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Yang F, Tiano J, Mittal S, Turakhia M, Jacobowitz I, Greenberg Y. Towards a Mechanistic Understanding and Treatment of a Progressive Disease: Atrial Fibrillation. J Atr Fibrillation 2017; 10:1627. [PMID: 29250240 DOI: 10.4022/jafib.1627] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 06/19/2017] [Accepted: 08/14/2017] [Indexed: 01/08/2023]
Abstract
Atrial fibrosis appears to be a key factor in the genesis and/or perpetuation of atrial fibrillation (AF). The pathological distribution of atrial fibrosis is geographically consistent with the attachments between the posterior left atrium and the pericardium along the reflections where wall stiffness is increased and structural changes are found. While there is a wide range of complex etiological factors and electrophysiological mechanisms in AF, there is evidence for a common pathophysiological pathway that could account for deliberate substrate formation and progression of AF. Anatomical stresses along the atrium, mediated by the elastic modulus mismatch between atrial tissue and the pericardium, result in inflammatory and fibrotic changes which create the substrate for atrial fibrillation. This may explain the anatomical predominance of pulmonary vein triggers earlier in the development of atrial fibrillation and the increasing involvement of the atrium as the disease progresses. Ablative treatments that address the progressive nature of atrial fibrillation and fibrosis may yield improved success rates.
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Affiliation(s)
- Felix Yang
- Maimonides Medical Center (Brooklyn, NY)
| | | | | | - Mintu Turakhia
- Stanford University (Stanford, CA).,VA Palo Alto Health Care System (Palo Alto, CA)
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2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation: Executive summary. Heart Rhythm 2017; 14:e445-e494. [DOI: 10.1016/j.hrthm.2017.07.009] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, Akar JG, Badhwar V, Brugada J, Camm J, Chen PS, Chen SA, Chung MK, Nielsen JC, Curtis AB, Davies DW, Day JD, d’Avila A, de Groot N(N, Di Biase L, Duytschaever M, Edgerton JR, Ellenbogen KA, Ellinor PT, Ernst S, Fenelon G, Gerstenfeld EP, Haines DE, Haissaguerre M, Helm RH, Hylek E, Jackman WM, Jalife J, Kalman JM, Kautzner J, Kottkamp H, Kuck KH, Kumagai K, Lee R, Lewalter T, Lindsay BD, Macle L, Mansour M, Marchlinski FE, Michaud GF, Nakagawa H, Natale A, Nattel S, Okumura K, Packer D, Pokushalov E, Reynolds MR, Sanders P, Scanavacca M, Schilling R, Tondo C, Tsao HM, Verma A, Wilber DJ, Yamane T. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2017; 14:e275-e444. [PMID: 28506916 PMCID: PMC6019327 DOI: 10.1016/j.hrthm.2017.05.012] [Citation(s) in RCA: 1370] [Impact Index Per Article: 195.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Hugh Calkins
- Johns Hopkins Medical Institutions, Baltimore, MD
| | | | - Riccardo Cappato
- Humanitas Research Hospital, Arrhythmias and Electrophysiology Research Center, Milan, Italy (Dr. Cappato is now with the Department of Biomedical Sciences, Humanitas University, Milan, Italy, and IRCCS, Humanitas Clinical and Research Center, Milan, Italy)
| | | | - Eduardo B. Saad
- Hospital Pro-Cardiaco and Hospital Samaritano, Botafogo, Rio de Janeiro, Brazil
| | | | | | - Vinay Badhwar
- West Virginia University School of Medicine, Morgantown, WV
| | - Josep Brugada
- Cardiovascular Institute, Hospital Clínic, University of Barcelona, Catalonia, Spain
| | - John Camm
- St. George’s University of London, London, United Kingdom
| | | | | | | | | | | | - D. Wyn Davies
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - John D. Day
- Intermountain Medical Center Heart Institute, Salt Lake City, UT
| | | | | | - Luigi Di Biase
- Albert Einstein College of Medicine, Montefiore-Einstein Center for Heart & Vascular Care, Bronx, NY
| | | | | | | | | | - Sabine Ernst
- Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Guilherme Fenelon
- Albert Einstein Jewish Hospital, Federal University of São Paulo, São Paulo, Brazil
| | | | | | | | | | - Elaine Hylek
- Boston University School of Medicine, Boston, MA
| | - Warren M. Jackman
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Jose Jalife
- University of Michigan, Ann Arbor, MI, the National Center for Cardiovascular Research Carlos III (CNIC) and CIBERCV, Madrid, Spain
| | - Jonathan M. Kalman
- Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia
| | - Josef Kautzner
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Hans Kottkamp
- Hirslanden Hospital, Department of Electrophysiology, Zurich, Switzerland
| | | | | | - Richard Lee
- Saint Louis University Medical School, St. Louis, MO
| | - Thorsten Lewalter
- Department of Cardiology and Intensive Care, Hospital Munich-Thalkirchen, Munich, Germany
| | | | - Laurent Macle
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montréal, Canada
| | | | - Francis E. Marchlinski
- Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, Philadelphia, PA
| | | | - Hiroshi Nakagawa
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX
| | - Stanley Nattel
- Montreal Heart Institute and Université de Montréal, Montreal, Canada, McGill University, Montreal, Canada, and University Duisburg-Essen, Essen, Germany
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | | | - Evgeny Pokushalov
- State Research Institute of Circulation Pathology, Novosibirsk, Russia
| | | | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | | | - Claudio Tondo
- Cardiac Arrhythmia Research Center, Centro Cardiologico Monzino, IRCCS, Department of Cardiovascular Sciences, University of Milan, Milan, Italy
| | | | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Toronto, Canada
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Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, Akar JG, Badhwar V, Brugada J, Camm J, Chen PS, Chen SA, Chung MK, Nielsen JC, Curtis AB, Davies DW, Day JD, d'Avila A, de Groot NMSN, Di Biase L, Duytschaever M, Edgerton JR, Ellenbogen KA, Ellinor PT, Ernst S, Fenelon G, Gerstenfeld EP, Haines DE, Haissaguerre M, Helm RH, Hylek E, Jackman WM, Jalife J, Kalman JM, Kautzner J, Kottkamp H, Kuck KH, Kumagai K, Lee R, Lewalter T, Lindsay BD, Macle L, Mansour M, Marchlinski FE, Michaud GF, Nakagawa H, Natale A, Nattel S, Okumura K, Packer D, Pokushalov E, Reynolds MR, Sanders P, Scanavacca M, Schilling R, Tondo C, Tsao HM, Verma A, Wilber DJ, Yamane T. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation: Executive summary. J Arrhythm 2017; 33:369-409. [PMID: 29021841 PMCID: PMC5634725 DOI: 10.1016/j.joa.2017.08.001] [Citation(s) in RCA: 182] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Key Words
- AAD, antiarrhythmic drug
- AF, atrial fibrillation
- AFL, atrial flutter
- Ablation
- Anticoagulation
- Arrhythmia
- Atrial fibrillation
- Atrial flutter
- Atrial tachycardia
- CB, cryoballoon
- CFAE, complex fractionated atrial electrogram
- Catheter ablation
- LA, left atrial
- LAA, left atrial appendage
- LGE, late gadolinium-enhanced
- LOE, level of evidence
- MRI, magnetic resonance imaging
- OAC, oral anticoagulation
- RF, radiofrequency
- Stroke
- Surgical ablation
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Affiliation(s)
- Hugh Calkins
- Johns Hopkins Medical Institutions, Baltimore, MD
| | | | - Riccardo Cappato
- Humanitas Research Hospital, Arrhythmias and Electrophysiology Research Center, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy.,IRCCS, Humanitas Clinical and Research Center, Milan, Italy
| | | | - Eduardo B Saad
- Hospital Pro-Cardiaco and Hospital Samaritano, Botafogo, Rio de Janeiro, Brazil
| | | | | | - Vinay Badhwar
- West Virginia University School of Medicine, Morgantown, WV
| | - Josep Brugada
- Cardiovascular Institute, Hospital Clínic, University of Barcelona, Catalonia, Spain
| | - John Camm
- St. George's University of London, London, United Kingdom
| | | | | | | | | | | | - D Wyn Davies
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - John D Day
- Intermountain Medical Center Heart Institute, Salt Lake City, UT
| | | | | | - Luigi Di Biase
- Albert Einstein College of Medicine, Montefiore-Einstein Center for Heart & Vascular Care, Bronx, NY
| | | | | | | | | | - Sabine Ernst
- Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Guilherme Fenelon
- Albert Einstein Jewish Hospital, Federal University of São Paulo, São Paulo, Brazil
| | | | | | | | | | - Elaine Hylek
- Boston University School of Medicine, Boston, MA
| | - Warren M Jackman
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Jose Jalife
- University of Michigan, Ann Arbor, MI, the National Center for Cardiovascular Research Carlos III (CNIC) and CIBERCV, Madrid, Spain
| | - Jonathan M Kalman
- Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia
| | - Josef Kautzner
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Hans Kottkamp
- Hirslanden Hospital, Department of Electrophysiology, Zurich, Switzerland
| | | | | | - Richard Lee
- Saint Louis University Medical School, St. Louis, MO
| | - Thorsten Lewalter
- Department of Cardiology and Intensive Care, Hospital Munich-Thalkirchen, Munich, Germany
| | | | - Laurent Macle
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montréal, Canada
| | | | - Francis E Marchlinski
- Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, Philadelphia, PA
| | | | - Hiroshi Nakagawa
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX
| | - Stanley Nattel
- Montreal Heart Institute and Université de Montréal, Montreal, Canada, McGill University, Montreal, Canada, and University Duisburg-Essen, Essen, Germany
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | | | - Evgeny Pokushalov
- State Research Institute of Circulation Pathology, Novosibirsk, Russia
| | | | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | | | - Claudio Tondo
- Cardiac Arrhythmia Research Center, Centro Cardiologico Monzino, IRCCS, Department of Cardiovascular Sciences, University of Milan, Milan, Italy
| | | | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Toronto, Canada
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Choi EK, Zhao Y, Everett TH, Chen PS. Ganglionated plexi as neuromodulation targets for atrial fibrillation. J Cardiovasc Electrophysiol 2017; 28:1485-1491. [PMID: 28833764 DOI: 10.1111/jce.13319] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 08/07/2017] [Accepted: 08/09/2017] [Indexed: 11/26/2022]
Abstract
The autonomic nervous system plays an important role in the genesis of atrial fibrillation and is one of the candidate targets for atrial fibrillation therapy. This review focuses on the role of the autonomic nervous system in atrial fibrillation development and discusses the results of the ganglionated plexi catheter and surgical ablation in preclinical and clinical studies. The heart is innervated by the extrinsic and intrinsic autonomic nervous systems. The intrinsic autonomic nervous system consists of multiple ganglionated plexi and axons, which innervate the neighboring atrial myocardium and control their electrophysiological properties. Abnormal autonomic innervation has been observed in an animal model of atrial fibrillation and in humans. Direct recordings of autonomic nerve activity in canine models showed that atrial tachyarrhythmia episodes were invariably preceded by intrinsic cardiac autonomic nerve activity, thus supporting the importance of intrinsic cardiac autonomic nerve activity as the triggers for atrial tachyarrhythmia. Targeting ganglionated plexi with catheter ablation improves the outcomes of paroxysmal atrial fibrillation ablation in addition to pulmonary vein antrum isolation. Ablation of ganglionated plexi alone without pulmonary vein isolation is also useful in controlling paroxysmal atrial fibrillation in some patients. However, surgical ganglionated plexi ablation in patients with a large left atrium, persistent atrial fibrillation, and/or a history of prior catheter ablation does not result in additional benefits. These different outcomes suggest that ganglionated plexi ablation is effective in managing patients with paroxysmal atrial fibrillation, but its effects in patients with persistent atrial fibrillation and advanced atrial diseases might be limited.
