/ml), (p=.0002, and , p=.0001, respectively). Immunostaining demonstrated nerve sprouting and hyperinnervation in both SGs after MI. The nerve densities (µm2/ganglion cell) in SG 1 week after MI, 1 month after MI and in control groups, respectively, were: GAP43, 278±96, 225±39 and 149±57 (p=.01); SYN, 244±152, 268±115 and 102±60 (p=.02); TH, 233±71, 180±50 and 135±68 (p=.047); ChAT, 244±100, 208±46 and 130±41 µm2/cell (p=.01).
MI increases serum NGF levels and induces nerve sprouting and hyperinnervation in bilateral SGs for at least 1 month after MI. The hyperinnervation includes both postganglionic adrenergic axons and preganglionic cholinergic axons in the SG.
Myocardial Infarction; Ventricular Arrhythmia; Autonomic Nervous System; Stellate Ganglion; Nerve Sprouting; Sudden Cardiac Death
Calcium transient triggered firing (CTTF) is induced by large intracellular calcium (Cai) transient and short action potential duration (APD). We hypothesized that CTTF underlies the mechanisms of early afterdepolarization (EAD) and spontaneous recurrent atrial fibrillation (AF) in transgenic (Tx) mice with overexpression of transforming growth factor β1 (TGF-β1).
Methods and Results
MHC-TGFcys33ser Tx mice develop atrial fibrosis because of elevated levels of TGF-β1. We studied membrane potential and Cai transients of isolated superfused atria from Tx and wild-type (Wt) littermates. Short APD and persistently elevated Cai transients promoted spontaneous repetitive EADs, triggered activity and spontaneous AF after cessation of burst pacing in Tx but not Wt atria (39% vs. 0%, P=0.008). We were able to map optically 4 episodes of spontaneous AF re-initiation. All first and second beats of spontaneous AF originated from the right atrium (4/4, 100%), which is more severely fibrotic than the left atrium. Ryanodine and thapsigargin inhibited spontaneous re-initiation of AF in all 7 Tx atria tested. Western blotting showed no significant changes of calsequestrin or sarco/endoplasmic reticulum Ca2+-ATPase 2a.
Spontaneous AF may occur in the Tx atrium because of CTTF, characterized by APD shortening, prolonged Cai transient, EAD and triggered activity. Inhibition of Ca2+ release from the sarcoplasmic reticulum suppressed spontaneous AF. Our results indicate that CTTF is an important arrhythmogenic mechanism in TGF-β1 Tx atria.
Arrhythmia; Atrial fibrillation; Ca2+ triggers; Intracellular calcium; Optical mapping; Transgenic mice models
We previously reported that IKAS are heterogeneously upregulated in failing rabbit ventricles and play an important role in arrhythmogenesis. This study goal is to test the hypothesis that subtype 2 of the small‐conductance Ca2+ activated K+ (SK2) channel and apamin‐sensitive K+ currents (IKAS) are upregulated in failing human ventricles.
Methods and Results
We studied 12 native hearts from transplant recipients (heart failure [HF] group) and 11 ventricular core biopsies from patients with aortic stenosis and normal systolic function (non‐HF group). IKAS and action potential were recorded with patch‐clamp techniques, and SK2 protein expression was studied by Western blotting. When measured at 1 μmol/L Ca2+ concentration, IKAS was 4.22 (median) (25th and 75th percentiles, 2.86 and 6.96) pA/pF for the HF group (n=11) and 0.98 (0.54 and 1.72) pA/pF for the non‐HF group (n=8, P=0.008). IKAS was lower in the midmyocardial cells than in the epicardial and the endocardial cells. The Ca2+ dependency of IKAS in HF myocytes was shifted leftward compared to non‐HF myocytes (Kd 314 versus 605 nmol/L). Apamin (100 nmol/L) increased the action potential durations by 1.77% (−0.9% and 7.3%) in non‐HF myocytes and by 11.8% (5.7% and 13.9%) in HF myocytes (P=0.02). SK2 protein expression was 3‐fold higher in HF than in non‐HF.
There is heterogeneous upregulation of IKAS densities in failing human ventricles. The midmyocardial layer shows lower IKAS densities than epicardial and endocardial layers of cells. Increase in both Ca2+ sensitivity and SK2 protein expression contributes to the IKAS upregulation.
arrhythmia; calcium; heart failure; ion channels
Purpose of review
The autonomic nerve system is a potentially potent modulator of the initiation and perpetuation of atrial fibrillation (AF). This review will briefly summarize the neural mechanisms of AF.
