Spatially discordant voltage alternans cause wavebreaks in ventricular fibrillation

BACKGROUND Ventricular fibrillation (VF) is characterized by complex ECG patterns emanating from multiple, short-lived, reentrant electrical waves. The incessant breakup and creation of new daughter waves (wavebreaks) perpetuate VF. Dispersion of refractoriness (static or dynamic) has been implicated as a mechanism underlying wavebreaks. OBJECTIVE The purpose of this study was to investigate the mechanisms underlying wavefront instability in VF by localizing wave fractionation sites (the appearance of multiple waves) and their relationship to local spatial dispersion of voltage (V-m) oscillations. METHODS Wave fractionations were identified by tracking V. oscillations optically at unprecedented spatial (100 x 100 pixels) and temporal (2,000 frames per second) resolution using a CMOS camera viewing the surface (1 x 1 cm(2)) of perfused guinea pig hearts (n = 6). VF was induced by burst stimulation, and wavefront dynamics were highlighted using region-based image analysis to automatically detect wavebreaks. Direct detection of wavebreak Locations by image analysis was more reliable than the phasereconstruction method because baseline noise obstructed the correct identification of phase singularities by detecting false-positives. RESULTS Wave fractionations (34 +/- 4 splits/s.cm(2))fell into three categories: decremental conduction (49% +/- 7%), wave collisions (32% +/- 8%), and wavebreaks (17 +/- 2%). Wavebreaks occurred at a frequency of 5.8 +/- 1 Splits/s.cm(2) and did not preferentially occur at anatomic obstacles (i.e., coronary vessels) but coincided with discordant alternans where V-m amplitudes and durations shifted from high to Low to from Low to high on opposite sides of wavebreak sites. CONCLUSION Spatial discordant alternans cause wavebreaks most likely because they are sites of abrupt dispersion of refractoriness.