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Affiliation(s)
- Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ye Zhao
- Department of Cardiac Surgery, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Thomas H Everett
- The Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Peng-Sheng Chen
- The Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
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56
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Efficacy of ganglionated plexi ablation in addition to pulmonary vein isolation for paroxysmal versus persistent atrial fibrillation: a meta-analysis of randomized controlled clinical trials. J Interv Card Electrophysiol 2017; 50:253-260. [DOI: 10.1007/s10840-017-0285-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 08/29/2017] [Indexed: 02/05/2023]
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WITHDRAWN: 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. J Arrhythm 2017. [DOI: 10.1016/j.joa.2017.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Bárta J, Brát R. Assessment of the effect of left atrial cryoablation enhanced by ganglionated plexi ablation in the treatment of atrial fibrillation in patients undergoing open heart surgery. J Cardiothorac Surg 2017; 12:69. [PMID: 28818088 PMCID: PMC5561587 DOI: 10.1186/s13019-017-0625-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Accepted: 07/13/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of our study was to investigate, whether enhancement of left atrial cryoablation by ablation of the autonomic nervous system of left atrium leads to influencing the outcomes of surgical treatment of atrial fibrillation in patients with structural heart disease undergoing open-heart surgery. METHODS The observed patient file consisted of 100 patients, who have undergone a combined open-heart surgery at our department between July 2012 and December 2014. The patients were indicated for the surgical procedure due to structural heart disease, and suffered from paroxysmal, persistent, or long-standing persistent atrial fibrillation. In all cases, left atrial cryoablation was performed in the extent of isolation of pulmonary veins, box lesion, connecting lesion with mitral annulus, amputation of the left atrial appendage and connecting lesion of the appendage base with left pulmonary veins. Furthermore, 35 of the patients underwent mapping and radiofrequency ablation of ganglionated plexi, together with discision and ablation of the ligament of Marshall (Group GP). A control group was consisted of 65 patients without ganglionated plexi intervention (Group LA). The main primary outcome was establishment and duration of sinus rhythm in the course of one-year follow-up. RESULTS Evaluation of the number of patients with a normal sinus rhythm in per cent has shown comparable values in both groups (Group GP - 93.75%, Group LA - 86.67%, p = 0.485); comparable results were also observed in patients with normal sinus rhythm without anti-arrhythmic treatment in the 12th month (Group GP - 50%, Group LA - 47%, p = 0.306). We have not observed any relation between the recurrence of atrial fibrillation and the presence of a mitral valve surgery, or between the presence of a mitral and tricuspid valves surgery and between the left atrial diameter > 50 mm. CONCLUSIONS Enhancement of left atrial cryoablation by gangionated plexi ablation did not influence the outcomes of surgical ablation due to atrial fibrillation in our population in the course of 12-month follow-up. TRIAL REGISTRATION The study was approved retrospectively by the Ethics Committee of the University Hospital Ostrava ( reference number 867/2016).
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Affiliation(s)
- Jiří Bárta
- Cardiac Surgery, University Hospital Ostrava, 17.listopadu 1790, 708 52, Ostrava-Poruba, Czech Republic.
| | - Radim Brát
- Cardiac Surgery, University Hospital Ostrava, 17.listopadu 1790, 708 52, Ostrava-Poruba, Czech Republic
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Roukoz H, Benditt DG. Atrial arrhythmias after lung transplantation. Trends Cardiovasc Med 2017; 28:53-61. [PMID: 28797718 DOI: 10.1016/j.tcm.2017.07.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 07/25/2017] [Accepted: 07/26/2017] [Indexed: 10/19/2022]
Abstract
Atrial arrhythmias are a common complication after lung transplant (LT), occurring in about 16-46% of LT patients early postoperatively, and in about 14% during longer-term follow-up. They have a significant impact on postoperative in-hospital length of stay and may have an impact on overall mortality. In this report, we review the incidence and risk factors of post lung transplant AA, their pathogenesis and their impact on short- and long-term outcomes. Pharmacological management options are reviewed. In brief, early atrial arrhythmias tend to be mostly atrial fibrillation and are treated acutely with a rate control strategy followed if needed by rhythm control for 4-6 weeks. Late atrial arrhythmias >6 months after LT tend to be more frequently organized atrial flutters amenable to ablation therapy. Long-term anticoagulation is controversial especially in patients with bilateral lung transplant who received surgical pulmonic vein isolation, however anticoagulation is still favored especially in single LT patients. More studies are needed to further document the pathophysiology of early versus late atrial arrhythmias and whether long-term anticoagulation is needed.
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Affiliation(s)
- Henri Roukoz
- Cardiology Division, Electrophysiology Section, University of Minnesota, Minneapolis, MN.
| | - David G Benditt
- Cardiology Division, Electrophysiology Section, University of Minnesota, Minneapolis, MN
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Rivarola EW, Hachul D, Wu T, Pisani C, Hardy C, Raimundi F, Melo S, Darrieux F, Scanavacca M. Targets and End Points in Cardiac Autonomic Denervation Procedures. Circ Arrhythm Electrophysiol 2017; 10:e004638. [PMID: 28202630 DOI: 10.1161/circep.116.004638] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 12/23/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Autonomic denervation is an alternative approach for patients with symptomatic bradycardia. No consensus exists on the critical targets and end points of the procedure. The aim of this study was to identify immediate end points and critical atrial regions responsible for vagal denervation. METHODS AND RESULTS We enrolled 14 patients (50% men; age: 34.0±13.8 years) with cardioinhibitory syncope, advanced atrioventricular block or sinus arrest, and no structural heart disease. Anatomic mapping of ganglionated plexuses was performed, followed by radiofrequency ablation. Heart rate, sinus node recovery time, Wenckebach cycle length, and atrial-His (AH) interval were measured before and after every radiofrequency pulse. Wilcoxon signed-rank test was used for comparison. Significant shortening of the R-R interval (P=0.0009), Wenckebach cycle length (P=0.0009), and AH intervals (P=0.0014) was observed after ablation. The heart rate elevation was 23.8±12.5%, and the Wenckebach cycle length and AH interval shortening was 18.1±11% and 24.6±19%, respectively. Atropine bolus injection (0.04 mg/kg) did not increase heart rate further. Targeting a single spot of the left side (64% of the patients) or right side (36%) of the interatrial septum was observed to be responsible for ≥80% of the final R-R and AH interval shortening during ablation. CONCLUSIONS Targeting specific sites of the interatrial septum is followed by an increase in heart rate and atrioventricular nodal conduction properties and might be critical for vagal attenuation. The R-R interval, Wenckebach cycle length, and AH interval shortening, associated with a negative response to atropine, could be considered immediate end points of the procedure.
