Clinical phenotypes in acute and chronic infarction explained through human ventricular electromechanical modelling and simulations
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eLife assessment
This important study contributes to the current knowledge in the field of acute and chronic infarction. It is a significant study because the results provide convincing evidence for the need to incorporate additional risk factors for assessing patients after myocardial infarction.
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Abstract
Sudden death after myocardial infarction (MI) is associated with electrophysiological heterogeneities and ionic remodelling, which are reflected as variable phenotypes. Low ejection fraction (EF) is used in risk stratification, but its mechanistic links with the post-MI pro-arrhythmic heterogeneities are unknown. We aim to provide a mechanistic explanation of clinical phenotypes in acute and chronic MI, from ionic remodeling to ECG and EF, using human electromechanical modelling and simulation to augment experimental and clinical investigations. A human ventricular electromechanical modelling and simulation framework is constructed and validated with rich experimental and clinical datasets. Abnormalities caused by scar and border zone ionic remodeling are introduced in varying degrees as reported in experimental data obtained in acute and chronic infarction. Simulations enabled reproducing and explaining clinical phenotypes post-MI, from ionic remodelling to ECGs and pressure-volume loops. In acute MI, T-wave inversion and Brugada phenocopy were explained by up to 57 ms of local APD prolongation and activation failure due to the inhibition of potassium, sodium and calcium channels in the border zone. In chronic MI, upright tall T-waves highlight large repolarisation dispersion caused by uneven potassium channel expression in border and remote zones, which promoted ectopic propagation at fast pacing. Post-MI ionic remodelling reduced EF by up to 10% through inhibition of calcium transient amplitude due to weaker calcium currents or SERCA activity, but the EF at resting heart rate was not sensitive to the extent of repolarisation heterogeneity and the risk of repolarisation abnormalities at fast pacing. Multi-scale modelling and simulation coherently integrates experimental and clinical data at subcellular, tissue, and organ scales to unravel electromechanical disease mechanisms in MI. In acute post-MI, ionic remodelling and its effect on refractoriness and propagation failure in the BZ have a strong impact on phenotypic ECG variability, whereas in chronic post-MI, the repolarisation dispersion across the BZ is crucial. T-wave and QT abnormalities are better indicators of repolarisation heterogeneities than EF in post-MI.
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eLife assessment
This important study contributes to the current knowledge in the field of acute and chronic infarction. It is a significant study because the results provide convincing evidence for the need to incorporate additional risk factors for assessing patients after myocardial infarction.
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Reviewer #1 (Public Review):
Summary:
In this study by Zhou, Wang, and colleagues, the authors utilize biventricular electromechanical simulations to illustrate how different degrees of ionic remodeling can contribute to different ECG morphologies that are observed in either acute or chronic post-myocardial infarction (MI) patients. Interestingly, the simulations show that abnormal ECG phenotypes - associated with a higher risk of sudden cardiac death - are predicted to have almost no correspondence with left ventricular ejection fraction, which is conventionally used as a risk factor for arrhythmia.Strengths:
The numerical simulations are state-of-the-art, integrating detailed electrophysiology and mechanical contraction predictions, which are often modeled separately. The simulation provides mechanistic interpretation, down to the …Reviewer #1 (Public Review):
Summary:
In this study by Zhou, Wang, and colleagues, the authors utilize biventricular electromechanical simulations to illustrate how different degrees of ionic remodeling can contribute to different ECG morphologies that are observed in either acute or chronic post-myocardial infarction (MI) patients. Interestingly, the simulations show that abnormal ECG phenotypes - associated with a higher risk of sudden cardiac death - are predicted to have almost no correspondence with left ventricular ejection fraction, which is conventionally used as a risk factor for arrhythmia.Strengths:
The numerical simulations are state-of-the-art, integrating detailed electrophysiology and mechanical contraction predictions, which are often modeled separately. The simulation provides mechanistic interpretation, down to the level of single-cell ionic current remodeling, for different types of ECG morphologies observed in post-MI patients. Collectively, these results demonstrate compelling and significant evidence for the need to incorporate additional risk factors for assessing post-MI patients.Weaknesses:
The study is rigorous and well-performed. However, some aspects of the methodology could be clearer, and the authors could also address some aspects of the robustness of the results. Specifically, does variability in ionic currents inherent in different patients, or the location/size of the infarct and surrounding remodeled tissue impact the presentation of these ECG morphologies? -
Reviewer #2 (Public Review):
Summary:
The authors constructed multi-scale modeling and simulation methods to investigate the electrical and mechanical properties of acute and chronic myocardial infarction (MI). They simulated three acute MI conditions and two chronic MI conditions. They showed that these conditions gave rise to distinct ECG characteristics that have been seen in clinical settings. They showed that the post-MI remodeling reduced ejection fraction up to 10% due to weaker calcium current or SR calcium uptake, but the reduction of ejection fraction is not sensitive to remodeling of the repolarization heterogeneities.Strengths:
The major strength of this study is the construction of computer modeling that simulates both electrical behavior and mechanical behavior for post-MI remodeling. The links of different …Reviewer #2 (Public Review):
Summary:
The authors constructed multi-scale modeling and simulation methods to investigate the electrical and mechanical properties of acute and chronic myocardial infarction (MI). They simulated three acute MI conditions and two chronic MI conditions. They showed that these conditions gave rise to distinct ECG characteristics that have been seen in clinical settings. They showed that the post-MI remodeling reduced ejection fraction up to 10% due to weaker calcium current or SR calcium uptake, but the reduction of ejection fraction is not sensitive to remodeling of the repolarization heterogeneities.Strengths:
The major strength of this study is the construction of computer modeling that simulates both electrical behavior and mechanical behavior for post-MI remodeling. The links of different heterogeneities due to MI remodeling to different ECG characteristics provide some useful information for understanding complex clinical problems.Weaknesses:
The rationale (e.g., physiological or medical bases) for choosing the 3 acute MI and 2 chronic MI settings is not clear. Although the authors presented a huge number of simulation data, in particular in the supplemental materials, it is not clearly stated what novel findings or mechanistic insights this study gained beyond the current understanding of the problem. -
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