Sustained Reentry in the Left Ventricle of Fibrillating Pig Hearts
It has been proposed that ventricular fibrillation (VF) is driven by sustained reentry. However, mapping studies have not detected such “mother rotors” in large mammalian hearts. We mapped VF from three 21×12 unipolar electrode arrays in 6 pigs. Two of the arrays were adjacent to each other on the left-ventricular epicardium. Electrode spacing was 2 mm. The third array consisted of 21 needles (0.5-mm diameter, 12 electrodes, 1-mm spacing) inserted in a row (2-mm spacing) between the epicardial arrays. A total of 88 5-second VF epochs were analyzed with automatic reentry detection algorithms. Although intramural reentry was sporadically present (29 total occurrences), it was always short-lived with a mean life span of 127±57 ms. However, in 3 of the 6 animals, sustained epicardial reentry (ie, reentry persisting for more than a few cycles) was consistently present, often lasting for several seconds. For each epoch, we computed indices characterizing (1) the relative duration of reentry on the two epicardial arrays (R), (2) the flow of wavefronts between epicardial arrays (W), and (3) the relative activation rates of the two epicardial arrays (F). R did not correlate with either W or F indicating that rotor-containing regions did not produce a net outflow of wavefronts and were not faster than neighboring regions. Thus, sustained epicardial, but not intramural, rotors were consistently present in some large animal hearts during VF. However, we found no evidence that these rotors were responsible for sustaining VF through the mechanisms outlined in the mother rotor hypothesis.
Recent work has suggested that ventricular fibrillation (VF) is driven by one or more sustained stationary sources. In this model, the sources spawn wavefronts that propagate away from the source, eventually fragmenting on functional or anatomical obstacles to form the complex activation patterns characteristic of VF.1–3 Sustained functional reentry has been put forward as the most likely cause of the high-frequency sources. Indeed, in isolated guinea pig hearts, it was shown that sustained rotors (“mother rotors”) underlay the fastest activating epicardial regions during VF.2 However, in larger hearts more comparable in size to human hearts, although epicardial reentry has been observed, it is rare and generally short-lived.3–6 One possible explanation for this apparent paucity of reentry is that sustained reentry exists, but is intramurally oriented, and so cannot be detected by epicardial mapping.7
In the present study, we tested for the presence of sustained rotors in the left ventricles (LVs) of open-chest, fibrillating pig hearts. We mapped VF patterns simultaneously from a row of needle electrodes to detect intramural reentry and from two adjacent epicardial arrays to detect epicardial reentry. We found that although intramural reentry was present, it was always short-lived. Surprisingly, sustained epicardial reentry (ie, reentry persisting for more than a few cycles), which was previously found to be rare in large hearts, was common in half of the animals we studied.
Materials and Methods
Animal Preparation and Instrumentation
The use of experimental animals in this study was approved by the Institutional Animal Care and Use Committee at the University of Alabama at Birmingham. Six healthy domestic farm pigs (Snyder Farms, Cullman, Ala) of either sex were studied. Heart and body weights are given in the Table. Anesthesia was induced with 4.4 mg/kg telazol, 2.2 mg/kg xyalzine, and 0.04 mg/kg atropine. The animals were intubated and anesthesia was maintained with isoflurane (1 to 4%). Physiological conditions were maintained throughout the experiment as previously described.5 The chest was opened by a median sternotomy, and the pericardial sac was opened to expose the heart.
We used three planar electrode arrays: two were on the anterior left ventricular epicardium, and the third, which consisted of a row of multipole needle electrodes, was within the wall (Figures 1A and 1B). The two epicardial electrode plaques were sutured to the heart. We refer to the array closest to the septum as “septal” and to the other as “lateral.” Each array contained 252 electrodes in a 21×12 array. The electrodes were silver balls 1 mm in diameter with 2-mm spacing (on centers). The plaques were made of 2-mm thick Silastic sheeting to conform to the shape of the heart. The plaques were aligned along their long edges and separated by a plastic template through which the needles were inserted. The combined epicardial arrays covered about 20% of the epicardium and the needle array spanned about half the distance from the apex to the atrioventricular groove.
The needle template was 2 mm wide and 4 mm tall with the top and bottom edges parallel and ground to approximate the curvature of the heart. The 21 needle holes in the template were parallel and spaced by 2 mm. The tops of the holes were flared to accept a cone formed on the needle bases with enamel paint. The press-fit between this cone and the template prevented the needles from backing out of the heart during the experiment and ensured that electrodes on adjacent needles remained in registration. The first electrode on each needle was 2 mm below the epicardium. To avoid damage to coronary arteries, the plaques and template were positioned so that the needles were inserted in a watershed between epicardial arteries.
