Alternating membrane potential/calcium interplay underlies repetitive focal activity in a genetic model of calcium‐dependent atrial arrhythmias
Authors: Lou Qing , Belevych Andriy E. , Radwański Przemysław B. , Liu Bin , Kalyanasundaram Anuradha , Knollmann Bjorn C. , Fedorov Vadim V. , Györke Sándor 
Published: November 2014

Key points
Atrial fibrillation is often initiated and perpetuated by abnormal electrical pulses repetitively originating from regions outside the heart's natural pacemaker.
In this study we examined the causal role of abnormal calcium releases from the sarcoplasmic reticulum in producing repetitive electrical discharges in atrial cells and tissues.
Calsequestrin2 is a protein that stabilizes the closed state of calcium release channels, i.e. the ryanodine receptors. In the atria from mice predisposed to abnormal calcium releases secondary to the absence of calsequestrin2, we observed abnormal repetitive electrical discharges that may lead to atrial fibrillation.
Here, we report a novel pathological rhythm generator. Specifically, abnormal calcium release leads to electrical activation, which in turn results in another abnormal calcium release. This process repeats itself and thus sustains the repetitive electrical discharges.
These results suggest that improving the stability of ryanodine receptors might be useful to treat atrial fibrillation.
AbstractAberrant diastolic calcium (Ca) release due to leaky ryanodine receptors (RyR2s) has been recently associated with atrial fibrillation (AF) and catecholaminergic polymorphic ventricular tachycardia (CPVT). However, it remains unclear how diastolic Ca release contributes to the rising of rapid repetitive focal activity, which is considered as a common AF triggering mechanism. To address this question, we conducted simultaneous voltage/Ca optical mapping in atrial tissue and one‐/two‐dimensional confocal imaging in atrial tissue and myocytes from wild‐type (WT, n = 15) and CPVT mice lacking calsequestrin 2 (Casq2−/−, n = 45), which promotes diastolic Ca release. During β‐adrenergic stimulation (100 nm isoproterenol), only Casq2−/− atrial myocytes showed pacing‐induced self‐sustained repetitive activity (31 ± 21 s vs. none in WT). Importantly, in atrial tissue, this repetitive activity could translate to Ca‐dependent focal arrhythmia. Ectopic action potential (AP) firing during repetitive activity occurred only when diastolic Ca release achieved a sufficient level of synchronization. The AP, in turn, synchronized subsequent diastolic Ca release by temporally aligning multiple sources of Ca waves both within individual myocytes and throughout the atrial tissue. This alternating interplay between AP and diastolic Ca release perpetuates the self‐sustaining repetitive activity. In fact, pharmacological disruption of synchronized diastolic Ca release (by ryanodine) prevented aberrant APs; and vice versa, the inhibition of AP (by TTX or 0 Na, 0 Ca solution) de‐synchronized diastolic Ca release. Taken together, these results suggest that a cyclical interaction between synchronized diastolic Ca release and AP forms a pathological rhythm generator that is involved in Ca‐dependent atrial arrhythmias in CPVT.