51
|
Fang P, Wang X, Zhang M, Liu J, Wei Y, Wang J, Yang H, Xie X, Tang S. A sudden increase in heart rate during ablation of the right superior pulmonary venous vestibule is correlated with pain-relief in patients undergoing atrial fibrillation ablation. BMC Cardiovasc Disord 2023; 23:92. [PMID: 36803298 PMCID: PMC9938558 DOI: 10.1186/s12872-023-03121-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 02/14/2023] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND A sudden increase in heart rate (HR) during ablation of the right superior pulmonary venous vestibule (RSPVV) is often detected in patients undergoing circumferential pulmonary vein isolation (CPVI). In our clinical practices, we observed that some patients had few complaints of pain during the procedures under conscious sedation. AIM We aimed to investigate whether there is a correlation between a sudden increase in HR during AF ablation of the RSPVV and pain relief under conscious sedation. METHODS We prospectively enrolled 161 consecutive paroxysmal AF patients who underwent the first ablation from July 1, 2018, to November 30, 2021. Patients were assigned to the R group when they had a sudden increase in HR during the ablation of the RSPVV, and the others were assigned to the NR group. Atrial effective refractory period and HR were measured before and after the procedure. Visual Analogue Scale (VAS) scores, vagal response (VR) during ablation, and the amount of fentanyl used were also documented. RESULTS Eighty-one patients were assigned to the R group, and the remaining 80 were assigned to the NR group. The post-ablation HR (86.3 ± 8.8 vs. 70.0 ± 9.4 b/min; p ≤ 0.001) was higher in the R group than in pre-ablation. Ten patients in the R group had VRs during CPVI, as well as 52 patients in the NR group. The VAS score [2.3 (1.3-3.4) vs. 6.0 (4.4-6.9); p ≤ 0.001)] and the amount of fentanyl used (107 ± 12 vs. 172 ± 26 ug; p ≤ 0.001) were significantly lower in the R group. CONCLUSION A sudden increase in HR during the ablation of the RSPVV was correlated with pain relief in patients undergoing AF ablation under conscious sedation.
Collapse
Affiliation(s)
- Ping Fang
- grid.186775.a0000 0000 9490 772XAnhui Medical University, Hefei, 230000 Anhui China ,grid.452929.10000 0004 8513 0241Department of Cardiology, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, 230000 Anhui China
| | - Xianghai Wang
- grid.452929.10000 0004 8513 0241Department of Cardiology, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, 230000 Anhui China
| | - Meijun Zhang
- grid.452929.10000 0004 8513 0241Department of Intensive Care Medicine, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, 241001 Anhui China
| | - Jichun Liu
- grid.452929.10000 0004 8513 0241Department of Cardiology, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, 230000 Anhui China
| | - Youquan Wei
- grid.452929.10000 0004 8513 0241Department of Cardiology, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, 230000 Anhui China
| | - Jinfeng Wang
- grid.452929.10000 0004 8513 0241Department of Cardiology, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, 230000 Anhui China
| | - Hao Yang
- grid.452929.10000 0004 8513 0241Department of Cardiology, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, 230000 Anhui China
| | - Xiangrong Xie
- grid.452929.10000 0004 8513 0241Department of Cardiology, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, 230000 Anhui China
| | - ShengXing Tang
- Anhui Medical University, Hefei, 230000, Anhui, China. .,Department of Cardiology, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, 230000, Anhui, China.
| |
Collapse
|
52
|
Kim MY, Nesbitt J, Koutsoftidis S, Brook J, Pitcher DS, Cantwell CD, Handa B, Jenkins C, Houston C, Rothery S, Jothidasan A, Perkins J, Bristow P, Linton NWF, Drakakis E, Peters NS, Chowdhury RA, Kanagaratnam P, Ng FS. Immunohistochemical characteristics of local sites that trigger atrial arrhythmias in response to high-frequency stimulation. Europace 2023; 25:726-738. [PMID: 36260428 PMCID: PMC9935019 DOI: 10.1093/europace/euac176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 08/19/2022] [Indexed: 01/26/2023] Open
Abstract
AIMS The response to high frequency stimulation (HFS) is used to locate putative sites of ganglionated plexuses (GPs), which are implicated in triggering atrial fibrillation (AF). To identify topological and immunohistochemical characteristics of presumed GP sites functionally identified by HFS. METHODS AND RESULTS Sixty-three atrial sites were tested with HFS in four Langendorff-perfused porcine hearts. A 3.5 mm tip quadripolar ablation catheter was used to stimulate and deliver HFS to the left and right atrial epicardium, within the local atrial refractory period. Tissue samples from sites triggering atrial ectopy/AF (ET) sites and non-ET sites were stained with choline acetyltransferase (ChAT) and tyrosine hydroxylase (TH), for quantification of parasympathetic and sympathetic nerves, respectively. The average cross-sectional area (CSA) of nerves was also calculated. Histomorphometry of six ET sites (9.5%) identified by HFS evoking at least a single atrial ectopic was compared with non-ET sites. All ET sites contained ChAT-immunoreactive (ChAT-IR) and/or TH-immunoreactive nerves (TH-IR). Nerve density was greater in ET sites compared to non-ET sites (nerves/cm2: 162.3 ± 110.9 vs. 69.65 ± 72.48; P = 0.047). Overall, TH-IR nerves had a larger CSA than ChAT-IR nerves (µm2: 11 196 ± 35 141 vs. 2070 ± 5841; P < 0.0001), but in ET sites, TH-IR nerves were smaller than in non-ET sites (µm2: 6021 ± 14 586 vs. 25 254 ± 61 499; P < 0.001). CONCLUSIONS ET sites identified by HFS contained a higher density of smaller nerves than non-ET sites. The majority of these nerves were within the atrial myocardium. This has important clinical implications for devising an effective therapeutic strategy for targeting autonomic triggers of AF.
Collapse
Affiliation(s)
- Min-young Kim
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK
- Department of Cardiology, Hammersmith Hospital, 72 Du Cane Rd, London, W12 0HS, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
| | - James Nesbitt
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK
- Department of Cardiology, Hammersmith Hospital, 72 Du Cane Rd, London, W12 0HS, UK
| | - Simos Koutsoftidis
- Imperial Centre for Cardiac Engineering, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
| | - Joseph Brook
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
| | - David S Pitcher
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
| | - Chris D Cantwell
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
| | - Balvinder Handa
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK
- Department of Cardiology, Hammersmith Hospital, 72 Du Cane Rd, London, W12 0HS, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
| | - Catherine Jenkins
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
| | - Charles Houston
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
| | - Stephen Rothery
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
- The Facility for Imaging by Light Microscopy, Sir Alexander Fleming Building, South Kensington Campus, Imperial College London, Exhibition Road, London SW7 2AZ, UK
| | - Anand Jothidasan
- Department of Cardiothoracic Surgery, Royal Brompton and Harefield NHS Foundation Trust, 1 Manresa Rd, London SW3 6LR, UK
| | - Justin Perkins
- Royal Veterinary College, 4 Royal College St, London NW1 0TU, UK
| | - Poppy Bristow
- Royal Veterinary College, 4 Royal College St, London NW1 0TU, UK
| | - Nick W F Linton
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK
- Department of Cardiology, Hammersmith Hospital, 72 Du Cane Rd, London, W12 0HS, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
| | - Emm Drakakis
- Imperial Centre for Cardiac Engineering, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
| | - Nicholas S Peters
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK
- Department of Cardiology, Hammersmith Hospital, 72 Du Cane Rd, London, W12 0HS, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
| | - Rasheda A Chowdhury
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
| | - Prapa Kanagaratnam
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK
- Department of Cardiology, Hammersmith Hospital, 72 Du Cane Rd, London, W12 0HS, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
| | - Fu Siong Ng
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK
- Department of Cardiology, Hammersmith Hospital, 72 Du Cane Rd, London, W12 0HS, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
| |
Collapse
|
53
|
Intrinsic Cardiac Neuromodulation in the Management of Atrial Fibrillation- A Potential Missing Link? Life (Basel) 2023; 13:life13020383. [PMID: 36836740 PMCID: PMC9966489 DOI: 10.3390/life13020383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/14/2023] [Accepted: 01/26/2023] [Indexed: 01/31/2023] Open
Abstract
Atrial fibrillation (AF) is the most common supraventricular arrhythmia that is linked with higher cardiovascular morbidity and mortality. Recent evidence has demonstrated that catheter-based pulmonary vein isolation (PVI) is not only a viable alternative but may be superior to antiarrhythmic drug therapy for long-term freedom from symptomatic AF episodes, a reduction in the arrhythmia burden, and healthcare resource utilization with a similar risk of adverse events. The intrinsic cardiac autonomic nervous system (ANS) has a significant influence on the structural and electrical milieu, and imbalances in the ANS may contribute to the arrhythmogenesis of AF in some individuals. There is now increasing scientific and clinical interest in various aspects of neuromodulation of intrinsic cardiac ANS, including mapping techniques, ablation methods, and patient selection. In the present review, we aimed to summarize and critically appraise the currently available evidence for the neuromodulation of intrinsic cardiac ANS in AF.
Collapse
|
54
|
Karatela MF, Fudim M, Mathew JP, Piccini JP. Neuromodulation therapy for atrial fibrillation. Heart Rhythm 2023; 20:100-111. [PMID: 35988908 DOI: 10.1016/j.hrthm.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/07/2022] [Accepted: 08/12/2022] [Indexed: 02/08/2023]
Abstract
Atrial fibrillation has a multifactorial pathophysiology influenced by cardiac autonomic innervation. Both sympathetic and parasympathetic influences are profibrillatory. Innovative therapies targeting the neurocardiac axis include catheter ablation or pharmacologic suppression of ganglionated plexi, renal sympathetic denervation, low-level vagal stimulation, and stellate ganglion blockade. To date, these therapies have variable efficacy. As our understanding of atrial fibrillation and the cardiac nervous system expands, our approach to therapeutic neuromodulation will continue evolving for the benefit of those with AF.
Collapse
Affiliation(s)
- Maham F Karatela
- Cardiac Electrophysiology Section, Duke Heart Center and Department of Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Marat Fudim
- Cardiac Electrophysiology Section, Duke Heart Center and Department of Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Jonathan P Piccini
- Cardiac Electrophysiology Section, Duke Heart Center and Department of Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
| |
Collapse
|
55
|
Ezzeddine FM, Darlington AM, DeSimone CV, Asirvatham SJ. Catheter Ablation of Ventricular Fibrillation. Card Electrophysiol Clin 2022; 14:729-742. [PMID: 36396189 DOI: 10.1016/j.ccep.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Ventricular fibrillation (VF) is a common cause of sudden cardiac death (SCD) and is unfortunately without a cure. Current therapies focus on prevention of SCD, such as implantable cardioverter-defibrillator (ICD) implantation and anti-arrhythmic agents. Significant progress has been made in improving our understanding and ability to target the triggers of VF, via advanced mapping and ablation techniques, as well as with autonomic modulation. However, the critical substrate for VF maintenance remains incompletely defined. In this review, we discuss the evidence behind the basic mechanisms of VF and review the current role of catheter ablation in patients with VF.