Each needle contained 12 silver electrodes spaced by 1 mm. We used higher spatial resolution along the needles because propagation orthogonal to the epicardium may be slow because it is always transverse to the muscle fibers. The needles were fabricated from glass-reinforced epoxy according to a new design.8 The needle shafts were 0.5 mm in diameter, which is about half the diameter of traditional steel needle electrodes and minimizes damage to the myocardium. We showed in our previous publication that such a needle array does not affect VF activation patterns.8
The reference electrode for the unipolar recordings was attached to the right leg. A mesh electrode was sutured to the LV apex and a catheter electrode (6.9 cm long, 6.3 cm2 area) was inserted into the superior vena cava for defibrillation shocks.
Mapping Data Acquisition
Before the needles were inserted through the template, the epicardial arrays were connected to a 528-channel mapping system.9 The unipolar electrograms were bandpass filtered from 0.5 to 500 Hz, sampled at 2 kHz, and recorded digitally with 14-bit resolution.
VF was induced with 1- to 2-second bursts of 60-cycle current delivered to the anterior right ventricular (RV) epicardium. Cardiac perfusion was not maintained during VF. Two to four VF episodes were induced and mapped in each animal. After 30 seconds of fibrillation, the hearts were defibrillated with a biphasic shock at the minimum reliable strength (typically 400 to 500 V). After defibrillation, VF reinduction was not attempted for at least 15 minutes.
We then inserted the needles and connected them to a second 528-channel mapping system. The two mapping systems were synchronized to a common clock to ensure time-alignment of the two mapping data streams. After waiting 30 minutes for any injury potentials to subside, we repeated the above fibrillation/defibrillation sequence 3 to 5 times in each animal.
Example VF electrograms from both an epicardial and an intramural electrode are shown in Figure 1C. Online Figure 1 (which can be found in the online data supplement available at http://www. circresaha.org) shows all 12 electrograms recorded from a single needle during VF.
Automatic Reentry Detection
Each fibrillation episode from each recording array was divided into 4 consecutive 5-second epochs beginning 4, 9, 14, and 19 seconds after VF induction. A total of 73 epochs were analyzed before the needles were inserted and 88 after. Because of technical problems, 3 epochs before needles and 4 after could not be analyzed. Each epoch was processed by algorithms that automatically decompose VF into individual wavefronts10 and identify reentry.6 Briefly, all electrograms were median filtered (7-point) and then differentiated (7-point), and all samples (the datum corresponding to a single temporal sample at a single recording site) at which dV/dt<−0.5 V/s were deemed active. Individual wavefronts were identified by grouping active samples that were adjacent in time and space. In our definition of a wavefront, a wavefront ends when it fragments, at which time the two or more resulting wavefronts begin. Conversely, when two or more wavefronts collide and coalesce, the original wavefronts end and a new wavefront begins.10 We identified wavefronts that entered or exited the recording array from the edge of the epicardial mapped region as previously described11 and noted which edge(s) were involved.
InL was computed by finding all wavefronts that entered the lateral array from the edge abutting the septal array11 and summing the areas that the wavefronts swept out10 as they propagated in the lateral mapped region. InS is the corresponding value for the septal array. WSL ranges from −1 to 1. We computed this parameter using areas swept out rather than a raw wavefront count so that large wavefronts having more influence on the VF activation pattern contribute more to WSL than do small wavefronts. When WSL=0, wavefronts originating in the septal array have the same influence on the lateral array that wavefronts originating in the lateral array have on the septal array. When WSL=1, wavefronts from the lateral array have no influence on the septal array and the converse when WSL=−1.
We used our previously described methods to identify reentry.6 Briefly, we grouped wavefronts related by fragmentation and collision events into groups called “components.” Each component was inspected to determine if it contained a sequence of wavefronts that activated tissue more than once. If it did, it was deemed reentrant. We identified the path followed by the wavetip and determined the time span during which each reentrant component was present. We also identified closed loops in the wavetip path. Each such loop corresponds to a cycle of reentry. We computed the spatial centroid of each loop.
