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Anesthesiology:
Review Article

Excitation-contraction Coupling in the Heart and the Negative Inotropic Action of Volatile Anesthetics

Hanley, Peter J. M.B.Ch.B.,Ph.D.*; ter Keurs, Henk E.D.J. M.D.,Ph.D.†; Cannell, Mark B. Ph.D.‡
Section Editor(s): Warltier, David C. M.D., Ph.D., Editor

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IN a comprehensive review in 1987, Rusy and Komai1 discussed the possible mechanisms by which volatile anesthetics inhibit cardiac contraction. Since that time, there have been advancements in the understanding of excitation-contraction coupling, cardiac mechanics, and the actions of volatile anesthetics. There are essentially three major factors that determine the force of contraction of heart muscle cells: the magnitude of cytosolic Ca2+ increase after electrical excitation, the responsiveness of the contractile proteins to Ca2+, and the sarcomere length (SL) at which the contractile proteins are activated. Hence, there are two possible ultimate direct negative inotropic actions of volatile anesthetics: a reduction in Ca2+ availability or a decrease in the Ca2+-responsiveness (Ca2+-sensitivity or maximal Ca2+-activated force) of the contractile apparatus. The rate of relaxation of the muscle cells, on the other hand, depends on the rate at which Ca2+ is cleared from the cytosol, which facilitates its dissociation from the regulatory proteins of the contractile system. The control of calcium cycling and the activity of the contractile proteins consume energy that must be continuously supplied by the mitochondria, another potential site volatile of anesthetic action.
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Part I: Excitation-contraction Coupling and the Contractile Machinery

Fig. 1
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A diagram of cardiac excitation-contraction coupling is shown in figure 1. Action potentials, initiated by sinoatrial nodal cells, are rapidly conducted throughout the heart, facilitated by the His-Purkinje system, and activate the force (pressure) generating myocardial cells within the ventricles. Rapid depolarization in myocytes is mediated by voltage-gated Na+ channels, different subtypes of which are located in the transverse tubules (Nav1.1, Nav1.3, and Nav1.6) and intercalated disks (Nav1.5).2 The depolarization of the cell leads to the activation of L-type Ca2+ channels, which are primarily encoded by the α1C gene (Cav1.2),3 and are the next key element in cardiac excitation-contraction coupling. In addition, other ionic currents, such as that attributable to Na/Ca exchange, as well as chloride and potassium currents, all shape the action potential, whose duration is ∼300 ms. The action potential spreads from cell to cell, a process that is facilitated by Nav1.5 channels (in the intercalated disks) and extensive gap junctions between cells, each of which is connected to ∼15 of its neighbors.4 In ventricular cells, the action potential passes into transverse tubules (t-tubules) that serve to minimize delay in excitation throughout the cell.5
Surface membrane depolarization promotes the influx of Ca2+ via the voltage-gated L-type (also called dihydropyridine-sensitive) Ca2+ channels and possibly the Na/Ca exchanger (NCX). In the case of the L-type Ca2+ channel, Ca2+ influx is limited by both Ca2+-dependent inactivation as well as voltage-dependent and time-dependent inactivation.6–9 Ca2+-dependent inactivation depends on both the Ca2+ that enters the cell via the channel itself (e.g., Bechem and Pott10) and Ca2+ release from intracellular stores.11,12 The intracellular mechanism of Ca2+-dependent inactivation appears to involve calmodulin.13,14
Although Ca2+ influx via L-type calcium channels will increase intracellular Ca2+ directly by a small amount, the influx of Ca2+ is normally amplified by a larger release of Ca2+ from the sarcoplasmic reticulum (SR) in a process known as Ca2+-induced Ca2+ release (CICR).15 This mechanism resides in the Ca2+-dependent gating of ryanodine-sensitive Ca2+-release channels in the SR (ryanodine receptors; RyRs) and of the three isoforms known, the RyR2 isoform predominates in heart (for review of junctional proteins, see Muller et al.16). Because activation of RyRs depends only on an elevation in intracellular Ca2+, any source of Ca2+ could, in principle, activate CICR.
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Alternative Trigger of CICR
The NCX, which serves as the primary route for Ca2+ extrusion at rest,17,18 can be reversed during depolarization as a result of the action potential to bring Ca2+ into the cell. This Na/Ca exchange “reverse mode” Ca2+ influx has also been implicated in triggering CICR.19–21 Although this possibility was first demonstrated under pathologic conditions of calcium overload, where the cell is highly sensitive to trigger calcium concentrations,19 subsequent experiments showed that conditions which would lead to NCX reversal (such as strong depolarization or increased intracellular Na+ concentrations) could also trigger CICR.20–22 It has even been suggested that the NCX might be a major source of trigger Ca2+ during the normal action potential,21 although this has been debated.23 Blockade of NCX with an inhibitory peptide suggested that only up to 27% of the trigger might be attributable to NCX.22 In addition to the membrane potential, internal Na+ concentrations will also be critical for determining the NCX contribution.24 During the upstroke of the action potential, Na+ influx might increase Na+ concentrations locally to promote reverse mode exchange20,25 as well modify SR Ca2+ content.26 Some researchers have been unable to demonstrate potent triggering of CICR at negative potentials by reverse mode exchange when the Na+ current is activated,24,27 and it is likely that a major part of this controversy resides in the difficulty of obtaining good voltage control during the Na+ current while also trying to prevent all Ca2+ influx via L-type Ca2+ channels by pharmacological agents.
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Colocalization of Dihydropyridine Receptors and RyRs
The reliability of excitation-contraction coupling is also dependent on the physical relation between the proteins that provide/regulate the triggers for CICR as well as the location of the RyRs that respond to the trigger signal. The membranes of the t-system and the terminal cisternae of the SR are closely opposed in junctional areas or “dyads,”28 and such structures will increase the reliability of CICR by limiting diffusional loss of the trigger Ca2+ signal within them.29–31 Although the dihydropyridine receptors (L-type Ca2+ channels) and the RyRs (Ca2+-release channels) are colocalized,32,33 a combination of immunofluorescence and data deconvolution techniques have led to the suggestion34 that neither voltage-gated Na+ channels nor the NCX are located in the dyad. On the contrary, more recent immunolocalization data from Thomas et al.35 suggest that the NCX is indeed concentrated in t-tubules.