Collapse
Affiliation(s)
- Fatima M Ezzeddine
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN, USA
| | - Ashley M Darlington
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN, USA
| | - Christopher V DeSimone
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN, USA
| | - Samuel J Asirvatham
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN, USA.
| |
Collapse
|
56
|
González-Suárez A, O’Brien B, O’Halloran M, Elahi A. Pulsed Electric Field Ablation of Epicardial Autonomic Ganglia: Computer Analysis of Monopolar Electric Field across the Tissues Involved. BIOENGINEERING (BASEL, SWITZERLAND) 2022; 9:bioengineering9120731. [PMID: 36550937 PMCID: PMC9774172 DOI: 10.3390/bioengineering9120731] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 11/09/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Pulsed Electric Field (PEF) ablation has been proposed as a non-thermal energy to treat atrial fibrillation (AF) by epicardial ablation of ganglionated plexi (GP), which are embedded within epicardial fat. Our objective was to study the distribution of the electric field through the involved tissues (fat, GPs, myocardium and blood) during epicardial PEF ablation. METHODS A two-dimensional model was built considering different tissue layers below the ablation device which consists of an irrigated electrode. The 1000 V/cm threshold was used to estimate the 'PEF-zone'. RESULTS The PEF-zone was almost 100% circumscribed in the epicardial fat layer, with very little incidence in the myocardium. The presence of the saline on the epicardial fat causes the PEF-zone to spread laterally around the electrode from ~5 mm to ~15 mm, relatively independently of how embedded the electrode is in the saline layer. For a saline layer well spread over the tissue surface and an electrode fully embedded in the saline layer, the PEF-zone width decreases as the fat layer thickens: from ~15 mm for fat thickness of 1 and 2 mm, down to ~10 mm for fat thickness of 5 mm. The presence of a GP in the center of the fat layer hardly affects the size of the PEF-zone, but significantly alters the distribution of the electric field around the GP, resulting in progressively lower values than in the surrounding adipose tissue as the fat layer thickness increased. CONCLUSIONS Our results suggest how some procedural (irrigation) and anatomical parameters (fat thicknesses and presence of GPs) could be relevant in terms of the size of the tissue area affected by pulsed field ablation.
Collapse
Affiliation(s)
- Ana González-Suárez
- School of Engineering, University of Galway, H91 TK33 Galway, Ireland
- Translational Medical Device Lab, University of Galway, H91 YR71 Galway, Ireland
- Correspondence:
| | - Barry O’Brien
- AtriAN Medical Limited, Unit 204, NUIG Business Innovation Centre, Upper Newcastle, H91 W60E Galway, Ireland
| | - Martin O’Halloran
- School of Engineering, University of Galway, H91 TK33 Galway, Ireland
- Translational Medical Device Lab, University of Galway, H91 YR71 Galway, Ireland
| | - Adnan Elahi
- School of Engineering, University of Galway, H91 TK33 Galway, Ireland
- Translational Medical Device Lab, University of Galway, H91 YR71 Galway, Ireland
| |
Collapse
|
57
|
Kahle AK, Klatt N, Jungen C, Dietenberger A, Kuklik P, Münkler P, Willems S, Nikolaev V, Pauza DH, Scherschel K, Meyer C. Acute Modulation of Left Ventricular Control by Selective Intracardiac Sympathetic Denervation. JACC Clin Electrophysiol 2022; 9:371-384. [PMID: 36752452 DOI: 10.1016/j.jacep.2022.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 10/06/2022] [Accepted: 10/07/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND The sympathetic nervous system plays an integral role in cardiac physiology. Nerve fibers innervating the left ventricle are amenable to transvenous catheter stimulation along the coronary sinus (CS). OBJECTIVES The aim of the present study was to modulate left ventricular control by selective intracardiac sympathetic denervation. METHODS First, the impact of epicardial CS ablation on cardiac electrophysiology was studied in a Langendorff model of decentralized murine hearts (n = 10 each, ablation and control groups). Second, the impact of transvenous, anatomically driven axotomy by catheter-based radiofrequency ablation via the CS was evaluated in healthy sheep (n = 8) before and during stellate ganglion stimulation. RESULTS CS ablation prolonged epicardial ventricular refractory period without (41.8 ± 8.4 ms vs 53.0 ± 13.5 ms; P = 0.049) and with β1-2-adrenergic receptor blockade (47.8 ± 7.8 ms vs 73.1 ± 13.2 ms; P < 0.001) in mice. Supported by neuromorphological studies illustrating a circumferential CS neural network, intracardiac axotomy by catheter ablation via the CS in healthy sheep diminished the blood pressure increase during stellate ganglion stimulation (Δ systolic blood pressure 21.9 ± 10.9 mm Hg vs 10.5 ± 12.0 mm Hg; P = 0.023; Δ diastolic blood pressure 9.0 ± 5.5 mm Hg vs 3.0 ± 3.5 mm Hg; P = 0.039). CONCLUSIONS Transvenous, anatomically driven axotomy targeting nerve fibers along the CS enables acute modulation of left ventricular control by selective intracardiac sympathetic denervation.
Collapse
Affiliation(s)
- Ann-Kathrin Kahle
- Division of Cardiology, Angiology, and Intensive Care Medicine, Cardiac Neuro- and Electrophysiology Research Consortium, EVK Düsseldorf, Düsseldorf, Germany; Institute of Neural and Sensory Physiology, Cardiac Neuro- and Electrophysiology Research Consortium, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany; German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany; Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Niklas Klatt
- German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany; Department of Cardiology, Schön Klinik Neustadt in Holstein, Neustadt in Holstein, Germany
| | - Christiane Jungen
- German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany; Clinic for Cardiology, University Heart and Vascular Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Aaron Dietenberger
- Clinic for Cardiology, University Heart and Vascular Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Pawel Kuklik
- Department of Cardiology and Internal Intensive Care Medicine, Asklepios Hospital St. Georg, Hamburg, Germany
| | - Paula Münkler
- German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany; Clinic for Cardiology, University Heart and Vascular Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Stephan Willems
- German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany; Department of Cardiology and Internal Intensive Care Medicine, Asklepios Hospital St. Georg, Hamburg, Germany
| | - Viacheslav Nikolaev
- German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany; Institute of Experimental Cardiovascular Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dainius H Pauza
- Institute of Anatomy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Katharina Scherschel
- Division of Cardiology, Angiology, and Intensive Care Medicine, Cardiac Neuro- and Electrophysiology Research Consortium, EVK Düsseldorf, Düsseldorf, Germany; Institute of Neural and Sensory Physiology, Cardiac Neuro- and Electrophysiology Research Consortium, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany; German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany
| | - Christian Meyer
- Division of Cardiology, Angiology, and Intensive Care Medicine, Cardiac Neuro- and Electrophysiology Research Consortium, EVK Düsseldorf, Düsseldorf, Germany; Institute of Neural and Sensory Physiology, Cardiac Neuro- and Electrophysiology Research Consortium, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany; German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany.
| |
Collapse
|
58
|
Vandenberk B, Lei LY, Ballantyne B, Vickers D, Liang Z, Sheldon RS, Chew DS, Aksu T, Raj SR, Morillo CA. Cardioneuroablation for vasovagal syncope: A systematic review and meta-analysis. Heart Rhythm 2022; 19:1804-1812. [PMID: 35716859 DOI: 10.1016/j.hrthm.2022.06.017] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 06/09/2022] [Accepted: 06/12/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Cardioneuroablation (CNA) has emerged as promising therapy for patients with refractory vasovagal syncope (VVS). OBJECTIVE The purpose of this study was to provide a freedom from syncope estimate for CNA, including subgroup analysis by method and target of ablation. METHODS A systematic search was performed in MEDLINE and EMBASE according to the PRISMA guidelines until February 14, 2022. Observational studies and clinical trials reporting freedom from syncope were included. Meta-analysis was performed with a random-effects model. RESULTS A total of 465 patients were included across 14 studies (mean age 39.8 ± 4.0 year; 53.5% female). Different techniques were used to guide CNA: 50 patients (10.8%) by mapping fractionated electrograms, 73 (15.7%) with the spectral method, 210 (45.2%) with high-frequency stimulation, 73 (15.7%) with a purely anatomically guided method, and 59 (12.6%) with a combination. The target was biatrial in 168 patients (36.1%), left atrium only in 259 (55.7%), and right atrium only in 38 (8.2%). The freedom from syncope was 91.9% (95% confidence interval [CI] 88.1%-94.6%; I2 = 6.9%; P = .376). CNA limited to right atrial ablation was associated with a significant lower freedom from syncope (81.5%; 95% CI 51.9%-94.7%; P <.0001) vs left atrial ablation only (94.0%; 95% CI 88.6%--6.9%) and biatrial ablation (92.7%; 95% CI 86.8%-96.1%). Subgroup analysis according to the technique used to identify ganglionated plexi did not show any significant difference in freedom from syncope (P = .206). CONCLUSION This meta-analysis suggests a high freedom from syncope after CNA in VVS. Well-designed, double-blind, multicenter, sham-controlled randomized clinical trials are needed to provide evidence for future guidelines.
Collapse
Affiliation(s)
- Bert Vandenberk
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium.
| | - Lucy Y Lei
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brennan Ballantyne
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - David Vickers
- Mozell Core Analysis Lab, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Zhiying Liang
- Mozell Core Analysis Lab, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert S Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Derek S Chew
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Tolga Aksu
- Yeditepe University Hospital, Department of Cardiology, Istanbul, Turkey
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carlos A Morillo
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
59
|
Abstract
INTRODUCTION Cardioneuroablation is increasingly being utilized to improve outcomes in patients with vagally mediated bradyarrhythmias. However, there are still controversial issues in the field including patient selection, safety and efficacy, and procedural end-points. AREAS COVERED In this review, the current role of cardioneuroablation is summarized, and controversial issues related to the modality are discussed. EXPERT OPINION According to small open-label cohort studies, overall freedom from syncope recurrence was higher than 90% after cardioneuroablation in patients with vasovagal syncope (VVS). Use of the electrogram-based strategy or high-frequency stimulation demonstrate similar success rate except in procedures limited to the right atrium. Based on a recently published randomized controlled trial and metanalysis, it may be possible now to make a strong recommendation for cardioneuroablation in patients <40 years of age, and those with the cardioinhibitory or mixed type of VVS who continue to experience frequent and/or burdensome syncope recurrences. Considering patients with VVS are prone to significant placebo/expectation effect, sham-controlled trials may help to quantify the placebo effect. In well-selected patients with functional atrioventricular block and sinus bradycardia, may result in encouraging medium-term outcomes. However, functional bradycardia is identified in a minority of patients presenting with high-grade atrioventricular block or sinus node dysfunction.
