Gross and microscopic anatomy of the human intrinsic cardiac nervous system

Potential clinical relevance of the 'little brain' on the mammalian heart

It is hypothesized that the heart possesses a nervous system intrinsic to it that represents the final relay station for the co-ordination of regional cardiac indices. This 'little brain' on the heart is comprised of spatially distributed sensory (afferent), interconnecting (local circuit) and motor (adrenergic and cholinergic efferent) neurones that communicate with others in intrathoracic extracardiac ganglia, all under the tonic influence of central neuronal command and circulating catecholamines. Neurones residing from the level of the heart to the insular cortex form temporally dependent reflexes that control overlapping, spatially determined cardiac indices. The emergent properties that most of its components display depend primarily on sensory transduction of the cardiovascular milieu. It is further hypothesized that the stochastic nature of such neuronal interactions represents a stabilizing feature that matches cardiac output to normal corporal blood flow demands. Thus, with regard to cardiac disease states, one must consider not only cardiac myocyte dysfunction but also the fact that components within this neuroaxis may interact abnormally to alter myocyte function. This review emphasizes the stochastic behaviour displayed by most peripheral cardiac neurones, which appears to be a consequence of their predominant cardiac chemosensory inputs, as well as their complex functional interconnectivity. Despite our limited understanding of the whole, current data indicate that the emergent properties displayed by most neurones comprising the cardiac neuroaxis will have to be taken into consideration when contemplating the targeting of its individual components if predictable, long-term therapeutic benefits are to accrue.

Autonomic mechanism to explain complex fractionated atrial electrograms (CFAE)

OBJECTIVE

To simulate complex fractionated atrial electrograms (CFAE) during sustained atrial fibrillation (AF) in experimental animals.

BACKGROUND

The mechanism(s) underlying CFAE has not been fully elucidated.

METHODS

Twenty-two dogs were subjected to a right and/or left thoracotomy. A gauze patch soaked with acetylcholine (ACh) was placed on the right atrial appendage (RAA) to induce sustained AF. During AF, varying concentrations of ACh (1, 10, 100 mM) were "painted" on the RA where electrograms showed regular organized activity. In another six dogs, anterior right ganglionated plexi (ARGP) near the sino-atrial node and inferior right GP (IRGP) at the junction of inferior vena cava and atria were sequentially ablated. In five dogs, ACh was injected into ARGP to induce CFAE.

RESULTS

During sustained AF, local "painting" with ACh 1 mM and 10 mM induced intermittent CFAE in 1 of 11 and 10 of 11 dogs, respectively. With 100 mM ACh, all 11 showed CFAE (two intermittent, nine continuous). In six other dogs, continuous CFAE induced by topical application of 100 mM ACh were markedly attenuated by ARGP + IRGP ablation. In another five of five dogs, ACh injection into ARGP induced a gradient of CFAE with the continuous CFAE always occurring near the ARGP and CFAE also occurring at left pulmonary vein-atrial junctions. During ARGP ablation, AF was terminated in all five dogs immediately after regularization of the rotor-like electrograms or continuous CFAE.

CONCLUSIONS

This study demonstrates an autonomic basis for CFAE formation, suggesting that graded hyperactive states of the autonomic nervous system (ANS) may induce various types of CFAE observed clinically.

Site Localization and Characterization of Pain During Radiofrequency Ablation of the Pulmonary Veins

BACKGROUND

Characteristics of radiofrequency (RF) lesions producing pain with an 8-mm catheter during pulmonary vein (PV) ablation have not been prospectively studied.

METHODS

We studied 46 (30 men, age 56 +/- 10 years) patients with AF who underwent RF ablation of PVs. PV isolation was achieved by using an 8F, 8-mm Biosense ablation catheter (Biosense Webster, Diamond Bar, CA, USA) guided by intracardiac echocardiography (ICE). An electroanatomic map was used to document the location of all RF lesions and the time; PV location and maximum temperature of every lesion were recorded. Location of the esophagus was determined by magnetic resonance imaging prior to the procedure and by both ICE and barium swallows during procedure.

RESULT

A total of 1,448 (33 +/- 12) RF lesions were delivered to 180 veins. Thirty-nine patients (85%) had at least one lesion associated with pain (mean: 8 +/- 5 lesions) during ablation. The RF generator setting during lesions resulting in pain sensation was 48.6 +/- 7.0 Watts and 51.5 +/- 2.9 degrees C. Maximum temperature attained at the time of pain sensation was 45.7 +/- 4.2 degrees C. By logistic regression analysis the left superior PV (OR 1.54, CI 1.06-2.24, LS vs RI, P < 0.05) and left inferior PV (OR 2.74, CI 1.79-4.19, LI vs RI, P < 0.001) location were both positively correlated with the production of pain. The location of lesions associated with pain was not near the esophagus during any of the pain-producing lesions.

CONCLUSION

Pain sensation is relatively common during RF ablation of PVs. There was no correlation between pain and the location of esophagus. Pain was more common during RF ablation of left inferior and left superior PVs.

Evidence-based approach to ablating atrial fibrillation

Catheter ablation of atrial fibrillation (AF) has made considerable advances over the past decade. Although pulmonary vein (PV) isolation has proven to be a reliable curative treatment, especially for paroxysmal AF, it still has several issues to resolve. Because the AF mechanisms are complex and multifactorial, especially in persistent or permanent AF, they cannot be eliminated altogether by PV isolation alone. Beyond PV isolation, several other techniques have shown promise in improving the long-term success. Several recent reports comparing the superiority between AF ablation and antiarrhythmic drug therapy have shown early evidence suggesting that AF ablation warrants consideration as a first-line therapy in selected patients.

Recent insights into the pathophysiology of atrial fibrillation

Although the problem of atrial fibrillation is now widely appreciated, the fundamental mechanisms that lead to arrhythmia onset and persistence have been difficult to elucidate. As a result, available pharmacologic therapies have focused more on modifying ion channel activity than on the underlying mechanisms. Recent studies suggest an important role for alterations in autonomic regulation, neurohormonal activation, and a systemic inflammatory state in the genesis and persistence of atrial fibrillation. The relative contributions of these distinct pathways to atrial fibrillation likely vary from patient to patient, and within a patient, as a function of age. Tailored therapies, together with patient-specific ablative interventions, may increase the success with which atrial fibrillation is treated and minimize the occurrence of life-threatening thromboembolic complications.

Ganglionated plexi modulate extrinsic cardiac autonomic nerve input: effects on sinus rate, atrioventricular conduction, refractoriness, and inducibility of atrial fibrillation

OBJECTIVES

This study sought to systematically investigate the interactions between the extrinsic and intrinsic cardiac autonomic nervous system (ANS) in modulating electrophysiological properties and atrial fibrillation (AF) initiation.

BACKGROUND

Systematic ganglionated plexi (GP) ablation to evaluate the extrinsic and intrinsic cardiac ANS relationship has not been detailed.

METHODS

The following GP were exposed in 28 dogs: anterior right GP (ARGP) near the sinoatrial node, inferior right ganglionated plexi (IRGP) at the junction of the inferior vena cava and atria, and superior left ganglionated plexi (SLGP) near the junction of left superior pulmonary vein and left pulmonary artery. With unilateral vagosympathetic trunk stimulation (0.6 to 8.0 V, 20 Hz, 0.1 ms in duration), sinus rate (SR), and ventricular rate (VR) during AF were compared before and after sequential ablation of SLGP, ARGP, and IRGP.

RESULTS

The SLGP ablation significantly attenuated the SR and VR slowing responses with right or left vagosympathetic trunk stimulation. Subsequent ARGP ablation produced additional effects on SR slowing but not VR slowing. After SLGP + ARGP ablation, IRGP ablation eliminated VR slowing but did not further attenuate SR slowing with vagosympathetic trunk stimulation. Unilateral right and left vagosympathetic trunk stimulation shortened the effective refractory period and increased AF inducibility of atrium and pulmonary vein near the ARGP and SLGP, respectively. The ARGP ablation eliminated ERP shortening and AF inducibility with right vagosympathetic trunk stimulation, whereas SLGP ablation eliminated ERP shortening but not AF inducibility with left vagosympathetic trunk stimulation.

CONCLUSIONS

The GP function as the "integration centers" that modulate the autonomic interactions between the extrinsic and intrinsic cardiac ANS. This interaction is substantially more intricate than previously thought.

Vagal responses induced by endocardial left atrial autonomic ganglion stimulation before and after pulmonary vein antrum isolation for atrial fibrillation

BACKGROUND

Elimination of vagal inputs into the left atrium (LA) may be necessary for successful catheter ablation of atrial fibrillation (AF). These vagal inputs are clustered in autonomic ganglia (AG) that are close to the pulmonary vein antrum (PVA) borders, but whether standard intracardiac echocardiography (ICE)-guided PVA isolation (PVAI) affects these inputs is unknown.