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Affiliation(s)
- Esteban W Rivarola
- From the Unidade Clínica de Arritmia, Heart Institute, University of São Paulo Medical School, Brazil
| | - Denise Hachul
- From the Unidade Clínica de Arritmia, Heart Institute, University of São Paulo Medical School, Brazil
| | - Tan Wu
- From the Unidade Clínica de Arritmia, Heart Institute, University of São Paulo Medical School, Brazil
| | - Cristiano Pisani
- From the Unidade Clínica de Arritmia, Heart Institute, University of São Paulo Medical School, Brazil
| | - Carina Hardy
- From the Unidade Clínica de Arritmia, Heart Institute, University of São Paulo Medical School, Brazil
| | - Fabrizio Raimundi
- From the Unidade Clínica de Arritmia, Heart Institute, University of São Paulo Medical School, Brazil
| | - Sissy Melo
- From the Unidade Clínica de Arritmia, Heart Institute, University of São Paulo Medical School, Brazil
| | - Francisco Darrieux
- From the Unidade Clínica de Arritmia, Heart Institute, University of São Paulo Medical School, Brazil
| | - Mauricio Scanavacca
- From the Unidade Clínica de Arritmia, Heart Institute, University of São Paulo Medical School, Brazil.
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Suwalski G, Marczewska MM, Kaczejko K, Mróz J, Gryszko L, Cwetsch A, Skrobowski A. Left Atrial Ganglionated Plexi Detection is Related to Heart Rate and Early Recurrence of Atrial Fibrillation after Surgical Ablation. Braz J Cardiovasc Surg 2017; 32:118-124. [PMID: 28492793 PMCID: PMC5409258 DOI: 10.21470/1678-9741-2016-0059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 12/26/2016] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION: Left atrial ganglionated plexi ablation is an adjuvant technique used to increase the success rate of surgical ablation of atrial fibrillation. Ganglionated plexi ablation requires previous detection. We aimed to assess determinants of successful ganglionated plexi detection and to correlate range of ganglionated plexi ablation with risk of early atrial fibrillation recurrence. METHODS: The study involved 34 consecutive patients referred for surgical coronary revascularization with concomitant atrial fibrillation ablation. Ganglionated plexi detection was done by inducing vagal reflexes in the area of the pulmonary veins and left atrial fat pads. RESULTS: Detection of GP was successful in 85% of the patients. There was no difference in preoperative characteristics nor in atrial fibrillation type between patients in whom ganglionated plexi detection was successful and others. The number of detected ganglionated plexi correlated significantly only with preoperative resting heart rate. Significant negative correlation was found in patients with preoperative heart rate>75 beat/min in terms of total number of detected ganglionated plexi (P=0.04). Average number of detected ganglionated plexi was significantly higher in patients with in-hospital atrial fibrillation recurrence requiring electrical cardioversion (3.8±3) in comparison to rest of the study population (2±1.3; P=0.02). In patients in whom 4 or more ganglionated plexi were detected, significantly increased risk of in-hospital atrial fibrillation recurrence was observed (OR 15; 95% CI 1.5-164; P=0.003). CONCLUSION: Left atrial ganglionated plexi detection was unsuccessful in a considerable percentage of patients. Preoperative heart rate significantly influenced positive ganglionated plexi detection and number of ablated ganglia. Higher number of detected ganglionated plexi was related with early recurrence of atrial fibrillation.
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Affiliation(s)
- Grzegorz Suwalski
- Department of Cardiac Surgery, Military Institute of Medicine, Warsaw, Poland
| | - Małgorzata M Marczewska
- Department of Internal Diseases, Arterial Hypertension and Angiology, Medical University of Warsaw, Poland
| | - Kamil Kaczejko
- Department of Cardiac Surgery, Military Institute of Medicine, Warsaw, Poland
| | - Jakub Mróz
- Department of Cardiac Surgery, Military Institute of Medicine, Warsaw, Poland
| | - Leszek Gryszko
- Department of Cardiac Surgery, Military Institute of Medicine, Warsaw, Poland
| | - Andrzej Cwetsch
- Department of Cardiac Surgery, Military Institute of Medicine, Warsaw, Poland
| | - Andrzej Skrobowski
- Department of Cardiac Surgery, Military Institute of Medicine, Warsaw, Poland
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Yamagata K, Doi A, Kawata H, Makimoto H, Yokoyama T, Inoue Y, Okamura H, Noda T, Shimizu W, Aihara N, Maki T, Kamakura S, Kusano K, Satomi K. Persistent tachycardia within isolated pulmonary veins during atrial fibrillation ablation. Heart Vessels 2017; 32:1006-1012. [PMID: 28283739 DOI: 10.1007/s00380-017-0963-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 02/24/2017] [Indexed: 10/20/2022]
Abstract
During circumferential pulmonary vein (PV) isolation for ongoing atrial fibrillation (AF), distinguishing passive conduction to the pulmonary vein (PV) from rapid PV arrhythmia in the isolated PV is difficult. Hence, the purpose of this study is to investigate both the feasibility of distinguishing the PV tachycardia after circumferential PV isolation and the electrophysiological characteristics of these tachycardia. Among 178 consecutive patients who underwent circumferential PV isolation during ongoing AF, fibrillatory PV converted to a regular cycle length PV tachycardia independent of the atrial rhythm (=independent PV tachycardia) in 13 PVs among 12 (7%) patients. We classified independent PV tachycardia according to 3 different atrial rhythms: sinus rhythm (type 1, n = 2), atrial tachycardia (type 2, n = 4), and AF (type 3, n = 6). independent PV tachycardia was observed in 3 right PV and 10 left PV (P = 0.0864). There were 10 mappable independent PV tachycardia, in which 8 were focal and 2 were macroreentrant tachycardia. i-PVT can be diagnosed in a small number of patients who underwent circumferential PV isolation during AF. The main mechanism or independent PV tachycardia was focal tachycardia mainly in the left PV.
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Affiliation(s)
- Kenichiro Yamagata
- Department of Arrhythmia and Electrophysiology, National Cerebral and Cardiovascular Center, 5-7-1, Fujishirodai, Suita, Osaka, Japan.
| | - Atsushi Doi
- Department of Arrhythmia and Electrophysiology, National Cerebral and Cardiovascular Center, 5-7-1, Fujishirodai, Suita, Osaka, Japan
| | - Hiro Kawata
- Department of Arrhythmia and Electrophysiology, National Cerebral and Cardiovascular Center, 5-7-1, Fujishirodai, Suita, Osaka, Japan
| | - Hisaki Makimoto
- Department of Arrhythmia and Electrophysiology, National Cerebral and Cardiovascular Center, 5-7-1, Fujishirodai, Suita, Osaka, Japan
| | - Teruki Yokoyama
- Department of Arrhythmia and Electrophysiology, National Cerebral and Cardiovascular Center, 5-7-1, Fujishirodai, Suita, Osaka, Japan
| | - Yuko Inoue
- Department of Arrhythmia and Electrophysiology, National Cerebral and Cardiovascular Center, 5-7-1, Fujishirodai, Suita, Osaka, Japan
| | - Hideo Okamura
- Department of Arrhythmia and Electrophysiology, National Cerebral and Cardiovascular Center, 5-7-1, Fujishirodai, Suita, Osaka, Japan
| | - Takashi Noda
- Department of Arrhythmia and Electrophysiology, National Cerebral and Cardiovascular Center, 5-7-1, Fujishirodai, Suita, Osaka, Japan
| | - Wataru Shimizu
- Department of Arrhythmia and Electrophysiology, National Cerebral and Cardiovascular Center, 5-7-1, Fujishirodai, Suita, Osaka, Japan.,Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Naohiko Aihara
- Department of Arrhythmia and Electrophysiology, National Cerebral and Cardiovascular Center, 5-7-1, Fujishirodai, Suita, Osaka, Japan
| | - Takayuki Maki
- Department of Cardiology, Matsue Seikyo Hospital, Matsue, Japan
| | - Shiro Kamakura
- Department of Arrhythmia and Electrophysiology, National Cerebral and Cardiovascular Center, 5-7-1, Fujishirodai, Suita, Osaka, Japan
| | - Kengo Kusano
- Department of Arrhythmia and Electrophysiology, National Cerebral and Cardiovascular Center, 5-7-1, Fujishirodai, Suita, Osaka, Japan
| | - Kazuhiro Satomi
- Department of Arrhythmia and Electrophysiology, National Cerebral and Cardiovascular Center, 5-7-1, Fujishirodai, Suita, Osaka, Japan.,Department of Cardiology, Tokyo Medical University, Tokyo, Japan
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64
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Association of SCN10A Polymorphisms with the Recurrence of Atrial Fibrillation after Catheter Ablation in a Chinese Han Population. Sci Rep 2017; 7:44003. [PMID: 28281580 PMCID: PMC5345091 DOI: 10.1038/srep44003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 02/02/2017] [Indexed: 11/08/2022] Open
Abstract
The nonsynonymous SCN10A single nucleotide polymorphism (SNP) rs6795970 has been reported to associate with PR interval and atrial fibrillation (AF) and in strong linkage disequilibrium (LD) with the AF-associated SNP rs6800541. In this study, we investigated whether rs6795970 polymorphisms are associated with AF recurrence after catheter ablation. A total of 502 consecutive patients with AF who underwent catheter ablation were included. AF recurrence was defined as a documented episode of any atrial arrhythmias lasting ≥30 s after a blanking period of 3 months. AF recurrence was observed between 3 and 12 months after catheter ablation in 24.5% of the patients. There was a significant difference in the allele distribution (p = 7.86 × 10−5) and genotype distribution (p = 1.42 × 10−5) of rs6795970 between the AF recurrence and no recurrence groups. In a multivariate analysis, we identified the following independent predictors of AF recurrence: the rs6795970 genotypes in an additive model (OR 0.36, 95%CI 0.22~0.60, p = 7.04 × 10−5), a history of AF ≥36 months (OR 3.57, 95%CI 2.26~5.63, p = 4.33 × 10−8) and left atrial diameter (LAD) ≥40 mm (OR 1.85, 95%CI 1.08~3.19, p = 0.026). These data suggest that genetic variation in SCN10A may play an important role in predicting AF recurrence after catheter ablation in the Chinese Han population.
