1 Laboratory of Experimental Anesthesiology and Cellular Physiology, UPRES EA 3212, Centre Hospitalier Universitaire, Côte de Nacre, Caen, France. 2 Department of Anesthesiology, Centre Hospitalier Universitaire, Caen, France Département dAnesthésie-Réanimation, CHU de Caen, Avenue Côte de Nacre, F-14033 Caen Cedex, France. E-mail: hanouz-jl@chu-caen.fr
Accepted for publication: July 23, 2002
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Abstract |
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Methods. In a double-chamber bath, guinea-pig right ventricular muscle strips were subjected partly to normal conditions and partly to 30 min of simulated ischaemia (hypoxia, hyperkalaemia, acidosis, and lack of nutritional substrate) followed by 30 min of reperfusion. Action potential parameters were recorded continuously in the normal zone and in the ischaemic reperfused zone. Spontaneous arrhythmias and conduction blocks were noted. The electro physiological effects of morphine were studied at 0.01 and 0.1 µM.
Results. In control conditions, morphine did not modify action potential parameters of resting membrane potential, maximal upstroke velocity (Vmax), action potential amplitude (APA) and action potential duration at 50 and 90% of repolarization. Morphine reduced ischaemia-induced depolarization and lessened the ischaemia-induced decrease in APA and Vmax. Morphine significantly decreased the occurrence of conduction block during simulated ischaemia (20% at 0.01 and 0.1 µM vs 67% in the control group, P<0.05) and reperfusion-induced arrhythmias (40% at 0.01 µM and 30% at 0.1 µM vs 92% in the control group, P<0.05).
Conclusions. In ischaemicreperfused guinea-pig myocardium, morphine at clinically relevant concentrations decreased ischaemia-induced conduction blocks and reperfusion-induced ventricular arrhythmias.
Br J Anaesth 2002; 89: 88895
Keywords: analgesics opioid, morphine; heart, arrhythmia; heart, ischaemia; heart, reperfusion injury
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Introduction |
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The purpose of our study was to examine the effect of clinically relevant concentrations of morphine administered during ischaemia and reperfusion on the time-course parameters of the action potential and on the incidence of arrhythmias in isolated guinea-pig myocardium.
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Material and methods |
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Guinea-pigs of either sex weighing 300400 g were killed by cervical dislocation after brief ether anaesthesia, and immediately exsanguinated. The heart was quickly removed at room temperature into oxygenated Tyrodes solution containing (mM) 135 Na+, 4 K+, 1.8 Ca2+, 1.8 H2PO4, 25 HCO3, 117.8 Cl and 5.5 glucose.
A myocardial strip (15 mm long, 5 mm wide, 1.5 mm thick) was carefully dissected from the free wall of the right ventricle. The strip was pinned, endocardial surface upwards, in a special perfusion chamber. This chamber (5 ml) was bisected by a thin latex membrane including a centrally located hole that allowed the preparation to be passed through and divided into two zones, called the normal zone (NZ) and the altered zone (AZ). The two compartments were perfused independently by a peristaltic pump at 2 ml min1, bubbled with carbogen (95% oxygen, 5% carbon dioxide). The pH of the Tyrodes solution was equilibrated to 7.35 (0.05) with dilute hydrochloric acid and the temperature was maintained at 36.5°C with a water-circulating thermostat-controlled bath (Polystat 5HP; Bioblock, Illkirch, France). To check for the absence of leakage between the two compartments, we injected methylene blue dye into one compartment after the experiment.
Data acquisition and analysis
Preparations were stimulated at 1 Hz with two bipolar silicon-coated electrodes positioned in the NZ and in the AZ. A commutator allowed stimulation of the preparation through one or the other stimulating electrode. Stimuli were rectangular pulses of 12 V depolarizing voltage, duration 2 ms, delivered by a programmable stimulator (model SMP 310; Biologic, Grenoble, France). Preparations that needed pulses stronger than 5 V to elicit action potentials were discarded because there could have been a conduction block at the level of the latex separating membrane. During the protocol, stimulation was stopped whenever sustained spontaneous arrhythmias occurred. Action potential parameters were recorded simultaneously in both myocardial regions using glass microelectrodes pulled from borosilicate filament tubes (GC 200F-15; Phymep, France) on a single-barrelled microelectrode puller (Narashige, distributed by OSI, France). Microelectrodes were filled with potassium chloride 3 M (tip resistance 1030 M) and coupled to a silversilver chloride microelectrode holder leading to a home-built, high-impedance capacitance-neutralizing amplifier. A ball-shaped reference silversilver chloride electrode was positioned in the superfusate of each compartment.
Action potentials (AP) were monitored on a digital oscilloscope (Gould Instrument Systems, Cleveland, OH, USA). The following AP parameters were automatically stored and measured using a cardiac AP automatic acquisition system and processing device (Datapac; Biologic): resting membrane potential (RMP); action potential amplitude (APA), action potential duration at 50% of full repolarization (APD50); action potential duration at 90% of full repolarization (APD90); and maximal upstroke velocity (Vmax). Whenever possible, the same impalement was maintained throughout the experiment; when it was lost, readjustment was attempted. If the readjusted parameters differed by less than 10% from previous values, experiments were continued; otherwise they were terminated.