OBJECTIVE

The purpose of this study was to assess whether standard ICE-guided PVAI affects vagal responses induced by endocardial AG stimulation in the LA.

METHODS

Twenty consecutive patients undergoing first-time PVAI (group 1) and 20 consecutive patients undergoing repeat PVAI for AF recurrence (group 2) were enrolled in the study. Before ablation, electrical stimulation (20 Hz, pulse duration 10 ms, voltage range 12-20 V) was performed through an 8-mm-tip ablation catheter. Based on prior data, regions around all four PVA borders were carefully mapped and stimulated to localize AG inputs. A positive stimulated vagal response was defined as atrioventricular (AV) block, asystole, or increase in mean RR interval by >50%. Locations of positive vagal responses were recorded wth biplane fluoroscopy and CARTO. All patients then underwent standard ICE-guided PVAI by an operator blinded to the locations of vagal responses. Stimulation of the AG locations was then repeated postablation.

RESULTS

Patients (age 54 +/- 11 years, 30% female, ejection fraction 54% +/- 7%) had a history of paroxysmal (75%) and persistent (25%) AF. In group 1, vagal responses were induced in all 20 patients around a mean of 3.8 +/- 0.4 PVAs per patient. The most common response was asystole (53%), mean RR slowing >50% (28%), and AV block (20%). Postablation, vagal responses could no longer be induced in all 20 patients. A diminished response was induced (RR slowing <50%) in 2/20 patients around one PVA each. In group 2, vagal responses were not induced in any of the 20 repeat patients. Stimulation capture postablation was confirmed because transient, nonsustained (<30 seconds) AF or atrial flutter was induced in all 40 patients with stimulation, whether vagal responses were induced or not.

CONCLUSIONS

Standard ICE-guided PVAI eliminates vagal responses induced by AG stimulation. Responses are not seen in patients presenting for repeat PVAI, despite clinical recurrence of AF.

Gradients of Atrial Refractoriness and Inducibility of Atrial Fibrillation due to Stimulation of Ganglionated Plexi

INTRODUCTION

The mechanism(s) whereby atrial ectopy induces atrial fibrillation (AF) is still poorly understood.

METHODS AND RESULTS

In 12 dogs, we determined the refractory period (RP) along the right atrium (RA) and right superior pulmonary vein (RSPV), and AF inducibility with and without concurrent stimulation of the anterior right ganglionated plexi (ARGP) at the base of the RSPV. Multielectrode catheters were attached to the RSPV and RA with the distal electrodes close to ARGP. The RP and window of vulnerability (WOV), i.e., the longest S1-S2 minus the shortest S1-S2 at which AF was induced, were measured before and during incremental levels of ARGP stimulation. Mapping of the onset of AF was performed using the EnSite mapping system (St. Jude Medical, St. Paul, MN, USA) positioned in the RA. A single premature depolarization (PD) from the RSPV that did not induce AF without ARGP stimulation could do so with ARGP stimulation. The onset of AF consistently arose at the myocardium subtending the ARGP. With GP stimulation, the average WOV at the RSPV-atrial junction was significantly wider than at the RA appendage (65 +/- 27 vs. 8 +/- 17 msec, P < 0.05) or further along the RSPV sleeve (48 +/- 39 vs. 10 +/- 20 msec, P < 0.05). Even without GP stimulation, high intensity (10-20 mA) premature stimuli delivered at the RA appendage induced AF, originating from atrial tissue subtending the ARGP, presumably due to axonal conduction that activated the ARGP.

CONCLUSION

GP stimulation, subthreshold for atrial excitation, converts isolated PDs into AF-inducing PDs, suggesting that autonomic tone may play a critical role in the initiation of paroxysmal AF.

Autonomic ganglionated plexi: characterization and effect of epicardial microwave ablation in a canine model of vagally induced acute atrial fibrillation

OBJECTIVE

: Autonomic ganglionated plexi (GP) in fat pads near the pulmonary veins may contribute to initiation and maintenance atrial fibrillation (AF). We attempted to localize these plexi in a canine model, and evaluate the efficacy of microwave ablation in eliminating their vagal reflexes.

METHODS

: 8 Mongrel dogs (25-31 kg), underwent cervical vagal trunk stimulation to produce AV nodal block and sustained AF. Sternotomy was performed and the epicardial fat on the posterior left atrium and pulmonary veins was locally stimulated at high-frequency (20 Hz, 3-5 mA). Locations that produced a vagal response were identified and in 7 dogs ablated using the Flex 4 epicardial microwave ablation probe (Guidant Corp) at 65 watts/90 sec. One animal was a control and not ablated. Vagal responses were retested with local stimulation as well as stimulation of the cervical vagal trunks. The presence of AV block and duration of sustained AF was recorded.

RESULTS

: Baseline cervical vagal stimulation produced AV block and AF in all the animals. Local high-frequency stimulation (HFS) elicited vagal responses at the junction of the inferior vena cava and the middle pulmonary vein (IVC-MPV) in 8 animals, the base of the left pulmonary veins/ligament of Marshall (LoM) in 5 animals, and between the upper and lower right pulmonary veins (RPV) in 2 animals. Microwave ablation at the IVC-MPV eliminated the vagal response upon local fat pad HFS. Cervical vagal trunk stimulation yielded less AV block (n = 2) or no AV block (n = 5) after microwave ablation of the IVC-MPV alone (n = 4) or in conjunction with LoM area ablation (n = 3). The average duration of AF during cervical vagal stimulation decreased significantly from baseline (52.7 ± 27.0 sec) versus after fat pad ablation (13.8 ± 20.3 sec, p = 0.004).

CONCLUSIONS

: In a canine model we found the primary epicardial autonomic ganglionated plexi to be at the junction of the IVC-MPV. Epicardial microwave ablation of this GP eliminated the vagal response during local fat pad stimulation; and attenuated or eliminated AV block and induction of sustained AF during cervical vagal trunk stimulation. Epicardial microwave ablation of the ganglionated plexi in epicardial fat pads is feasible and can eliminate vagal reflexes that maybe important in atrial fibrillation.

Autonomic nerves in pulmonary veins

Rapid repetitive activities arising from pulmonary veins may initiate atrial fibrillation. The basis of these rapid repetitive activities remains unclear, but recent evidence suggests that the autonomic nervous system plays an important role in their formation. Pulmonary veins and the adjoining left atrium are highly innervated structures. This review summarizes recent developments in the understanding of the anatomy of autonomic nerves in and around pulmonary veins and their implications for atrial fibrillation.

Occipital artery injections of 5-HT may directly activate the cell bodies of vagal and glossopharyngeal afferent cell bodies in the rat

The primary objective of this study was to determine whether circulating factors gain direct access to and affect the activity of vagal afferent cell bodies in the nodose ganglia and glossopharyngeal afferents cell bodies in the petrosal ganglia, of the rat. We found that the occipital and internal carotid arteries provided the sole blood supply to the nodose ganglia, and that i.v. injections of the tracer, Basic Blue 9, elicited strong cytoplasmic staining in vagal and glossopharyngeal afferent cell bodies that was prevented by prior ligation of the occipital but not the internal carotid arteries. We also found that occipital artery injections of 5-HT elicited pronounced dose-dependent reductions in heart rate and diastolic arterial blood pressure that were (1) virtually abolished after application of the local anesthetic, procaine, to the ipsilateral nodose and petrosal ganglia, (2) markedly attenuated after transection of the ipsilateral vagus between the nodose ganglion and brain and virtually abolished after subsequent transection of the ipsilateral glossopharyngeal nerve between the petrosal ganglion and the brain, (3) augmented after ipsilateral transection of the aortic depressor and carotid sinus nerves, and (4) augmented after transection of all ipsilateral glossopharyngeal and vagal afferent nerves except for vagal cardiopulmonary afferents. These findings suggest that blood-borne 5-HT in the occipital artery gains direct access to and activates the cell bodies of vagal cardiopulmonary afferents of the rat and glossopharyngeal afferents of undetermined modalities.

Atrial fibrillation may be a vascular disease: the role of the pulmonary vein

Recent years have seen an enormous amount of experimental and clinical research into role of the pulmonary veins (PVs) in atrial fibrillation (AF). The PVs contain cardiomyocytes with easily inducible arrhythmogenic activity due to the enhanced automaticity, induction of triggered activity, and genesis of microreentrant circuits. The enhanced automaticity, induced triggered activity, either alone or in combination with the reentrant mechanisms, may play a role in the initiation of PVs AF. Detailed mapping studies suggest that reentry within the PVs is most likely responsible for their arrhythmogenicity. There is no doubt that the PVs represent the most important source of arrhythmogenic activity in patients with paroxysmal AF. In AF patients with risk factors for development of AF, the presence of the pathological situation is important in enhancing the PV arrhythmogenic activity. Coronary sinus or superior vena cava may also be a source of rapid repetitive electrical activity during AF. Thus, AF should be considered a kind of vascular disease. Moreover, in patients with paroxysmal AF originating from the PVs, a wide spectrum of atrial arrhythmias may coexist, including paroxysms of atrial premature, tachycardia, flutter and fibrillation. This kind of arrhythmias should be named as PV atrial arrhythmias. These new views will help understand the mechanism, diagnosis and treatment method for AF.