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Afzal MR, Samanta A, Chatta J, Ansari B, Atherton S, Sabzwari S, Turagam M, Lakkireddy D, Houmsse M. Adjunctive ablation strategies improve the efficacy of pulmonary vein isolation in non-paroxysmal atrial fibrillation: a systematic review and meta-analysis. Expert Rev Cardiovasc Ther 2017; 15:227-235. [DOI: 10.1080/14779072.2017.1294064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Muhammad R. Afzal
- Division of Cardiovascular Medicine, Department of Internal Medicine, Electrophysiology Section, Ross Heart Hospital, The Wexner Medical Center at the Ohio State University Medical Center, Columbus, OH, USA
| | - Anweshan Samanta
- Division of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Jawaria Chatta
- Division of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Brihh Ansari
- Division of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Sam Atherton
- Division of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Syed Sabzwari
- Division of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Mohit Turagam
- Division of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Dhanunjaya Lakkireddy
- Division of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Mahmoud Houmsse
- Division of Cardiovascular Medicine, Department of Internal Medicine, Electrophysiology Section, Ross Heart Hospital, The Wexner Medical Center at the Ohio State University Medical Center, Columbus, OH, USA
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66
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Han X, Li J. Catheter Ablation of Atrial Fibrillation: Where Are We? CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2017. [DOI: 10.15212/cvia.2016.0060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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67
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Jungen C, Scherschel K, Eickholt C, Kuklik P, Klatt N, Bork N, Salzbrunn T, Alken F, Angendohr S, Klene C, Mester J, Klöcker N, Veldkamp MW, Schumacher U, Willems S, Nikolaev VO, Meyer C. Disruption of cardiac cholinergic neurons enhances susceptibility to ventricular arrhythmias. Nat Commun 2017; 8:14155. [PMID: 28128201 PMCID: PMC5290156 DOI: 10.1038/ncomms14155] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 11/28/2016] [Indexed: 12/19/2022] Open
Abstract
The parasympathetic nervous system plays an important role in the pathophysiology of atrial fibrillation. Catheter ablation, a minimally invasive procedure deactivating abnormal firing cardiac tissue, is increasingly becoming the therapy of choice for atrial fibrillation. This is inevitably associated with the obliteration of cardiac cholinergic neurons. However, the impact on ventricular electrophysiology is unclear. Here we show that cardiac cholinergic neurons modulate ventricular electrophysiology. Mechanical disruption or pharmacological blockade of parasympathetic innervation shortens ventricular refractory periods, increases the incidence of ventricular arrhythmia and decreases ventricular cAMP levels in murine hearts. Immunohistochemistry confirmed ventricular cholinergic innervation, revealing parasympathetic fibres running from the atria to the ventricles parallel to sympathetic fibres. In humans, catheter ablation of atrial fibrillation, which is accompanied by accidental parasympathetic and concomitant sympathetic denervation, raises the burden of premature ventricular complexes. In summary, our results demonstrate an influence of cardiac cholinergic neurons on the regulation of ventricular function and arrhythmogenesis. Catheter ablation is a common therapy for atrial fibrillation but disrupts cardiac cholinergic neurons. Here the authors report that cholinergic neurons innervate heart ventricles and show that their ablation leads to increased susceptibility to ventricular arrhythmias in mouse models and in patients.
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Affiliation(s)
- Christiane Jungen
- Department of Cardiology-Electrophysiology, cardiac Neuro- and Electrophysiology Research Group (cNEP), University Heart Center, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, 13347 Berlin, Germany
| | - Katharina Scherschel
- Department of Cardiology-Electrophysiology, cardiac Neuro- and Electrophysiology Research Group (cNEP), University Heart Center, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, 13347 Berlin, Germany
| | - Christian Eickholt
- Department of Cardiology-Electrophysiology, cardiac Neuro- and Electrophysiology Research Group (cNEP), University Heart Center, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Pawel Kuklik
- Department of Cardiology-Electrophysiology, cardiac Neuro- and Electrophysiology Research Group (cNEP), University Heart Center, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Niklas Klatt
- Department of Cardiology-Electrophysiology, cardiac Neuro- and Electrophysiology Research Group (cNEP), University Heart Center, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, 13347 Berlin, Germany
| | - Nadja Bork
- DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, 13347 Berlin, Germany.,Institute of Experimental Cardiovascular Research, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Tim Salzbrunn
- Department of Cardiology-Electrophysiology, cardiac Neuro- and Electrophysiology Research Group (cNEP), University Heart Center, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Fares Alken
- Department of Cardiology-Electrophysiology, cardiac Neuro- and Electrophysiology Research Group (cNEP), University Heart Center, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Stephan Angendohr
- Department of Cardiology-Electrophysiology, cardiac Neuro- and Electrophysiology Research Group (cNEP), University Heart Center, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Christiane Klene
- Department of Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Janos Mester
- Department of Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Nikolaj Klöcker
- Institute of Neural and Sensory Physiology, Medical Faculty, University of Düsseldorf, Universitätsstrasse 1, 40225 Düsseldorf, Germany
| | - Marieke W Veldkamp
- Academic Medical Center, University of Amsterdam, Department of Clinical and Experimental Cardiology, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Udo Schumacher
- Institute of Anatomy and Experimental Morphology, University Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Stephan Willems
- Department of Cardiology-Electrophysiology, cardiac Neuro- and Electrophysiology Research Group (cNEP), University Heart Center, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, 13347 Berlin, Germany
| | - Viacheslav O Nikolaev
- DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, 13347 Berlin, Germany.,Institute of Experimental Cardiovascular Research, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Christian Meyer
- Department of Cardiology-Electrophysiology, cardiac Neuro- and Electrophysiology Research Group (cNEP), University Heart Center, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, 13347 Berlin, Germany
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68
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Chen YH, Lu ZY, Xiang Y, Hou JW, Wang Q, Lin H, Li YG. Cryoablation vs. radiofrequency ablation for treatment of paroxysmal atrial fibrillation: a systematic review and meta-analysis. Europace 2017; 19:784-794. [DOI: 10.1093/europace/euw330] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 09/19/2016] [Indexed: 12/31/2022] Open
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69
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Abstract
Ganglionated plexi (GP), consisting of conglomerations of autonomic ganglia on the epicardial surface of the heart, have been shown to play a significant role in different arrhythmias, including atrial fibrillation. GP ablation has become an adjunctive procedure in the treatment of atrial fibrillation, while it has been used successfully in preliminary studies in vasovagal syncope. This review will present the current data on the physiology and clinical applications of GP ablation in the treatment of atrial fibrillation and other diseases.
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Affiliation(s)
- Stavros Stavrakis
- University of Oklahoma Health Sciences Center,Oklahoma City, Oklahoma, USA
| | - Sunny Po
- University of Oklahoma Health Sciences Center,Oklahoma City, Oklahoma, USA
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70
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Buckley U, Rajendran PS, Shivkumar K. Ganglionated plexus ablation for atrial fibrillation: Just because we can, does that mean we should? Heart Rhythm 2017; 14:133-134. [PMID: 28007095 PMCID: PMC5378161 DOI: 10.1016/j.hrthm.2016.09.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Indexed: 11/23/2022]
Affiliation(s)
- Una Buckley
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Center of Excellence, Los Angeles, California
| | - Pradeep S Rajendran
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Center of Excellence, Los Angeles, California,; Molecular, Cellular and Integrative Physiology Program, David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Center of Excellence, Los Angeles, California,; Molecular, Cellular and Integrative Physiology Program, David Geffen School of Medicine, UCLA, Los Angeles, California.