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Elementary Ca2+ Release Events: Ca2+ Sparks
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Over the past decade new insights into the basic events underlying CICR have been obtained by application of confocal microscopy and fluorescent calcium indicators. Such experiments have shown that the close opposition of the dihydropyridine receptors and the RyRs enables local control of Ca2+ release into the cytosol as proposed by Stern.36 In this model, it is not the global cytosolic concentrations of Ca2+ (or any other messenger) that are important but rather the micro-environment around the RyR. The importance of local rather than global signals is based on the idea that most biologic processes are inherently nonlinear. Thus, in terms of cardiac excitation-contraction coupling, we must consider the microscopic environment produced by the local activation of trigger mechanisms (such as L-type Ca2+ channels) and the behavior of a local cluster of RyRs in their vicinity. The discovery of “Ca2+ sparks” or microscopic release events resulting from the local coactivation of a cluster of RyRs5,37,38 has reinforced this idea. Ca2+ sparks are seen both as spontaneous and evoked microscopic SR release events inside the cell. The latter generally require the use of Ca2+ channel antagonists to reduce the probability of spark activation so that individual sparks can be observed.37,39 From the site of release (near z-lines) the Ca2+ spark diffuses to cover a region of the cell approximately 2 μm in diameter5 with a slightly greater spread in the longitudinal direction40 (fig. 2). When measured at room temperature, the Ca2+ spark reaches a peak in ∼10 ms and lasts ∼40–80 ms and peak Ca2+ during the spark is typically 200–400 nm. The decay of the Ca2+ spark is a result of both Ca2+ diffusion and SR uptake.41 When sparks are activated by depolarization, they summate to produce a larger and slower Ca2+ transient, and the reduced rate of decline of Ca2+ can be ascribed to the loss of the diffusive component of spark decay; during the whole-cell Ca2+ transient Ca2+ is globally increased so diffusion cannot serve to reduce Ca2+.5
From studying Ca2+ sparks we now know that excitation-contraction coupling in the heart is attributable to the spatio-temporal summation of a very large number of “elementary” Ca2+ sparks.37,42,43 It has been estimated that during excitation-contraction coupling the spontaneous spark rate is increased by a factor of ∼10,000 by a “local” 100-fold increase in Ca2+ resulting from the trigger Ca2+ influx.44 Such a local increase in Ca2+ is consistent with some computer simulations of changes in Ca2+ attributable to L-type Ca2+ channels.31 Moreover, the latency for SR Ca2+ release is <2 ms,45 consistent with the rate of RyR opening expected from such high local trigger Ca2+ concentrations.30 Although strictly speaking, Ca2+ sparks cannot be elemental if attributable to the concerted activation of a number of local RyRs in a cluster,40 the fact that evoked Ca2+ sparks appear to have a modal amplitude distribution at fixed locations within the cell46 suggests that each spark site behaves in an “all or none” fashion and are therefore “elementary” in a functional sense (but see Lipp and Niggli47). In any case, it is generally agreed that coordinated activation of multiple spark sites gives rise to the global increase in cytosolic [Ca2+] that occurs under normal conditions. More recently, Wang et al.48 have shown that the local increase in Ca2+ concentration (“sparklet”) produced by an extended (drug modified) opening of a single L-type Ca2+ channel can trigger a cluster of about 4–6 peripheral RyRs, which then produce a spark. On the other hand, from both experimental and theoretical approaches, both Bridge et al.46 and Soeller and Cannell49 suggest that sparks may in fact arise from somewhat larger clusters of RyRs, consisting of >15 receptors. The number of RyRs underlying a Ca2+ spark is important because it sets limits on the degree to which different amounts of Ca2+ may be released by modulation of RyR open probability as well as the “safety factor” inherent in RyR activation.
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SR Ca2+ Content
The amount of Ca2+ released into the cytosol depends not only on the magnitude of the Ca2+-influx current (the trigger for Ca2+ release) but also on the SR Ca2+ content.50,51 For a given concentration of trigger Ca2+, the Ca2+ release increases as a function of SR Ca2+ content. High SR luminal [Ca2+] appears to increase the open probability of the RyRs,52,53 which may explain why transient inward currents, afterdepolarizations, and aftercontractions are often seen when the SR contains a high Ca2+ load. Under steady state conditions (constant heart rate and constant neurohumoral input), the magnitudes of Ca2+ influx and efflux across the sarcolemma are balanced, and thus there is no net change in mean SR Ca2+ content. After β1-receptor stimulation, for example, L-type Ca2+ current as well as SR Ca2+-pump activity increases, resulting in net Ca2+ influx over successive contraction cycles that loads Ca2+ into the SR. The increase in Ca2+ current (trigger Ca2+) and SR Ca2+ store induced by β1-receptor stimulation gives rise to larger Ca2+ transients and therefore more contractile protein activation. However, it is still unclear whether this is accompanied by an increase in the number of Ca2+ sparks as well as individual spark amplitude.
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Ca2+ Transport Systems
The increase in cytosolic [Ca2+] and the accompanying force development after electrical activation is transient because Ca2+ is rapidly removed from the cytosol after release. There are four main Ca2+ transport systems that remove Ca2+ from the cytosol: the SR Ca2+-pump (sarco-endoplasmic reticular Ca2+-adenosine triphosphate [ATP]ase), the sarcolemmal Ca2+-pump (Ca2+-ATPase), the NCX, and the mitochondrial Ca2+-uniporter (fig. 1). Although the relative contributions of these systems is species-dependent, the predominant Ca2+ transport systems are the SR Ca2+-ATPase and the NCX.50,54,55 The activity of the SR Ca2+-ATPase can be increased by cAMP-dependent phosphorylation of the endogenous inhibitor phospholamban,56 whereas the activity of the NCX can be modulated by phosphorylation via protein kinase C.57 The NCX exchanges 3 Na+ for 1 Ca2+, and therefore it is electrogenic. Hence, its direction (Ca2+-influx versus Ca2+-efflux mode) is determined by the prevailing transmembrane gradients for Na+ and Ca2+, as well as membrane potential.58,59 Indeed, the NCX may transiently reverse after membrane depolarization, especially during the peak of the action potential. It should be reiterated that the magnitude and direction of the NCX is strongly (in a cubic fashion) dependent on intracellular [Na+], as discussed in detail by Cooper et al.58 (see also Evans and Cannell24). Hence, the activity of the Na pump (Na+,K+-ATPase) plays a critical role in determining the Gibbs free energy of the exchanger. It should also be noted that activation of the exchanger after spontaneous Ca2+ release after the Ca2+ transient (in Ca2+ overloaded cells60 or in nonuniform cardiac muscle61) will lead to current flow across the membrane which can lead to after depolarizations sufficiently large to produce action potentials and extrasystoles.