Interactive atrial neural network: Determining the connections between ganglionated plexi

BACKGROUND

The electrophysiologic functions of the intrinsic cardiac autonomic nervous system (ANS) are not well understood.

OBJECTIVES

The purpose of this study was to investigate the functional interactions between ganglionated plexi within the intrinsic cardiac ANS.

METHODS

The hearts of 21 dogs were exposed via right and/or left thoracotomy to expose the (1) anterior right ganglionated plexi near the caudal end of the sinoatrial node, (2) inferior right ganglionated plexi at the junction of inferior vena cava and atria, and (3) superior left ganglionated plexi near the junction of left superior pulmonary vein and left pulmonary artery. Ganglionated plexi were stimulated at 0.6 to 8.0 V (square waves, 20 Hz, 0.1-ms duration). Sinus rate, AH interval during atrial pacing, and ventricular rate during atrial fibrillation were compared before and after ganglionated plexi stimulation and after their ablation.

RESULTS

Anterior right ganglionated plexi stimulation induced significant AH prolongation and slowing of ventricular rate and sinus rate. When inferior right ganglionated plexi was ablated, slowing of sinus rate by anterior right ganglionated plexi stimulation was unaltered, but inhibition of AV conduction was eliminated. Superior left ganglionated plexi stimulation induced similar effects on sinus and AV nodal function, and sinus rate slowing was markedly attenuated by anterior right ganglionated plexi ablation. Ablation of both anterior right ganglionated plexi and inferior right ganglionated plexi eliminated AV conduction inhibition but not sinus rate slowing by superior left ganglionated plexi stimulation.

CONCLUSION

This study provides functional evidence for the interconnections between ganglionated plexi to modulate sinus and AV nodal function, supporting clinical evidence that interconnections within the intrinsic cardiac ANS are critical elements in identifying the targets for atrial fibrillation ablation.

Selective Atrial Vagal Denervation Guided by Evoked Vagal Reflex to Treat Patients With Paroxysmal Atrial Fibrillation

BACKGROUND

The aim of this study was to evaluate whether selective radiofrequency (RF) catheter ablation of the atrial sites in which high-frequency stimulation induces vagal reflexes prevents paroxysmal atrial fibrillation (AF).

METHODS AND RESULTS

Ten patients with episodes suggestive of vagal-induced paroxysmal AF and no heart disease were selected for percutaneous epicardial and endocardial mapping of the atria to search for sites in which high-frequency transcatheter stimulation (20 Hz,) induced vagal reflexes. A vagal response defined as AV block of > 2 seconds was elicited in 7 of 10 patients (70%) with an average of 5 +/- 2.4 (range, 2 to 9) sites per patient, and RF pulses (21.0 +/- 12.0 per patient) were applied at those sites to eliminate all evoked vagal reflexes. The 3 patients in whom evoked vagal reflexes were not obtained underwent circumferential pulmonary vein ablation with an average of 58.0 +/- 13.9 RF pulses per patient (P = 0.022). Autonomic evaluation was performed before and 48 hours and 3 months after the procedure and was consistent with vagal withdrawal in all patients. Two of the 7 patients who underwent denervation remained asymptomatic without the use of antiarrhythmic medication at a mean follow-up of 8.3 +/- 2.8 months (range, 5 to 15 months); 4 had frequent recurrences and were referred for circumferential pulmonary vein ablation; and 1 had few AF episodes without antiarrhythmic medication. The 3 patients without evoked vagal reflexes who underwent circumferential pulmonary vein ablation remained asymptomatic without antiarrhythmic medication. One patient had acute delayed gastric emptying after atrial vagal denervation.

CONCLUSIONS

RF catheter ablation of selected atrial sites in which high-frequency stimulation induced vagal reflexes may prevent AF recurrences in selected patients with apparently vagal-induced paroxysmal AF.

The neural basis of atrial fibrillation

This review addresses recent basic and clinical studies which suggest that targeting autonomic nerves and ganglia on the heart can result in suppression of atrial fibrillation (AF) with less damage to myocardium than the presently employed procedure which involves extensive pulmonary vein (PV) isolation from the rest of the left atrium.

CLINICAL STUDIES

Clinical electrophysiologists in 1998 discovered that the majority of patients with paroxysmal form of AF, resistant to drugs and cardioversion, had focal, ectopic firing arising from the myocardial sleeves covering the PVs. They developed a strategy which called for inducing radiofrequency lesions which would supposedly isolate the PVs from the atria thereby curing this form of AF. To date this strategy has had limited success (70-85%). A new approach relies on targeting the ganglionated plexi (GP) at the entrances of the PVs. Several clinical reports provide evidence that this new approach can increase the success rate for radiofrequency ablation of paroxysmal AF (91-99%).

BASIC STUDIES

Experimental investigations in animal studies, both in vivo and in vitro, have accumulated evidence for a mechanistic basis for the ablation of GP to terminate paroxysmal AF. Specifically, release of the neurotransmitter, acetylcholine, from these GP causes shortening of atrial and PV sleeve refractoriness. In addition, the concomitant release of adrenergic neurotransmitters mobilizes excess calcium intracellularly leading to early afterdepolarizations and triggered firing particularly in PV cells. We conclude that hyperactivity of these local cardiac GP play a critical role in initiating the paroxysmal form of AF resistant to drugs and cardioversion. Targeting the GP for ablation can substantially increase the success rate for terminating AF in these patients.

Location and variability of epicardiac ganglia in human fetuses

The aim of the study was to determine the morphology of epicardiac ganglia in human fetuses at different stages of their development as these ganglia are considered to be of a pivotal clinical importance. Twenty-one fetal hearts were investigated applying a technique of histochemistry for acetylcholinesterase to visualize the epicardiac neural ganglionated plexus with its subsequent stereoscopic examination on total organs. In all of the examined fetuses, epicardiac neural plexus with numerous ganglia was well recognizable and could be clearly differentiated into seven ganglionated subplexuses, topography and structural organization of which were typical for hearts of adult human. The largest ganglion number comprising 77% of all counted ganglia was identified on the dorsal atrial surface. Fetal epicardiac plexus in gestation period of 15-40 weeks contained 929 +/- 62 ganglia, but ganglion amount did vary substantially from heart to heart. In conclusion, this study implies that the human fetal epicardiac ganglia occupy their definitive location already at gestation period from 15 weeks and their number as well as distribution on heart surface presumably is not age dependent.

Experimental Model Simulating Right Ventricular Outflow Tract Tachycardia: A Novel Technique to Initiate RVOT-VT

BACKGROUND

The mechanism(s) whereby a discrete area of myocardium in the RVOT becomes arrhythmogenic remains unknown.

METHODS

In 13 dogs, a circular catheter was placed in the proximal pulmonary artery (PA) to contact the endovascular circumference of the PA. A 50-msec train of high-frequency stimulation (HFS, 200 Hz), coupled to atrial pacing, was applied at each bipolar pair of the circular catheter. The coupling interval was adjusted so that the 50-msec train occurred during the ventricular refractory period, that is, the QRS complex, in order to prevent stimulation of the myocardial sleeve within the proximal PA.

RESULTS

In all dogs, HFS induced ventricular premature depolarizations and VTs with a left bundle branch block (LBBB) morphology and inferior axis (average 6.8 +/- 1.6 V). Earliest activation was consistently recorded from the proximal PA. Esmolol, a short-acting beta-blocker (1 mg/kg), was administered intravenously in 11 dogs. The inducible ventricular ectopy was abolished in 10 dogs (>12 V, P < 0.05) and the response to HFS was blunted in one dog (10-11 V). After 30 minutes, the response to HFS returned to pre-esmolol levels.

CONCLUSIONS

Stimulation of the sympathetic input to the proximal PA induces ventricular ectopy and VTs exhibiting a left bundle branch block morphology and inferior axis, closely simulating clinical RVOT-VT. Beta-blockade either abolishes or blunts this response, corroborating the sympathetic etiology in this model and in some clinical cases of RVOT tachycardias.

Autonomic Innervation and Segmental Muscular Disconnections at the Human Pulmonary Vein-Atrial Junction

OBJECTIVES

This study sought to examine the muscle connections and autonomic nerve distributions at the human pulmonary vein (PV)-left atrium (LA) junction.

BACKGROUND

One approach to catheter ablation of atrial fibrillation (AF) is to isolate PV muscle sleeves from the LA. Elimination of vagal response further improves success rates.

METHODS

We performed immunohistochemical staining on 192 circumferential venoatrial segments (32 veins) harvested from 8 autopsied human hearts using antibodies to tyrosine hydroxylase (TH) and choline acetyltransferase (ChAT).