Complex interactions exist between the sympathetic and parasympathetic nervous system on the atrial electrophysiologic properties. Direct autonomic recordings in canine models demonstrated simultaneous sympathovagal discharges are the most common triggers of paroxysmal atrial tachycardia and paroxysmal AF. Also, intrinsic cardiac autonomic nerve can serve as a sole triggering factor for the initiation of AF. Modulation of autonomic nervous system (ANS) by electrical stimulation has been tried as a treatment strategy clinically and experimentally. Recent studies showed that autonomic nervous system modulation can suppress the stellate ganglion nerve activity and reduce the incidence of paroxysmal atrial tachyarrhythmias in ambulatory dogs.
The autonomic nerve system influences the initiation and perpetuation of AF. Scientific advances toward a better understanding of the complex interrelationships of the various components of the ANS will hopefully lead to improvement of treatments for this common arrhythmia.
Autonomic nerve; atrial fibrillation; vagal nerve stimulation
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inheritable myocardial disorder associated with fibrofatty replacement of myocardium and ventricular arrhythmia. A subset of ARVC is categorized as Naxos disease, which is characterized by ARVC and a cutaneous disorder. A homozygous loss-of-function mutation of the Plakoglobin (Jup) gene, which encodes a major component of the desmosome and the adherens junction, had been identified in Naxos patients, although the underlying mechanism remained elusive. We generated Jup mutant mice by ablating Jup in cardiomyocytes. Jup mutant mice largely recapitulated the clinical manifestation of human ARVC: ventricular dilation and aneurysm, cardiac fibrosis, cardiac dysfunction and spontaneous ventricular arrhythmias. Ultra-structural analyses revealed that desmosomes were absent in Jup mutant myocardia, whereas adherens junctions and gap junctions were preserved. We found that ventricular arrhythmias were associated with progressive cardiomyopathy and fibrosis in Jup mutant hearts. Massive cell death contributed to the cardiomyocyte dropout in Jup mutant hearts. Despite the increase of β-catenin at adherens junctions in Jup mutant cardiomyoicytes, the Wnt/β-catenin-mediated signaling was not altered. Transforming growth factor-beta-mediated signaling was found significantly elevated in Jup mutant cardiomyocytes at the early stage of cardiomyopathy, suggesting an important pathogenic pathway for Jup-related ARVC. These findings have provided further insights for the pathogenesis of ARVC and potential therapeutic interventions.
We hypothesize that unresponsiveness of superior sinoatrial node (SAN) to sympathetic stimulation is strongly associated with the development of symptomatic bradycardia in patients with atrial fibrillation (AF).
Methods and Results
We performed 3-dimensional endocardial mapping in healthy control (Group 1, n=10) and in patients with AF without (Group 2, n=57) or with (Group 3, n=15) symptomatic bradycardia at baseline and during isoproterenol infusion. Corrected SAN recovery time was abnormal in 0%, 11% and 36% of groups 1, 2 and 3, respectively (p=0.02). At baseline, 90%, 26% and 7% (p<0.001) of the patients had multicentric SAN activation patterns. For groups 1, 2 and 3, respectively, the median distance from the superior vena cava-right atrial junction to the most cranial earliest activation site (EAS) was 5.0 (25–75 percentile range, 3.5–21.3) mm, 10.0 (4–20) mm and 17.5 (12–34) mm at baseline (p=0.01), and was 4.0 (0–5) mm, 5.0 (1–10) mm and 15.0 (5.4–33.3) mm during isoproterenol infusion (p=0.01), suggesting upward shift of EAS during isoproterenol infusion. However, while the EAS during isoproterenol infusion was at the upper 1/3 of crista terminalis in 100% of Group 1 and 78% of Group 2 patients, only 20% of the groups 3 patients moved EAS to that region (p < 0.001).
Superior SAN serves as the EAS during sympathetic stimulation in normal patients and in most patients with AF without symptomatic bradycardia. In contrast, unresponsiveness of superior SAN to sympathetic stimulation is a characteristic finding in patients with AF and symptomatic bradycardia.
sinoatrial node; nervous system; sympathetic; atrial fibrillation; sick sinus syndrome; pacemakers
AHA Scientific Statements; atrial fibrillation; atrium; epidemiology; prevention; risk factors
Anodal stimulation hyperpolarizes cell membrane and increases intracellular Ca2+ (Cai) transient. This study tested the hypothesis that The maximum slope of Cai decline (–(dCai/dt)max) corresponds to the timing of anodal dip on the strength-interval curve and the initiation of repetitive responses and ventricular fibrillation (VF) after a premature stimulus (S2).