Collapse
Affiliation(s)
- Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, Istanbul, Turkey
| | - Asad Khan
- Department of Cardiology, Rush Medical College, Chicago, IL, USA
| | - Henry Huang
- Department of Cardiology, Rush Medical College, Chicago, IL, USA
| |
Collapse
|
60
|
Zerpa Acosta JC, Oliveira de Souza K, Ortencio FA, Cunha Pachon CT, Pachon Mateos EI, Pachon Mateos JC. Carotid sinus syndrome treated by cardioneuroablation: Is sinus node denervation enough? Insights from a syncope recurrence report. HeartRhythm Case Rep 2022; 9:48-52. [PMID: 36685681 PMCID: PMC9845552 DOI: 10.1016/j.hrcr.2022.10.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Juan Carlos Zerpa Acosta
- HCor, São Paulo Heart Hospital, São Paulo, Brazil,Address reprint requests and correspondence: Dr Juan Carlos Zerpa Acosta, 550 Rua Muniz de Sousa, Aclimacao, São Paulo, SP 01534-000, Brazil.
| | | | | | | | | | - Jose Carlos Pachon Mateos
- HCor, São Paulo Heart Hospital, São Paulo, Brazil,USP, São Paulo University, São Paulo, Brazil,IDPC – Sao Paulo Dante Pazzanese Cardiology Institute, São Paulo, Brazil
| |
Collapse
|
61
|
Ascione C, Benabou L, Hocini M, Jaïs P, Haïssaguerre M, Duchateau J. Cardioneuroablation: Don't underestimate the posteromedial left atrial ganglionated plexus. HeartRhythm Case Rep 2022; 9:67-69. [PMID: 36860755 PMCID: PMC9968900 DOI: 10.1016/j.hrcr.2022.10.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Ciro Ascione
- Address reprint requests and correspondence: Dr Ciro Ascione, Division of Cardiac Electrophysiology, CHU de Bordeaux, Av. Magellan, 33604 Pessac, France.
| | | | | | | | | | | |
Collapse
|
62
|
de Asmundis C, Pannone L, Lakkireddy D, Beaver TM, Brodt CR, Lee RJ, Sorgente A, Gauthey A, Monaco C, Overeinder I, Bala G, Almorad A, Ströker E, Sieira J, Brugada P, Chierchia GB, La Meir M, Olshansky B. Targeted Treatment of Inappropriate Sinoatrial Node Tachycardia Based on Electrophysiological and Structural Mechanisms. Am J Cardiol 2022; 183:24-32. [PMID: 36127177 DOI: 10.1016/j.amjcard.2022.07.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/06/2022] [Accepted: 07/08/2022] [Indexed: 11/01/2022]
Abstract
The purpose of this review is to determine the causal mechanisms and treatment of inappropriate sinoatrial tachycardia (IST), defined as a non-physiological elevation in resting heart rate. IST is defined as a resting daytime sinus rate >100 beats/minute and an average 24-hour heart rate >90 beats/minute. Potential causal mechanisms include sympathetic receptor hypersensitivity, blunted parasympathetic tone, or enhanced intrinsic automaticity within the sinoatrial node (SAN) pacemaker-conduction complex. These anomalies may coexist in the same patient. Recent ex-vivo near-infrared transmural optical imaging of the SAN in human and animal hearts provides important insights into the functional and molecular features of this complex structure. In particular, it reveals the existence of preferential sinoatrial conduction pathways that ensure robust SAN activation with electrical conduction. The mechanism of IST is debated because even high-resolution electroanatomical mapping approaches cannot reveal intramural conduction in the 3-dimensional SAN complex. It may be secondary to enhanced automaticity, intranodal re-entry, or sinoatrial conduction pathway re-entry. Different pharmacological approaches can target these mechanisms. Long-acting β blockers in IST can act on both primarily increased automaticity and dysregulated autonomic system. Ivabradine targets sources of increased SAN automaticity. Conventional or hybrid ablation may target all the described abnormalities. This review provides a state-of-the-art overview of putative IST mechanisms. In conclusion, based on current knowledge, pharmacological and ablation approaches for IST, including the novel hybrid SAN sparing ablation, are discussed.
Collapse
Affiliation(s)
- Carlo de Asmundis
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium.
| | - Luigi Pannone
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | | | - Thomas M Beaver
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida
| | | | - Randall J Lee
- Section of Cardiology, University of California at San Francisco, San Francisco, California
| | - Antonio Sorgente
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Anaïs Gauthey
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Cinzia Monaco
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Ingrid Overeinder
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Gezim Bala
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Alexandre Almorad
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Erwin Ströker
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Juan Sieira
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Pedro Brugada
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Gian-Battista Chierchia
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Mark La Meir
- Cardiac Surgery Department, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, Brussels, Belgium
| | - Brian Olshansky
- Division of Cardiology, University of Iowa Hospitals, Iowa City, Iowa
| |
Collapse
|
63
|
Quantitative aspects of nitric oxide production in the heart. Mol Biol Rep 2022; 49:11113-11122. [DOI: 10.1007/s11033-022-07889-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 08/18/2022] [Indexed: 10/14/2022]
|
64
|
Gronda E, Dusi V, D’Elia E, Iacoviello M, Benvenuto E, Vanoli E. Sympathetic activation in heart failure. Eur Heart J Suppl 2022; 24:E4-E11. [PMID: 35991621 PMCID: PMC9385124 DOI: 10.1093/eurheartjsupp/suac030] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Sympathetic activation has been long appreciated exclusively as a fundamental compensatory mechanism of the failing heart and, thus, welcome and to be supported. In the initial clinical phases of heart failure (HF), the sympathetic nervous system overdrive plays a compensatory function aimed at maintaining an adequate cardiac output despite the inotropic dysfunction affecting the myocardium. However, when the sympathetic reflex response is exaggerated it triggers a sequence of unfavourable remodelling processes causing a further contractile deterioration that unleashes major adverse cardiovascular consequences, favouring the HF progression and the occurrence of fatal events. Eventually, the sympathetic nervous system in HF was demonstrated to be a ‘lethality factor’ and thus became a prominent therapeutic target. The existence of an effective highly specialized intracardiac neuronal network immediately rules out the old concept that sympathetic activation in HF is merely the consequence of a drop in cardiac output. When a cardiac damage occurs, such as myocardial ischaemia or a primary myocardial disorder, the adaptive capability of the system may be overcame, leading to excessive sympatho-excitation coupled with attenuation till to abolishment of central parasympathetic drive. Myocardial infarction causes, within a very short time, both a functional and anatomical remodelling with a diffuse up-regulation of nerve growth factor (NGF). The subsequent nerve sprouting signal, facilitated by a rise in the levels of NGF in the left stellate ganglion and in the serum, triggers an increase in cardiac nerve density in both peri-infarct and non-infarcted areas. Finally, NFG production decreases over time, supposedly as an adaptative response to the prolonged exposure to sympathetic overactivity, leading in the end to a reduction in sympathetic nerve density. Accordingly, NGF levels were markedly reduced in patients with severe congestive heart failure. The kidney is the other key player of the sympathetic response to HF as it indeed reacts to under-perfusion and to loop diuretics to preserve filtration at the cost of many pathological consequences on its physiology. This vicious loop ultimately participates to the chronic and disruptive sympathetic overdrive. In conclusion, sympathetic activation is the natural physiological consequence to life stressors but also to any condition that may harm our body. It is the first system of reaction to any potential life-threatening event. However, in any aspect of life over reaction is never effective but, in many instances, is, actually, life threatening. One for all is the case of ischaemia-related ventricular fibrillation which is, strongly facilitated by sympathetic hyperactivity. The take home message? When, in a condition of harm, everybody is yelling failure is just around the corner.
Collapse
Affiliation(s)
- E Gronda
- U.O.C. Nefrologia, Dialisi e Trapianto Renale dell’Adulto, Programma Cardiorenale, Dipartimento di Medicina e Specialità Mediche, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico , Milano , Italy
- Area Cardiorenale Metabolica Associazione nazionale Medici Cardiologi Ospedalieri Italia
| | - V Dusi
- Cardiology Division, Department of Medical Sciences, University of Turin , Torino , Italy
| | - E D’Elia
- Cardiovascular Department, Papa Giovanni XXIII Hospital , Bergamo , Italy
| | - M Iacoviello
- Area Cardiorenale Metabolica Associazione nazionale Medici Cardiologi Ospedalieri Italia
- S.C. Cardiologia, AOU Policlinico Riuniti di Foggia, Dipartimento di Scienze Mediche e Chirurgiche, Università degli Studi , Foggia , Italy
| | - E Benvenuto
- Area Cardiorenale Metabolica Associazione nazionale Medici Cardiologi Ospedalieri Italia
- U.O.C. di Cardiologia-UTIC-Emodinamica PO ‘G. Mazzini’ Teramo , Italy
| | - E Vanoli
- Department of Molecular Medicine, University of Pavia , Pavia , Italy
- Department of Medicine, Cardiology and Rehabilitation Sacra Famiglia Hospital , Erba , Italy
| |
Collapse
|
65
|
Del Monte A, Pannone L, Bisignani A, Osório TG, Iacopino S, Chierchia GB, de Asmundis C. Cryoballoon ablation for atrial fibrillation: Effects on neuromodulation. Front Cardiovasc Med 2022; 9:958316. [PMID: 35966567 PMCID: PMC9366392 DOI: 10.3389/fcvm.2022.958316] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/28/2022] [Indexed: 11/16/2022] Open
Abstract
Pulmonary vein isolation (PVI) represents the mainstay of atrial fibrillation (AF) ablation, and PVI with cryoballoon catheter (CB) ablation (CB-A) has proven to be as effective and safe as radiofrequency ablation (RF-A). Although AF is initiated by triggers arising from the pulmonary veins (PV) and non-PV foci, the intrinsic cardiac nervous system (ICNS) plays a significant role in the induction and maintenance of AF. The ICNS is an epicardial neural system composed of ganglionated plexi (GPs) and a complex network of interconnecting neurons. In the left atrium, the major GPs are located in proximity to the PV-left atrial junction. Vagal reactions have been described as markers of autonomic modulation during PVI with both RF-A and CB-A. The occurrence of neuromodulation during PVI with CB-A may be explained by both the anatomical relationship between the GPs and the PVs and the characteristics of the CB. Due to the CB/PV size mismatch, the CB creates a wide ablation area that extends from the PV ostium toward the antrum, possibly including the GPs. Although targeted GPs ablation, as a supplemental strategy to PVI, has been associated with a better AF outcome in patients undergoing RF-A, the additional clinical benefit of neuromodulation during PVI with CB-A remains a matter of debate. In this review, we provide an overview of the anatomy of the ICNS, the relationship between the ICNS and AF pathophysiology, and the current evidence on the clinical relevance of neuromodulation during PVI with CB-A.
Collapse
Affiliation(s)
- Alvise Del Monte
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Luigi Pannone
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Antonio Bisignani
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Thiago G. Osório
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Saverio Iacopino
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
- Arrhythmology Department, Maria Cecilia Hospital, Cotignola, Italy
| | - Gian-Battista Chierchia
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
- *Correspondence: Gian-Battista Chierchia
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| |
Collapse
|
66
|
Kim MY, Aksu T. Ganglionated plexus ablation and pulmonary vein isolation: the future of AF ablation. J Interv Card Electrophysiol 2022:10.1007/s10840-022-01253-6. [PMID: 35593930 DOI: 10.1007/s10840-022-01253-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Min-Young Kim
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, Istanbul, 34742, Turkey.
| |
Collapse
|
67
|
Cardioneuroablation for vagally mediated bradyarrhythmias: Are we there yet? Heart Rhythm 2022; 19:1253-1254. [PMID: 35597424 DOI: 10.1016/j.hrthm.2022.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 05/16/2022] [Indexed: 11/24/2022]
|
68
|
Lee CC, Chen SY, Lee TM. 17β-Oestradiol facilitates M2 macrophage skewing and ameliorates arrhythmias in ovariectomized female infarcted rats. J Cell Mol Med 2022; 26:3396-3409. [PMID: 35514058 PMCID: PMC9189348 DOI: 10.1111/jcmm.17344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 02/13/2022] [Accepted: 03/25/2022] [Indexed: 11/27/2022] Open
Abstract
Epidemiological studies have suggested a lower incidence of arrhythmia‐induced sudden cardiac death in women than in men. 17β‐oestradiol (E2) has been reported to have a post‐myocardial infarction antiarrhythmic effect, although the mechanisms have yet to be elucidated. We investigated whether E2‐mediated antioxidation regulates macrophage polarization and affects cardiac sympathetic reinnervation in rats after MI. Ovariectomized Wistar rats were randomly assigned to placebo pellets, E2 treatment, or E2 treatment +3‐morpholinosydnonimine (a peroxynitrite generator) and followed for 4 weeks. The infarct sizes were similar among the infarcted groups. At Day 3 after infarction, post‐infarction was associated with increased superoxide levels, which were inhibited by administering E2. E2 significantly increased myocardial IL‐10 levels and the percentage of regulatory M2 macrophages compared with the ovariectomized infarcted alone group as assessed by immunohistochemical staining, Western blot and RT‐PCR. Nerve growth factor colocalized with both M1 and M2 macrophages at the magnitude significantly higher in M1 compared with M2. At Day 28 after infarction, E2 was associated with attenuated myocardial norepinephrine levels and sympathetic hyperinnervation. These effects of E2 were functionally translated in inhibiting fatal arrhythmias. The beneficial effect of E2 on macrophage polarization and sympathetic hyperinnervation was abolished by 3‐morpholinosydnonimine. Our results indicated that E2 polarized macrophages into the M2 phenotype by inhibiting the superoxide pathway, leading to attenuated nerve growth factor‐induced sympathetic hyperinnervation after myocardial infarction.