RESULTS

Muscular discontinuities of widths 0.1 to 5.5 mm (1.1 +/- 1.0 mm) and abrupt 90 degrees changes in fiber orientation were found in 70 of 192 (36%) and 36 of 192 (19%) of PV-LA junctions, respectively. Although these anisotropic features were more common in the anterosuperior junction (p < 0.01), they were also present around the entire PV-LA junction. Autonomic nerve density was highest in the anterosuperior segments of both superior veins (p < 0.05 versus posteroinferior) and inferior segments of both inferior veins (p < 0.05 vs. superior), highest in the LA within 5 mm of the PV-LA junction (p < 0.01), and higher in the epicardium than endocardium (p < 0.01). Adrenergic and cholinergic nerves were highly co-located at tissue and cellular levels. A significant proportion (30%) of ganglion cells expressed dual adrenocholinergic phenotypes.

CONCLUSIONS

Muscular discontinuities and abrupt fiber orientation changes are present in >50% of PV-LA segments, creating significant substrates for re-entry. Adrenergic and cholinergic nerves have highest densities within 5 mm of the PV-LA junction, but are highly co-located, indicating that it is impossible to selectively target either vagal or sympathetic nerves during ablation procedures.

Structure of peripheral synapses: autonomic ganglia

Final motor neurons in sympathetic and parasympathetic ganglia receive synaptic inputs from preganglionic neurons. Quantitative ultrastructural analyses have shown that the spatial distribution of these synapses is mostly sparse and random. Typically, only about 1%-2% of the neuronal surface is covered with synapses, with the rest of the neuronal surface being closely enclosed by Schwann cell processes. The number of synaptic inputs is correlated with the dendritic complexity of the target neuron, and the total number of synaptic contacts is related to the surface area of the post-synaptic neuron. Overall, most neurons receive fewer than 150 synaptic contacts, with individual preganglionic inputs providing between 10 and 50 synaptic contacts. This variation is probably one determinant of synaptic strength in autonomic ganglia. Many neurons in prevertebral sympathetic ganglia receive additional convergent synaptic inputs from intestinofugal neurons located in the enteric plexuses. The neurons support these additional inputs via larger dendritic arborisations together with a higher overall synaptic density. There is considerable neurochemical heterogeneity in presynaptic boutons. Some synapses apparently lack most of the proteins normally required for fast transmitter release and probably do not take part in conventional ganglionic transmission. Furthermore, most preganglionic boutons in the ganglionic neuropil do not form direct synaptic contacts with any neurons. Nevertheless, these boutons may well contribute to slow transmission processes that need not require conventional synaptic structures.

Diverse Myocardial Extension and Autonomic Innervation on Ligament of Marshall in Humans

INTRODUCTION

The ligament of Marshall (LOM) or the oblique vein of Marshall (VOM) in the left atrium (LA) is one of the origins of nonpulmonary vein ectopies causing atrial fibrillation. The distributions of myocardial bundles (Marshall bundles; MBs) and autonomic nerves adjacent to the LOM have not been completely elucidated.

METHODS AND RESULTS

Twenty-eight human hearts were examined postmortem. The inferolateral LA myocardium was dissected en block and cut perpendicularly to the atrioventricular ring. The specimens were sectioned at 1-mm intervals and stained with hematoxylin and eosin, and Azan-Mallory. In addition, S-100 and tyrosine hydroxylase (TH) were employed for the immunohistochemical analysis of the sympathetic and parasympathetic fibers. In 25 cases, MBs were observed. Although the MBs surrounded the VOM at the coronary sinus (CS) juncture, they gradually diminished in density toward the distal venous branch. The connections of the MBs and LA myocardium were frequently observed in the CS juncture and anterior wall of the left pulmonary vein (PV)-LA junctions. TH-stained sympathetic nerve fibers were densely distributed around the PV-LA junctions. On the other hand, non-TH-stained parasympathetic ganglions were mainly observed at the CS juncture.

CONCLUSIONS

MB-LA connections were mainly observed at the CS juncture and PV-LA junctions. The association between sympathetic nerve fibers and MBs was distinct at the PV-LA junctions. At the CS juncture, the regression of the sympathetic nerve fibers and the increase of parasympathetic ganglions were observed. The diverse arrangement and autonomic innervation of MBs seem to characterize the LOM region in humans.

Feasibility study of endocardial mapping of ganglionated plexuses during catheter ablation of atrial fibrillation

BACKGROUND

Numerous reports have demonstrated an association between autonomic tone and atrial fibrillation (AF). Pulmonary vein (PV) denervation during catheter ablation of AF has been shown to significantly reduce recurrence of AF.

OBJECTIVES

The purpose of this study was to assess the safety and efficacy of high-frequency stimulation at mapping cardiac ganglionated plexuses in patients undergoing catheter ablation of AF.

METHODS

Fourteen patients with a history of symptomatic AF underwent a single transseptal approach and electroanatomic mapping of the left atrium, right atrium, and coronary sinus. Using high-frequency stimulation with patients under general anesthesia (20-50 Hz, 5-15 V, pulse width 10 ms), mapping of ganglionated plexuses was performed. Radiofrequency (RF) ablation was performed during AF guided by complex fractionated atrial electrograms. Lesions were mostly delivered circumferentially in the antral area of the PVs, predominantly over and adjacent to regions of ganglionated plexuses.

RESULTS

There was a mean of 4 +/- 1 (range 2-6) ganglionated plexuses per patient, and a mean total of 3 +/- 1 RF applications were delivered over positive vagal sites. Although a vagal response occurred infrequently during ablation (0.9%), postablation high-frequency stimulation failed to provoke a vagal response in 30 (88%) of 34 previously positive vagal sites that underwent ablation.

CONCLUSION

Ganglionated plexuses can be precisely mapped using high-frequency stimulation and are located predominantly in the path of lesions delivered during ablation of AF. Objective documentation of modification of autonomic tone can be documented in the majority of patients. Future studies are required to determine the specific role of mapping and targeting of ganglionated plexuses in patients undergoing catheter ablation of AF.

Electrical stimulation to identify neural elements on the heart: their role in atrial fibrillation

EXPERIMENTAL STUDIES

Anesthetized dogs were subjected to a right then left thoracotomy. Two modes of electrical stimulation were used to activate ganglionated plexi (GP) on the epicardium of the atria: (1) Near the base of each pulmonary vein (PV), trains of high frequency stimuli (HFS) were coupled to each atrial paced beat so as to fall within the refractory period to achieve nerve stimulation without atrial excitation; and (2) Continuous HFS was applied via plaque electrodes sutured to epicardial fat pads (containing a GP) near the right superior (RS) and left superior (LS) PVs. The chest was then closed. An ablation catheter, inserted percutaneously, was positioned fluoroscopically in the right atrium across from the epicardial plaque electrode near the RSPV. Transeptal puncture was used to place an ablation catheter at the LSPV-left atrial junction. HFS applied to each of the epicardial fat pads induced atrial fibrillation (AF) and also caused high grade AV block due to a strong parasympathetic effect on the AV node. Radiofrequency ablation from the right and left atrial endocardium abolished the vagal response to HFS delivered to the plaque electrodes on the fat pads close to the RSPV and LSPV, respectively.

CLINICAL STUDIES

Sixty (60) patients with paroxysmal or persistent AF underwent PV antrum isolation (27 patients) or PV antrum isolation plus left atrial GP ablation (33 patients). Endocardial HFS at the border of the PV antra near the 4 GPs produced AF and high grade AV block (vagal response) during AF. RFA at these sites abolished the vagal response. Testing in a small number of patients with very short follow-up suggests that adding GP ablation to PV antrum isolation may increase ablation success (absence of AF recurrence) from 70% to 91%.

CONCLUSIONS

These basic and clinical studies suggest that localized cardiac autonomic ganglia (GPs) may play a critical role in the initiation and maintenance of AF.

Experimental model for paroxysmal atrial fibrillation arising at the pulmonary vein-atrial junctions

BACKGROUND

The mechanism(s) by which pulmonary veins (PVs) become ectopically active and subsequently initiate and sustain atrial fibrillation (AF) remains poorly understood.

OBJECTIVES

The purpose of this study was to produce an acute canine model of paroxysmal AF arising from the PVs.

METHODS

In 11 dogs, a thoracotomy was performed and a 26-gauge needle with a polyethylene tube attached was inserted into a fat pad containing autonomic ganglia at the base of the PV. The 11 dogs were divided into two groups: acetylcholine (ACh) 1-10 mM (group I, n = 5) or carbachol (CARB) 1-10 mM (group II, n = 6) injected (0.5 mL) into the fat pad.