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71
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Xhaet O, DE Roy L, Floria M, Deceuninck O, Blommaert D, Dormal F, Ballant E, LA Meir M. Integrity of the Ganglionated Plexi Is Essential to Parasympathetic Innervation of the Atrioventricular Node by the Right Vagus Nerve. J Cardiovasc Electrophysiol 2016; 28:432-437. [PMID: 28032928 DOI: 10.1111/jce.13156] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 12/12/2016] [Accepted: 12/27/2016] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Radiofrequency isolation of pulmonary vein can be accompanied by transient sinus bradycardia or atrioventricular nodal (AVN) block, suggesting an influence on vagal cardiac innervation. However, the importance of the atrial fat pads in relation with the vagal innervation of AVN in humans remains largely unknown. The aim of this study was to evaluate the role of ganglionated plexi (GP) in the innervation of the AVN by the right vagus nerve. METHODS AND RESULTS Direct epicardial high-frequency stimulation (HFS) of the GP (20 patients) and the right vagus nerve (10 patients) was performed before and after fat pad exclusion or destruction in 20 patients undergoing thoracoscopic epicardial ablation for the treatment of persistent AF. Asystole longer than 3 seconds or acute R-R prolongation over 25% was considered as a positive response to HFS. Prior to the ablation, positive responses to HFS were detected in 3 GPs in 7 patients (35%), 2 GPs in 5 patients (25%), and one GP in 8 patients (40%). After exclusion of the fat pads, all patients had a negative response to HFS. All the patients who exhibited a positive response to right vagus nerve stimulation (n = 10) demonstrated negative responses after the ablation. CONCLUSION The integrity of the GP is essential for the right vagus nerve to exert physiological effects of on AVN in humans.
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Affiliation(s)
- Olivier Xhaet
- Université catholique de Louvain, CHU UCL Namur, Département de médecine, Service de cardiologie, Unité de rythmologie, Yvoir, Belgium
| | - Luc DE Roy
- Université catholique de Louvain, CHU UCL Namur, Département de médecine, Service de cardiologie, Unité de rythmologie, Yvoir, Belgium
| | - Mariana Floria
- Université catholique de Louvain, CHU UCL Namur, Département de médecine, Service de cardiologie, Unité de rythmologie, Yvoir, Belgium.,Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Olivier Deceuninck
- Université catholique de Louvain, CHU UCL Namur, Département de médecine, Service de cardiologie, Unité de rythmologie, Yvoir, Belgium
| | - Dominique Blommaert
- Université catholique de Louvain, CHU UCL Namur, Département de médecine, Service de cardiologie, Unité de rythmologie, Yvoir, Belgium
| | - Fabien Dormal
- Université catholique de Louvain, CHU UCL Namur, Département de médecine, Service de cardiologie, Unité de rythmologie, Yvoir, Belgium
| | - Elisabeth Ballant
- Université catholique de Louvain, CHU UCL Namur, Département de médecine, Service de cardiologie, Unité de rythmologie, Yvoir, Belgium
| | - Mark LA Meir
- Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Centre for Cardiovascular Diseases, Brussels, Belgium
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72
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Stirbys P. Neuro-atriomyodegenerative origin of atrial fibrillation and superimposed conventional risk factors: continued search to configure the genuine etiology of "eternal arrhythmia". J Atr Fibrillation 2016; 9:1503. [PMID: 29250260 PMCID: PMC5673319 DOI: 10.4022/jafib.1503] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Revised: 12/19/2016] [Accepted: 12/22/2016] [Indexed: 01/26/2023]
Abstract
Atrial fibrillation (AF) is the most challenging rhythm disturbance worldwide. Arrhythmia and its behavior represent complex pathogenesis highly opposing to contemporary curative modalities. Increasing age of patients carries a certain level of risk for AF. Some underlying diseases in concordance with aging actually accelerate the occurrence of AF. Underestimated superimposed risk factors - aging plus any known risk factor or condition (hypertension, diabetes etc.) - elicit great interest and concern. In light of these concerns we offer an elaborated universal hypothesis in attempt to elucidate the genuine origin of AF substrate. Putative chronic toxicity - toxins and/or involution related pseudo-toxins potentially generate micro- and macro-structural changes in atrial myocardium thus inciting both intracellular damage (degeneration of myocites, apoptosis) and extracellular fibrotic proliferation (interstitial fibrosis, formation of matrices, degeneration of cells with fibrotic replacement). The co-products of related underlying diseases in cooperation with cellular senescence, endogenous overproduction of specific lipids/lipoproteins and other pro-atherosclerotic and/or inflammatory components generate a total atrial response - vascular/microvascular damage, intracellular and extracellular injuries. These organizational arrangements covering the entire atrial myocardium and perhaps ganglionated plexi/autonomic branches of the nervous system eventually cause clinical havoc - atrial overstretch, atrial adaptation/maladaptation, electromechanical dysfunction, arrhythmias, heart failure, etc. In essence, valvular heart disease potentially evokes similar changes "violating" thin atrial walls to obey the same scenario. Depicted atriomyodegenerative processes most likely represent the true nature of AF substrate development. Available clinical and morphological evidence potentially designates the atriomyodegenerative or plausible neuro-atriomyodegenerative origin of AF. Deductively fusion of reasons rather than purely heterogeneity is responsible for AF induction. Thus, the uniform approach and synoptic vision of clinical and pathohistological entity may offer an alternative or refreshed viewpoint in AF substrate formation.
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73
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Qin M, Liu X, Wu SH, Zhang XD. Atrial Substrate Modification in Atrial Fibrillation: Targeting GP or CFAE? Evidence from Meta-Analysis of Clinical Trials. PLoS One 2016; 11:e0164989. [PMID: 27764185 PMCID: PMC5072654 DOI: 10.1371/journal.pone.0164989] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 10/04/2016] [Indexed: 11/19/2022] Open
Abstract
Several clinically relevant outcomes post atrial substrate modification in patients with atrial fibrillation (AF) have not been systematically analyzed among published studies on adjunctive cardiac ganglionated plexi (GP) or complex fractionated atrial electograms (CFAE) ablation vs. pulmonary vein isolation (PVI) alone. Out of 176 reports identified, the present meta-analysis included 14 randomized and non-randomized controlled trials (1613 patients) meeting inclusion criteria. Addition of GP ablation to PVI significantly increased freedom from atrial tachyarrhythmia in short- (OR: 1.72; P = 0.003) and long-term (OR: 2.0, P = 0.0006) follow-up, while adjunctive CFAE ablation did not after one or repeat procedure (P<0.05). The percentage of atrial tachycardia or atrial flutter (AT/AFL) after one procedure was higher for CFAE than GP ablation. In sub-analysis of non-paroxysmal AF, relative to PVI alone, adjunctive GP but not CFAE ablation significantly increased sinus rhythm maintenance (OR: 1.88, P = 0.01; and OR:1.24, P = 0.18, respectively). Meta regression analysis of the 14 studies indicated that sample size was significant source of heterogeneity either in outcomes after one or repeat procedure. In conclusion, in patients with AF, adjunctive GP but not CFAE ablation appeared to significantly add to the beneficial effects on sinus rhythm maintenance of PVI ablation alone; and CFAE ablation was associated with higher incidence of subsequent AT/AFL.
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Affiliation(s)
- Mu Qin
- Department of Cardiology, Shanghai Chest Hospital Affiliated to Shanghai Jiaotong University, Shanghai 200030, China
| | - Xu Liu
- Department of Cardiology, Shanghai Chest Hospital Affiliated to Shanghai Jiaotong University, Shanghai 200030, China
- * E-mail:
| | - Shao-Hui Wu
- Department of Cardiology, Shanghai Chest Hospital Affiliated to Shanghai Jiaotong University, Shanghai 200030, China
| | - Xiao-Dong Zhang
- Department of Cardiology, Shanghai Chest Hospital Affiliated to Shanghai Jiaotong University, Shanghai 200030, China
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74
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Romanov A, Minin S, Breault C, Pokushalov E. Visualization and ablation of the autonomic nervous system corresponding to ganglionated plexi guided by D-SPECT 123I-mIBG imaging in patient with paroxysmal atrial fibrillation. Clin Res Cardiol 2016; 106:76-78. [PMID: 27752762 DOI: 10.1007/s00392-016-1045-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 10/11/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Alexander Romanov
- State Research Institute of Circulation Pathology, Novosibirsk, Russia.
| | - Stanislav Minin
- State Research Institute of Circulation Pathology, Novosibirsk, Russia
| | | | - Evgeny Pokushalov
- State Research Institute of Circulation Pathology, Novosibirsk, Russia
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75
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Jiang RH, Hu GS, Liu Q, Sheng X, Sun YX, Yu LU, Zhang P, Zhang ZW, Chen SQ, Ye Y, Zhu J, Fu GS, Jiang CY. Impact of Anatomically Guided Ganglionated Plexus Ablation on Electrical Firing from Isolated Pulmonary Veins. Pacing Clin Electrophysiol 2016; 39:1351-1358. [PMID: 27723101 DOI: 10.1111/pace.12957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 09/04/2016] [Accepted: 09/20/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND The mechanisms underlying atrial fibrillation (AF) initiation and pulmonary vein isolation (PVI) effectiveness remain unclear. Ganglionated plexus (GPs) have been implicated in AF initiation and maintenance. In this study, we evaluated the impact of GP ablation in patients with pulmonary vein (PV) firing after PVI. METHODS Patients with drug-refractory paroxysmal AF undergoing radiofrequency catheter ablation therapy with PVI were screened. Among 840 cases over a 3.75-year period, 12 cases were identified with persistent PV firing (left = 4 and right = 8) after PVI was achieved and left atrial sinus rhythm restored. Adjacent GP ablation was performed anatomically and followed if necessary by additional PV ablation. RESULTS In eight patients, PV firing was terminated during GP ablation outside of the circumferential ablation line. In one patient, additional PV ablation resulted in cessation of PV firing and in the remaining three patients, firing could not be terminated by GP ablation or additional PVI. CONCLUSION GP ablation outside of wide antral circumferential line frequently results in the cessation of rapid firing from electrically isolated PVs. These observations suggest that interactions between left atrium and PV beyond electrical conduction warrant consideration in AF mechanisms.