Collapse
Affiliation(s)
| | - Syue-Yi Chen
- Cardiovascular Institute, An Nan Hospital, China Medical University, Tainan, Taiwan
| | - Tsung-Ming Lee
- Cardiovascular Institute, An Nan Hospital, China Medical University, Tainan, Taiwan.,Department of Medicine, China Medical University, Taichung, Taiwan
| |
Collapse
|
69
|
Do U, Kim M, Cho MS, Nam GB, Choi KJ, Kim J. Effect on sinus cycle length and atrioventricular node function after high-power short-duration versus conventional radiofrequency catheter ablation in paroxysmal atrial fibrillation. INTERNATIONAL JOURNAL OF ARRHYTHMIA 2022. [DOI: 10.1186/s42444-022-00063-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The efficacy and safety of high-power, short-duration (HPSD) radiofrequency catheter ablation for atrial fibrillation (AF) have been demonstrated in several studies. We aimed to evaluate and compare the effects of the conventional method and the HPSD method for AF ablation on the sinus and AV node function in patients with paroxysmal AF.
Methods
The medical records of patients with paroxysmal AF who underwent pulmonary vein isolation (PVI) were retrieved from a prospectively collected AF ablation registry at a large-sized tertiary center. The HPSD group (n = 41) was distinguished from the conventional ablation group (n = 198) in terms of the power (50 W vs. 20–40 W) and duration (6–10 s vs. 20–30 s) of radiofrequency energy delivery during PVI. Peri-procedural changes in cardiac autonomy were assessed in terms of the changes in sinus cycle length (SCL), block cycle length (BCL), and effective refractory period (ERP) of the atrioventricular node (AVN).
Results
The SCL, BCL, and ERP of the AVN at baseline and post-ablation were not significantly different between the conventional ablation group and the HPSD group. Shortening of the SCL, BCL, and ERP of the AVN was observed immediately after AF ablation in both groups. One-year recurrence of AF/atrial flutter (35.1% vs. 20.3%; P = 0.011) and atrial flutter (13.8% vs. 4.7%; P = 0.015) were higher in the HPSD group than in the conventional ablation group.
Conclusion
Both the HPSD and the conventional ablation method resulted in post-ablation vagal modification as evidenced by the shortening of SCL, BCL, and ERP of the AVN. One-year recurrence of atrial flutter and AF/atrial flutter was higher in patients who underwent the HPSD method.
Collapse
|
70
|
Maciejewski C, Peller M, Lodziński P, Koźluk E, Piątkowska A, Rodkiewicz D, Sierakowska I, Roman N, Wiśniewska D, Żółcińska D, Rymaszewska D, Opolski G, Grabowski M, Balsam P. Is Increased Resting Heart Rate after Radiofrequency Pulmonary Vein Isolation a Predictor of Favorable Long-Term Outcome of the Procedure? J Clin Med 2022; 11:jcm11082159. [PMID: 35456252 PMCID: PMC9025177 DOI: 10.3390/jcm11082159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 03/21/2022] [Accepted: 04/04/2022] [Indexed: 12/05/2022] Open
Abstract
Background: Increased resting heart rate (RHR) after pulmonary vein isolation (PVI) for treatment of atrial fibrillation (AF) is a common observation, possibly resulting from ganglionated plexus modification during ablation. Previous trials have suggested that an increase in RHR after ablation might be related to higher efficacy of the procedure. The aim of this study was to determine whether or not higher increase in RHR after radiofrequency (RF) PVI might predict better long-term outcome of the procedure in a real-life cohort of patients in whom index ablation for paroxysmal AF was performed. Material and methods: The health records of patients who underwent index point-by-point or drag lesion RF PVI for paroxysmal AF in our department between January 2014 and November 2018 were analyzed. Resting heart rate (RHR) was determined from 12-lead ECG recorded prior to the ablation and before discharge to evaluate changes in RHR after PVI. Only patients in sinus rhythm before the procedure and at discharge were included in the analysis. Telephone follow-up was collected for evaluation of arrhythmia recurrence status. Results: A total of 146 patients who underwent PVI for paroxysmal AF were included. Mean follow-up time was 3.5 years. RHR increased from 64 [58.5−70], prior to procedure, to 72 [64.25−80] bpm at discharge (p < 0.001). Higher increase in RHR was not protective from arrhythmia recurrence in long-term observation in both univariable HR = 1.001 (CI 0.99−1.017, p = 0.857) and multivariable analyses HR = 1.001 (CI 0.99−1.02, p = 0.84). Conclusions: RHR after PVI increased in comparison to baseline in our cohort. However, we did not observe higher increase in RHR to be associated with more favorable long-term effectiveness of the procedure.
Collapse
|
71
|
Kharbanda RK, van der Does WFB, van Staveren LN, Taverne YJHJ, Bogers AJJC, de Groot NMS. Vagus Nerve Stimulation and Atrial Fibrillation: Revealing the Paradox. Neuromodulation 2022; 25:356-365. [PMID: 35190246 DOI: 10.1016/j.neurom.2022.01.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 12/28/2021] [Accepted: 01/04/2022] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVE The cardiac autonomic nervous system (CANS) plays an important role in the pathophysiology of atrial fibrillation (AF). Cardiovascular disease can cause an imbalance within the CANS, which may contribute to the initiation and maintenance of AF. Increased understanding of neuromodulation of the CANS has resulted in novel emerging therapies to treat cardiac arrhythmias by targeting different circuits of the CANS. Regarding AF, neuromodulation therapies targeting the vagus nerve have yielded promising outcomes. However, targeting the vagus nerve can be both pro-arrhythmogenic and anti-arrhythmogenic. Currently, these opposing effects of vagus nerve stimulation (VNS) have not been clearly described. The aim of this review is therefore to discuss both pro-arrhythmogenic and anti-arrhythmogenic effects of VNS and recent advances in clinical practice and to provide future perspectives for VNS to treat AF. MATERIALS AND METHODS A comprehensive review of current literature on VNS and its pro-arrhythmogenic and anti-arrhythmogenic effects on atrial tissue was performed. Both experimental and clinical studies are reviewed and discussed separately. RESULTS VNS exhibits both pro-arrhythmogenic and anti-arrhythmogenic effects. The anatomical site and stimulation settings during VNS play a crucial role in determining its effect on cardiac electrophysiology. Since the last decade, there is accumulating evidence from experimental studies and randomized clinical studies that low-level VNS (LLVNS), below the bradycardia threshold, is an effective treatment for AF. CONCLUSION LLVNS is a promising novel therapeutic modality to treat AF and further research will further elucidate the underlying anti-arrhythmogenic mechanisms, optimal stimulation settings, and site to apply LLVNS.
Collapse
Affiliation(s)
- Rohit K Kharbanda
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | | | - Yannick J H J Taverne
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | | |
Collapse
|
72
|
Aksu T, Gupta D, D'Avila A, Morillo CA. Cardioneuroablation for Vasovagal Syncope and Atrioventricular Block: A Step-by-Step Guide. J Cardiovasc Electrophysiol 2022; 33:2205-2212. [PMID: 35362165 DOI: 10.1111/jce.15480] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/28/2022] [Accepted: 03/30/2022] [Indexed: 11/29/2022]
Abstract
Catheter based cardioneuroablation is increasingly being utilized to improve outcomes in patients with vasovagal syncope and atrioventricular block due to vagal hyperactivity. There is now increasing convergence amongst enthusiasts on its various aspects, including patient selection, technical steps, and procedural end-points. This pragmatic review aims to take the reader through a step-by-step approach to cardioneuroablation: we begin with a brief overview of the anatomy of intrinsic cardiac autonomic nervous system, before focusing on the indications, pre- and post-procedure management, necessary equipment, and its potential limitations. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Tolga Aksu
- Yeditepe University Hospital, Department of Cardiology, Istanbul, Turkey
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Andre D'Avila
- Department of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Carlos A Morillo
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
73
|
Kuniewicz M, Karkowski G, Gosnell M, Goncerz G, Badacz R, Rajs T, Legutko J. Anatomical and electrophysiological localization of ganglionated plexi using high-density 3D CARTO mapping system. TRANSLATIONAL RESEARCH IN ANATOMY 2022. [DOI: 10.1016/j.tria.2022.100202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
74
|
Intrinsic cardiac neurons of the adult pigs: chemical types, abundance, parameters and distribution within ganglionated plexus. Ann Anat 2022; 243:151935. [DOI: 10.1016/j.aanat.2022.151935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/04/2022] [Accepted: 03/09/2022] [Indexed: 11/18/2022]
|
75
|
Brain-heart communication in health and diseases. Brain Res Bull 2022; 183:27-37. [PMID: 35217133 DOI: 10.1016/j.brainresbull.2022.02.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/09/2022] [Accepted: 02/16/2022] [Indexed: 12/19/2022]
Abstract
Tight connections between the brain and heart have attracted a considerable amount of attention. This review focuses on the anatomical (extrinsic cardiac autonomic nervous system and intrinsic cardiac autonomic nervous system) and functional (neuroendocrine-heart axis and neuroimmune-heart axis) connections between the brain and heart, the linkage between central nervous system diseases and cardiovascular diseases, the harm of sympathetic hyperactivity to the heart, and current neuromodulation therapies. Depression is a comorbidity of cardiovascular diseases, and the two are causally related. This review summarizes the mechanisms and treatment of depression and cardiovascular diseases, providing theoretical evidence for basic research and clinical studies to improve treatment options.
Collapse
|
76
|
Stress-related dysautonomias and neurocardiology-based treatment approaches. Auton Neurosci 2022; 239:102944. [DOI: 10.1016/j.autneu.2022.102944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 10/13/2021] [Accepted: 01/16/2022] [Indexed: 11/21/2022]
|
77
|
Kay MW, Jain V, Panjrath G, Mendelowitz D. Targeting Parasympathetic Activity to Improve Autonomic Tone and Clinical Outcomes. Physiology (Bethesda) 2022; 37:39-45. [PMID: 34486396 PMCID: PMC8742722 DOI: 10.1152/physiol.00023.2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
In this review we will briefly summarize the evidence that autonomic imbalance, more specifically reduced parasympathetic activity to the heart, generates and/or maintains many cardiorespiratory diseases and will discuss mechanisms and sites, from myocytes to the brain, that are potential translational targets for restoring parasympathetic activity and improving cardiorespiratory health.