RESULTS

Within 2 to 5 minutes after injection of parasympathomimetics into the fat pad, a sequence of heart rate slowing, spontaneous premature depolarizations, and spontaneous AF was observed in four of 11 dogs. In seven dogs, single premature extrastimuli easily induced AF. AF was sustained for an average of 10 minutes (ACh) and 38 minutes (CARB), with the shortest AF cycle length seen at the PV-atrial junction adjacent to the fat pad (AF cycle length 75 +/- 41 ms for ACh and 37 +/- 12 ms for CARB).

CONCLUSION

Acute autonomic remodeling produced by injection of parasympathomimetics into the fat pad resulted in spontaneous or easily induced sustained AF with short AF cycle length; the most rapid firing rate was observed in the PV and atria adjacent to the injected fat pad. These findings resemble paroxysmal AF in patients, suggesting that hyperactive autonomic ganglia may be a critical element in patients exhibiting focal AF arising from the PV.

Development of a multi-channel system for intrinsic cardiac neural recording

Recent clinical evidence suggests that abnormal neural input can contribute to the onset perpetuation of atrial arrhythmias, such that neural elements have become potential targets for ablation. A better understanding of the influence of the cardiac autonomous nervous system is required to improve therapy. We have developed a multi-channel system to record neural activity simultaneously at different intra and pericardiac locations. The paper presents the specific requirements to be met for recording neuronal extracellular potentials in these repertoires of neurons and the solutions that were adopted.

Experimental model of inappropriate sinus tachycardia: initiation and ablation

OBJECTIVE

The purpose of the present study was to develop an experimental model of inappropriate sinus tachycardia (IST) by injecting a catecholamine into a fat pad containing autonomic ganglia (AG) innervating the sinus node (SN).

METHODS

Initial protocols in 3 groups of pentobarbital anesthetized dogs consisted of (1) slowing the heart rate (HR) by electrical stimulation of AG in the fat pad; (2) the effect of intravenous injection of epinephrine (0.1-0.3 mg) on the HR and systolic blood pressure (BP); (3) the response of SN rate to intravenously injected isoproterenol (1 microgm/kg). These studies established a reference for the response to epinephrine injection (mean dose 0.2 +/- 0.9 mg, n = 14) into the fat pad at the base of the right superior pulmonary vein (RSPV). ECG leads, right atrial and His bundle electrograms, BP and core body temperature were continuously monitored.

RESULTS

Epinephrine, injected into the fat pad, caused a significant increase in heart rate (HR, average: 211 +/- 11/min, p < 0.05 compared to control) but little change in systolic BP, 149 +/- 10 mmHg, p = NS (Group I, N = 8). The tachycardia lasted >30 minutes. Ice mapping and P wave morphology showed the tachycardia origin in the SN in 6/8 and in the crista terminalis (CT) in 2. Injection of 0.4 cc of formaldehyde into the FP restored HR (159 +/- 16) toward baseline (154 +/- 18). In Group II (N = 6), the same regimen induced a significant increase in both HR and systolic BP (194 +/- 17/min and 230 +/- 24 mmHg, respectively) compared to control values (143 +/- 23/min, 162 +/- 24 mmHg) which lasted for > 30 minutes. Ice mapping and P wave morphology showed that the pacemaker was in the SN (1), overlying the CT (2), or atrioventricular junction (2). Formaldehyde (0.4 cc) injected into the FP restored both HR and systolic BP toward baseline values (148 +/- 29/min and 152 +/- 24 mmHg, p = NS) and prevented, slowing of the HR by electrical stimulation of the AG; moreover, the same dose of epinephrine injected intravenously increased HR and SBP but only for 2-5 minutes; Isoproterenol (1 microg/kg) injected intravenously induced essentially the same increase in sinus rate after AG ablation as in the control state (194 +/- 15/min vs 193 +/- 23/min, p = NS).

CONCLUSION

Experimental IST is mainly localized in the SN or CT. Ablation of the AG terminates IST without impairing the SN response to an adrenergic challenge.

Innovations in cardiovascular pathology: anatomic and electrophysiologic determinants associated with ablation of atrial arrhythmias

The pathologist is required to evaluate hearts and surgical specimens following innovative therapies to ablate arrhythmias. For the treatment or cure of atrial fibrillation, ablation of the pulmonary vein sleeves and left atrium is increasingly encountered. The recognized contribution of the right atrium, Bachmann's bundle and other sites such as the vein of Marshall and epicardial ganglia has given rise to specific procedures to target these areas. Improved and safe power sources are needed to achieve these goals. Catheters and devices have been developed using different energy types to create therapeutic lesions. The pathologist will encounter different sources of energy and catheter and probe device modifications for surgical and catheter-based endocardial and epicardial therapy. This article reviews the pathology of ablation and the recent innovations in the treatment of atrial arrhythmias.

Effects of Pulmonary Vein Ablation on Regional Atrial Vagal Innervation and Vulnerability to Atrial Fibrillation in Dogs

INTRODUCTION

Pulmonary vein (PV) isolation has proven to be an effective therapy for atrial fibrillation (AF). However, clinical evidence suggests that suppression of AF after PV isolation could not be fully attributed to the interruption of electrical conduction in and out of the PVs. Furthermore, little is known regarding the effects of ablation around the PVs on the atrial electrophysiological properties. We aimed to study the changes in atrial response to vagal stimulation (VS) after PV ablation (PVA).

METHODS

We studied 11 adult mongrel dogs under general anesthesia. Bilateral cervical sympathovagal trunks were decentralized. Propranolol was given to block sympathetic effects. Multipolar catheters were placed into right atrial appendage (RAA), distal and proximal coronary sinus (CSD, CSP), and left atrial free wall (LAFW). PVA was performed via trans-septal approach. Atrial effective refractory period (AERP) and vulnerability window (VW) of AF were measured with and without VS before and after ablation to isolate the PVs.

RESULTS

After ablation, AERP shortening in response to VS significantly decreased in the left atrium (43.64 +/- 21.57 vs 11.82 +/- 9.82 msec, P < 0.001 at LAFW; 50.91 +/- 26.25 vs 11.82 +/- 14.01 msec, P < 0.001 at CSP; 50 +/- 31.94 vs 17.27 +/- 20.54 msec, P < 0.005 at CSD), while the response to VS did not change significantly at RAA (58.18 +/- 28.22 vs 50.91 +/- 22.12 msec, P = 0.245). After ablation, atrial fibrillation VW during VS narrowed (20.63 +/- 11.48 vs 5.63 +/- 8.63 msec, P < 0.03 at LAFW; 26.25 +/- 12.46 vs 5.00 +/- 9.64 msec, P = 0.001 at CSP; 28.75 +/- 18.47 vs 6.88 +/- 7.53 msec, P < 0.02 at CSD, and 33.75 +/- 24.5 vs 16.25 +/- 9.91 msec, P = 0.03 at RAA).

CONCLUSIONS

Ablation around the PV ostia diminishes left atrial response to VS and decreases the atrial VW. The attenuated vagal response after ablation may contribute to the suppression of AF.

Heart rate variability analysis in the assessment of autonomic function in heart failure

Heart rate is not static, but rather changes continuously in response to physical and mental demands. In fact, an invariant heart rate is associated with disease processes such as heart failure. Heart rate variability analysis is a noninvasive technique used to quantify fluctuations in heart rate. In this article, the authors review neural control of heart rate, briefly describe heart rate variability, and summarize research data demonstrating that heart failure is associated with altered heart rate variability. In addition, the authors present evidence that heart failure patients with decreased heart rate variability are at risk for future cardiac events, heart transplantations, and death.

Rapid and Stable Re-Entry Within the Pulmonary Vein as a Mechanism Initiating Paroxysmal Atrial Fibrillation

OBJECTIVES

We investigated the hypothesis that re-entrant pulmonary vein (PV) tachycardias may serve as a mechanism for initiating and sustaining paroxysmal atrial fibrillation (PAF).

BACKGROUND

The mechanisms of rapid repetitive discharges from the PV initiating PAF remain incompletely understood. Pulmonary vein myocardial sleeves appear to provide a favorable substrate for re-entry formation.

METHODS

The electrophysiologic properties of canine PV sleeves were investigated using a combination of high-resolution optical mapping (n = 5) and extracellular bipolar and intracellular microelectrode recordings (n = 56) in a superfused PV preparation.

RESULTS

From the left atrium to distal PV, there was progressive shortening of the action potential (AP) duration, reduction in AP and bipolar electrogram amplitude, and depolarization of resting membrane potentials. Sustained PV tachycardias were induced exclusively in the presence of acetylcholine (10(-7) to 10(-6) mol/l, n = 12). Sustained PV tachycardias were rapid (mean cycle length = 93 +/- 15 ms), regular, and capable of induction, termination, and resetting by single extrastimuli. Re-entry as the mechanism underlying PV tachycardias was confirmed by optical mapping (n = 5). Acetylcholine also reduced the slope of the AP restitution curve and suppressed AP alternans (n = 6). Importantly, PV tachycardias exhibited 1:1 conduction into the atrium at short cycle lengths (<100 ms), emphasizing the potential role of re-entrant PV tachycardia in atrial fibrillation.

