Stereoselective Block of Cardiac Sodium Channels by Bupivacaine in Guinea Pig Ventricular Myocytes
Authors: Valenzuela Carmen , Snyders Dirk J. , Bennett Paul B. , Tamargo Juan , Hondeghem Luc M. 
Published: June 2012

Background
Bupivacaine is a potent local anesthetic widely used for prolonged local and regional anesthesia. However, accidental intravascular injection of bupivacaine can produce severe arrhythmias and cardiac depression. Although used clinically as a racemic mixture,
S
(−)-bupivacaine appears less toxic than the
R
(+)-enantiomer despite at least equal potency for local anesthesia. If the
R
(+)-enantiomer is more potent in blocking cardiac sodium channels, then the
S
(−)-enantiomer could be used with less chance of cardiovascular toxicity. Therefore, we tested whether such stereoselectivity existed in the bupivacaine affinity for the cardiac sodium channel.

Methods and Results
The inhibitory effects on the cardiac sodium current (I
Na
) of 10 μmol/L
R
(+)- and
S
(−)-bupivacaine were investigated by use of the whole-cell voltage clamp technique in isolated guinea pig ventricular myocytes. Both enantiomers produced similar but limited levels of tonic block (6% and 8%). During long depolarizations (5 seconds at 0 mV),
R
(+)-bupivacaine induced a significantly larger inhibition of I
Na
: 72±2% versus 58±3% for the
S
(−)-enantiomer (
P
<.01). Development of block was slow, but its rate was faster for
R
(+)-bupivacaine [time constant, 1.84±0.16 versus 2.56±0.26 seconds for the
S
(−)-enantiomer,
P
<.05]. The voltage dependence of the availability of the Na
+
current was shifted to more hyperpolarizing potentials compared with the control;
R
(+)-bupivacaine induced a larger shift than
S
(−)-bupivacaine (37±2 versus 30±2 mV,
P
<.05). These data indicate stereoselective interactions with the inactivated state. In addition, both enantiomers induced substantial use-dependent block during 2.5-Hz pulse trains with medium (100-ms) and short (10-ms) depolarizations but without stereoselective difference. A stepwise approach was used to model these experimental results and to derive apparent affinities and rate constants. We initially assumed that bupivacaine interacted only with the rested and inactivated states of the Na
+
channel. The apparent affinities of the inactivated state for
S
(−)- and
R
(+)-bupivacaine were 4.8 and 2.9 μmol/L, respectively. With the derived binding and unbinding rate constants, this model reproduced the stereoselective block during long depolarizations but failed to predict the use-dependent block induced by trains of short (10-ms) depolarizations. To account for the observed use-dependent interactions, it was necessary to include interactions with the activated state, which resulted in adequate reproduction of the experimental results. The apparent affinities of the activated or open state for
S
(−)- and
R
(+)-bupivacaine were 4.3 and 3.3 μmol/L, respectively.

Conclusions
Both the large level of pulse-dependent block and the failure of the pure inactivated-state block model indicate that bupivacaine interacts with the activated (or open) state of the cardiac sodium channel in addition to its block of the inactivated state. The bupivacaine-induced block of the inactivated state of the Na
+
channel displayed stereoselectivity, with
R
(+)-bupivacaine interacting faster and more potently. Both enantiomers also bind with high affinity to the activated or open state of the channel, but this interaction did not display stereoselectivity, although the binding to the activated or open state was faster for
S
(−)- than for
R
(+)-bupivacaine. The higher potency of
R
(+)-bupivacaine to block the inactivated state of the cardiac Na
+
channel may explain its higher toxicity because of the large contribution of the inactivated-state block during the plateau phase of the cardiac action potential. These results would support the use of the
S
(−)-enantiomer to reduce cardiac toxicity.