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Volume 7, Issue 1, Pages 88-95 (January 2010) Mechanisms of sinoatrial node dysfunction in a canine model of pacing-induced atrial fibrillation Boyoung Joung, MD, PhD, Shien-Fong Lin, PhD, Zhenhui Chen, PhD, Patrick S. Antoun, MD, Mitsunori Maruyama, MD, Seongwook Han, MD, PhD, Gianfranco Piccirillo, MD, PhD, Marcelle Stucky, BS, Douglas P. Zipes, MD, FHRS, Peng-Sheng Chen, MD, FHRS, Mithilesh Kumar Das, MD Heart Rhythm Volume 7, Issue 1, Pages 88-95 (January 2010) DOI: 10.1016/j.hrthm.2009.09.018 Copyright © 2010 Terms and Conditions

Figure 1 Experimental protocol for induction of atrial fibrillation. Heart Rhythm 2010 7, 88-95DOI: (10.1016/j.hrthm.2009.09.018) Copyright © 2010 Terms and Conditions

Figure 2 Atrial fibrillation and sinoatrial node dysfunction in vivo. A: Stored atrial electrogram (EGM) showing atrial fibrillation. B: Sinus pauses documented by Holter monitoring. (a) Sinus pause of 5.2 seconds during ventricular pacing at 90 bpm. (b) Sinus pause of 7 seconds during ventricular pacing at 50 bpm. p = P wave. Heart Rhythm 2010 7, 88-95DOI: (10.1016/j.hrthm.2009.09.018) Copyright © 2010 Terms and Conditions

Figure 3 Impaired isoproterenol-induced heart rate increase in right atria (RA) from atrial fibrillation (AF) dogs. Isoproterenol dose–response curve was determined for 7 normal and 7 AF dogs. Compared to normal RA (squares), AF RA (circles) showed significantly impaired heart rate increase during isoproterenol infusion (P = .03). Heart Rhythm 2010 7, 88-95DOI: (10.1016/j.hrthm.2009.09.018) Copyright © 2010 Terms and Conditions

Figure 4 Isoproterenol response of normal dogs. A: Epicardial photographs of perfused right atrial (RA) preparation with 35 × 35-mm optical field of view. B: Baseline. C: Isoproterenol infusion of 0.3 μmol/L. (a) RA Vm isochronal map. (b) Cai (red) and Vm (blue) tracings from superior (S), mid (M), and inferior (I) sinoatrial nodes. Note heart rate increase and shifting of the leading pacemaker site to the superior sinoatrial node with robust late diastolic Cai elevation (arrows). The unit of numbers on the RA Vm isochronal map is milliseconds. Earliest activation of the RA was considered as 0 ms. IVC = inferior vena cava; RAA = right atrial appendage; SVC = superior vena cava. Heart Rhythm 2010 7, 88-95DOI: (10.1016/j.hrthm.2009.09.018) Copyright © 2010 Terms and Conditions

Figure 5 Complete absence of late diastolic Cai elevation in atrial fibrillation dogs during isoproterenol infusion. A: Epicardial photograph of a perfused right atrial (RA) preparation with 35 × 35-mm optical fields of view. B: Baseline. C: Isoproterenol infusion of 1.0 μmol/L. (a) RA Vm isochronal map. (b) Cai (red) and Vm (blue) tracings from superior (S), mid (M), and inferior (I) sinoatrial nodes. Late diastolic Cai elevation was not observed at any dosage of isoproterenol infusion. The unit of numbers on the RA Vm isochronal map is milliseconds. Earliest activation of the RA was considered as 0 ms. IVC = inferior vena cava; RAA = right atrial appendage; SVC = superior vena cava. Heart Rhythm 2010 7, 88-95DOI: (10.1016/j.hrthm.2009.09.018) Copyright © 2010 Terms and Conditions

Figure 6 A: Transient late diastolic Cai elevation (LDCAE) in atrial fibrillation (AF) dogs during isoproterenol infusion. (a)–(c) show isoproterenol infusion of 0.03, 0.1, and 1.0 μmol/L, respectively. (a) Note isoproterenol-induced LDCAE at mid sinoatrial node (arrows) during isoproterenol infusion of 0.1 μmol/L. (c) Rhythm was generated from the inferior right atrium (RA). B: Complete absence of LDCAE in AF dogs during caffeine bolus injection. (a) Caffeine response in normal RA. Note increase of heart rate and superior shift of the leading pacemaker site with robust LDCAE (arrows). (b) Caffeine responses in AF RA. There was no LDCAE from the sinoatrial node. Heart rate was increased by acceleration of ectopic focus. Upper panels show RA Vm isochronal maps. Lower panels show Cai (red) and Vm (blue) tracings from superior (S), mid (M), and inferior (I) sinoatrial nodes, respectively. The unit of numbers on the RA Vm isochronal map is milliseconds. Earliest activation of the RA was considered as 0 ms. RAA = right atrial appendage; SVC = superior vena cava. Heart Rhythm 2010 7, 88-95DOI: (10.1016/j.hrthm.2009.09.018) Copyright © 2010 Terms and Conditions

Figure 7 Origin of heart rhythm during acceleration of heart rate in each of the seven right atria (RAs) from atrial fibrillation (AF) dogs. A: AF RA without late diastolic Cai elevation (LDCAE) (n = 4). Note heart rate increase by acceleration of ectopic foci or inferior sinoatrial node (SAN) (black arrow). B: AF RA with transient LDCAE (n = 3). Note heart rate increase by LDCAE from mid SAN (red arrow). ISO = isoproterenol. Heart Rhythm 2010 7, 88-95DOI: (10.1016/j.hrthm.2009.09.018) Copyright © 2010 Terms and Conditions

Figure 8 Impaired sarcoplasmic reticulum Ca2+ handing in atrial fibrillation (AF) dogs. A: Comparison of (a) slope of late diastolic Cai elevation (LDCAE), (b) slope of Cai upstroke, and (c) 90% Cai relaxation time measured from the superior sinoatrial node between normal and AF dogs at baseline and isoproterenol infusion. Responses after isoproterenol infusion are grouped by heart rate. B: Comparison of (a) sarcoplasmic reticulum Ca2+-ATPase 2a (SERCA2a) and ryanodine receptor (RyR) and (b) SERCA2a and phospholamban (PLB) at the superior sinoatrial node between normal and AF dogs. Upper and lower panels show representative immunoblot and relative values, respectively. Heart Rhythm 2010 7, 88-95DOI: (10.1016/j.hrthm.2009.09.018) Copyright © 2010 Terms and Conditions