CONCLUSIONS

Pulmonary veins provide a favorable substrate for re-entry formation. Heterogeneity of the electrophysiologic properties and marked abbreviation of action potential duration and refractoriness by acetylcholine combine to produce rapid and stable re-entrant PV tachycardias. Elevated parasympathetic tone and re-entrant PV tachycardia may serve as a mechanism underlying the perpetuation of PAF.

Autonomically Induced Conversion of Pulmonary Vein Focal Firing Into Atrial Fibrillation

OBJECTIVES

This study was designed to determine the mechanism(s) whereby focal firing from pulmonary veins (PVs) is converted into atrial fibrillation (AF).

BACKGROUND

The mechanism(s) whereby PV focal firing or even a single PV depolarization is converted into AF is unknown.

METHODS

In 14 anesthetized dogs a right thoracotomy was performed to expose the right superior pulmonary vein (RSPV). An octapolar electrode catheter was sutured alongside the RSPV so that the distal electrode pair was adjacent to the fat pad containing autonomic ganglia (AG) at the veno-left atrial (LA) junction. An acrylic plaque electrode on the fat pad allowed AG stimulation at voltages ranging from 0.6 to 4.0 V. Multi-electrode catheters were sutured to the atria with their distal electrode pairs at the fat pad-atrial junctions. Right superior pulmonary vein focal firing consisted of S(1)-S(1) = 330 ms followed by as many as 11 atrial premature depolarizations (APDs) (A(2)-A(12)) whose coupling interval just exceeded RSPV refractoriness.

RESULTS

Autonomic ganglia stimulation, without atrial excitation, caused a reduction in heart rate (HR): control 142 +/- 15/min, 4.0 V; 75 +/- 30/min, p </=0.05. The fewest number of APDs from the RSPV required to induce AF during AG stimulation was as follows: control (no stimulation) 7 +/- 4, 2.4 V; 3 +/- 1, p </=0.05. In seven dogs, lidocaine (2%, 0.4 cc), a neuronal blocker, was injected into the fat pad, resulting in the loss of AF inducibility in six of seven dogs at the same AG stimulation levels. Three of seven dogs showed AF inducibility only with AG stimulation >/=9.3 V.

CONCLUSIONS

The effects of AG stimulation at the base of the RSPV can provide a substrate for the conversion of PV firing into AF.

Quantitative study of nerves of the human left atrium

OBJECTIVES

To quantify and study the distribution of innervation of the left atrium and the pulmonary veins in humans.

BACKGROUND

Damage to cardiac nerves has been hypothesized as the explanation for successful radiofrequency ablation of atrial fibrillation.

METHODS

From January 2003 to September 2003, histologic and quantitative studies of innervation of the left atrium and the pulmonary veins was performed in 43 consecutive necropsied adult hearts (30 men and 3 women; mean age 45.5 +/- 12.4 years). The left atrium was sectioned in 1-cm slices from left to right, with the plane of section perpendicular to the long axis of the heart. Sections of the pulmonary veins at their ostia and sections 1 cm away of this structure also were obtained. Nerve fiber density was counted manually for each case and expressed as the mean number per slice.

RESULTS

Numerous epicardial nerve fibers and ganglia having distinct patterns of distribution in the left atrium were found. Nerve density was significantly higher at the ostia of the four pulmonary veins than in their distal part (7.1 +/- 2.1 vs 5.2 +/- 1.3 for left upper pulmonary vein; 6.3 +/- 1.5 vs 5.2 +/- 1.7 for right upper pulmonary vein; 7.4 +/- 2 vs 5.9 +/- 2 for left lower pulmonary vein; 6.7 +/- 1.8 vs 3.9 +/- 1.3 for right lower pulmonary vein). The left superior vein was significantly more innervated than the right inferior vein (12.3 +/- 3 vs 10.6 +/- 1.4). Gradients of innervation were found from right to left (9.8 +/- 4.6 vs 18.5 +/- 6.6, P < .05) and from the front to the rear of the atrium (17.2 +/- 6.4 vs 20.7 +/- 6.5, P < .05). The same heterogeneous distribution was observed at the myocardial level but with thinner nerve fibers, making quantification difficult. Only very thin nerve fibers were present in the endocardium.

CONCLUSIONS

The human left atrium exhibits several gradients of innervation at discrete sites. These findings may have clinical implications for radiofrequency ablation of atrial fibrillation.

Pulmonary Veins:. Anatomy, Electrophysiology, Tachycardia, and Fibrillation

Recent years have seen an enormous amount of experimental and clinical research into role of the pulmonary veins (PVs) in atrial fibrillation (AF). Advanced imaging techniques have confirmed the findings of earlier postmortem studies and added further dimension to our knowledge of PV anatomy. Such work is vital for an effective approach to successful ablation of AF. Detailed mapping studies suggest that reentry within the PVs is most likely responsible for their arrhythmogenicity, although focal or triggered activity cannot be excluded. Further work also implicates the posterior left atrium in the genesis of AF. Investigation into the interplay between the PVs and left atrium has led to a reevaluation of the mechanisms underlying AF and suggests that the PVs may play a role in both the initiation and maintenance of this arrhythmia. In order for electrophysiologists to further develop the technical approach to ablation of AF and improve the clinical outcomes, these crucial issues must be resolved.

MHC class II antigen-expressing cells in cardiac ganglia of the rat

Cardiac ganglia develop destructive ganglionitis in chronic Chagas' disease and rheumatic heart disease. This ganglionitis is associated with periganglionic infiltrations and is suspected of developing secondary to epicardial inflammation. If so, it would be expected that cardiac ganglia (1) are equipped with an inventory of immune competent cells allowing the initiation of inflammatory processes, and (2) are not effectively protected from the milieu of the surrounding tissue by metabolically active diffusion barriers. These problems were addressed in specified pathogen-free rats by electron microscopy and immunohistochemistry with markers for dendritic cells, monocytes/macrophages, and perineurial barriers. In contrast to nerve fascicles, cardiac ganglia are only partially enveloped by perineurial cells. Inside the ganglia, ramified cells with major histocompatibility complex class II antigen (reacting with monoclonal antibody OX6) on their surface and exhibiting an ultrastructure typical of dendritic cells are numerous, comprising nearly 5% of all cells within ganglia. The ratio of the number of these cells to that of neurons is 1:2. Cells reacting with monoclonal antibodies ED1 and ED2, markers for monocytes/macrophages, constitute 1.8% and 1.6% of the ganglionic cell population, respectively. Such cells are less frequent in the cervical trunk of the vagus nerve. Thus, the inventory of immune competent cells in rat cardiac ganglia is consistent with the view that the abundance of antigen-presenting cells correlates with the permeability of the barriers providing protection from blood-borne and tissue-borne factors.

Cardiac neuronal hierarchy in health and disease

The cardiac neuronal hierarchy can be represented as a redundant control system made up of spatially distributed cell stations comprising afferent, efferent, and interconnecting neurons. Its peripheral and central neurons are in constant communication with one another such that, for the most part, it behaves as a stochastic control system. Neurons distributed throughout this hierarchy interconnect via specific linkages such that each neuronal cell station is involved in temporally dependent cardio-cardiac reflexes that control overlapping, spatially organized cardiac regions. Its function depends primarily, but not exclusively, on inputs arising from afferent neurons transducing the cardiovascular milieu to directly or indirectly (via interconnecting neurons) modify cardiac motor neurons coordinating regional cardiac behavior. As the function of the whole is greater than that of its individual parts, stable cardiac control occurs most of the time in the absence of direct cause and effect. During altered cardiac status, its redundancy normally represents a stabilizing feature. However, in the presence of regional myocardial ischemia, components within the intrinsic cardiac nervous system undergo pathological change. That, along with any consequent remodeling of the cardiac neuronal hierarchy, alters its spatially and temporally organized reflexes such that populations of neurons, acting in isolation, may destabilize efferent neuronal control of regional cardiac electrical and/or mechanical events.

Parasympathetic control of the heart. I. An interventriculo-septal ganglion is the major source of the vagal intracardiac innervation of the ventricles

The locations, projections, and functions of the intracardiac ganglia are incompletely understood. Immunocytochemical labeling with the general neuronal marker protein gene product 9.5 (PGP 9.5) was used to determine the distribution of intracardiac neurons throughout the cat atria and ventricles. Fluorescence microscopy was used to determine the number of neurons within these ganglia. There are eight regions of the cat heart that contain intracardiac ganglia. The numbers of neurons found within these intracardiac ganglia vary dramatically. The total number of neurons found in the heart (6,274 +/- 1,061) is almost evenly divided between the atria and the ventricles. The largest ganglion is found in the interventricular septum (IVS). Retrogradely labeled fluorescent tracer studies indicated that the vagal intracardiac innervation of the anterior surface of the right ventricle originates predominantly in the IVS ganglion. A cranioventricular (CV) ganglion was retrogradely labeled from the anterior surface of the left ventricle but not from the anterior surface of the right ventricle. These new neuroanatomic data support the prior physiological hypothesis that the CV ganglion in the cat exerts a negative inotropic effect on the left ventricle. A total of three separate intracardiac ganglia innervate the left ventricle, i.e., the CV, IVS, and a second left ventricular (LV2) ganglion. However, the IVS ganglion provides the major source of innervation to both the left and right ventricles. This dual innervation pattern may help to coordinate or segregate vagal effects on left and right ventricular performance.