Collapse
Affiliation(s)
- Matthew W. Kay
- 1Department of Biomedical Engineering, George Washington University, Washington, District of Columbia
| | - Vivek Jain
- 2Division of Pulmonary Medicine, Department of Medicine, George Washington University, Washington, District of Columbia
| | - Gurusher Panjrath
- 3Division of Cardiology, Department of Medicine, George Washington University, Washington, District of Columbia
| | - David Mendelowitz
- 4Department of Pharmacology and Physiology, George Washington University, Washington, District of Columbia
| |
Collapse
|
78
|
Aksu T, Baysal E, Lakkireddy D, Yalin K, Gopinathannair R. Comparison of Fragmented Electrogram Based Strategy and High Frequency Stimulation for Detection of Ganglionated Plexi. J Atr Fibrillation 2021; 13:2440. [PMID: 34950325 DOI: 10.4022/jafib.2440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 07/14/2020] [Accepted: 07/28/2020] [Indexed: 11/10/2022]
Abstract
Ganglionated plexus (GP) ablation is an emerging technique in patients with cardioinhibitory vasovagal syncope and vagally mediated atrial fibrillation. Localization of GPs can be impacted by the technique used. A reproducible methodology for GP detection is needed to account for individual variations during electrophysiologic study. In this article, we aim to compare and contrast high-frequency stimulation vs. a fragmented electrogram guided strategy for GP localization.
Collapse
Affiliation(s)
- Tolga Aksu
- University of Health Sciences, Kocaeli Derince Training and Research Hospital, Department of Cardiology, Kocaeli, Turkey
| | - Erkan Baysal
- University of Health Sciences, Gazi Yaşargil Training and Research Hospital, Department of Cardiology, Diyarbakır, Turkey
| | | | - Kivanc Yalin
- Istanbul University-Cerrahpasa, Faculty of Medicine, Department of Cardiology, Istanbul, Turkey
| | | |
Collapse
|
79
|
Lemery R. Programmed Electrical (Nerve) Stimulation and Extensive LA Denervation in Patients with Paroxysmal Atrial Fibrillation. Heart Rhythm 2021; 19:525-526. [PMID: 34958939 DOI: 10.1016/j.hrthm.2021.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 12/23/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Robert Lemery
- AZ Heart Rhythm Center and St-Joseph Hospital, Dignity Health, Phoenix, Arizona.
| |
Collapse
|
80
|
Peters DC, Lamy J, Sinusas AJ, Baldassarre LA. Left atrial evaluation by cardiovascular magnetic resonance: sensitive and unique biomarkers. Eur Heart J Cardiovasc Imaging 2021; 23:14-30. [PMID: 34718484 DOI: 10.1093/ehjci/jeab221] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/12/2021] [Indexed: 12/12/2022] Open
Abstract
Left atrial (LA) imaging is still not routinely used for diagnosis and risk stratification, although recent studies have emphasized its importance as an imaging biomarker. Cardiovascular magnetic resonance is able to evaluate LA structure and function, metrics that serve as early indicators of disease, and provide prognostic information, e.g. regarding diastolic dysfunction, and atrial fibrillation (AF). MR angiography defines atrial anatomy, useful for planning ablation procedures, and also for characterizing atrial shapes and sizes that might predict cardiovascular events, e.g. stroke. Long-axis cine images can be evaluated to define minimum, maximum, and pre-atrial contraction LA volumes, and ejection fractions (EFs). More modern feature tracking of these cine images provides longitudinal LA strain through the cardiac cycle, and strain rates. Strain may be a more sensitive marker than EF and can predict post-operative AF, AF recurrence after ablation, outcomes in hypertrophic cardiomyopathy, stratification of diastolic dysfunction, and strain correlates with atrial fibrosis. Using high-resolution late gadolinium enhancement (LGE), the extent of fibrosis in the LA can be estimated and post-ablation scar can be evaluated. The LA LGE method is widely available, its reproducibility is good, and validations with voltage-mapping exist, although further scan-rescan studies are needed, and consensus regarding atrial segmentation is lacking. Using LGE, scar patterns after ablation in AF subjects can be reproducibly defined. Evaluation of 'pre-existent' atrial fibrosis may have roles in predicting AF recurrence after ablation, predicting new-onset AF and diastolic dysfunction in patients without AF. LA imaging biomarkers are ready to enter into diagnostic clinical practice.
Collapse
Affiliation(s)
- Dana C Peters
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Jérôme Lamy
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Albert J Sinusas
- Department of Cardiology, Yale School of Medicine, New Haven, CT, USA
| | | |
Collapse
|
81
|
Vassallo F, Silva ED, Meigre LL, Cunha C, Serpa E, Simões Jr A, Carloni H, Volponi C. Initial Experience with Fractionation Mapping in the Identification of Vagal Ganglionated Plexus During Cardioneuroablation. JOURNAL OF CARDIAC ARRHYTHMIAS 2021. [DOI: 10.24207/jca.v34i3.3461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
This is a series case report of five symptomatic patients presented with diagnosis of sinus bradycardia, first and second degrees atrioventricular (AV) blocks, that were referred to pacemaker implantation. During the screening, a functional cause for the bradycardia and AV blocks were documented by treadmill stress test, 24-hour Holter monitoring and atropine test. After the confirmation of the diagnosis, patients were submitted to cardioneuroablation on an anatomical basis supported by a tridimensional electroanatomical fractionation mapping software. The technique and the acute and short-term results of the cardioneuroablation are described.
Collapse
|
82
|
Fang P, Wang J, Wei Y, Wang X, Yang H, Zhang M. Vagal response during circumferential pulmonary vein isolation decreases the recurrence of atrial fibrillation in the short-term in patients with paroxysmal atrial fibrillation: A prospective, observational study. J Electrocardiol 2021; 69:145-150. [PMID: 34763218 DOI: 10.1016/j.jelectrocard.2021.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 06/02/2021] [Accepted: 10/20/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Vagal responses (VRs) are often seen in patients undergoing circumferential pulmonary vein isolation (CPVI). The possible mechanism of VR is that CPVI creates a coincidental modification of the cardiac ganglionated plexi (GP). AIM To investigate whether the presence of VR during CPVI impacts post-ablation recurrence in patients with paroxysmal atrial fibrillation (AF). METHODS A total of 112 consecutive patients with symptomatic paroxysmal AF who underwent CPVI for the first time from October 1, 2017 to April 30, 2019 were prospectively enrolled, of which two were lost the follow-up. Patients were divided into two groups based on whether VRs were experienced during CPVI. Electrophysiological parameters, including atrial effective refractory period (AERP) and mean heart rate (MHR), were measured before and post-ablation. The patients were then followed up for 12 months. RESULTS The 71 patients who had experienced VRs during CPVI were assigned to group B, and the remaing 39 patients who did not experience VR during CPVI were assigned to group A. The MHR (79.6 ± 8.3 vs 70.4 ± 7.8 b/min; p ≤ 0.001) was significantly higher; and the AERP (244 ± 22 vs 215 ± 27 ms; p ≤ 0.001) was prolonged in group B compared to respective pre-ablation values. There were no significant changes in the MHR (69.5 ± 7.9 vs 69.7 ± 8.7 b/min; p = 0.541) and AERP (224 ± 28 vs 225 ± 33 ms; p = 0.542) in group A. During the first four months of follow-up after ablation, the MHR gradually slowed down to pre-procedural levels in group B. The recurrence of AF (6/71 vs 7/39; p = 0.023) significantly decreased in group B relative to group A during the first 6 months after ablation, but there was no significant difference (14/71 vs 9/39; p = 0.598) at the end of the 12-month follow-up period. CONCLUSION Patients with paroxysmal AF who develop VRs during CPVI might have a decreased recurrence of AF and accelerated MHR in the short-term.
Collapse
Affiliation(s)
- Ping Fang
- Department of Cardiology, The First Affifiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, Anhui 241001, China.
| | - Jinfeng Wang
- Department of Cardiology, The First Affifiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, Anhui 241001, China
| | - Youquan Wei
- Department of Cardiology, The First Affifiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, Anhui 241001, China
| | - Xianghai Wang
- Department of Cardiology, The First Affifiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, Anhui 241001, China
| | - Hao Yang
- Department of Cardiology, The First Affifiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, Anhui 241001, China
| | - Meijun Zhang
- Department of Intensive Care Medicine, The First Affifiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, Anhui 241001, China.
| |
Collapse
|
83
|
Nishida T, Takitsume A, Sugiura J, Keshi A, Kanaoka K, Hirai K, Yano H, Hashimoto Y, Ueda T, Nakagawa H, Onoue K, Soeda T, Watanabe M, Kawakami R, Saito Y. Catheter ablation of ganglionated plexi in patients with adenosine triphosphate-induced atrial fibrillation after pulmonary vein isolation. Heart Vessels 2021; 37:854-866. [PMID: 34741632 DOI: 10.1007/s00380-021-01979-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 10/22/2021] [Indexed: 11/24/2022]
Abstract
Intravenous ATP may induce atrial fibrillation (AF). ATP shares similar receptor-effector coupling systems with acetylcholine. However, the association between an ATP injection and the hyperactivity of the intrinsic cardiac autonomic nervous system, known as ganglionated plexi (GPs), is not well understood. We describe a series of patients with non-pulmonary vein (PV) trigger sites provoked by an ATP injection, and assess the feasibility of a ganglionated plexus (GP) ablation. We retrospectively analyzed 547 patients (69% male; mean age 67.4 ± 10.4 years; 38.5% non-paroxysmal AF) who underwent a total of 604 ablation procedures. Intravenous ATP was administered with an isoproterenol infusion during sinus rhythm after a pulmonary vein isolation in 21.3%, Box isolation in 78.6%, and SVC isolation in 52.0% of the procedures, respectively. We reviewed the incidence, the distribution of the foci, and the ablation outcomes in patients with ATP-induced AF. A total of seven patients (1.3%) had ATP-induced AF. Foci were identified in the coronary sinus (CS) in six patients, right atrial posterior wall (RAPW) adjacent to the interatrial groove in two, mitral annulus in two, ligament of Marshall in one, right septum below the foramen ovale in one and left atrial posterior wall in one, respectively. Among these trigger foci, we confirmed the vagal response by high-frequency stimulation in the CS and RAPW in six and two patients, respectively. After a median RF time of 2.9 min (range 2.5-11.3) targeting these foci, in five of six patients who received a repeat ATP injection, the AF became non-inducible. ATP-provoked trigger foci were distributed among certain sites that overlapped with the distribution of the GPs. The GP ablation was effective for this rare, but challenging situation.