According to excitable media theory, the wavetip of a functionally reentrant wave in two dimensions generalizes to a linear filament in three dimensions.12 If a 3-dimensional reentrant wave is imaged on a plane that intersects the filament, it will appear to be a 2-dimensional spiral wave; this is true regardless of the intersection angle.12 Thus, our reentry detection algorithms work exactly the same for our epicardial and intramural data. The algorithms find reentrant waves that complete at least one cycle; they are not affected by motion of the filament.6
where the RS are the life spans of individual reentrant components on the septal array, and N is the total number of such components in the epoch. The RL and M are the corresponding values for the lateral array. When RSL is large and positive, it indicates the presence of a sustained rotor on the septal array, but not the lateral array, and the converse for large negative values. Values near 0 indicate the absence of reentry or equal reentry on both arrays. This index assumes that temporal overlap of reentry is negligible. Examination of the reentry lifespan plots in Figure 2 and online Figures 2 and 3 of the online data supplement shows that this is a good assumption.
We approximated the global activation rate of each recording array for each epoch using a method similar to our previous publication.5 We summed the signals from all 252 electrodes and approximated the power spectrum of the resulting time series using Welch’s method13 with segments 2.5 seconds long (5000 temporal samples) overlapping by 1.25 seconds. We found the frequency with maximum power between 0 to 50 Hz (P) and then computed the power-weighted average of all frequencies in the range 0.25P to 1.75P. This procedure returns a frequency near the peak when the spectrum contains a single sharp peak. When multiple peaks are present, all contribute to the returned value according to the power they contain. These calculations were performed using Matlab 6 (The Mathworks, Inc).
where FS and FL are the global activation rates on the septal and lateral arrays, respectively. This index ranges from −1 to 1, with positive values indicating faster activation on the septal array.
Data are given as mean±SD. Although intramural reentry was present, it was infrequent and short-lived. In all VF episodes, there were a total of 29 intramural reentrant circuits; the mean life span of intramural reentry was 127±57 ms (range: 62 to 320 ms). In contrast, reentry on the epicardium was much more common and often long-lived. Figure 2 shows the life spans of individual reentrant circuits in 4 VF episodes from 3 animals. Similar plots for all episodes are available in online Figure 2.
Two distinct patterns are apparent in these plots. In the first, instances of reentry are temporally scattered and short-lived (epicardial data in Figures 2B and 2C and all intramural data). In the second pattern, instances of reentry lasting hundreds of milliseconds follow one another in close succession (Figures 2A and 2D). The example animation in the online data supplement shows VF patterns on all three arrays for the shaded interval in online Figure 2A. A sustained rotor is clearly visible near the left edge of the septal array. In addition to the rotor, a breakthrough wavefront also occurs periodically near the center of the septal array and then propagates onto the lateral array. Activation on the intramural array generally begins near the center of the endocardial edge and propagates upward and then toward the base and apex. This wavefront is phase-locked and probably contiguous with the breakthrough activation on the septal array. Activation on the lateral array is nonreentrant and spreads from the edge abutting the septal array and from additional breakthrough sites. The rotor in the animation persisted until about 20 seconds after induction. During this time, activation patterns on the lateral and intramural arrays were more variable with breakthrough sites appearing, disappearing, and moving. At about 20 seconds after induction, the rotor on the septal array moved off the left edge, and one of the breakthrough activations on the lateral array evolved into a new, counter-rotating rotor. The new rotor persisted for about 2 seconds (Figure 2A).
Although the rotor in the animation appears continuous, in Figure 2A, it is represented by a train of three bars. The breaks between the bars are due to the tip of the reentrant wave momentarily moving out of the mapped region or to isolated failures of electrograms to meet the −0.5 V/s activation threshold. Examining animations of the other mapping episodes showed that this was generally the case for trains of automatically identified reentrant circuits.