Parasympathetic control of the heart. II. A novel interganglionic intrinsic cardiac circuit mediates neural control of heart rate

Intracardiac pathways mediating the parasympathetic control of various cardiac functions are incompletely understood. Several intracardiac ganglia have been demonstrated to potently influence cardiac rate [the sinoatrial (SA) ganglion], atrioventricular (AV) conduction (the AV ganglion), or left ventricular contractility (the cranioventricular ganglion). However, there are numerous ganglia found throughout the heart whose functions are poorly characterized. One such ganglion, the posterior atrial (PA) ganglion, is found in a fat pad on the rostral dorsal surface of the right atrium. We have investigated the potential impact of this ganglion on cardiac rate and AV conduction. We report that microinjections of a ganglionic blocker into the PA ganglion significantly attenuates the negative chronotropic effects of vagal stimulation without significantly influencing negative dromotropic effects. Because prior evidence indicates that the PA ganglion does not project to the SA node, we neuroanatomically tested the hypothesis that the PA ganglion mediates its effect on cardiac rate through an interganglionic projection to the SA ganglion. Subsequent to microinjections of the retrograde tracer fast blue into the SA ganglion, >70% of the retrogradely labeled neurons found within five intracardiac ganglia throughout the heart were observed in the PA ganglion. The neuroanatomic data further indicate that intraganglionic neuronal circuits are found within the SA ganglion. The present data support the hypothesis that two interacting cardiac centers, i.e., the SA and PA ganglia, mediate the peripheral parasympathetic control of cardiac rate. These data further support the emerging concept of an intrinsic cardiac nervous system.

Electron microscopic study of intrinsic cardiac ganglia in the adult human

The aim of the present study was to describe in detail the ultrastructure of intrinsic cardiac ganglionic cells in the healthy human as these cells appear to be directly involved in the development of tachycardia, atrioventricular block, ventricular fibrillation, and sudden cardiac death. Tissues examined in this study were obtained from hearts of 10 adult humans of either sex aged 22-80 years at autopsy performed no more than 8 h after death. The examined human intrinsic cardiac nerve cells were in most respects typical autonomic neurons surrounded by a sheath of satellite cells that was either uni- or multilayered. In addition to regular unmyelinated axons, prominent large axon terminals containing lamellated dense bodies, mitochondria and vesicles in the cytoplasm were observed in the ganglion neuropil. Synaptic profiles were more common in the ganglion neuropil than on neuronal somata. According to axon terminal contents, synaptic profiles were of three types. The most common Type 1 synaptic profiles contained a predominance of small clear, with a few larger dense-cored vesicles and mitochondria. Type 2 synaptic profiles, in addition to the same components as in Type 1, had glycogen-like particles. Type 3 vesicle-containing profiles clearly differed from both the previous ones as they were the largest in diameter and included plentifiul large clear pleomorphic or dense-cored vesicles together with small clear and larger dense-cored vesicles, mitochondria, dense and multivesicular bodies. Independently of age of the human, the most frequent neuronal abnormality was an abundant accumulation of inclusions inside of somata and dendrites that, in profile, appeared like circular membranous or fine granular bodies variable in electron density. In addition to inclusions, some neuronal somata and dendrites had strongly swollen mitochondria filled up with granular material in spite of their close association with normal looking ganglionic neurons. Structures resembling an axon growth cone in profile were revealed inside of cardiac ganglia derived from an 80 year old man. In conclusion, the present results provide baseline information on the normal ultrastructure of intracardiac ganglia in healthy humans which may be useful for assessing and interpreting the degree of damage of ganglionic cells both in autonomic and sensory neuropathies of the human heart.

The monkey (Macaca fascicularis) heart neural structures and conducting system: an immunochemical study of selected neural biomarkers and glutamate receptors

The neural markers, protein gene product 9.5 (PGP 9.5), neurofilaments (NF) and glutamate receptors (GluRs) were visualized by immunohistochemistry in the monkey heart. PGP 9.5 showed the greatest affinity for intramural ganglia cells and nerve fibres. Structural components of the conducting system were also stained, particularly the bundle of His, AV node and Purkinje fibres. Anti-NF 200 and NF 160 showed strong, preferential affinity to nerve fibres and ganglia throughout the heart. Further studies concentrated on the presence and the distribution of glutamate receptors: NMDAR 1, GluR 1, GluR 2/3, GluR 5/6/7, mGluR 2/3, and mGluR 5. Positive immunoreactivity of GluRs was evident in nerve terminals within the atrium, myocardium, intramural ganglia and elements of the conducting system. The intensity of the stain varied for each antibody according to the anatomical distribution within neural structures and conducting system. The specificity of immunolabelling was confirmed by absorption studies with each corresponding peptide. There is preferential affinity to and differential distribution of staining with PGP 9.5, NFs and several subtypes of GluRs in the various components of the cardiac conducting system in adult monkeys. The expression of specific neural markers and glutamate receptors common to nerve fibers and ganglia cells is consistent to our previous report in rodents. These expressions suggests that such structures in the heart share common characteristics with a variety of neural tissues and hence are potential targets for neurotoxins. Furthermore, the strong affinity and specific distribution of several subtypes of GluRs in the monkey heart fosters our view that these receptors may be able to influence the physiology and pathophysiology of cardiac rhythm and excitation. Hence as in the brain, the GluRs may be involved in the mediation of excitatory effects in the heart.

Porcine intrinsic cardiac ganglia

The gross, light, and electron microscopic anatomies of the porcine intrinsic cardiac nervous system were investigated in 26 pigs to facilitate functional studies in this model. Gross anatomy: Numerous ganglia and interconnecting nerves (ganglionated plexuses) were found to be concentrated in epicardial fat in five atrial and six ventricular regions. The five atrial ganglionated plexuses identified were (1) the ventral right atrial, (2) the right vena cava-right atrial, (3) the dorsal atrial, (4) the interatrial septal, and (5) the left superior vena cava-left atrial ones. Six ventricular ganglionated plexuses were identified in close proximity to the (1) roots of the aorta and pulmonary artery (craniomedial), extending along the left main coronary artery to the (2) ventral interventricular and (3) circumflex coronary arteries. (4) A ganglionated plexus was identified around the origin of the dorsal interventricular coronary artery, as well as the (5) right main and (6) right marginal coronary arteries. Isolated neurons were identified scattered throughout the cranial interventricular septum. Microscopic anatomy: Approximately 3,000 neuronal somata were estimated to compose this intrinsic cardiac nervous system. Some ganglia contained more than 100 neurons. Neuronal somata had dimensions of roughly 33.1 (short axis) by 46.3 (long axis) microm. Most were multipolar, a small population of unipolar neurons being identified in atrial and ventricular tissues. At the electron microscopic level, asymmetrical axodendritic synapses with small clear, round vesicles were identified, some containing large dense-cored vesicles. In summary, porcine intrinsic cardiac neurons are concentrated in 11 distinct atrial and ventricular ganglionated plexuses. These extensive plexuses, along with fewer scattered neurons, display varied neuronal morphology and synaptology that represent the anatomical substrate for complex information processing within the intrinsic cardiac component of the porcine cardiac neuronal hierarchy. These anatomical data provide a framework for physiological analyses of the porcine intrinsic cardiac nervous system.

Natriuretic peptides in relation to the cardiac innervation and conduction system

During the past two decades, the heart has been known to undergo endocrine action, harbouring peptides with hormonal activities. These, termed "atrial natriuretic peptide (ANP)," "brain natriuretic peptide (BNP)," and "C-type natriuretic peptide (CNP)," are polypeptides mainly produced in the cardiac myocardium, where they are released into the circulation, producing profound hypotensive effects due to their diuretic, natriuretic, and vascular dilatory properties. It is, furthermore, well established that cardiac disorders such as congestive heart failure and different forms of cardiomyopathy are combined with increased expression of ANP and BNP, leading to elevated levels of these peptides in the plasma. Besides the occurrence of natriuretic peptides (NPs) in the ordinary myocardium, the presence of ANP in the cardiac conduction system has been described. There is also evidence of ANP gene expression in nervous tissue such as the nodose ganglion and the superior cervical ganglion of the rat, ganglia known to be involved in the neuronal regulation of the heart. Furthermore, in the mammalian heart, ANP appears to affect the cardiac autonomic nervous system by sympathoinhibitory and vagoexcitatory actions. This article provides an overview of the relationship between the cardiac conduction system, the cardiac innervation and NPs in the mammalian heart and provides data for the concept that ANP is also involved in neuronal cardiac regulation.