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Affiliation(s)
- Ru-Hong Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Gen-Sheng Hu
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Department of Cardiology, The First People's Hospital of Wuhu City, Anhui, China
| | - Qiang Liu
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xia Sheng
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ya-Xun Sun
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - L U Yu
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Pei Zhang
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zu-Wen Zhang
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shi-Quan Chen
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yang Ye
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jun Zhu
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Guo-Sheng Fu
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chen-Yang Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
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76
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Czick ME, Shapter CL, Silverman DI. Atrial Fibrillation: The Science behind Its Defiance. Aging Dis 2016; 7:635-656. [PMID: 27699086 PMCID: PMC5036958 DOI: 10.14336/ad.2016.0211] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 02/11/2016] [Indexed: 12/19/2022] Open
Abstract
Atrial fibrillation (AF) is the most prevalent arrhythmia in the world, due both to its tenacious treatment resistance, and to the tremendous number of risk factors that set the stage for the atria to fibrillate. Cardiopulmonary, behavioral, and psychological risk factors generate electrical and structural alterations of the atria that promote reentry and wavebreak. These culminate in fibrillation once atrial ectopic beats set the arrhythmia process in motion. There is growing evidence that chronic stress can physically alter the emotion centers of the limbic system, changing their input to the hypothalamic-limbic-autonomic network that regulates autonomic outflow. This leads to imbalance of the parasympathetic and sympathetic nervous systems, most often in favor of sympathetic overactivation. Autonomic imbalance acts as a driving force behind the atrial ectopy and reentry that promote AF. Careful study of AF pathophysiology can illuminate the means that enable AF to elude both pharmacological control and surgical cure, by revealing ways in which antiarrhythmic drugs and surgical and ablation procedures may paradoxically promote fibrillation. Understanding AF pathophysiology can also help clarify the mechanisms by which emerging modalities aiming to correct autonomic imbalance, such as renal sympathetic denervation, may offer potential to better control this arrhythmia. Finally, growing evidence supports lifestyle modification approaches as adjuncts to improve AF control.
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Affiliation(s)
| | | | - David I. Silverman
- Echocardiography Laboratory, Hartford Hospital, Hartford, CT 06106, USA.
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77
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Michaud GF, Kumar S. Surgical Ganglionic Plexus Ablation in Atrial Fibrillation. J Am Coll Cardiol 2016; 68:1166-1168. [DOI: 10.1016/j.jacc.2016.07.731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 07/20/2016] [Indexed: 10/21/2022]
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78
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Choi EK, Chen PS. Is the Atrial Neural Plexis a Therapeutic Target in Atrial Fibrillation? Methodist Debakey Cardiovasc J 2016; 11:82-6. [PMID: 26306124 DOI: 10.14797/mdcj-11-2-82] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Circumferential pulmonary vein isolation is the mainstay of atrial fibrillation (AF) ablation, but alternative approaches and techniques have been developed to improve the outcomes. One of these additional ablation targets are ganglionated plexi of the intrinsic cardiac autonomic system that contain a variety of sympathetic and parasympathetic neurons that communicate with the extrinsic cardiac autonomic nervous system. The ganglionated plexi of the heart do not serve as a simple relay station but could modulate the autonomic interaction between the extrinsic and intrinsic cardiac autonomic system. Intrinsic cardiac autonomic nerve activity is an invariable trigger of paroxysmal atrial tachyarrhythmia, including atrial fibrillation. Although multiple studies have shown that ganglionated plexi play an important role in initiating atrial fibrillation, there is no consensus on a standardized protocol for selecting target sites and determining how ganglionated plexi ablation can best be accomplished. Recent clinical trials have demonstrated the feasibility and efficacy of ganglionated plexi ablation in addition to pulmonary vein isolation, but novel technologies and strategies are necessary to improve the current ablation techniques in managing patients with atrial fibrillation. This review focuses on the relationship between atrial ganglionated plexi and atrial fibrillation and the potential benefits and limitations of ganglionated plexi ablation in the management of atrial fibrillation.
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Affiliation(s)
- Eue-Keun Choi
- Seoul National University Hospital, Seoul, Republic of Korea
| | - Peng-Sheng Chen
- Indiana University School of Medicine, Indianapolis, Indiana
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79
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Yang Y, Liu Q, Wu Z, Li X, Xiao Y, Tu T, Zhou S. Stiff Left Atrial Syndrome: A Complication Undergoing Radiofrequency Catheter Ablation for Atrial Fibrillation. J Cardiovasc Electrophysiol 2016; 27:884-9. [PMID: 26920815 DOI: 10.1111/jce.12966] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Revised: 01/28/2016] [Accepted: 02/15/2016] [Indexed: 11/30/2022]
Abstract
Radiofrequency catheter ablation for atrial fibrillation is an effective approach for treating atrial fibrillation. Its complications have attracted much attention, of which the stiff left atrial syndrome is a recently discovered complication that has not been completely understood. This study aims to investigate the concept, pathologic basis, clinical characteristics, predictors, and treatment protocols of the stiff left atrial syndrome after radiofrequency ablation for atrial fibrillation.
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Affiliation(s)
- Yufan Yang
- Cardiac Catheterization Lab of Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China.,Department of Cardiology of Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Qiming Liu
- Cardiac Catheterization Lab of Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China.,Department of Cardiology of Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Zhihong Wu
- Cardiac Catheterization Lab of Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China.,Department of Cardiology of Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Xuping Li
- Cardiac Catheterization Lab of Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China.,Department of Cardiology of Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Yichao Xiao
- Cardiac Catheterization Lab of Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China.,Department of Cardiology of Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Tao Tu
- Cardiac Catheterization Lab of Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China.,Department of Cardiology of Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Shenghua Zhou
- Cardiac Catheterization Lab of Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China.,Department of Cardiology of Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
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80
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SHARMA PARIKSHITS, KASIRAJAN VIGNESHWAR, ELLENBOGEN KENNETHA, KONERU JAYANTHIN. Interconnections between Left Atrial Ganglionic Plexi: Insights from Minimally Invasive Maze Procedures and Their Outcomes. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2016; 39:427-33. [DOI: 10.1111/pace.12823] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 01/17/2016] [Accepted: 01/19/2016] [Indexed: 12/01/2022]
Affiliation(s)
- PARIKSHIT S. SHARMA
- Division of Cardiology; Virginia Commonwealth University Medical Center; Richmond Virginia
| | - VIGNESHWAR KASIRAJAN
- Division of Cardiology; Virginia Commonwealth University Medical Center; Richmond Virginia
| | - KENNETH A. ELLENBOGEN
- Division of Cardiology; Virginia Commonwealth University Medical Center; Richmond Virginia
| | - JAYANTHI N. KONERU
- Division of Cardiology; Virginia Commonwealth University Medical Center; Richmond Virginia
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81
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Madhavan M, Venkatachalam KL, Swale MJ, Desimone CV, Gard JJ, Johnson SB, Suddendorf SH, Mikell SB, Ladewig DJ, Nosbush TG, Danielsen AJ, Knudson M, Asirvatham SJ. Novel Percutaneous Epicardial Autonomic Modulation in the Canine for Atrial Fibrillation: Results of an Efficacy and Safety Study. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2016; 39:407-17. [PMID: 26854009 DOI: 10.1111/pace.12824] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 12/24/2015] [Accepted: 01/28/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Endocardial ablation of atrial ganglionated plexi (GP) has been described for treatment of atrial fibrillation (AF). Our objective in this study was to develop percutaneous epicardial GP ablation in a canine model using novel energy sources and catheters. METHODS Phase 1: The efficacy of several modalities to ablate the GP was tested in an open chest canine model (n = 10). Phase 2: Percutaneous epicardial ablation of GP was done in six dogs using the most efficacious modality identified in phase 1 using two novel catheters. RESULTS Phase 1: Direct current (DC) in varying doses (blocking [7-12 μA], electroporation [300-500 μA], ablation [3,000-7,500 μA]), radiofrequency ablation (25-50 W), ultrasound (1.5 MHz), and alcohol (2-5 mL) injection were successful at 0/8, 4/12, 5/7, 3/8, 1/5, and 5/7 GP sites. DC (500-5,000 μA) along with alcohol irrigation was tested in phase 2. Phase 2: Percutaneous epicardial ablation of the right atrium, oblique sinus, vein of Marshall, and transverse sinus GP was successful in 5/6 dogs. One dog died of ventricular fibrillation during DC ablation at 5,000 μA. Programmed stimulation induced AF in six dogs, preablation and no atrial arrhythmia in three, flutter in one, and AF in one postablation. Heart rate, blood pressure, effective atrial refractory period, and local atrial electrogram amplitude did not change significantly postablation. Microscopic examination showed elimination of GP, and minimal injury to atrial myocardium. CONCLUSION Percutaneous epicardial ablation of GP using DC and novel catheters is safe and feasible and may be used as an adjunct to pulmonary vein isolation in the treatment of AF in order to minimize additional atrial myocardial ablation.