Methods and Results
We simultaneously mapped membrane potential (Vm) and Cai in 23 rabbit ventricles. A dip was observed on the anodal strength-interval curve. During the anodal dip, ventricles were captured by anodal break excitation directly under the S2 electrode. The Cai following anodal stimuli is larger than that following cathodal stimuli. The S1-S2 intervals of the anodal dip (203 ± 10 ms) coincided with the -(dCai/dt)max (199 ± 10 ms, p=NS). BAPTA-AM (n=3), INCX inhibition by low extracellular Na+ (n=3), and combined ryanodine and thapsigargin infusion (n=2) eliminated the anodal supernormality. Strong S2 during the relative refractory period (n=5) induced 29 repetitive responses and 10 VF episodes. The interval between S2 and the first non-driven beat was coincidental with the time of -(dCai/dt)max.
Larger Cai transient and INCX activation induced by anodal stimulation produces anodal supernormality. Time of maximum INCX activation is coincidental to the induction of non- driven beats from the Cai sinkhole after a strong premature stimulation.
anodal dip; anodal stimulus; intracellular calcium; Na+-Ca2+ exchanger current
We tested the hypothesis that heart failure (HF) results in right atrial ganglionated plexus (RAGP) denervation which contributes to sinoatrial node dysfunction.
HF is associated with sinoatrial node dysfunction. However, the detailed mechanisms remain unclear.
We recorded nerve activity (NA) from the RAGP, right stellate ganglion (SG) and right vagal nerve in 7 ambulatory dogs at baseline and after pacing-induced HF. We also determined the effects of RAGP stimulation in isolated normal and HF canine right atria (RA).
Nerve activities in both the SG and vagal were significantly higher in HF than at baseline. The relationship between 1-min integrated nerve activities of vagal and RAGP showed either a positive linear correlation (Group 1, n=4) or an L-shaped correlation (Group 2, n=3). In all dogs, a reduced heart rate was observed when vagal-NA was associated with simultaneously increased RAGP-NA. On the other hand, when vagal-NA was not associated with increased RAGP-NA, the heart rate was not reduced. The induction of HF significantly decreased RAGP-NA in all dogs (P<0.05). Stimulating the superior RAGP in isolated right atrium significantly reduced the sinus rate in normal but not the HF hearts. Immunohistochemical staining revealed lower densities of tyrosine hydroxylase and choline acetyltransferase -positive nerve tissues in HF RAGP than normal (P<0.001 and P=0.001, respectively).
The RAGP nerve activity is essential for the vagal nerve to counterbalance the stellate ganglion in sinus rate control. In heart failure, RAGP denervation and decreased RAGP nerve activity contribute to the sinus node dysfunction.
heart failure; nervous system; autonomic; sinoatrial node
Recent evidence indicates that spontaneous sarcoplasmic reticulum Ca release and Na-Ca exchanger current activation contribute to the sinoatrial node (SAN) automaticity. These findings suggest that SAN activity may share mechanisms that underlie both automaticity and triggered activity. The aim of this study is to test the hypothesis that spontaneous, non-voltage gated, intracellular Ca (Cai) elevation may induce delayed afterdepolarization (DAD) in intact SAN during isoproterenol infusion.
Methods and Results
We simultaneously mapped Cai and membrane potential in 31 isolated Langendorff-perfused canine right atriums (RA). Isoproterenol increased heart rate and late diastolic Cai elevation (LDCAE) of the superior SAN, leading to consistent SAN automaticity in all 31 RAs. However, DAD-like diastolic depolarizations (DD) were transiently observed in 4 RAs during isoproterenol infusion. These DAD-like DDs were preceded by LDCAE, but did not trigger a full action potential. The LDCAE preceding DAD-like DDs had smaller amplitude (0.41 ± 0.08 AU vs. 0.48 ± 0.07 AU, p=0.001) and less steep slopes (3.7 ± 1.3 AU/s vs. 4.8 ± 1.4 AU/s, p=0.001) than that of sinus beats. The coupling interval of DAD-like DDs was longer than that of the preceding normal beats (407 ± 48 ms vs. 371 ± 44 ms, p=0.002).
The isoproterenol-induced LDCAE of superior SAN induced a full action potential in most cases. However, if the LDCAE was too small to trigger an action potential, then it induces only DAD-like DD. The failure of DAD-like DD to consistently trigger a sinus beat is a novel mechanism of atrial arrhythmogenesis.
calcium dynamics; sympathetic nervous system; triggered activity; sinoatrial node; afterdepolarization
Whether autonomic nerve activity is important in the development of pacing-induced sustained atrial fibrillation (AF) is unclear.