A sustained rotor was present in at least one VF episode in 3 of 6 animals (animals 1, 5, and 6; see online Figure 2). To verify that the sustained reentry did not result from the needle array, we repeated the analysis for the VF episodes recorded before the needles were inserted. The results were similar, with sustained reentry present in the same 3 animals (online Figure 3). In the animals in which sustained rotors were present, rotors were not always present in all VF episodes; however, there were no clearly favored episodes (eg, those early or late in the experiment; online Figures 2 and 3). In addition, when an episode contained sustained rotors, the rotors were not always present in all epochs. Rotors were more likely to be present in the second half of the episode than the first half, although this was not universally true (online Figures 2 and 3). This is consistent with our earlier observation that reentry stabilizes as VF progresses.6
Figure 3 shows the trajectory of the reentrant wavetip for the entire 5-second epoch containing the shaded region in Figure 2A. The core of the rotor was fixed within a compact region, but meandered somewhat from cycle to cycle. This behavior can also be seen in Figure 4A, which plots the centroid of each reentrant cycle in a color that corresponds to its time. There does not appear to be spatial progression through the colors between light green and orange, indicating that there was little temporal drift of the rotor. The sustained rotor in Figures 2D and 4D also meandered within a compact region; however, in this case, there is some evidence for progressive drift upward and to the left. Similar patterns were observed for the other sustained rotors we mapped (online Figures 4 and 5). When sustained reentry was not present, the loop centroids were more diffuse, yet still tended to cluster in favored regions (Figures 4B and 4C; online Figures 4 and 5). This is consistent with the spatial distribution of reentry we observed on the RV during VF in our previous study.6
There was no difference in body weight between the animals with sustained reentry and those without (P>0.25). However, the heart weight was significantly smaller (P<0.05) in the sustained reentry animals (177±21 g) than the others (213±6 g).
In all VF epochs, all electrodes that were circumscribed by loops of the wavetip paths6 registered at least one activation either in that epoch or in another recorded from the same animal. Thus, in all cases, reentry was either purely functional or anchored to anatomical obstacles smaller than our interelectrode spacing of 2 mm.
Activation rates on the three arrays were as follows: septal, 9.97±1.25 s−1; lateral, 10.05±1.28 s−1; and intramural, 10.10±1.26 s−1. Repeated measures ANOVA showed that the lateral array was slightly but significantly faster than the septal array (P<0.05), and that the intramural array was significantly faster than the mean of the epicardial arrays (P<0.001).
The indices RSL, WSL, and FSL were computed for VF episodes recorded both before and after needle insertion. The means of all three indices were significantly different from 0 by one-sample t test.RSL was −200±1200 ms, indicating that reentry was more common on the lateral array. WSL was 0.16±0.65, indicating that wavefronts from the septal array had more influence on the lateral array than the converse. FSL was 0.003±0.017, indicating that when the preneedle data are included in the analysis, the septal array was slightly faster than the lateral array.
To determine if there was a relationship between the relative presence of reentry on the two epicardial arrays and either the flow of wavefronts between the arrays or the relative activation rate, we plotted RSL against both WSL (Figure 5) and FSL (Figure 6). Linear regression analysis showed that neither WSL nor FSL predicted RSL: in both cases, P>0.5 and the R values were 0.04 and 0.05, respectively.
The major findings of this study are as follows: (1) sustained rotors were frequently present during VF in the left ventricles of swine hearts in an in situ heart preparation; (2) the sustained rotors were always epicardial; although we did detect intramural reentry, it was infrequent and short-lived; (3) we found no evidence that the sustained rotors were responsible for sustaining VF through the mechanisms outlined in the “mother rotor” hypothesis.
Sustained Reentry During VF
Reentry has been observed during fibrillation in large mammalian hearts or heart preparations in a number of studies; however, it is generally described as short-lived and spatially and temporally unstable.3–6,14,15 Although sustained reentry sometimes occurred in these studies, it was rare.3,6,15 This apparent paucity of sustained epicardial reentry was our motivation for mapping intramurally in the present study; thus, our finding that sustained epicardial, but not intramural, reentry was common was surprising.
There are at least two possible reasons why sustained reentry was only observed in half of our animals. One is that in the animals in which sustained reentry was not observed, it was, in fact, present but located in unmapped regions of the heart. This issue can be resolved, at least for epicardial reentry, using a mapping technology that images the entire epicardium, eg, panoramic mapping.16 Another possible explanation is that sustained reentry is dependent on the size of the heart. We found that the hearts with sustained reentry were significantly smaller than the hearts without. This is consistent with other reports in the literature. Several previous studies have found sustained reentry during VF in guinea pig and rabbit hearts,1,2,17,18 yet long-lived rotors have been reported to be very rare in species with hearts more comparable in size to humans.4–6 It has also been reported that progressive mass reduction of ventricular slabs simplifies VF patterns and increases the life span of reentry.19
It is unclear why the epicardial reentry that was so prominent in 3 of our 6 animals has not been previously observed. One possible explanation is that we mapped from the LV, whereas most previous whole-heart studies mapped from the RV.4,5,14 However, in one of our previous studies, although we mapped from a similar LV region as well as the RV in an animal preparation almost identical to that of the present study, we did not detect sustained rotors on the LV.5 In that study, the heart weight was 209±30 g, which is similar to the nonreentry animals in the present study. Thus, the lack of sustained reentry may have been due to the size of the hearts.