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Affiliation(s)
- Malini Madhavan
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - K L Venkatachalam
- Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Jacksonville, Florida.,Department of Surgical Research, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Susan B Johnson
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Scott H Suddendorf
- Department of Research Administrative Services, Mayo Clinic, Rochester, Minnesota
| | - Susan B Mikell
- Department of Research Administrative Services, Mayo Clinic, Rochester, Minnesota
| | - Dorothy J Ladewig
- Department of Research Administrative Services, Mayo Clinic, Rochester, Minnesota
| | | | | | - Mark Knudson
- Mayo Clinic, Rochester, Minnesota.,EnteroMedics, Inc, St. Paul, Minnesota
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82
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Kyriacou A, Hayat S, Qureshi N, Peters NS, Kanagaratnam P, Lim PB. Dissociated pulmonary vein potentials: Expression of the cardiac autonomic nervous system following pulmonary vein isolation? HeartRhythm Case Rep 2016; 1:401-405. [PMID: 26949598 PMCID: PMC4750876 DOI: 10.1016/j.hrcr.2015.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- Andreas Kyriacou
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Sajad Hayat
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Norman Qureshi
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Nicholas S Peters
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Prapa Kanagaratnam
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Phang Boon Lim
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Imperial College Healthcare NHS Trust, London, United Kingdom
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83
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van der Does LJME, Yaksh A, Kik C, Knops P, Lanters EAH, Teuwen CP, Oei FBS, van de Woestijne PC, Bekkers JA, Bogers AJJC, Allessie MA, de Groot NMS. QUest for the Arrhythmogenic Substrate of Atrial fibRillation in Patients Undergoing Cardiac Surgery (QUASAR Study): Rationale and Design. J Cardiovasc Transl Res 2016; 9:194-201. [PMID: 26935733 PMCID: PMC4873535 DOI: 10.1007/s12265-016-9685-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 02/17/2016] [Indexed: 01/19/2023]
Abstract
The heterogeneous presentation and progression of atrial fibrillation (AF) implicate the existence of different pathophysiological processes. Individualized diagnosis and therapy of the arrhythmogenic substrate underlying AF may be required to improve treatment outcomes. Therefore, this single-center study aims to identify the arrhythmogenic areas underlying AF by intra-operative, high-resolution, multi-site epicardial mapping in 600 patients with different heart diseases. Participants are divided into 12 groups according to the underlying heart diseases and presence of prior AF episodes. Mapping is performed with a 192-electrode array for 5–10 s during sinus rhythm and (induced) AF of the entire atrial surface. Local activation times are converted into activation and wave maps from which various electrophysiological parameters are derived. Postoperative cardiac rhythm registrations and a 5-year follow-up will show the incidence of postoperative and persistent AF. This project provides the first step in the development of a tool for individual AF diagnosis and treatment.
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Affiliation(s)
- Lisette J M E van der Does
- Translational Electrophysiology, Department of Cardiology, Erasmus Medical Center, Thorax Center, PO Box 2040, s Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Ameeta Yaksh
- Translational Electrophysiology, Department of Cardiology, Erasmus Medical Center, Thorax Center, PO Box 2040, s Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Charles Kik
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Paul Knops
- Translational Electrophysiology, Department of Cardiology, Erasmus Medical Center, Thorax Center, PO Box 2040, s Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Eva A H Lanters
- Translational Electrophysiology, Department of Cardiology, Erasmus Medical Center, Thorax Center, PO Box 2040, s Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Christophe P Teuwen
- Translational Electrophysiology, Department of Cardiology, Erasmus Medical Center, Thorax Center, PO Box 2040, s Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Frans B S Oei
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Jos A Bekkers
- 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
| | - Maurits A Allessie
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Natasja M S de Groot
- Translational Electrophysiology, Department of Cardiology, Erasmus Medical Center, Thorax Center, PO Box 2040, s Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.
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84
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Gaita F, Castagno D. Electrophysiologically Guided Substrate Modification During Sinus Rhythm: Personalized Approach to Nonparoxysmal Atrial Fibrillation. Circ Arrhythm Electrophysiol 2016; 9:e003832. [PMID: 26857910 DOI: 10.1161/circep.116.003832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Fiorenzo Gaita
- From the Division of Cardiology, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy.
| | - Davide Castagno
- From the Division of Cardiology, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Turin, Italy
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85
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Lemery R. Bradycardia with cooling and cryo: A reminder of the autonomic effects of cold stimuli on the heart. Heart Rhythm 2016; 13:1018-1019. [PMID: 26767424 DOI: 10.1016/j.hrthm.2015.12.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Indexed: 11/17/2022]
Affiliation(s)
- Robert Lemery
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Canada.
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86
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Putting together the clues of the everlasting neuro-cardiac liaison. BIOCHIMICA ET BIOPHYSICA ACTA-MOLECULAR CELL RESEARCH 2016; 1863:1904-15. [PMID: 26778332 DOI: 10.1016/j.bbamcr.2016.01.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 12/22/2015] [Accepted: 01/04/2016] [Indexed: 12/17/2022]
Abstract
Starting from the late embryonic development, the sympathetic nervous system extensively innervates the heart and modulates its activity during the entire lifespan. The distribution of myocardial sympathetic processes is finely regulated by the secretion of limiting amounts of pro-survival neurotrophic factors by cardiac cells. Norepinephrine release by the neurons rapidly modulates myocardial electrophysiology, and increases the rate and force of cardiomyocyte contractions. Sympathetic processes establish direct interaction with cardiomyocytes, characterized by the presence of neurotransmitter vesicles and reduced cell-cell distance. Whether such contacts have a functional role in both neurotrophin- and catecholamine-dependent communication between the two cell types, is poorly understood. In this review we will address the effects of the sympathetic neuron activity on the myocardium and the hypothesis that the direct neuro-cardiac contact might have a key role both in norepinephrine and neurotrophin mediated signaling. This article is part of a Special Issue entitled: Cardiomyocyte Biology: Integration of Developmental and Environmental Cues in the Heart edited by Marcus Schaub and Hughes Abriel.
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87
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Ripplinger CM, Noujaim SF, Linz D. The nervous heart. PROGRESS IN BIOPHYSICS AND MOLECULAR BIOLOGY 2016; 120:199-209. [PMID: 26780507 DOI: 10.1016/j.pbiomolbio.2015.12.015] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 12/29/2015] [Accepted: 12/31/2015] [Indexed: 12/23/2022]
Abstract
Many cardiac electrophysiological abnormalities are accompanied by autonomic nervous system dysfunction. Here, we review mechanisms by which the cardiac nervous system controls normal and abnormal excitability and may contribute to atrial and ventricular tachyarrhythmias. Moreover, we explore the potential antiarrhythmic and/or arrhythmogenic effects of modulating the autonomic nervous system by several strategies, including ganglionated plexi ablation, vagal and spinal cord stimulations, and renal sympathetic denervation as therapies for atrial and ventricular arrhythmias.
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Affiliation(s)
- Crystal M Ripplinger
- Department of Pharmacology, University of California Davis, 451 Health Sciences Drive, Davis, CA 95616, USA.
| | - Sami F Noujaim
- Molecular Pharmacology and Physiology, University of South Florida, 12901 Bruce B Downs Blvd, Tampa, FL 33612, USA.
| | - Dominik Linz
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, 66421 Homburg, Saar, Germany.
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88
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Syed FF, Oral H. Electrophysiological Perspectives on Hybrid Ablation of Atrial Fibrillation. J Atr Fibrillation 2015; 8:1290. [PMID: 27957227 DOI: 10.4022/jafib.1290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 10/05/2015] [Accepted: 12/14/2015] [Indexed: 12/14/2022]
Abstract
To overcome limitations of minimally invasive surgical ablation as a standalone procedure in eliminating atrial fibrillation (AF), hybrid approaches incorporating adjunctive endovascular catheter ablation have been proposed in recent years. The endovascular component targets residual conduction gaps and identifies additional electrophysiological targets with the goal of minimizing recurrent atrial arrhythmia. We performed a systematic review of published studies of hybrid AF ablation, analyzing 432 pooled patients (19% paroxysmal, 29% persistent, 52% long-standing persistent) treated using three different approaches: A. bilateral thoracoscopy with bipolar radiofrequency (RF) clamp-based approach; B. right thoracoscopic suction monopolar RF catheter-based approach; and C. subxiphoid posterior pericardioscopic ("convergent") approach. Freedom from recurrence off antiarrhythmic medications at 12 months was seen in 88.1% [133/151] for A, 73.4% [47/64] for B, and 59.3% [80/135] for C, with no significant difference between paroxysmal (76.9%) and persistent/long-standing persistent AF (73.4%). Death and major surgical complications were reported in 8.5% with A, 0% with B and 8.6% with C. A critical appraisal of hybrid ablation is presented, drawing from experiences and insights published over the years on catheter ablation of AF, with a discussion of the rationale underlying hybrid ablation, its strengths and limitations, where it may have a unique role in clinical management of patients with AF, which questions remain unanswered and areas for further investigation.