We tested the hypothesis that patterns of baseline autonomic nerve activities are important in the development of pacing-induced sustained AF.
We implanted radiotransmitters in 12 ambulatory dogs to record left stellate ganglion nerve activity (SGNA) and vagal nerve activity (VNA). Sustained (>48 hrs) AF was induced with intermittent rapid atrial pacing.
At baseline (before pacing), the one-min integrated nerve activity between SGNA and VNA demonstrated either a single linear relationship with excellent correlation (Group 1, N=3, r=0.816±0.105) or non-linear relationships with poor correlation (Group 2, N=9, r=0.316±0.162, P<0.05 compared with Group 1). Group 1 dogs had higher VNA (97.0±11.5 mV-s) compared to Group 2 (33.4±21.7 mV-s, P<0.001). Group 1 dogs had more frequent sympathovagal coactivation episodes than Group 2 (50±19/d vs. 15±6/d, P<0.05) and more paroxysmal atrial tachycardia (PAT; 5±1/d vs. 2±1/d, P<0.05) at baseline. Sustained AF occurred after 16±4 d (range 13–20 d) of pacing in Group 1 and after 46±18 d (range 23–72 d) of pacing in Group 2 (P<0.05). In the week before the development of sustained AF, the VNA of Group 2 dogs had significantly (P<0.05) increased compared to baseline.
Ambulatory dogs with good linear sympathovagal correlation and higher vagal tone at baseline have more PAT episodes at baseline and faster induction of sustained AF by rapid pacing. Rapid atrial pacing increased the VNA of the remaining dogs before the induction of sustained AF.
Autonomic nervous system; Nerve recording; Atrial fibrillation; Arrhythmia; Atrial pacing
Both phase-2 and phase-3 early afterdepolarizations (EADs) occur in long QT syndromes, but their respective roles in generating arrhythmias in intact cardiac tissue are incompletely understood.
Methods and Results
Intracellular Ca (Cai) and membrane voltage (Vm) were optically mapped in a quasi 2-dimensional model of cryoablated Langendorff-perfused rabbit ventricles (n = 16). E-4031 (an IKr blocker) combined with reduced extracellular K ([K+]o) and Mg ([Mg2+]o) prolonged action potential duration (APD) heterogeneously and induced phase-2 and phase-3 EADs. While phase-2 EADs were Cai-dependent, phase-3 EADs were not. The origins of 47 triggered activity (TA) episodes were attributed to phase-2 EADs in 12 episodes (26%) and phase-3 EADs in 35 episodes (74%). When phase-2 EADs accompanied phase-3 EADs, they accentuated APD heterogeneity, creating a large Vm gradient across the boundary between long and short APD regions from which TA emerged. The amplitude of phase-3 EADs correlated with the Vm gradient (r = 0.898, P < 0.001). Computer simulation studies showed that coupling of cells with heterogeneous repolarization could extrinsically generate phase-3 EADs via electrotonic current flow. Alternatively, reduced IK1 caused by low [K+]o could generate intrinsic phase-3 EADs capable of inducing TA at the boundary zone.
Phase-3 EADs can be extrinsic due to electrotonic current across steep repolarization gradients, or intrinsic due to low IK1, and do not require spontaneous sarcoplasmic reticulum Ca release. Reduction of IK1 by low [K+]o strongly promotes ventricular arrhythmias mediated by phase-3 EADs in acquired long QT syndrome due to IKr blockade.
action potentials; calcium; depolarization; long-QT syndrome; torsade de pointe
Early afterdepolarizations (EADs) are an important cause of lethal ventricular arrhythmias in long QT syndromes and heart failure, but the mechanisms by which EADs at the cellular scale cause arrhythmias such as polymorphic ventricular tachycardia (PVT) and Torsades de Pointes (TdP) at the tissue scale are not well-understood. Here we summarize recent progress in this area, discussing i) the ionic basis of EADs, ii) evidence that deterministic chaos underlies the irregular behavior of EADs, iii) mechanisms by which chaotic EADs synchronize in large numbers of coupled cells in tissue to overcome the source-sink mismatches, v) how this synchronization process allows EADs to initiate triggers and generate mixed focal-reentrant ventricular arrhythmias underlying PVT and TdP, and vi) therapeutic implications.
Arrhythmias; afterdepolarizations; chaos synchronization; computer modeling; nonlinear dynamics; Torsades de Pointes; triggered activity; sudden cardiac death; systems biology