Experimental protocol
After a 2 h equilibration period (when AP parameters were stabilized), simulated ischaemia was induced for 30 min in the AZ compartment by superfusion with modified Tyrodes solution, while the NZ compartment was maintained in normal conditions. The modified Tyrodes solution differed from normal by elevated potassium concentration (from 4 to 12 mM), decreased HCO3 concentration (from 25 to 9 mM), leading to a decrease in pH [from 7.35 (0.05) to 6.90 (0.05)], and decreased PO2 by replacement of 95% oxygen5% carbon dioxide with a gas mixture containing 95% nitrogen and 5% carbon dioxide and withdrawal of glucose. These modifications, combining hypoxia, hyperkalaemia, acidosis and lack of substrate, reproduced in vitro the electrophysiological abnormalities induced in vivo by ischaemia.6 814 After 30 min of simulated ischaemia, a 30 min reperfusion period was initiated by reperfusing Tyrodes solution rebubbled with 95% oxygen5% carbon dioxide mixture.
During both simulated ischaemia and reperfusion, conduction disturbances10 13 and arrhythmias6 10 13 were recorded: (i) conduction blocks between the AZ and the NZ; (ii) spontaneous arrhythmias independent of stimulation [one or two extrasystoles, salvos (310 AP), sustained activities (>10 AP)]; and (iii) loss of responsiveness to a constant stimulation intensity. Stimulation was stopped whenever sustained arrhythmias occurred.
During the simulated ischaemia and reperfusion phases, Tyrodes solution with 0.01 or 0.1 µM morphine (n=10 for each group) added or Tyrodes solution alone (n=12) was superfused randomly in both compartments (NZ and AZ). Thus, the electrophysiological effects of morphine on AP parameters and the incidence of arrhythmias were investigated simultaneously in normal (NZ) and altered (AZ) conditions.
Statistical analysis
All results are expressed as mean (SD). Multiple comparison of continuous variables was performed by repeated-measures analysis of variance followed by comparison with control or initial values (measurement before initiation of the ischaemic period) using the Bonferroni post hoc test. Fishers exact test was used for comparison of non-parametric categorical data. All P values were two-tailed, and P<0.05 was required to reject the null hypothesis.
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Results |
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Morphine effects on action potential parameters in ischaemicreperfused simulated conditions
Morphine reduced the ischaemia-induced depolarization [29 (5)% and 24 (5)% in the presence of morphine 0.01 and 0.1 µM respectively, compared with 32 (1)% for the control group after 30 min of ischaemia; P<0.001 for each group]. The ischaemia-induced decrease in APA [31 (5)% and 27 (6)% in the presence of morphine 0.01 and 0.1 µM respectively, compared with 39 (9)% for the control group after 30 min of ischaemia; P<0.001 for each group] and Vmax [54 (7)% and 56 (12)% in the presence of morphine 0.01 and 0.1 µM respectively, compared with 71 (19)% in the control group after 30 min of ischaemia; P<0.001 for each group] were significantly attenuated by morphine. As shown in Table 2, the ischaemia-induced AP shortenings were not affected by morphine whatever the concentration tested. At the end of the reperfusion, RMP, APA, Vmax, APD50 and APD90 in the AZ reached baseline values and were comparable between groups (Table 2).
Morphine effects on ischaemiareperfusion-induced conduction disturbances
As shown in Figure 1, conduction blocks occurred after 15 (7) min in the control group, 16 (14) min in the presence of 0.01 µM morphine and after 21 (7) min in the presence of 0.1 µM morphine. At the end of the ischaemic period there was no significant difference between groups in the incidence of loss of responsiveness (1% for control group and 0% for the morphine groups). Reperfusion of AZ induced complete recovery of responsiveness in all experimental groups.
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Discussion |
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Our results show that morphine did not affect AP parameters in normoxic conditions. This is in accordance with previous results showing that morphine, even at high concentrations, did not significantly modify electrophysiological parameters recorded on isolated myocardium.15 16 Although Hung and colleagues have shown that morphine decreases the sodium inward current (INa) in human and rat isolated myocytes, this effect became significant at concentrations 100-fold higher than those tested in our study.17 Additionally, Hung and colleagues showed that morphine at 30 µM did not affect the inward calcium current, the transient outward potassium current or the inwardly rectifying potassium currents.17 In our study we tested the effects of morphine 0.01 and 0.1 µM because these concentrations are in the range of plasma concentrations measured in clinical practice, taking the protein binding of morphine into account.18 To our knowledge, there are no studies dealing with the effects of clinically relevant concentrations of morphine on ion transmembrane currents in myocardial cells.