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Activation of the Contractile System
Activation of the contractile system by Ca2+ is mediated by its binding to the regulatory protein troponin C (TnC).62 The contractile proteins (myofibrils), which occupy around 60% of the cell volume,63,64 consist of thick (myosin) and thin (actin) filaments which are arranged between z-lines to form sarcomeres, the repeating units of the myofibrils (fig. 1). The thin filaments are ∼1 μm in length and protrude from anchoring points on the z-line.65,66 Tropomyosin lies in the groove between the two actin chains of the thin filament and its movements are regulated by the Ca2+-sensitive troponin complex.67 Interdigitating with the thin filaments are the thick filaments, the globular heads of which form the cross-bridges which interact with the thin filament and contain actomyosin-ATPase.
The troponin complex has three subunits: TnC (the Ca2+-binding subunit), troponin T (the tropomyosin-binding subunit), and troponin I (the inhibitory subunit). Compared with its skeletal counterpart, the cardiac troponin I isoform has a longer amino terminus containing two phosphorylation sites that are substrates for cAMP-dependent protein kinase A.68 When troponin I is bisphosphorylated, the Ca2+ off-rate of TnC is increased, which enhances the relaxation rate of a contraction.68,69 Cardiac TnC has three Ca2+-binding sites, unlike the skeletal isoform, which has four.56,70 Two of the sites bind both Ca2+ and Mg2+, whereas the other site specifically binds Ca2+ and therefore serves as the regulatory site. In resting cardiac muscle, cytosolic [Ca2+] is low (∼70 nm)71 and the Ca2+-specific site of TnC (with a dissociation constant of ∼500 nm)55 is unoccupied.72 In this state, tropomyosin, lying in the groove of the thin filament, prevents interaction of the myosin heads (cross-bridges) with actin (but see Perry73). When cytosolic [Ca2+] increases, after membrane depolarization and CICR, Ca2+ binds to TnC, which causes tropomyosin to move out of the actin groove, thereby allowing myosin to interact with actin, producing force or shortening (for review, see Perry73).
The mechanism by which myosin interacts with actin and uses the energy from ATP hydrolysis to produce mechanical work is known as the “cross-bridge theory of sliding filaments” and was first proposed in 1957 by Huxley.74 This mechanism has been extensively reviewed.70,75 As long as Ca2+ is bound to TnC, the myosin head can form cross-bridges with nearby binding sites on the thin filament. The generation of force or the relative sliding of the filaments is thought to be brought about by rotation of the head, the swinging cross-bridge model.76,77 The biochemical steps that drive cross-bridge cycling (hydrolysis of ATP via actomyosin-ATPase) have been largely characterized.78 Basically, ATP binds to myosin, causing the globular head domain to detach from actin, and its subsequent hydrolysis sets the myosin head into a high energy state. Ishijima et al.79 have simultaneously measured the mechanical events and actomyosin-ATPase activity of a single-headed myosin molecule interacting with an actin filament. Under these artificial conditions, force generation did not always coincide with the release of adenosine diphosphate from the myosin head (as previously thought) but could occur several hundred milliseconds after release. The authors proposed that the mechanical and biochemical events of cross-bridge cycling are not tightly coupled in that a myosin head can undergo several conformational changes during a single actomyosin-ATPase cycle. However, it should be stressed that the exact nanomechanics and stoichiometry of cross-bridge cycling still remain to be elucidated.80
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Responsiveness of the Contractile Proteins to Ca2+
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Although intracellular [Ca2+] is the major determinant of force at any given SL, the development of force is also dependent on the responsiveness of the contractile proteins to Ca2+. Responsiveness refers to the relation between force and intracellular [Ca2+] (fig. 3), often expressed as pCa (−log10[Ca2+]). The pCa-force relation can be modulated by various factors such as ionic strength, temperature, pH, [Pi], SL (fig. 3), and phosphorylation state of the contractile apparatus.56 The [Ca2+] at which force is half-maximal provides an index of ‘Ca2+-sensitivity' of the contractile system whereas the force obtained at TnC-saturating [Ca2+] gives “maximal Ca2+-activated force.” Ca2+ binding to TnC is cooperative, that is, the binding of one Ca2+ ion facilitates the binding of the next one. This gives rise to a steep pCa-force relation.
The relation between intracellular [Ca2+] and force has been well characterized using chemically or mechanically “skinned” muscle preparations. Skinning renders the sarcolemma freely permeable to ions and small molecules, and thus this technique allows the intracellular environment to be well controlled. However, Marban et al.81 showed that the relation between intracellular [Ca2+] and force is strikingly steeper in intact cardiac muscle than is reported for skinned muscle preparations. This apparent difference was reexamined by Gao et al.,82 who determined the intracellular [Ca2+]-force relation before and after skinning in the same muscle preparation (rat cardiac trabecula). The [Ca2+] required for half-maximal force was considerably higher after skinning, suggesting that the skinning procedure may damage or remove components involved in the regulation of actin-myosin interaction. Hence, data obtained from experiments employing skinned muscle preparations cannot be readily extrapolated to the intact system.
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Length-dependence of Passive and Ca2+-activated Force
One of the major determinants of force is the SL at which the contractile proteins are activated83,84 (fig. 3).Typically, cardiac myocytes have a slack (resting) length of ∼1.9 μm and can be extended to SLs of up to ∼2.3–2.4 μm. In intact cardiac muscle, twitch force (or stress, which is force/cross-sectional area) increases steeply as a function of SL (the Frank-Starling mechanism). This steep increase in force as a function of SL is thought to be attributable largely to a length-dependent increase in the sensitivity of the contractile system to Ca2+, mediated by increased affinity of Ca2+ binding to TnC.62,72 An increase in overlap of thick and thin myofilaments, a reduction in interfilament lattice spacing,62,85 and an increase in intracellular Ca2+ release86,87 are thought to contribute to the increase in force when SL is increased.
