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The circle of reentry: Characteristics of trigger-substrate interaction leading to sudden cardiac arrest

Sudden cardiac death is often caused by ventricular arrhythmias driven by reentry. Comprehensive characterization of the potential triggers and substrate in survivors of sudden cardiac arrest has provided insights into the trigger-substrate interaction leading to reentry. Previously, a “Triangle of...

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Autores principales: Cluitmans, Matthijs J. M., Bayer, Jason, Bear, Laura R., ter Bekke, Rachel M. A., Heijman, Jordi, Coronel, Ruben, Volders, Paul G. A.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Frontiers Media S.A. 2023
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10150924/
https://www.ncbi.nlm.nih.gov/pubmed/37139119
http://dx.doi.org/10.3389/fcvm.2023.1121517
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author Cluitmans, Matthijs J. M.
Bayer, Jason
Bear, Laura R.
ter Bekke, Rachel M. A.
Heijman, Jordi
Coronel, Ruben
Volders, Paul G. A.
author_facet Cluitmans, Matthijs J. M.
Bayer, Jason
Bear, Laura R.
ter Bekke, Rachel M. A.
Heijman, Jordi
Coronel, Ruben
Volders, Paul G. A.
author_sort Cluitmans, Matthijs J. M.
collection PubMed
description Sudden cardiac death is often caused by ventricular arrhythmias driven by reentry. Comprehensive characterization of the potential triggers and substrate in survivors of sudden cardiac arrest has provided insights into the trigger-substrate interaction leading to reentry. Previously, a “Triangle of Arrhythmogenesis”, reflecting interactions between substrate, trigger and modulating factors, has been proposed to reason about arrhythmia initiation. Here, we expand upon this concept by separating the trigger and substrate characteristics in their spatial and temporal components. This yields four key elements that are required for the initiation of reentry: local dispersion of excitability (e.g., the presence of steep repolarization time gradients), a critical relative size of the region of excitability and the region of inexcitability (e.g., a sufficiently large region with early repolarization), a trigger that originates at a time when some tissue is excitable and other tissue is inexcitable (e.g., an early premature complex), and which occurs from an excitable region (e.g., from a region with early repolarization). We discuss how these findings yield a new mechanistic framework for reasoning about reentry initiation, the “Circle of Reentry.” In a patient case of unexplained ventricular fibrillation, we then illustrate how a comprehensive clinical investigation of these trigger-substrate characteristics may help to understand the associated arrhythmia mechanism. We will also discuss how this reentry initiation concept may help to identify patients at risk, and how similar reasoning may apply to other reentrant arrhythmias.
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spelling pubmed-101509242023-05-02 The circle of reentry: Characteristics of trigger-substrate interaction leading to sudden cardiac arrest Cluitmans, Matthijs J. M. Bayer, Jason Bear, Laura R. ter Bekke, Rachel M. A. Heijman, Jordi Coronel, Ruben Volders, Paul G. A. Front Cardiovasc Med Cardiovascular Medicine Sudden cardiac death is often caused by ventricular arrhythmias driven by reentry. Comprehensive characterization of the potential triggers and substrate in survivors of sudden cardiac arrest has provided insights into the trigger-substrate interaction leading to reentry. Previously, a “Triangle of Arrhythmogenesis”, reflecting interactions between substrate, trigger and modulating factors, has been proposed to reason about arrhythmia initiation. Here, we expand upon this concept by separating the trigger and substrate characteristics in their spatial and temporal components. This yields four key elements that are required for the initiation of reentry: local dispersion of excitability (e.g., the presence of steep repolarization time gradients), a critical relative size of the region of excitability and the region of inexcitability (e.g., a sufficiently large region with early repolarization), a trigger that originates at a time when some tissue is excitable and other tissue is inexcitable (e.g., an early premature complex), and which occurs from an excitable region (e.g., from a region with early repolarization). We discuss how these findings yield a new mechanistic framework for reasoning about reentry initiation, the “Circle of Reentry.” In a patient case of unexplained ventricular fibrillation, we then illustrate how a comprehensive clinical investigation of these trigger-substrate characteristics may help to understand the associated arrhythmia mechanism. We will also discuss how this reentry initiation concept may help to identify patients at risk, and how similar reasoning may apply to other reentrant arrhythmias. Frontiers Media S.A. 2023-04-17 /pmc/articles/PMC10150924/ /pubmed/37139119 http://dx.doi.org/10.3389/fcvm.2023.1121517 Text en © 2023 Cluitmans, Bayer, Bear, ter Bekke, Heijman, Coronel and Volders. https://creativecommons.org/licenses/by/4.0/This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) (https://creativecommons.org/licenses/by/4.0/) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
spellingShingle Cardiovascular Medicine
Cluitmans, Matthijs J. M.
Bayer, Jason
Bear, Laura R.
ter Bekke, Rachel M. A.
Heijman, Jordi
Coronel, Ruben
Volders, Paul G. A.
The circle of reentry: Characteristics of trigger-substrate interaction leading to sudden cardiac arrest
title The circle of reentry: Characteristics of trigger-substrate interaction leading to sudden cardiac arrest
title_full The circle of reentry: Characteristics of trigger-substrate interaction leading to sudden cardiac arrest
title_fullStr The circle of reentry: Characteristics of trigger-substrate interaction leading to sudden cardiac arrest
title_full_unstemmed The circle of reentry: Characteristics of trigger-substrate interaction leading to sudden cardiac arrest
title_short The circle of reentry: Characteristics of trigger-substrate interaction leading to sudden cardiac arrest
title_sort circle of reentry: characteristics of trigger-substrate interaction leading to sudden cardiac arrest
topic Cardiovascular Medicine
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10150924/
https://www.ncbi.nlm.nih.gov/pubmed/37139119
http://dx.doi.org/10.3389/fcvm.2023.1121517
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