Our finding that activation on the intramural array was slightly (about 1%) but significantly faster than activation on the epicardial arrays suggests that intramural reentry may be preferred to epicardial reentry. Indeed, previous studies have documented intramural reentry during the transition from ventricular tachycardia to VF.20,21 Recently, Valderrabano et al15 used optical mapping of left- and right-ventricular wedge preparations to characterize intramural reentry during VF. They found intramural reentry in the LV in all of their mapped VF episodes, which they characterized as spatially and temporally unstable. The lifetimes of the reentrant circuits clustered around 4 cycles, although some persisted for more than 50 cycles. Of all activations in the LV preparations, 23% were part of a reentrant pathway.
However, this is more intramural reentry than we observed in the present study; we found that instances of intramural reentry were only sporadically present (online Figure 2) and never lasted for more than 320 ms. The difference may be due to the different preparations used. Although pigs were used in both studies, we used whole in situ hearts, whereas Valderrabano et al15 mapped from the cut surface of isolated perfused wedges of LV tissue. As we discuss above, reentry in this preparation may have been stabilized by the decreased mass of the preparation. In addition, the cut faces of the tissue preparation change the boundary conditions the VF wavefronts are subject to and may alter their behavior.
It is also possible that we underestimated intramural reentry because of the limited spatial coverage of our intramural array. This array was roughly centered on the LV free wall and spanned about half the distance from the apex to AV groove. It is possible that sustained intramural reentry was present, but never intersected this region. In addition, the first electrode on each needle was located 2 mm below the epicardium and the last 13 mm below. Thus, wavetips that consistently passed very close to either the epi- or endocardium would escape detection.
If sustained intramural reentry does in fact occur during VF and can appear anywhere in the ventricles with equal probability, we would expect to have observed it at least once in the 440 seconds of VF we mapped. The fact that we did not suggests that if sustained intramural reentry is present in VF, it occurs in favored regions that do not include our mapped region.
Sustained Reentry and the Maintenance of VF
Recent studies have suggested that VF is maintained by one or more sustained, stationary sources that emanate wavefronts at a high rate. These wavefronts eventually fragment on functional or anatomical obstacles to produce the complex activation patterns seen during VF.1–3 It was hypothesized that the sources are sustained rotors and as such, this model of VF is often called the “mother rotor” hypothesis. It was recently shown that in the guinea pig heart, sustained rotors often do drive VF.2 However, another recent study using isolated ventricular slabs from swine was unable to substantiate this role of sustained reentry in driving VF.22
A frequent feature of our data are the presence of a sustained rotor in one epicardial region coupled with the lack of sustained reentry in an adjacent region. If these sustained rotors were mother rotors, then activation wavefronts should propagate primarily from the array containing the rotor to the adjacent epicardial array. In quantitative terms, the index RSL, which expresses the relative amount of reentry on the two arrays, should correlate with WSL, which characterizes the flow of wavefronts between the arrays. Figure 5 shows that this was not the case: the R value of the correlation was 0.04, and the probability value was P>0.5. The Wsl index is based on epicardial wavefronts that pass between the two epicardial arrays along their common border. However, it is possible for wavefronts to skirt this line by propagating around its ends or underneath it. The lack of correlation between RSL and Wsl could have resulted from the majority of interarray wavefronts following such uninstrumented routes. However, because the common border is the most direct route between the arrays and because we have previously shown that epicardial wavefronts freely cross the border in this preparation,8 we believe this is unlikely.
The mother rotor hypothesis also predicts that the array with the rotor should have a faster activation rate than the adjacent array. In this case, RSL should correlate with the index FSL, which characterizes the relative activation rates of the adjacent epicardial arrays. Figure 6 shows that this was also not the case: the R value for the correlation was 0.05, and the probability value was P>0.5.
Thus, although we found frequent occurrences of sustained rotors during VF, we did not find evidence that they were the engine of VF as described by the mother rotor hypothesis; they may instead be patterns embedded within the overall VF pattern with only local influence. This notion is supported by the observation that sustained rotors appeared and disappeared during VF episodes and between VF episodes in the same animal. We cannot exclude that there were additional rotors located in unmapped regions that acted as mother rotors. An alternative to the mother rotor hypothesis is the multiple wavelet hypothesis, in which VF is maintained by continual fragmentation of wavefronts at either fixed23 or dynamic heterogeneities.24,25 This mechanism does not require the presence of sustained sources.