The exact mechanism by which an increase in SL causes an increase in myofilament Ca2+ responsiveness remains elusive. Fuchs and Smith72 argue that the sensitivity of the contractile system to Ca2+ is governed by myofilament lattice spacing rather than muscle length. It has been shown by radiographic diffraction that interfilament spacing decreases as SL increases in both intact and skinned cardiac muscle.88 Fitzsimons and Moss85 previously proposed that decreased interfilament spacing increases force development by increasing the probability that myosin will form strong cross-bridges with actin. Recent work from Konhilas et al.,89 suggests that changes in lattice spacing may not underlie length-dependent activation. These authors found that osmotic compression of the myofilament lattice spacing, which was measured by radiographic diffraction, did not alter Ca2+-sensitivity in skinned cardiac trabeculae. Hence, the sensor for SL changes probably does not reside in the interfilament space. The protein titin (also called connectin), which spans the entire sarcomere and interacts with the thick and thin filaments,90 is in a good position to sense SL changes, but whether this protein signals length changes to the regulatory proteins of the thin filament is not known.91,92
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Extension of cardiac muscle beyond a SL that optimizes actin-myosin interaction (a SL of 2.2–2.4 or so, depending on species), is prevented by the development of large parallel elastic forces,84,93,94 as shown in figs. 4A and 4B. The straightening of perimysial collagen fibers, which are thought to be the dominant contributors to passive force at SL >2.2 μm,95 is presumed to underlie this end-stop effect (figs. 4C and 4D).
At SLs < 2.1 μm, where passive force is less than 5% of maximal twitch force, titin overshadows collagen as the main contributor (>90%) to passive force.95 This large protein, sometimes referred to as the third filament of the contractile apparatus, is closely associated with the thick filaments in the A-band region.96,97 The elasticity of titin resides in its I-band portion, which spans from the z-line to the tip of the myosin filament.98 This elastic (I-band) segment of titin is shorter in cardiac muscle than in skeletal muscle and may explain why titin-based passive force is greater in cardiac than most skeletal muscle at a given SL. In addition to acting as a molecular spring, titin may also contribute to the viscoelastic properties of the sarcomeres by interacting with the thin filament.71,98,99
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Cardiac Energy Metabolism and Mitochondrial Function
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Cardiac myocytes, the functional unit of the heart (accounting for >90% of heart volume), require a continual supply of free energy to perform mechanical work, synthesize various molecules, and do electrochemical work (maintain ion gradients across membranes). This free energy comes from the oxidation of metabolic substrates such as long-chain fatty acids and, to a lesser extent, glucose and lactate.100–102 Mitochondria occupy ∼30% of the myocyte volume4,63,64 and have a highly ordered distribution in the living myocyte, lying in the interfibrillar space between z-lines (fig. 5). Oxygen is the ultimate acceptor of electrons when metabolic substrate is oxidized. Electrons are transferred to oxygen via the electron transport chain, a series of proton pumps and electron carriers located in the mitochondrial inner membrane. A proton gradient is established across the mitochondrial inner membrane, giving rise to a potential of ∼200 mV, as electrons are transferred along the various complexes of the electron transport chain. The energy stored in this electrochemical gradient is used to drive the synthesis of the energy carrier molecule ATP. Mitochondrial matrix ATP is then tranported via the ATP-adenosine diphosphate translocase to the cytosol where, via the creatine-creatine phosphate shuttle system,103 it serves as a readily accessible source of free energy for mechanical and electrochemical work.
Ultimately, all the energy used by the myocyte to maintain its structure and function is degraded to heat. From studies in which the rate of heat production of cardiac trabeculae of guinea pig was measured under various conditions, Schramm et al.104 deduced that actomyosin-ATPase, Ca2+-ATPase, and Na+,K+-ATPase accounted for 76%, 15%, and 9%, respectively, of the overall rate of ATP turnover. In accord with these results, Ebus and Stienen105 measured the rate of ATP hydrolysis in saponin-skinned trabeculae of rat and showed that approximately 15% of maximal Ca2+-activated ATPase was membrane-bound, around two thirds of which was attributable to the sarco-endoplasmic reticular Ca2+-ATPase. The source of the heart's extraordinarily high basal rate of metabolism, which accounts for 25–30% of the energy expenditure of the beating heart, remains unknown (for review, see Gibbs and Loiselle106).
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Mitochondrial Ca2+ Uptake
Mitochondrial Ca2+ influx occurs via a ruthenium-red sensitive Ca2+-uniporter107 (fig. 1), whereas its efflux is mediated by a Na/Ca exchange mechanism (and, indirectly, Na+-H+ exchange), the stoichiometry of which has not been established.108 Ca2+ influx into the mitochondria is thought to regulate metabolism because an increase in mitochondrial [Ca2+] stimulates ATP synthase109 and the activity of pyruvate dehydrogenase and α-ketoglutarate dehydrogenase, enzymes linked with the tricarboxylic acid cycle.110
Recent evidence suggests that cytosolic Ca2+ signals are probably communicated directly to the mitochondria. After selectively loading the fluorescent Ca2+ indicator rhod-2 into the mitochondria of electrically stimulated ventricular myocytes of rabbit, Trollinger et al.111 were able to demonstrate mitochondrial Ca2+ transients using confocal microscopy. In accord, in work with patch-clamped ferret or cat ventricular myocytes, Zhou et al.112 were also able to detect mitochondrial Ca2+ transients during a twitch, albeit only when the cytosolic resting [Ca2+] exceeded physiologic concentrations. Compared with the cytosolic Ca2+ transient, the kinetics of the mitochondrial Ca2+ transient were much slower. Griffiths,113 using cardiac myocytes and techniques to load indo-1 (a fluorescent Ca2+ indicator) selectively into mitochondria, found that mitochondrial transients accompanied twitches in guinea pig but not rat, suggesting that there may be species-differences in mitochondrial Ca2+ cycling. It should be noted that the surface area of the mitochondrial inner membrane is 10-fold higher than the area of the sarcolemma and t-tubule system.56 Hence, small changes in mitochondrial Ca2+ permeability could greatly influence Ca2+ distribution in the cell.