Myocardial blood flow after chronic cardiac decentralization in anesthetized dogs: effects of ACE-inhibition

Coronary blood flow regulation was studied in dogs with an intact or chronically decentralized intrinsic cardiac nervous system. We also examined the effect of angiotensin-converting enzyme inhibition (ACEI) on coronary autoregulatory pressure-flow relations and distribution of blood flow since the renin-angiotensin system may play a critical role in vasoregulation. Myocardial oxygen demand was reduced in the chronic decentralized dogs compared to the control dogs. The lower pressure limit of the autoregulatory pressure-flow relation was similar for the control and chronic decentralized dogs (47+/-2 and 44+/-7 mm Hg, respectively; p = NS). After ACEI, the lower pressure limit shifted leftward to 40 mm Hg (p=0.001) in both groups. Concomitant blockade of cyclooxygenase, bradykinin catabolism and nitric oxide synthase had no further effect on the lower pressure limit. Total myocardial blood flow was lower (p=0.001) in the chronic decentralized dogs compared to the control dogs, while transmural distribution of blood flow was preserved in both groups. The results show that even though myocardial oxygen requirements are lower in the chronically decentralized heart compared to controls, coronary autoregulation is maintained at levels observed in normally innervated hearts. The present findings indicate that intrinsic cardiac neurons contribute to coronary autoregulatory control and myocardial blood flow distribution even in the absence of cardiac connections to the central nervous system. In addition, in the chronic decentralized dog, ACEI allows the heart to work at lower coronary perfusion pressures while myocardial blood flow distribution is preserved.

Comparative quantitative study of the intrinsic cardiac ganglia and neurons in the rat, guinea pig, dog and human as revealed by histochemical staining for acetylcholinesterase

This study was conducted to determine the overall number of intrinsic neurons distributed through-out the entire heart, in which most neurons are located inside of intramural ganglia and are hidden to observers. For this reason, we attempted to ascertain: (1) how the number of neurons located inside of intrinsic cardiac ganglion is related to its area, and (2) whether this relationship is dependent on age and species of animals. Hearts of rats, guinea pigs, dogs and humans were used to examine intramural ganglia stained histochemically for acetylcholinesterase (AChE). The number and parameters of neurons located inside of 104 ganglia were estimated in serial sections. Although the revealed intrinsic cardiac ganglia varied extremely in shape and size, two different types were identified: the globular and plain ones. In the plain ganglia, perikarya of side by side situated neurons were always intensely stained for AChE and, being clearly discernible, they could be reliably counted in any plain ganglia on total heart preparations using a contact microscope. Contrarily, neuron somata in the globular ganglia were densely packed above one another and their perikarya were almost indiscernible for the observer. Counting of neurons located inside of globular ganglia was possible in serial sections only. The largest cardiac ganglia were revealed in dogs, in which some globular ganglia containing up to 2000 neurons occupied more than 1 mm2. In spite of evident species-dependent differences with respect to frequency of large ganglia, the majority of intrinsic cardiac ganglia both in humans and animals were comparatively small, involved approximately 100-200 nerve cells and occupied an area ranging from 0.01 to 0.17 mm2. Overall, the number of neurons located inside of globular ganglion was related to its area (correlation coefficient = 0.82). However, the correlation coefficients between the globular ganglion area and its neuron number were unequal in different species (0.92 in guinea pig; 0.80 in dog; 0.72 in human; and 0.44 in rat) as well as dependent on (1) ganglion size (0.8 for ganglia equal to or larger than 0.17 mm2 and 0.6 for ganglia smaller than 0.17 mm2) and (2) age of specimens (respectively, 0.98 for juvenile and 0.87 for adult dogs; 0.71 for infants and 0.54 for aged human). In all examined animals and humans, the mean measurements of neuron perikarya were similar (on average, 23 microm in width, 32 microm in length, and 615 microm2 in area) and differences between them were statistically insignificant. However, neuron perikarya of adult dogs and aged humans were significantly larger than those revealed in the juvenile dogs and infants, respectively. Based on the data of this study, we concluded that the number of intrinsic cardiac neurons may be approximated in the total heart preparation via counting and measuring of intramural ganglia, contours of which are well-discernible following a histochemical reaction for AChE.

Function of human intrinsic cardiac neurons in situ

We sought to determine the behavior of intrinsic cardiac neurons in human subjects undergoing cardiac surgery and to correlate their activity with hemodynamics status. A lead II electrocardiogram, pulmonary artery pressure, and systemic arterial pressure were recorded along with extracellular activity generated by right atrial neurons in 10 patients undergoing coronary artery bypass surgery. Identified neurons generated spontaneously activity that was, for the most part, unrelated to the cardiac cycle. Most neurons were activated by gentle mechanical distortion of ventricular epicardial loci. The activity generated by neurons in each patient increased when arterial pressure increased and decreased when arterial pressure fell. Intrinsic cardiac neurons continued to generate activity during cardioplegia and cardiopulmonary bypass, but at reduced levels. Normal neuronal activity was restored postbypass. It is concluded that human intrinsic cardiac neurons generate spontaneous activity and that many receive inputs from ventricular mechanosensory neurites. The latter may account for the fact that their behavior depends, in part, on cardiac dynamics. They are also sensitive to intravenously administered pharmacological agents. These data also indicate that cardiopulmonary bypass and cardioplegia do not induce residual depression of their function.

Endocardial stimulation of efferent parasympathetic nerves to the atrioventricular node in humans: optimal stimulation sites and the effects of digoxin

The purposes of this study were to identify optimal sites of stimulation of efferent parasympathetic nerve fibers to the human atrioventricular node via an endocardial catheter and to investigate the interaction between digoxin and vagal activation at the end organ.

METHODS

The ventricular rate was measured during atrial fibrillation, prior to and during parasympathetic nerve stimulation, in 8 patients taking digoxin and in 10 controls. High frequency electrical stimuli were delivered via an hexapolar or quadripolar electrode catheter, placed at the posteroseptal right atrium near the atrioventricular node (n=18 patients) or in the coronary sinus (n=12 of 18 patients). In 4 patients, stimulation was repeated after intravenous administration of 1 to 2 mg of atropine.

RESULTS

Nerve stimulation prolonged the R-R interval in all patients. Stimulation close to the posteroseptal right atrium led to maximal atrioventricular nodal slowing. The mean R-R intervals at baseline and during parasympathetic nerve stimulation (60 mA) from the posteroseptal right atrium and the proximal coronary sinus were 581+/-79 ms, 2440+/-466, and 900+/-228 ms respectively (p=0.0001). The response to nerve stimulation was greater in patients taking digoxin than in patients not taking the drug (p=0.02). Junctional rhythm occurred during nerve stimulation in 8/8 patients taking digoxin and 0/10 not taking the drug (p=0.0001). The response to stimulation was eliminated after atropine (p=0.01).

CONCLUSIONS

Parasympathetic nerves to the atrioventricular node were stimulated from the proximal coronary sinus as well as the posteroseptal right atrium. Stimulation at the posteroseptal right atrium resulted in the greatest response, and digoxin enhanced this response. The augmented response suggests that an interaction may exist between parasympathetic stimulation and digoxin at the end organ.

Morphological study of cultured cardiac ganglionic neurons from different postnatal stages of rats

This study sought to establish a culture model of cardiac ganglia (CG) neurons of the Sprague-Dawley (SD) rat which could by used to study the distinct characteristics of CG neurons. After culturing, the morphology and immunocytochemistry of CG neurons obtained on different days after birth were compared. Samples of CG neurons were taken from the posterior atrial wall of rats aged 7, 14, 21 and 40 postnatal days (designated as P7, P14, P21 and P40, respectively). During 3-6 days of culture, the morphological changes of the cultured neurons were monitored using a light microscope. Immunocytochemical staining of the neurofilaments (NF-L, -M and -H) was performed to identify the CG neurons and the changes in morphology. The differences in size of the CG soma of each culture were compared by morphometry. Frozen sections of CG neurons were used as the in vivo control of the above experiments. The results showed that the rate of growth in size of the CG soma was highest in the P7 group, and was slower after weaning (21 days after birth). Cultured neurons were categorized into unipolar-like (Type I), multipolar-like (Type II), and bipolar-like (Type III) based on their morphological characteristics. In NF immuocytochemical staining, there were strong responses to NF-H and NF-M in all cultures, but not to NF-L. More specifically, responses to NF-H were mainly observed in perikaryons and neurites, whereas the responses to NF-M were mainly in perikaryons. The present study has established a culture system for cardiac ganglia neurons of SD rats. Our results show that the intracardiac neurons were still developing in their somata and the processes and that various responses to different antibodies of NF for CG neurons occurred in different postnatal stages in rats.