Collapse
Affiliation(s)
- Taku Nishida
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan.
| | - Akihiro Takitsume
- Department of Cardiology, Nara Prefecture General Medical Center, Kashihara, Japan
| | - Junichi Sugiura
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Ayaka Keshi
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Koshiro Kanaoka
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Kaeko Hirai
- Department of Cardiology, Nara Prefecture Seiwa Medical Center, Kashihara, Japan
| | - Hiroki Yano
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Yukihiro Hashimoto
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Tomoya Ueda
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Hitoshi Nakagawa
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Kenji Onoue
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Tsunenari Soeda
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Makoto Watanabe
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Rika Kawakami
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Yoshihiko Saito
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| |
Collapse
|
84
|
Stoyek MR, Hortells L, Quinn TA. From Mice to Mainframes: Experimental Models for Investigation of the Intracardiac Nervous System. J Cardiovasc Dev Dis 2021; 8:149. [PMID: 34821702 PMCID: PMC8620975 DOI: 10.3390/jcdd8110149] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/28/2021] [Accepted: 11/01/2021] [Indexed: 01/17/2023] Open
Abstract
The intracardiac nervous system (IcNS), sometimes referred to as the "little brain" of the heart, is involved in modulating many aspects of cardiac physiology. In recent years our fundamental understanding of autonomic control of the heart has drastically improved, and the IcNS is increasingly being viewed as a therapeutic target in cardiovascular disease. However, investigations of the physiology and specific roles of intracardiac neurons within the neural circuitry mediating cardiac control has been hampered by an incomplete knowledge of the anatomical organisation of the IcNS. A more thorough understanding of the IcNS is hoped to promote the development of new, highly targeted therapies to modulate IcNS activity in cardiovascular disease. In this paper, we first provide an overview of IcNS anatomy and function derived from experiments in mammals. We then provide descriptions of alternate experimental models for investigation of the IcNS, focusing on a non-mammalian model (zebrafish), neuron-cardiomyocyte co-cultures, and computational models to demonstrate how the similarity of the relevant processes in each model can help to further our understanding of the IcNS in health and disease.
Collapse
Affiliation(s)
- Matthew R. Stoyek
- Department of Physiology and Biophysics, Dalhousie University, Halifax, NS 15000, Canada;
| | - Luis Hortells
- Institute for Experimental Cardiovascular Medicine, University Heart Centre Freiburg–Bad Krozingen, 79110 Freiburg, Germany;
- Faculty of Medicine, University of Freiburg, 79110 Freiburg, Germany
| | - T. Alexander Quinn
- Department of Physiology and Biophysics, Dalhousie University, Halifax, NS 15000, Canada;
- School of Biomedical Engineering, Dalhousie University, Halifax, NS 15000, Canada
| |
Collapse
|
85
|
Abstract
Vagal nerve stimulation (VNS) has a strong pathophysiological rationale as a potentially beneficial treatment for heart failure with reduced ejection fraction. Despite several promising preclinical studies and pilot clinical studies, the two large, controlled trials—NECTAR-HF and INOVATE-HF—failed to demonstrate the expected benefit. It is likely that clinical application of VNS in phase III studies was performed before a sufficient degree of understanding of the complex pathophysiology of autonomic electrical modulation had been achieved, therefore leading to an underestimation of its potential benefit. More knowledge on the complex dose–response issue of VNS (i.e., pulse amplitude, frequency, duration and duty cycle) has been gathered since these trials and a new randomized study is currently underway with an adaptive design and a refined approach in an attempt to deliver the proper dose to a more selected group of patients.
Collapse
Affiliation(s)
- Veronica Dusi
- Division of Cardiology, Department of Medical Sciences, Citta della Salute e della Scienza Hospital, University of Turin, Corso Bramante 88, 10126, Turin, Italy.
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Department of Medical Sciences, Citta della Salute e della Scienza Hospital, University of Turin, Corso Bramante 88, 10126, Turin, Italy
| |
Collapse
|
86
|
Morita N, Iida T, Nanao T, Ushijima A, Ueno A, Ikari Y, Kobayashi Y. Effect of ganglionated plexi ablation by high-density mapping on long-term suppression of paroxysmal atrial fibrillation - The first clinical survey on ablation of the dorsal right plexusus. Heart Rhythm O2 2021; 2:480-488. [PMID: 34667963 PMCID: PMC8505203 DOI: 10.1016/j.hroo.2021.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Background Long-term outcomes of suppressing paroxysmal atrial fibrillation (PAF) with additive ganglionated plexus (GP) ablation (GPA) remains unknown. Objectives The aim of the study is to assess potential role of additional GPA for PAF suppression. Methods This study consisted of 225 patients; 68 (group A: 58 male, aged 60 ± 11 years) underwent pulmonary vein isolation (PVI) alone and 157 (group B: 137 male, aged 61 ± 11 years) GPA followed by PVI. GPA was performed based on the high-density mapping with high-frequency stimulation (HFS) delivered to left atrial (LA) major GP. The latter 85 group B patients (54%) underwent ablation to a posteromedial area within superior vena cava as a part of dorsal right atrial GP (SVC-Ao GP). Results In group B, HFS was applied to 126 ± 32 sites, with a median of 47 GP sites (40.0%) being ablated. In patients undergoing an SVC-Ao GPA, HFS and the SVC-Ao GPA were applied at a median of 15 and 4 sites (29.4%), respectively. The PVI with a GPA provided higher PAF suppression than a PVI alone during more than 4 years of follow-up (56.7% vs 38.2%, odds ratio: 0.42, 95% confidence interval: 0.23-0.76, P < .05), but the SVC-Ao GPA did not provide further suppressive effects. Multivariate analyses revealed that tachycardia-bradycardia syndrome and non-PV foci were independent predictors of PAF recurrence after PVI with a GPA (P < .01). Conclusion GPA to LA major GP by high-density mapping provides long-term benefits for PAF suppression over 4 years of follow-up, but the effect of an empiric SVC-Ao GPA could not be appreciated, suggesting little effect on suppressing non-PV foci.
Collapse
Affiliation(s)
- Norishige Morita
- Division of Cardiology, Department of Medicine, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Takayuki Iida
- Division of Cardiology, Department of Medicine, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Tomihisa Nanao
- Division of Cardiology, Department of Medicine, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Akiko Ushijima
- Division of Cardiology, Department of Medicine, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Akira Ueno
- Division of Cardiology, Department of Medicine, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Yuji Ikari
- Division of Cardiology, Department of Medicine, Tokai University Hospital, Kanagawa, Japan
| | - Yoshinori Kobayashi
- Division of Cardiology, Department of Medicine, Tokai University Hachioji Hospital, Tokyo, Japan
| |
Collapse
|
87
|
Aksu T, De Potter T, John L, Osorio J, Singh D, Alyesh D, Baysal E, Kumar K, Mikaeili J, Dal Forno A, Yalin K, Akdemir B, Woods CE, Salcedo J, Eftekharzadeh M, Akgun T, Sundaram S, Aras D, Tzou WS, Gopinathannair R, Winterfield J, Gupta D, Davila A. Procedural and short-term results of electroanatomic-mapping-guided ganglionated plexus ablation by first-time operators: A multicenter study. J Cardiovasc Electrophysiol 2021; 33:117-122. [PMID: 34674347 DOI: 10.1111/jce.15278] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 09/26/2021] [Accepted: 10/18/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Single-center observational studies have shown promising results with fragmented electrogram (FE)-guided ganglionated plexus (GP) ablation in patients with vagally mediated bradyarrhythmia (VMB). We aimed to compare the acute procedural characteristics during FE-guided GP ablation in patients with VMB performed by first-time operators and those of a single high-volume operator. METHODS AND RESULTS This international multicenter cohort study included data collected over 2 years from 16 cardiac hospitals. The primary operators were classified according to their prior GP ablation experience: a single high-volume operator who had performed > 50 GP ablation procedures (Group 1), and operators performing their first GP ablation cases (Group 2). Acute procedural characteristics and syncope recurrence were compared between groups. Forty-seven consecutive patients with VMB who underwent FE-guided GP ablation were enrolled, n = 31 in Group 1 and n = 16 in Group 2. The mean number of ablation points in each GP was comparable between groups. The ratio of positive vagal response during ablation on the left superior GP was higher in Group 1 (90.3% vs. 62.5%, p = .022). Ablation of the right superior GP increased heart rate acutely without any vagal response in 45 (95.7%) cases. The procedure time was longer in group 2 (83.4 ± 21 vs. 118.0 ± 21 min, respectively, p < .001). Over a mean follow-up duration of 8.0 ± 3 months (range 2-24 months), none of the patients suffered from syncope. CONCLUSION This multi-center pilot study shows for the first time the feasibility of FE-guided GP ablation across a large group of procedure-naïve operators.
Collapse
Affiliation(s)
- Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, Istanbul, Turkey
| | - Tom De Potter
- Department of Cardiology, OLV Hospital, Aalst, Belgium
| | - Leah John
- Department of Cardiology, Medical University of South Carolina, South Carolina, USA
| | - Jose Osorio
- Department of Electrophysiology, Arrhythmia Institute at Grandview, Alabama, USA
| | - David Singh
- Division of Cardiology, The Queen's Medical Center, Honolulu, Hawaii, USA
| | - Daniel Alyesh
- Department of Electrophysiology, Cardiac Electrophysiology, South Denver Cardiology Associates, Littleton, Colorado, USA
| | - Erkan Baysal
- Department of Cardiology, Gazi Yaşargil Training and Research Hospital, Diyarbakır, Turkey
| | - Kapil Kumar
- Department of Cardiology, Beth Israel Deaconess Medical Center, Boston, USA
| | - Javad Mikaeili
- Department of Electrophysiology, Day General Hospital, Tehran, Iran
| | | | - Kivanc Yalin
- Department of Cardiology, Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Baris Akdemir
- Department of Cardiology, Goztepe Medicalpark Hospital, Bahcesehir University, Istanbul, Turkey
| | - Christopher E Woods
- Department of Cardiology, Palo Alto Medical Foundation, Mills-Peninsula Medical Center, Burlingame, California, USA
| | - Jonathan Salcedo
- Department of Cardiology, Palo Alto Medical Foundation, Mills-Peninsula Medical Center, Burlingame, California, USA
| | | | - Taylan Akgun
- Basaksehir Cam and Sakura City Hospital, Başakşehir, Turkey
| | - Sri Sundaram
- Department of Electrophysiology, Cardiac Electrophysiology, South Denver Cardiology Associates, Littleton, Colorado, USA
| | | | - Wendy S Tzou
- Division of Cardiovascular Medicine, Cardiac Electrophysiology Section, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Rakesh Gopinathannair
- Department of Cardiology, Kansas City Heart Rhythm Institute and Research Foundation, Kansas City, Missouri, USA
| | - Jeffrey Winterfield
- Department of Cardiology, Medical University of South Carolina, South Carolina, USA
| | - Dhiraj Gupta
- Department of Electrophysiology, Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Andre Davila
- Department of Cardiology, Beth Israel Deaconess Medical Center, Boston, USA.,SOS Cardio Hospital, Florinapolis, Brazil
| |
Collapse
|
88
|
The "heart brain" and neuromodulation for vasovagal syncope. Auton Neurosci 2021; 236:102892. [PMID: 34666205 DOI: 10.1016/j.autneu.2021.102892] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 09/02/2021] [Accepted: 09/29/2021] [Indexed: 11/22/2022]
Abstract
It is well known that the autonomic nervous system (ANS) is a major contributor in etiopathogenesis of vasovagal syncope (VVS). Catheter based neuromodulation (CNA) of the intrinsic cardiac ANS has evolved rapidly from being an experimental unproven procedure to its current status as an increasingly performed ablation procedure in many major hospitals worldwide. The present review aims to bring the anatomical elements of intrinsic cardiac ANS and clinical application of intrinsic cardiac neuromodulation together, by reviewing anatomical terminologies and clinical data, in order to provide a practical assistance to the electrophysiology community.