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Neurohumoral Regulation of Contraction
Although neurohumoral regulation is outside the scope of this review (see, for example, Morris and Malbon114 or Xiao115), a brief overview of the major signaling pathways in the myocyte follows. Each myocyte has three major intracellular signaling cascades that are modulated via G protein-coupled surface receptors, each of which contains a conserved structure of seven transmembrane α-helices.116,117 The G protein-coupled receptors regulate the activity of various membrane-bound enzymes including adenylate cyclase, guanylate cyclase, and phospholipase C, which produce, respectively, the secondary messengers cAMP, cGMP, and DAG.118 In each case, the secondary messengers activate protein kinases (protein kinase A, protein kinase G, and protein kinase C, respectively) that phosphorylate specific amino acid residues on contractile proteins, ion channels, and pumps. The adrenergic receptors and the muscarinic cholinergic receptors are the most important G protein-coupled receptors in the heart. At least nine subtypes of adrenergic receptors have been cloned: three α1-receptors, three α2-receptors, and three β-receptors. When agonist is bound to the receptor the G proteins dissociate into effector subunits that modulate the activity of various membrane-bound targets such as adenylate cyclases, phospholipases, and ion channels. For example, when agonists bind to β1-receptors, the Gαs subunit dissociates and stimulates adenylate cyclase, which produces the secondary messenger cAMP, a protein kinase A activator. Protein kinase A phosphorylates the following: L-type Ca2+ channels (which increases Ca2+ influx), phospholamban (which enhances SR Ca2+-uptake, thereby increasing the rate of relaxation), RyRs (which may facilitate Ca2+ release, a controversial issue),119 troponin I (which reduces filament sensitivity to Ca2+ ions and by itself decreases force but accelerates relaxation), and myosin binding protein C. The net effect is positive inotropy and positive lusitropy (increased rate of relaxation). Stimulation of muscarinic receptors yields Gαi, which inhibits adenylate cyclase, producing the opposite effect to adrenergic receptor stimulation.
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Part II: Mechanisms of Negative Inotropy Induced by Volatile Anesthetics

Fig. 6
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Volatile anesthetics have been shown to inhibit or stimulate various cellular components such as ion channels, pumps, exchangers, enzymes, gap junctions, and components of the contractile system, as schematically illustrated in figure 6. Most studies have shown effects at moderately high concentrations, suggesting that volatile anesthetics may perturb lipid bilayers, which would explain why these lipophilic agents affect diverse molecular targets. However, the fundamental molecular mechanisms by which these agents inhibit or stimulate various membrane-bound proteins and the contractile apparatus remains unclear. For a recent discussion of the possible mechanisms by which molecules of volatile anesthetics interact with protein structures, lipid bilayers and various molecular interfaces, see a review by Urban.120
Anesthetic concentrations are usually expressed as mM, volume%, or their equivalent MAC (minimal alveolar [anesthetic] concentration) value, where 1 MAC is defined as the minimal alveolar (anesthetic) concentration at one atmospheric ambient pressure required to prevent movement in response to a noxious stimulus in 50% of animals.121 Anesthetic concentrations corresponding to 1 MAC (in rat) at 37°C, for example, are as follows: halothane (0.27 mm), isoflurane (0.31 mm), and sevoflurane (0.35 mm).122 When comparing studies performed at different temperatures, it is important to note that MAC expressed as volume% varies considerably with temperature, whereas the equivalent liquid-phase concentration, typically expressed in mM, changes little.122
Ultimately, for volatile anesthetics to inhibit cardiac contractility they must reduce Ca2+-availability or decrease the Ca2+-responsiveness of the contractile proteins. Although direct actions at the level of the contractile apparatus or components of excitation-contraction coupling are likely to be more important, volatile anesthetics could also inhibit contractile function indirectly by impairing mitochondrial energy supply.
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Anesthetic Effects on Ca2+ Availability
In 1986, Bosnjak and Kampine123 showed that halothane decreased the Ca2+ transient in cat papillary muscles that had been microinjected with aequorin. These authors also reported that halothane did not affect resting Ca2+ concentrations; however, the luminescence of aequorin is a quadratic function of [Ca2+] and, therefore, is not a suitable indicator for measuring resting Ca2+ concentrations.124 Another potential limitation of aequorin is that its light-emitting properties may be altered by direct interaction of the anesthetic with the photoprotein,125 although, in favor of aequorin, Housmans and Wanek126 recently reported that neither halothane nor isoflurane affected aequorin luminescence in the pCa range 2–8. In 1985, the ratiometric fluorescent Ca2+ indicators fura-2 and indo-1 were introduced,127 followed by fluo-3;128 these are technically less difficult to use than aequorin.
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A large number of studies using fluorescent Ca2+ indicators have corroborated the observations of Bosnjak and Kampine123 that volatile anesthetics dose-dependently decrease the amplitude of the intracellular Ca2+ transient in intact cardiac muscle.129–136 Hence, it is now well established that volatile anesthetics indeed decrease the amount of Ca2+ released into the cytosol after electrical stimulation. Figure 7 shows an example of the inhibitory effect of halothane on peak twitch intracellular [Ca2+], indexed as fura-2 fluorescence ratio. Note that the anesthetic had no effect on diastolic [Ca2+]. Moreover, in multicellular cardiac muscle preparations, it has also been shown that, after correcting fluorescent indicator signals for autofluorescence changes, volatile anesthetics have no effect on diastolic (resting) Ca2+ concentrations.129–131 We now turn our attention to the anesthetic actions that may be responsible for the decrease in the cytosolic Ca2+ transient.
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Anesthetic-induced Inhibition of L-type Ca2+ Current and Shortening of the Action Potential
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Studies using the single microelectrode voltage-clamp technique137–139 suggested that volatile anesthetics inhibit L-type Ca2+ channels. Indeed, using the patch-clamp technique, Bosnjak et al.140 showed that halothane, enflurane, and isoflurane reversibly decreased whole-cell Ca2+ current (which is predominantly L-type Ca2+ current) in canine ventricular myocytes. In whole-cell and cell-attached recordings using a similar preparation (rat myocytes), Pancrazio141 confirmed and extended this work. Halothane (0.9 mm) and isoflurane (0.8 mm) decreased the peak whole-cell Ca2+ current by ∼40% and ∼20%, respectively (fig. 8). In cell-attached recordings, the anesthetics decreased both mean open time and open probability without affecting single-channel conductance. The anesthetics also enhanced the slow component of inactivation without affecting the fast component. Inhibition of L-type Ca2+ current would lead to a decrease in SR Ca2+ content (an important determinant of contractility) over subsequent beats.
