TY - JOUR
T1 - The circle of reentry
T2 - Characteristics of trigger-substrate interaction leading to sudden cardiac arrest
AU - Cluitmans, Matthijs J.M.
AU - Bayer, Jason
AU - Bear, Laura R.
AU - ter Bekke, Rachel M. A.
AU - Heijman, Jordi
AU - Coronel, Ruben
AU - Volders, Paul G. A.
N1 - Funding Information: Matthijs Cluitmans is supported by the Hein Wellens Foundation, Health Foundation Limburg, Maastricht, The Netherlands, and a Veni grant from the Netherlands Organization for Scientific Research (TTW16772). Paul Volders is supported by The Netherlands CardioVascular Research Initiative (CVON2017-13 VIGILANCE and CVON2018B030 PREDICT2), Den Haag, The Netherlands. Jason Bayer is supported by the European Union's Horizon 2020 research and innovation program under the ERA-NET cofund action No. 680969 (ERA-CVD SICVALVES), cofunded by the French National Research Agency grant ANR-19-ECVD-0006. This work was furthermore supported by the French National Research Agency (ANR-10-IAHU04-LIRYC) and the Leducq foundation transatlantic network of excellence RHYTHM network (16CVD02). Publisher Copyright: 2023 Cluitmans, Bayer, Bear, ter Bekke, Heijman, Coronel and Volders.
PY - 2023
Y1 - 2023
N2 - 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.
AB - 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.
KW - arrhythmia
KW - electrocardiogaphy
KW - substrate
KW - sudden cardiac arrest
KW - trigger
UR - http://www.scopus.com/inward/record.url?scp=85158901188&partnerID=8YFLogxK
U2 - https://doi.org/10.3389/fcvm.2023.1121517
DO - https://doi.org/10.3389/fcvm.2023.1121517
M3 - Article
C2 - 37139119
SN - 2297-055X
VL - 10
JO - Frontiers in cardiovascular medicine
JF - Frontiers in cardiovascular medicine
M1 - 1121517
ER -