Collapse
|
89
|
Du X. Sympatho-adrenergic mechanisms in heart failure: new insights into pathophysiology. MEDICAL REVIEW (BERLIN, GERMANY) 2021; 1:47-77. [PMID: 37724075 PMCID: PMC10388789 DOI: 10.1515/mr-2021-0007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 06/02/2021] [Indexed: 09/20/2023]
Abstract
The sympathetic nervous system is activated in the setting of heart failure (HF) to compensate for hemodynamic instability. However, acute sympathetic surge or sustained high neuronal firing rates activates β-adrenergic receptor (βAR) signaling contributing to myocardial remodeling, dysfunction and electrical instability. Thus, sympatho-βAR activation is regarded as a hallmark of HF and forms pathophysiological basis for β-blocking therapy. Building upon earlier research findings, studies conducted in the recent decades have significantly advanced our understanding on the sympatho-adrenergic mechanism in HF, which forms the focus of this article. This review notes recent research progress regarding the roles of cardiac β2AR or α1AR in the failing heart, significance of β1AR-autoantibodies, and βAR signaling through G-protein independent signaling pathways. Sympatho-βAR regulation of immune cells or fibroblasts is specifically discussed. On the neuronal aspects, knowledge is assembled on the remodeling of sympathetic nerves of the failing heart, regulation by presynaptic α2AR of NE release, and findings on device-based neuromodulation of the sympathetic nervous system. The review ends with highlighting areas where significant knowledge gaps exist but hold promise for new breakthroughs.
Collapse
Affiliation(s)
- Xiaojun Du
- Faculty of Physiology and Pathophysiology, School of Basic Medical Sciences, Xi’an Jiaotong University Health Science Center, 76 West Yanta Road, Xi’an710061, Shaanxi, China
- Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC3004, Australia
| |
Collapse
|
90
|
Yalin K, Altinsoy M, Soysal A, Aksu T, Gopinathannair R, Braunstein E, Cheung J. Long-term Success of Partial Ganglionated Plexus Ablation in a Patient with Tachycardia-bradycardia Syndrome and Syncope: Whom and How? J Innov Card Rhythm Manag 2021; 12:4720-4725. [PMID: 34712507 PMCID: PMC8545434 DOI: 10.19102/icrm.2021.121006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
|
91
|
Julian K, Prichard B, Raco J, Jain R, Jain R. A review of cardiac autonomics: from pathophysiology to therapy. Future Cardiol 2021; 18:125-133. [PMID: 34547917 DOI: 10.2217/fca-2021-0041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The effective management of cardiovascular diseases requires knowledge of intrinsic and extrinsic innervation of the heart and an understanding of how perturbations of said components affect cardiac function. The innate cardiac conduction system, which begins with cardiac pacemaker cells and terminates with subendocardial Purkinje fibers, is modulated by said systems. The intrinsic component of the cardiac autonomic nervous system, which remains incompletely elucidated, consists of intracardiac ganglia and interconnecting neurons that tightly regulate cardiac electrical activity. Extrinsic components of the autonomic nervous system, such as carotid baroreceptors and renin-angiotensin-aldosterone system, modulate sympathetic input to the heart through the stellate ganglion and parasympathetic input via the vagus nerve. There remains a need for additional therapies to treat conditions, such as advanced heart failure and refractory arrhythmias, and a better understanding of autonomics may be key to their development.
Collapse
Affiliation(s)
| | | | - Joseph Raco
- Department of Internal Medicine, Penn State Milton S Hershey Medical Center, Hershey, PA, USA
| | - Rahul Jain
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Rohit Jain
- Department of Internal Medicine, Penn State Milton S Hershey Medical Center, Hershey, PA, USA
| |
Collapse
|
92
|
Krishnan A, Chilton E, Raman J, Saxena P, McFarlane C, Trollope AF, Kinobe R, Chilton L. Are Interactions between Epicardial Adipose Tissue, Cardiac Fibroblasts and Cardiac Myocytes Instrumental in Atrial Fibrosis and Atrial Fibrillation? Cells 2021; 10:2501. [PMID: 34572150 PMCID: PMC8467050 DOI: 10.3390/cells10092501] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 09/12/2021] [Accepted: 09/14/2021] [Indexed: 12/12/2022] Open
Abstract
Atrial fibrillation is very common among the elderly and/or obese. While myocardial fibrosis is associated with atrial fibrillation, the exact mechanisms within atrial myocytes and surrounding non-myocytes are not fully understood. This review considers the potential roles of myocardial fibroblasts and myofibroblasts in fibrosis and modulating myocyte electrophysiology through electrotonic interactions. Coupling with (myo)fibroblasts in vitro and in silico prolonged myocyte action potential duration and caused resting depolarization; an optogenetic study has verified in vivo that fibroblasts depolarized when coupled myocytes produced action potentials. This review also introduces another non-myocyte which may modulate both myocardial (myo)fibroblasts and myocytes: epicardial adipose tissue. Epicardial adipocytes are in intimate contact with myocytes and (myo)fibroblasts and may infiltrate the myocardium. Adipocytes secrete numerous adipokines which modulate (myo)fibroblast and myocyte physiology. These adipokines are protective in healthy hearts, preventing inflammation and fibrosis. However, adipokines secreted from adipocytes may switch to pro-inflammatory and pro-fibrotic, associated with reactive oxygen species generation. Pro-fibrotic adipokines stimulate myofibroblast differentiation, causing pronounced fibrosis in the epicardial adipose tissue and the myocardium. Adipose tissue also influences myocyte electrophysiology, via the adipokines and/or through electrotonic interactions. Deeper understanding of the interactions between myocytes and non-myocytes is important to understand and manage atrial fibrillation.
Collapse
Affiliation(s)
- Anirudh Krishnan
- College of Medicine and Dentistry, James Cook University, Townsville, QLD 4811, Australia;
| | - Emily Chilton
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC V5A 1S6, Canada;
| | - Jaishankar Raman
- Austin & St Vincent’s Hospitals, Melbourne University, Melbourne, VIC 3010, Australia;
- Applied Artificial Intelligence Institute, Deakin University, Melbourne, VIC 3217, Australia
- Department of Surgery, Oregon Health and Science University, Portland, OR 97239, USA
- School of Engineering, University of Illinois at Urbana-Champaign, Champaign, IL 61820, USA
| | - Pankaj Saxena
- Department of Cardiothoracic Surgery, Townsville University Hospital, Townsville, QLD 4814, Australia;
| | - Craig McFarlane
- Centre for Tropical Bioinformatics and Molecular Biology, Australian Institute of Tropical Health and Medicine, College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD 4811, Australia;
| | - Alexandra F. Trollope
- Centre for Molecular Therapeutics, Australian Institute of Tropical Health and Medicine, College of Medicine and Dentistry, James Cook University, Townsville, QLD 4811, Australia;
| | - Robert Kinobe
- Centre for Molecular Therapeutics, Australian Institute of Tropical Health and Medicine, College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD 4811, Australia;
| | - Lisa Chilton
- Centre for Molecular Therapeutics, Australian Institute of Tropical Health and Medicine, College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD 4811, Australia;
| |
Collapse
|
93
|
Zandstra TE, Notenboom RGE, Wink J, Kiès P, Vliegen HW, Egorova AD, Schalij MJ, De Ruiter MC, Jongbloed MRM. Asymmetry and Heterogeneity: Part and Parcel in Cardiac Autonomic Innervation and Function. Front Physiol 2021; 12:665298. [PMID: 34603069 PMCID: PMC8481575 DOI: 10.3389/fphys.2021.665298] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 08/26/2021] [Indexed: 11/17/2022] Open
Abstract
The cardiac autonomic nervous system (cANS) regulates cardiac adaptation to different demands. The heart is an asymmetrical organ, and in the selection of adequate treatment of cardiac diseases it may be relevant to take into account that the cANS also has sidedness as well as regional differences in anatomical, functional, and molecular characteristics. The left and right ventricles respond differently to adrenergic stimulation. Isoforms of nitric oxide synthase, which plays an important role in parasympathetic function, are also distributed asymmetrically across the heart. Treatment of cardiac disease heavily relies on affecting left-sided heart targets which are thought to apply to the right ventricle as well. Functional studies of the right ventricle have often been neglected. In addition, many principles have only been investigated in animals and not in humans. Anatomical and functional heterogeneity of the cANS in human tissue or subjects is highly valuable for understanding left- and right-sided cardiac pathology and for identifying novel treatment targets and modalities. Within this perspective, we aim to provide an overview and synthesis of anatomical and functional heterogeneity of the cANS in tissue or subjects, focusing on the human heart.
Collapse
Affiliation(s)
- Tjitske E. Zandstra
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Jeroen Wink
- Department of Anesthesiology, Leiden University Medical Center, Leiden, Netherlands
| | - Philippine Kiès
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Hubert W. Vliegen
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Martin J. Schalij
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Marco C. De Ruiter
- Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, Netherlands
| | - Monique R. M. Jongbloed
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
- Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, Netherlands
| |
Collapse
|
94
|
Aksu T, Gopinathannair R, Bozyel S, Yalin K, Gupta D. Cardioneuroablation for Treatment of Atrioventricular Block. Circ Arrhythm Electrophysiol 2021; 14:e010018. [PMID: 34465122 DOI: 10.1161/circep.121.010018] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
Collapse
Affiliation(s)
- Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, Istanbul, Turkey (T.A.)
| | | | - Serdar Bozyel
- Kocaeli Derince Training and Research Hospital, Turkey (S.B.)
| | - Kivanc Yalin
- Istanbul-Cerrahpasa University Hospital, Turkey (K.Y.)
| | - Dhiraj Gupta
- Liverpool Heart and Chest Hospital, United Kingdom (D.G.)
| |
Collapse
|
95
|
Scalco A, Moro N, Mongillo M, Zaglia T. Neurohumoral Cardiac Regulation: Optogenetics Gets Into the Groove. Front Physiol 2021; 12:726895. [PMID: 34531763 PMCID: PMC8438220 DOI: 10.3389/fphys.2021.726895] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 07/27/2021] [Indexed: 12/25/2022] Open
Abstract
The cardiac autonomic nervous system (ANS) is the main modulator of heart function, adapting contraction force, and rate to the continuous variations of intrinsic and extrinsic environmental conditions. While the parasympathetic branch dominates during rest-and-digest sympathetic neuron (SN) activation ensures the rapid, efficient, and repeatable increase of heart performance, e.g., during the "fight-or-flight response." Although the key role of the nervous system in cardiac homeostasis was evident to the eyes of physiologists and cardiologists, the degree of cardiac innervation, and the complexity of its circuits has remained underestimated for too long. In addition, the mechanisms allowing elevated efficiency and precision of neurogenic control of heart function have somehow lingered in the dark. This can be ascribed to the absence of methods adequate to study complex cardiac electric circuits in the unceasingly moving heart. An increasing number of studies adds to the scenario the evidence of an intracardiac neuron system, which, together with the autonomic components, define a little brain inside the heart, in fervent dialogue with the central nervous system (CNS). The advent of optogenetics, allowing control the activity of excitable cells with cell specificity, spatial selectivity, and temporal resolution, has allowed to shed light on basic neuro-cardiology. This review describes how optogenetics, which has extensively been used to interrogate the circuits of the CNS, has been applied to untangle the knots of heart innervation, unveiling the cellular mechanisms of neurogenic control of heart function, in physiology and pathology, as well as those participating to brain-heart communication, back and forth. We discuss existing literature, providing a comprehensive view of the advancement in the understanding of the mechanisms of neurogenic heart control. In addition, we weigh the limits and potential of optogenetics in basic and applied research in neuro-cardiology.