In addition to exerting a negative inotropic effect, inhibition of L-type Ca2+ current should also manifest as shortening of the action potential. Indeed, Lynch et al.137 found that halothane (>2%) shortened the action potential, measured in guinea pig papillary muscle. Subsequent studies, using enflurane and isoflurane in addition to halothane, have confirmed the observations of Lynch et al.137 that anesthetics shorten the action potential.138,139,142,143 Rithalia et al.144 showed that action potential duration was decreased to a greater extent in myocytes isolated from the endocardium than those isolated from the epicardium of rat heart. These authors speculated that this difference might account for the greater negative inotropic effect of halothane on the subendocardium. At lower halothane concentrations, which did not shorten action potential duration, negative inotropy was still observed by Lynch et al.,137 suggesting that additional actions underlie the negative inotropic actions of volatile anesthetics. In accord with Lynch et al.,137 Harrison et al.132 showed that the negative inotropic effect of halothane on rat ventricular myocytes was similar even when action potential duration was maintained constant by applying voltage clamp.
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Inhibitory and Stimulatory Effects of Anesthetics on K+ Channels
Halothane and isoflurane,145 as well as sevoflurane,146 have been shown to inhibit inwardly rectifying K+ (Kir) channels in guinea pig ventricular myocytes; that is, at potentials positive to the equilibrium potential for K+, the anesthetics increased outward current whereas at more negative potentials inward current was decreased. Transient outward K+ current (Ito), important in the early phase of action potential repolarization, has also been shown to be inhibited by halothane, as well as by isoflurane.147 Moreover, these anesthetics have been reported to inhibit delayed rectifier K+ current (IK)148 and Ca2+-activated K+ (KCa) channels.149 Unlike KATP channels, which are activated primarily under pathologic conditions, Kir channels, Ito, IK and KCa channels play important roles in stabilizing the resting potential or modifying the shape of the action potential under normal conditions.150
Volatile anesthetics have been reported to exert complex effects on sarcolemmal KATP channels. Using inside-out patches excised from rabbit ventricular myocytes, Han et al.151 found that isoflurane decreased the duration of KATP channel burst activity and increased the interburst interval without affecting channel kinetics within a burst. It should be noted that KATP channels characteristically exhibit rundown (decreasing Po as a function of time) and show intermittent burst activity after patch excision.152 These characteristics have been shown to be fully prevented by endogenous molecules such as PIP2 (phosphatidylinositol 4,5-bisphosphate) and long-chain acyl-CoA esters,152 suggesting that burst activity may in fact be restricted to excised patches and, possibly, pathologic conditions.152 Han et al.151 also showed that isoflurane shifted the relation between [ATP] and Po to the left; that is, it decreased the sensitivity of the channel to inhibitory ATP. More recently, Stadnicka and Bosnjak153 reported that isoflurane facilitates KATP channel opening at reduced pH. Hence, under physiologic (and pathologic) conditions isoflurane may facilitate KATP channel activation, which could explain, at least in part, its ability to shorten the action potential duration.
Volatile anesthetics have also been shown to confer ischemic-like preconditioning via putative mitochondrial KATP channels, with downstream signaling mediated by reactive oxygen species.154,155 Cope et al.,156 for example, demonstrated that halothane, enflurane, and isoflurane decreased infarction size by about 50% (compared to control conditions) in rabbit hearts subjected to regional ischemia either in vitro or in situ. In another study, the cardioprotective effect of isoflurane was shown to be blocked by 5-hydroxydecanoate, thereby implicating mitochondrial KATP channels as mediators of volatile anesthetic-induced preconditioning.155 In support of this conclusion, Nakae et al.157 recently reported that isoflurane increases the open probability of mitochondrial KATP channels reconstituted in lipid bilayers. However, there is controversy as to whether mitochondrial KATP channels play a role in preconditioning because the evidence for their involvement rests mainly on pharmacological foundations.158–161
Recently, volatile anesthetics have been shown to activate the two-pore domain K+ channels TASK and TREK,162,163 which may be important targets contributing to cerebral depression. Meuth et al.,164 for example, recently suggested that TASK1 and TASK3 contribute to the activity of thalamocortical relay neurons involved in sleep-wake cycles. TASK and TREK channels, which are weakly expressed in heart compared with the brain, may play a role in modulating resting membrane potential and repolarization, such that these channels could contribute to anesthetic-induced shortening of the action potential. Although the effects of volatile anesthetics on various K+ channels in the heart are unlikely to contribute significantly to the negative inotropy, their effects on the the action potential may contribute to anesthetic-induced arrhythmias.
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Anesthetic Effects on SR Ca2+ Content and Ca2+ Release
In 1990, Herland et al.165 showed that halothane stimulated Ca2+ efflux from the sarcoplasmic reticulum of chemically-skinned cardiac trabeculae. Connelly and Coronado166 confirmed this observation using an alternative approach. After incorporating SR-rich vesicles into artificial lipid bilayers, these authors found that halothane and enflurane, but not isoflurane, increased open probability of the Ca2+-release channel (RyR). In accord with these findings, Lynch and Frazer167 showed that halothane, but not isoflurane, enhanced the binding of [3H]-ryanodine to RYRs (note that ryanodine binds to RYRs with high affinity when channels are in the open state). Consistent with activation of the SR Ca2+-release channel, halothane, but not isoflurane, has been shown to evoke a transient increase in [Ca2+] in resting cardiac trabeculae.129 This transient effect has also been seen in electrically stimulated myocytes. Harrison et al.132 showed that application of halothane, but not isoflurane, transiently potentiated the Ca2+ transients and accompanying contractions of electrically paced myocytes (fig. 7).