Dr Ideker receives research funding from biomedical device manufacturers.
The work was supported in part by American Heart Association Grant 9820030SE and NIH grants HL-64184 and HL-24829.
- Received August 13, 2002.
- Revision received January 28, 2003.
- Accepted February 3, 2003.
Chen J, Mandapati R, Berenfeld O, Skanes AC, Jalife J. High frequency periodic sources underlie ventricular fibrillation in the isolated rabbit heart. Circ Res. 2000; 86: 86–93.
Samie FH, Berenfeld O, Anumonwo J, Mironov SF, Udassi S, Beaumont J, Taffet S, Pertsov AM, Jalife J. Rectification of the background potassium current: a determinant of rotor dynamics in ventricular fibrillation. Circ Res. 2001; 89: 1216–1223.
Zaitsev AV, Berenfeld O, Mironov SF, Jalife J, Pertsov AM. Distribution of excitation frequencies on the epicardial and endocardial surfaces of fibrillating ventricular wall of the sheep heart. Circ Res. 2000; 86: 408–417.
Lee JJ, Kamjoo K, Hough D, Hwang C, Fan W, Fishbein MC, Bonometti C, Ikeda T, Karagueuzian HS, Chen PS. Reentrant wave fronts in Wiggers’ stage II ventricular fibrillation: characteristics and mechanisms of termination and spontaneous regeneration. Circ Res. 1996; 78: 660–675.
Rogers JM, Huang J, Smith WM, Ideker RE. Incidence, evolution, and spatial distribution of functional reentry during ventricular fibrillation in pigs. Circ Res. 1999; 84: 945–954.
Berenfeld O, Pertsov A. Dynamics of intramural scroll waves in a 3-dimensional continuous myocardium with rotational anisotropy. J Theor Biol. 1999; 383–394.
Wolf PD, Rollins DE, Simpson EV, Smith WM, Ideker RE. A 528 channel system for the acquisition and display of defibrillation and electrocardiographic potentials.In: Murray M, Arzbaecher R, eds. Computers in Cardiology. London, UK: IEEE; 1993: 125–128.
Winfree AT. When Time Breaks Down. Princeton, NJ: Princeton University Press; 1987.
Valderrabano M, Lee MH, Ohara T, Lai AC, Fishbein MC, Lin SF, Karagueuzian HS, Chen PS. Dynamics of intramural and transmural reentry during ventricular fibrillation in isolated swine ventricles. Circ Res. 2001; 88: 839–848.
Gray R, Jalife J, Panfilov A, Baxter W, Cabo C, Davidenko J, Pertsov A. Mechanisms of cardiac fibrillation. Science. 1995; 270: 1222–1223.
Samie FH, Mandapati R, Gray RA, Watanabe Y, Zuur C, Beaumont J, Jalife J. A mechanism of transition from ventricular fibrillation to tachycardia: effect of calcium channel blockade on the dynamics of rotating waves. Circ Res. 2000; 86: 684–691.
Kim YH, Garfinkel A, Ikeda T, Wu TJ, Athill CA, Weiss JN, Karagueuzian HS, Chen PS. Spatiotemporal complexity of ventricular fibrillation revealed by tissue mass reduction in isolated swine right ventricle: further evidence for the quasiperiodic route to chaos hypothesis. J Clin Invest. 1997; 100: 2486–2500.
Janse MJ, van Capelle FJL, Morsink H, Kléber AG, Wilms-Schopman F, Cardinal R, d’Alnoncourt CN, Durrer D. Flow of “injury” current and patterns of excitation during early ventricular arrhythmias in acute regional myocardial ischemia in isolated porcine and canine hearts: evidence for two different arrhythmogenic mechanisms. Circ Res. 1980; 47: 151–165.
Pogwizd SM, Corr PB. Mechanisms underlying the development of ventricular fibrillation during early myocardial ischemia. Circ Res. 1990; 66: 672–695.
Valderrabano M, Yang J, Omichi C, Kil J, Lamp ST, Qu Z, Lin SF, Karagueuzian HS, Garfinkel A, Chen PS, Weiss JN. Frequency analysis of ventricular fibrillation in swine ventricles. Circ Res. 2002; 90: 213–222.
Garfinkel A, Kim YH, Voroshilovsky O, Qu ZL, Kil JR, Lee MH, Karagueuzian HS, Weiss JN, Chen PS. Preventing ventricular fibrillation by flattening cardiac restitution. Proc Nat Acad Sci U S A. 2000; 97: 6061–6066.