Our results confirm the ischaemia-induced decrease in RMP and AP parameters reported previously in similar studies.6 7 10 Furthermore, in AZ the ischaemia-induced decrease in RMP was attenuated by morphine at 0.01 and 0.1 µM. It is well known that depolarization of the RMP can lead to steady-state inactivation and slower reactivation of sodium channels, thereby reducing the number of channels available to carry INa during the action potential upstroke. Consequently, attenuated ischaemia-induced membrane depolarization measured in the presence of morphine should attenuate the ischaemia-induced decrease in INa, and thus the decreases in Vmax and APA. This is in agreement with our results showing that morphine attenuated the decrease in Vmax and APA measured during simulated ischaemia. Because depolarizing the RMP plays a pivotal role in the production of re-entrant arrhythmias during the acute phase of ischaemia,14 this result could explain, at least in part, the anti-arrhythmic effect of morphine reported here and in previous studies.2 19 20 Our study shows that morphine did not modify the ischaemia-induced decrease in APD50 and APD90. Although morphine 0.1 µM significantly attenuated the ischaemia-induced decrease in APD90, this effect remained modest. Ischaemia-induced shortening of AP duration has been related to the activation of an ATP-sensitive potassium (K-ATP) conductance.21 The direct effect of morphine on sarcolemmal K-ATP channels in myocytes remains unknown, but recent evidence suggests that mitochondrial K-ATP channels may be opened by opioid receptor stimulation, leading to a preconditioning state.2 22 Moreover, pretreatment of isolated rat hearts with a selective antagonist of the mitochondrial K-ATP channels abolished the anti-arrhythmic effect of 1-opioid receptor stimulation.2 However, sarcolemmal, but not mitochondrial, K-ATP channels are involved in the repolarization phase of the cardiac AP, supporting the unchanged AP duration reported in our study.
Our study shows that, during simulated myocardial ischaemia, morphine significantly decreased the occurrence of conduction blocks in the border zone. It is well known that slowing of conduction velocity, occurrence of conduction blocks and dispersion of the refractory period between an ischaemic zone and a non-ischaemic zone (border zone) favour the emergence of re-entry arrhythmias.13 14 This should be considered with the knowledge that morphine is used to treat chest pain associated with myocardial infarction. In contrast, morphine did not modify the occurrence of spontaneous arrhythmias during the ischaemic period, as reported previously.23 24 However, ischaemia-induced spontaneous arrhythmias are unlikely to be related to re-entry movement because it has been shown that they are independent of stimulation.7 Although Fryer and colleagues2 and Wang and colleagues19 reported an anti-arrhythmic effect of opioid receptor stimulation, in these studies opioid agonists were administered before myocardial ischaemia as triggers of preconditioning.3 4 In contrast, in our study morphine was administered throughout the duration of ischaemia and reperfusion, as might occur in clinical practice.
Our results show that morphine significantly decreased the incidence of reperfusion-induced repetitive responses around the border zone between AZ and NZ. This is in agreement with previous results showing that chronic morphine exposure significantly reduced the incidence and severity of reperfusion-induced arrhythmias in isolated rat hearts.25 The mechanisms involved in arrhythmias that occur during reperfusion and were morphine-sensitive in our experimental model are not completely understood, but might involve -24 and
-opioid2 receptors, adrenoceptor modulation,26 reduction of conduction block, sodium or calcium overload and possibly reactive oxygen species.27 The hypothesis of adrenoceptor modulation is supported by studies suggesting that the anti-arrhythmic effect of
- and
-opioid receptor stimulation resulted, at least in part, from negative modulation of ß-adrenoceptors and a decrease in intracellular calcium oscillations.26 28 So opioid receptor stimulation may be an important way to counteract the excitatory influence of the sympathetic nervous system, thus preventing dysrrhythmias arising from overactivity of adrenoceptors during ischaemia. Finally, further studies are needed to understand the precise mechanism involved in the anti-arrhythmic effect of morphine in ischaemicreperfused myocardium.
There are several limitations to our study. First, the simulated ischaemia used modified Tyrodes solution with acidosis, hyperkalaemia, hypoxia and lack of energetic substrates. As described previously,6 811 these conditions accurately reproduced the electrical alterations of cardiac APs observed in vivo during experimental myocardial ischaemia.12 Additionally, the reliability of the double-bath technique is demonstrated by the constancy of the AP parameters in the NZ, adjacent to the AZ. Secondly, the border between normal and ischaemicreperfused myocardium is probably narrower and more regular than it might be in clinical conditions. As shown previously,6 this border zone model reproduces arrhythmias similar to those observed in vivo during experimental transient coronary artery occlusion11 12 or in humans during coronary transluminal angioplasty and after thrombolytic therapy.28 Thirdly, the study was performed on guinea-pig myocardium, which differs from human myocardium, although the main ionic currents involved are qualitatively similar in the two species. Fourthly, the ischaemic conditions used here are severe and did not allow extrapolation of our results to less severe ischaemic insults. Finally, an in vitro model, however complex, cannot reproduce the in vivo situation exactly but may provide important information for the clinicians.29
In conclusion, our study of guinea-pig ventricular muscle shows that clinically relevant concentrations of morphine reduced ischaemia-induced electrophysiological changes, decreased the occurrence of conduction block during simulated ischaemia, and decreased the incidence of reperfusion-induced arrhythmias.
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Acknowledgements |
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