Halothane and, to a lesser extent, isoflurane have been reported to decrease the Ca2+ content of the SR of isolated intact myocytes132,133 (but see Hannon and Cody136) and intact cardiac trabeculae,130,131 whereas sevoflurane appears to have no effect.133,136 Moreover, isoflurane and sevoflurane, but not halothane, were found to decrease fractional release, the fraction of the content that is released after stimulation.133,136
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Anesthetic Effects on Sarcolemmal NCX
The sarcolemmal NCX is a potentially important target of volatile anesthetics because stimulation of its Ca2+-efflux mode (forward mode) would diminish the SR Ca2+ load and thereby decrease contractility. In a radioisotope study using rat myocyte suspensions, Haworth and Goknur168 found that halothane, isoflurane, and enflurane dose-dependently inhibited the reverse mode, Na+-dependent 45Ca2+ influx, of the NCX. This action could result in less trigger Ca2+ for CICR (see Part I). Anesthetic sensitivity of the predominant forward mode, Na+-induced Ca2+-efflux, was not tested. In a more recent study, halothane (1–2 MAC) and sevoflurane (1–2 MAC) were also found to inhibit both the forward and reverse modes of the NCX in fluo-3 loaded rat cardiac myocytes.169 On one hand, inhibition of the dominant forward (Ca2+-efflux) mode would be expected to produce positive inotropy whereas, on the other hand, inhibition of the reverse mode (Ca2+-influx) would produce the opposite effect. On balance, the above studies suggest that inhibition of the NCX would have either no net inotropic effect or, if anything, increase inotropy. It is worth noting that volatile anesthetics could exert a positive inotropic effect indirectly by inhibiting the Na+,K+-ATPase,170 which would cause intracellular [Na+] to increase (favoring reverse mode NCX activity).
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Anesthetic Inhibition of the Sarcolemmal and SR Ca2+ Pumps (Ca2+-ATPases)
After inhibiting the NCX with Na+- and Ca2+-free solution, Hannon and Cody136 showed that isoflurane and sevoflurane, but not halothane, decreased the rate of relaxation of caffeine-induced Ca2+ transients in ferret ventricular myocytes. The authors concluded that isoflurane and sevoflurane inhibited the sarcolemmal Ca2+-ATPase. However, inhibitory effects of the anesthetic on the sarco-endoplasmic reticular Ca2+-ATPase isoform in cardiac SR (sarco-endoplasmic reticular Ca2+-ATPase 2a)171 could have accounted, at least in part, for the observed reduction in the rate of Ca2+ extrusion. In line with the interpretation of Hannon and Cody,136 halothane and isoflurane have been reported to decrease surface membrane Ca2+-ATPase activity in erythrocytes172 and neurons.173 In any case, inhibition of the sarcolemmal Ca2+-pump (Ca2+-ATPase) would not be expected to produce a negative inotropic action but rather to produce positive inotropy secondary to facilitated SR Ca2+ loading. On the contrary, inhibitory effects of volatile anesthetics on sarco-endoplasmic reticular Ca2+-ATPase171,174 could contribute to the depletion of SR Ca2+ stores by volatile anesthetics.
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Gap Junctions
Halothane and isoflurane have been shown to uncouple electrically pairs of myocytes, indicating that these agents block gap junctions.175 In accord, Burt and Spray176 showed that halothane (2 mm) decreased gap junction conductance by reducing the number of open channels without affecting unitary conductance. In further work, He and Burt177 have shown that halothane gates gap junctions to the closed state, the extent of which is dependent on anesthetic concentration and the connexin composition of the channel. Heteromeric channels were found to be more sensitive to inhibition by halothane than homomeric channels composed of either connexin 40 or connexin 43. The ability of halothane to induce uncoupling would not inhibit the contractility of individual myocytes, but it may perturb the normal spread of excitation, rendering the heart more prone to arrhythmias.
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Anesthetic Effects on the Contractile Machinery and the pCa-force Relation
In addition to reducing Ca2+ availability, volatile anesthetics may also decrease the responsiveness of the contractile proteins to a given amount of Ca2+. Bosnjak and Kampine123 examined the effects of halothane on [Ca2+] (measured with aequorin) and tension, simultaneously measured in intact papillary muscle. Halothane decreased force proportionately more than peak Ca2+, suggesting that the anesthetic was having a direct inhibitory action at the level of the contractile proteins. In agreement with Bosnjak and Kampine,123 Housmans178 demonstrated that isoflurane depressed force, even when the Ca2+ transient (measured using aequorin) was restored to control concentrations by elevating extracellular [Ca2+].
Fig. 9
Fig. 9
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Many recent studies using various muscle preparations (single myocytes and thin ventricular trabeculae) have established that halothane and other anesthetics do indeed inhibit the Ca2+-responsiveness of the contractile proteins. For example, using thin ventricular trabeculae (diameter <250 μm) loaded with fluo-3, Hanley and Loiselle129 showed that force remained depressed when the cytosolic Ca2+ transient was restored to control concentrations by increasing extracellular [Ca2+] in the presence of halothane or isoflurane (fig. 9). Similar results with halothane and isoflurane were obtained by Jiang and Julian,130,131 who also used rat trabeculae. Furthermore, Davies et al.133 likewise found that halothane and isoflurane, but not sevoflurane, decreased Ca2+-responsiveness of the contractile proteins in fura-2-loaded rat ventricular myocytes. In contrast to Davies et al.,133 Bartunek and Housmans179 found that sevoflurane, in addition to decreasing Ca2+-availability, decreased myofibrillar Ca2+-responsiveness (see also Graham et al.180).
Fig. 10
Fig. 10
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Volatile anesthetics could depress myofibrillar Ca2+-responsiveness by decreasing Ca2+-sensitivity or maximal Ca2+-activated force of the contractile proteins. At least part of the depressive action of halothane and isoflurane is attributable to a reduction in maximal Ca2+-activated force because Hanley and Loiselle129 showed that these agents decreased maximum force when trabeculae were tetanized in the presence of ryanodine and high extracellular [Ca2+] (fig. 10). Whether volatile anesthetics shift the pCa-force relation in “intact” cardiac muscle remains to be elucidated.