Collapse
Affiliation(s)
- Arianna Scalco
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
- Veneto Institute of Molecular Medicine, Padova, Italy
| | - Nicola Moro
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
- Veneto Institute of Molecular Medicine, Padova, Italy
| | - Marco Mongillo
- Veneto Institute of Molecular Medicine, Padova, Italy
- Department of Biomedical Sciences, University of Padova, Padova, Italy
| | - Tania Zaglia
- Veneto Institute of Molecular Medicine, Padova, Italy
- Department of Biomedical Sciences, University of Padova, Padova, Italy
| |
Collapse
|
96
|
Vandenberk B, Morillo CA, Sheldon RS, Chew DS, Aksu T, Raj SR. Clinician needs and perceptions about cardioneuroablation for recurrent vasovagal syncope: An international clinician survey. Heart Rhythm 2021; 18:2160-2166. [PMID: 34419666 DOI: 10.1016/j.hrthm.2021.08.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/11/2021] [Accepted: 08/15/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Cardioneuroablation (CNA) targets the intrinsic cardiac autonomic nervous system ganglionated plexi located in the peri-atrial epicardial fat. There is increasing interest in CNA as a treatment of vasovagal syncope (VVS), despite no randomized clinical trial (RCT) data. OBJECTIVE The purpose of this study was to poll the opinion on CNA) for VVS. METHODS A REDCap (Research Electronic Data Capture) survey was administered to international physicians treating patients with VVS on their opinion about patient selection criteria, ablation approach, RCT design, and most appropriate end points for CNA procedures. RESULTS The survey was completed by 118 physicians; 86% were cardiac electrophysiologists. The majority of respondents (79%) would consider referring a patient with refractory VVS for CNA, and 27% have performed CNA for VVS themselves. Most felt patient selection should require a head-up tilt test with a cardioinhibitory response (67%) and suggest a minimum age of 18 years with a median of 3 (interquartile range 2-5) episodes in the past year. There were differences in patient selection between physicians who have performed CNA themselves and those who have not. The majority felt that the ablation strategy should include both atria (70%) with an anatomical approach in combination with autonomic stimulation (85%). Performing a sham procedure in the control arm was supported by 56% of respondents, providing equipoise in RCT design. The preferred primary outcome was freedom from syncope within 1 year of follow-up. CONCLUSION There is widespread support for well-designed RCTs to confirm the hypothesized clinical benefit of CNA, provide data to guide the risk-benefit equations during patient selection, and appropriately estimate the placebo effect.
Collapse
Affiliation(s)
- Bert Vandenberk
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Cardiology, University Hospitals Leuven, Leuven, Belgium.
| | - Carlos A Morillo
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert S Sheldon
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Derek S Chew
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, Istanbul, Turkey
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
97
|
Stavrakis S, Kulkarni K, Singh JP, Katritsis DG, Armoundas AA. Autonomic Modulation of Cardiac Arrhythmias: Methods to Assess Treatment and Outcomes. JACC Clin Electrophysiol 2021; 6:467-483. [PMID: 32439031 DOI: 10.1016/j.jacep.2020.02.014] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 02/06/2020] [Accepted: 02/14/2020] [Indexed: 02/08/2023]
Abstract
The autonomic nervous system plays a central role in the pathogenesis of multiple cardiac arrhythmias, including atrial fibrillation and ventricular tachycardia. As such, autonomic modulation represents an attractive therapeutic approach in these conditions. Notably, autonomic modulation exploits the plasticity of the neural tissue to induce neural remodeling and thus obtain therapeutic benefit. Different forms of autonomic modulation include vagus nerve stimulation, tragus stimulation, renal denervation, baroreceptor activation therapy, and cardiac sympathetic denervation. This review seeks to highlight these autonomic modulation therapeutic modalities, which have shown promise in early preclinical and clinical trials and represent exciting alternatives to standard arrhythmia treatment. We also present an overview of the various methods used to assess autonomic tone, including heart rate variability, skin sympathetic nerve activity, and alternans, which can be used as surrogate markers and predictors of the treatment effect. Although the use of autonomic modulation to treat cardiac arrhythmias is supported by strong preclinical data and preliminary studies in humans, in light of the disappointing results of a number of recent randomized clinical trials of autonomic modulation therapies in heart failure, the need for optimization of the stimulation parameters and rigorous patient selection based on appropriate biomarkers cannot be overemphasized.
Collapse
Affiliation(s)
- Stavros Stavrakis
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA.
| | - Kanchan Kulkarni
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jagmeet P Singh
- Cardiology Division, Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Antonis A Armoundas
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA; Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA.
| |
Collapse
|
98
|
Becker RC. Autonomic dysfunction in SARS-COV-2 infection acute and long-term implications COVID-19 editor's page series. J Thromb Thrombolysis 2021; 52:692-707. [PMID: 34403043 PMCID: PMC8367772 DOI: 10.1007/s11239-021-02549-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2021] [Indexed: 12/13/2022]
Abstract
Abstract The autonomic nervous system (ANS) is a complex network of nerves originating in the brain, brain stem, spinal cord, heart and extracardiac organs that regulates neural and physiological responses to internal and external environments and conditions. A common observation among patients with the 2019 Coronavirus (CoV) (SARS-severe acute respiratory syndrome CoV-2) (SARS-CoV-2) or COVID-19 [CO for corona, VI for virus, D for disease and 19 for when the outbreak was first identified (31 December 2019)] in the acute and chronic phases of the disease is tachycardia, labile blood pressure, muscular fatigue and shortness of breath. Because abnormalities in the ANS can contribute to each of these symptoms, herein a review of autonomic dysfunction in SARS-COV-2 infection is provided to guide diagnostic testing, patient care and research initiatives. Graphic abstract The autonomic nervous system is a complex network of nerves originating in the brain, brain stem, spinal cord, heart and extracardiac organs that regulates neural and physiological responses to internal and external environments and conditions. A common collection of signs and symptoms among patients with the 2019 Coronavirus (CoV) (SARS-severe acute respiratory syndrome CoV-2) (SARS-CoV-2) or COVID-19 [CO for corona, VI for virus, D for disease and 19 for when the outbreak was first identified (31 December 2019)] is tachycardia, labile blood pressure, muscular fatigue and shortness of breath. Abnormalities in the autonomic nervous system (ANS) can contribute to each of these identifiers, potentially offering a unifying pathobiology for acute, subacute and the long-term sequelae of SARS-CoV-2 infection (PASC) and a target for intervention.
Collapse
Affiliation(s)
- Richard C Becker
- Heart, Lung and Vascular Institute, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45267, USA.
| |
Collapse
|
99
|
The cardiac autonomic nervous system: an introduction. Herzschrittmacherther Elektrophysiol 2021; 32:295-301. [PMID: 34389873 DOI: 10.1007/s00399-021-00776-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/01/2021] [Indexed: 10/20/2022]
Abstract
In recent decades, numerous anatomical and physiological studies of the cardiac autonomic nervous system (ANS) have investigated the complex relationships between the brain and the heart. Autonomic activation not only alters heart rate, conduction, and hemodynamics, but also cellular and subcellular properties of individual myocytes. Moreover, the cardiac ANS plays an essential role in cardiac arrhythmogenesis. There is mounting evidence that neural modulation either by ablation or stimulation can effectively control a wide spectrum of cardiac arrhythmias. This article discusses anatomic aspects of the cardiac ANS, focusing on how autonomic activities influence cardiac electrophysiology. Specific autonomic triggers of various cardiac arrhythmias, in particular atrial fibrillation (AF) and ventricular arrhythmias, are also briefly discussed. Studies with heart-rate variability analysis indicate that, rather than being triggered by either vagal or sympathetic activity, the onset of AF can be associated with simultaneous discharge of both limbs, leading to an imbalance between these two arms of the cardiac ANS. At the same time, sudden cardiac death resulting from ventricular arrhythmias continues to be a significant health and societal burden. These nerve activities of the cardiac ANS can be targeted for the treatment for cardiac arrhythmias, in particular AF and ventricular tachyarrhythmias.
Collapse
|
100
|
Celotto C, Sánchez C, Mountris KA, Laguna P, Pueyo E. Location of Parasympathetic Innervation Regions From Electrograms to Guide Atrial Fibrillation Ablation Therapy: An in silico Modeling Study. Front Physiol 2021; 12:674197. [PMID: 34456743 PMCID: PMC8385640 DOI: 10.3389/fphys.2021.674197] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 06/11/2021] [Indexed: 01/18/2023] Open
Abstract
The autonomic nervous system (ANS) plays an essential role in the generation and maintenance of cardiac arrhythmias. The cardiac ANS can be divided into its extrinsic and intrinsic components, with the latter being organized in an epicardial neural network of interconnecting axons and clusters of autonomic ganglia called ganglionated plexi (GPs). GP ablation has been associated with a decreased risk of atrial fibrillation (AF) recurrence, but the accurate location of GPs is required for ablation to be effective. Although GP stimulation triggers both sympathetic and parasympathetic ANS branches, a predominance of parasympathetic activity has been shown. This study aims was to develop a method to locate atrial parasympathetic innervation sites based on measurements from a grid of electrograms (EGMs). Electrophysiological models representative of non-AF, paroxysmal AF (PxAF), and persistent AF (PsAF) tissues were developed. Parasympathetic effects were modeled by increasing the concentration of the neurotransmitter acetylcholine (ACh) in randomly distributed circles across the tissue. Different circle sizes of ACh and fibrosis geometries were considered, accounting for both uniform diffuse and non-uniform diffuse fibrosis. Computational simulations were performed, from which unipolar EGMs were computed in a 16 × 1 6 electrode mesh. Different distances of the electrodes to the tissue (0.5, 1, and 2 mm) and noise levels with signal-to-noise ratio (SNR) values of 0, 5, 10, 15, and 20 dB were tested. The amplitude of the atrial EGM repolarization wave was found to be representative of the presence or absence of ACh release sites, with larger positive amplitudes indicating that the electrode was placed over an ACh region. Statistical analysis was performed to identify the optimal thresholds for the identification of ACh sites. In all non-AF, PxAF, and PsAF tissues, the repolarization amplitude rendered successful identification. The algorithm performed better in the absence of fibrosis or when fibrosis was uniformly diffuse, with a mean accuracy of 0.94 in contrast with a mean accuracy of 0.89 for non-uniform diffuse fibrotic cases. The algorithm was robust against noise and worked for the tested ranges of electrode-to-tissue distance. In conclusion, the results from this study support the feasibility to locate atrial parasympathetic innervation sites from the amplitude of repolarization wave.
Collapse
Affiliation(s)
- Chiara Celotto
- Aragon Institute of Engineering Research-I3A-, University of Zaragoza, IIS Aragón, Zaragoza, Spain
- CIBER in Bioengineering, Biomaterials and Nanomedicine, Zaragoza, Spain
| | - Carlos Sánchez
- Aragon Institute of Engineering Research-I3A-, University of Zaragoza, IIS Aragón, Zaragoza, Spain
- CIBER in Bioengineering, Biomaterials and Nanomedicine, Zaragoza, Spain
| | - Konstantinos A. Mountris
- Aragon Institute of Engineering Research-I3A-, University of Zaragoza, IIS Aragón, Zaragoza, Spain
- CIBER in Bioengineering, Biomaterials and Nanomedicine, Zaragoza, Spain
| | - Pablo Laguna
- Aragon Institute of Engineering Research-I3A-, University of Zaragoza, IIS Aragón, Zaragoza, Spain
- CIBER in Bioengineering, Biomaterials and Nanomedicine, Zaragoza, Spain
| | - Esther Pueyo
- Aragon Institute of Engineering Research-I3A-, University of Zaragoza, IIS Aragón, Zaragoza, Spain
- CIBER in Bioengineering, Biomaterials and Nanomedicine, Zaragoza, Spain
| |
Collapse
|