Studies using chemically or mechanically skinned cardiac muscle preparations have shed light on the direct effects of volatile anesthetics on the contractile proteins. Halothane, enflurane, and isoflurane have been shown to decrease maximal Ca2+-activated force in detergent-skinned human181 and rat cardiac fibers.182 Herland et al.183 found that high doses of halothane, but not enflurane or isoflurane, decreased maximal Ca2+-activated force in mechanically disrupted or saponin-skinned rat cardiac muscle preparations. When membranes were further disrupted with Triton X-100, maximal Ca2+-activated force was decreased by both halothane and isoflurane but not by enflurane. Using Triton X-100-skinned rat cardiac muscle, Prakash et al.184 found that halothane and sevoflurane, at 1 or 2 MAC, decreased maximal Ca2+-activated force. Hence, the majority of data using skinned cardiac muscle, as well as the study of Hanley and Loiselle129 using intact trabeculae, indicate that volatile anesthetics decrease maximal Ca2+-activated force.
The next question is whether volatile anesthetics decrease the Ca2+-sensitivity (pCa for half-maximal activation) of the contractile proteins. Studies using skinned fibers have produced conflicting results. Murat et al.182 reported that halothane, enflurane, and isoflurane each increased the [Ca2+] for half-maximal activation in skinned cardiac fibers. In accord, Tavernier et al.181 found that halothane and isoflurane, each at 1 MAC, decreased Ca2+-sensitivity of the contractile proteins. However, Herland et al.183 found that the effect of anesthetics on Ca2+-sensitivity depended on the method of skinning employed. When the muscle was mechanically skinned or treated with saponin, sensitivity was increased by the anesthetics, whereas addition of Triton X-100 abolished the sensitizing effects of halothane and isoflurane and reduced the effect of enflurane. Hence, the disparate observed effects of anesthetics on Ca2+-sensitivity of the contractile proteins may reflect differences in technique, including differences in skinning procedure, species, muscle preparation, and anesthetic concentrations. Further studies using intact muscle preparations and graded tetani may help resolve whether volatile anesthetics decrease, increase, or have no effect on Ca2+-sensitivity of the contractile system. It should be noted that force will be reduced at any given [Ca2+] when sensitivity is unchanged but maximal Ca2+-activated force is reduced.
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Anesthetic Effects on Cross-bridge Cycling
Murat et al.185 examined the effects of volatile anesthetics on force and stiffness during rapid length perturbations at controlled levels of contractile activation. Halothane, enflurane and isoflurane each decreased active stiffness, increased the stiffness/force ratio and increased the time constant of force recovery. These findings indicated that the anesthetics decreased the number of force-generating cross-bridges, decreased the force per cross bridge and reduced the rate of actomyosin-ATPase activity. Halothane and isoflurane, as well as sevoflurane, were also found to decrease dynamic stiffness, as well as shortening amplitude, in intact ferret papillary muscles.186 In further work, Hannon et al.,135 using intact papillary muscles and ryanodine-induced tetani, found that isoflurane shifted the relation between [Ca2+] and rate of tension redevelopment toward higher [Ca2+], suggesting that the anesthetic reduced the rate of cross-bridge turnover. Thus, direct inhibitory effects of volatile anesthetics at the level of actin-myosin protein interaction may account for the ability of these agents to decrease maximal Ca2+-activated force.
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Inhibitory Effects of Anesthetics on Mitochondrial Function
Volatile anesthetics have long been known to impair nicotinamide adenine dinucleotide
(NADH) oxidation by mitochondria,187–190 suggesting that these agents may inhibit complex I (NADH:ubiquinone oxidoreductase) of the electron transport chain. Using isolated liver mitochondria, Hall et al.190 showed that halothane inhibited NADH oxidation at concentrations that did not affect succinate oxidation. Consistent with inhibition of NADH oxidation, halothane and isoflurane,129,191,192 as well as sevoflurane,193 have been shown to increase NADH fluorescence in intact cardiac muscle.
Fig. 11
Fig. 11
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Recently, Hanley et al.,194 using heart submitochondrial particles, have shown that halothane, isoflurane, and sevoflurane indeed inhibit the activity of NADH:ubiquinone oxidoreductase (complex I), which accounts for about 40% of the proton pumping capacity of the respiratory chain (fig. 11). Halothane also inhibited, albeit less potently, succinate dehydrogenase, the catalytic component of complex II (fig. 11). At concentrations equivalent to 2 MAC, halothane and isoflurane decreased activity of complex I by ∼20%, whereas sevoflurane decreased activity by ∼10%. Volatile anesthetics are usually administrated in combination with nitrous oxide (N2O), which has itself been reported to inhibit the respiratory chain, albeit at complex IV (cytochrome c oxidase).195,196
Could inhibitory effects on electron transport chain activity account for the negative inotropic action of volatile anesthetics? In 31P nuclear magnetic resonance studies, 1.5% halothane (2 MAC) was shown to not decrease creatine phosphate or ATP concentrations.197,198 Moreover, the observed ∼50% decrease in rate pressure product (an index of cardiac mechanical work) induced by halothane was not accompanied by an increase in the concentrations of Pi (inorganic phosphate) or H+, inhibitors of excitation-contraction coupling and the contractile apparatus,94 indicating that impairment of oxidative metabolism is not the major mechanism by which volatile anesthetics exert negative inotropy. Although effects of volatile anesthetics on mitochondrial function cannot explain the negative inotropy, the inhibition of the respiratory chain (energy supply) will decrease cardiac reserve.194 Inhibition at complex I may explain how volatile anesthetics increase the rate of production of reactive oxygen species, which are thought to mediate anesthetic-induced, ischemic-like preconditioning.154,199
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Conclusion

Although volatile anesthetics have been shown to target multiple sites in heart muscle cells, the sites of action responsible for negative inotropy are predominantly the L-type Ca2+ channels, the SR, and the contractile apparatus. Volatile anesthetics reduce L-type Ca2+ current (the trigger for SR Ca2+ release) and, depending on the agent used, deplete SR Ca2+ content or decrease fractional release of Ca2+ from the SR. These anesthetic actions depress the elevation in cytosolic [Ca2+] after membrane depolarization. This negative inotropic effect of reduced Ca2+-availability is compounded by inhibitory effects of the volatile anesthetics at the level of the contractile apparatus (decreased Ca2+-responsiveness). Volatile anesthetics impair cross-bridge cycling, decrease maximal Ca2+-activated force, and, possibly, shift the [Ca2+]-force relation to higher [Ca2+]. Anesthetic actions on mitochondrial function, K+ channels, the sarcolemmal Ca2+-ATPase, and the NCX probably contribute minimally to the negative inotropy.
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