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Affiliation(s)
- Faisal F Syed
- Cardiac Arrhythmia Service, University of Michigan, Ann Arbor, MI
| | - Hakan Oral
- Cardiac Arrhythmia Service, University of Michigan, Ann Arbor, MI
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89
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Davies EJ, Lines I, Dalrymple Hay M, Haywood GA. The Late Electrophysiological Consequences Of Posterior Wall Isolation In Patients With Atrial Fibrillation. J Atr Fibrillation 2015; 8:1194. [PMID: 27957201 DOI: 10.4022/jafib.1194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 06/30/2015] [Accepted: 07/27/2015] [Indexed: 11/10/2022]
Abstract
INTRODUCTION There are many different lesion sets that are used for the surgical ablation of atrial fibrillation (AF). One such pattern is the 'box set', a single ring of scar delivered anterior to the pulmonary veins, which aims to electrically isolate the posterior wall from the rest of the heart. However it remains unclear whether posterior wall isolation (PWI) is an effective lesion set for maintenance of sinus rhythm and whether it is necessary to achieve complete bidirectional block. We investigated the long-term integrity of the 'box set' lesion created during surgical AF ablation by epicardial High Intensity Focussed Ultrasound (HIFU). All patients had documented persistent or recurrent paroxysmal AF prior to surgery. We correlated this with subsequent success or failure in the abolition of atrial fibrillation. METHODS With regional ethical and R&D approval, 101 patients who had previously undergone HIFU AF ablation greater than 4 years ago were screened for inclusion in the study. 17 patients agreed to late electrophysiological study: 11 with on-going AF and 6 in normal sinus rhythm. Clinical history and 7-day holters were used to define the NSR group. We performed a diagnostic EP study using a transseptal approach in fully anticoagulated patients (INR>2.0 and ACT maintained at >300s). A catheter was placed in the coronary sinus (CS) and a circular multipolar mapping catheter was used to map the left atrium and pulmonary veins. Patients in atrial fibrillation were cardioverted. We recorded whether posterior wall (PW) and pulmonary vein (PV) isolation had been achieved at the surgical procedure. In selected cases we recorded a voltage map using either CARTO (Biosense- Webster) or NavX (St Jude Medical) to identify areas of ablation scar. RESULTS All 11 patients with AF had absence of PW+PV isolation with fractionated electrograms recorded across the PW. In the 6 patients with long-term freedom from AF, PW+PV isolation was confirmed in 4 (67%) and in 1 there was prolonged conduction across the box-set lesion with CS to PW activation time of around 200ms versus 45ms from mid-CS to left atrial appendage. Of the 4 patients with confirmed PW+PV isolation, 1 had dissociated spontaneous atrial potentials within the box set area and the other 3 had electrical silence throughout with inability to capture the posterior wall pacing at 10mA at multiple sites. CONCLUSIONS There appears to be a clear correlation between the successful restoration of long-term sinus rhythm and isolation / delayed conduction from the pulmonary veins and posterior wall. Given the advent of hybrid atrial fibrillation ablation techniques designed to deliver this lesion set, these findings are timely and highly relevant.
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Affiliation(s)
- E J Davies
- South West Cardiothoracic Centre, Plymouth, PL6 8DH. UK
| | - I Lines
- South West Cardiothoracic Centre, Plymouth, PL6 8DH. UK
| | | | - G A Haywood
- South West Cardiothoracic Centre, Plymouth, PL6 8DH. UK
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90
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Sugimura S, Kurita T, Kaitani K, Yasuoka R, Miyazaki S. Ectopies from the superior vena cava after pulmonary vein isolation in patients with atrial fibrillation. Heart Vessels 2015; 31:1562-9. [PMID: 26518692 DOI: 10.1007/s00380-015-0767-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 10/16/2015] [Indexed: 11/26/2022]
Abstract
Episodes of atrial fibrillation (AF) are mainly initiated by triggers from pulmonary veins (PVs). The superior vena cava (SVC) has been identified as a second major substrate of non-PV foci, but the electrophysiologic features of the SVC have not been fully investigated. We hypothesized that SVC ectopies are suppressed by predominant features of PV ectopies and tend to appear after PV isolation (PVI). We evaluated the electrophysiological characteristics and clinical implications of SVC ectopies in patients with AF during catheter ablation using high-dose isoproterenol and the atrial overdrive pacing maneuver. The manifestation patterns and modes of onset (coupling interval and appearance interval) of ectopies from both the PVs and SVC were investigated. 205 patients were enrolled [153 males and 52 females; mean age 64 ± 10 years; paroxysmal in 143 patients (69.8 %), persistent in 40 (19.5 %), and long-standing persistent in 22 patients (10.7 %)]. Before PVI, PV ectopies were detected in 182/205 patients (89 %). SVC ectopies were rarely observed before PVI but were significantly more frequent after the completion of PVI (3/205 vs. 14/205 patients, p = 0.011). The coupling interval (CI) and % CI (CI/preceding the A-A interval × 100) of PV ectopies were significantly shorter than those of SVC ectopies (211 ± 78 vs. 282 ± 106 ms, p = 0.021, and 34 ± 9 vs. 51 ± 17 %, p < 0.001, respectively). The appearance intervals of the PV ectopies were shorter than those of the SVC ectopies (6.3 ± 4.0 vs. 10.7 ± 6.7 s, p = 0.030). During repeat procedures, PVs with reconnection to the left atrium were less frequently observed in patients with SVC firing than in patients without SVC firing (1.7 ± 1.5 vs. 2.9 ± 1.1 PVs, p = 0.029). We demonstrated that PVI tends to manifest SVC ectopies with less spontaneous activity and that an elimination of predominant ectopies from the PVs may affect appearance of SVC ectopy.
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Affiliation(s)
- Sousuke Sugimura
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kinki University, 377-2 Onohigashi, Osaka-Sayama, 589-8511, Osaka, Japan
- Department of Clinical Laboratory, Tenri Hospital, 200 Mishima-cho, Tenri, 632-8552, Nara, Japan
| | - Takashi Kurita
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kinki University, 377-2 Onohigashi, Osaka-Sayama, 589-8511, Osaka, Japan.
| | - Kazuaki Kaitani
- Department of Cardiology, Tenri Hospital, 200 Mishima-cho, Tenri, 632-8552, Nara, Japan
| | - Ryobun Yasuoka
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kinki University, 377-2 Onohigashi, Osaka-Sayama, 589-8511, Osaka, Japan
| | - Shunichi Miyazaki
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kinki University, 377-2 Onohigashi, Osaka-Sayama, 589-8511, Osaka, Japan
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91
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Pokushalov E, Kozlov B, Romanov A, Strelnikov A, Bayramova S, Sergeevichev D, Bogachev-Prokophiev A, Zheleznev S, Shipulin V, Lomivorotov VV, Karaskov A, Po SS, Steinberg JS. Long-Term Suppression of Atrial Fibrillation by Botulinum Toxin Injection Into Epicardial Fat Pads in Patients Undergoing Cardiac Surgery: One-Year Follow-Up of a Randomized Pilot Study. Circ Arrhythm Electrophysiol 2015; 8:1334-41. [PMID: 26486855 DOI: 10.1161/circep.115.003199] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Accepted: 08/27/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Animal models suggest that the neurotransmitter inhibitor, botulinum toxin, when injected into the epicardial fat pads can suppress atrial fibrillation inducibility. The aim of this prospective randomized double-blind study was to compare the efficacy and safety of botulinum toxin injection into epicardial fat pads for preventing atrial tachyarrhythmias. METHODS AND RESULTS Patients with history of paroxysmal atrial fibrillation and indication for coronary artery bypass graft surgery were randomized to botulinum toxin (Xeomin, Merz, Germany; 50 U/1 mL at each fat pad; n=30) or placebo (0.9% normal saline, 1 mL at each fat pad; n=30) injection into epicardial fat pads during surgery. Patients were followed for 1 year to assess maintenance of sinus rhythm using an implantable loop recorder. All patients in both groups had successful epicardial fat pad injections without complications. The incidence of early postoperative atrial fibrillation within 30 days after coronary artery bypass graft was 2 of 30 patients (7%) in the botulinum toxin group and 9 of 30 patients (30%) in the placebo group (P=0.024). Between 30 days and up to the 12-month follow-up examination, 7 of the 30 patients in the placebo group (27%) and none of the 30 patients in the botulinum toxin group (0%) had recurrent atrial fibrillation (P=0.002). There were no complications observed during the 1-year follow-up. CONCLUSIONS Botulinum toxin injection into epicardial fat pads during coronary artery bypass graft provided substantial atrial tachyarrhythmia suppression both early as well as during 1-year follow-up, without any serious adverse events. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01842529.
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Affiliation(s)
- Evgeny Pokushalov
- From the State Research Institute of Circulation Pathology, Novosibirsk, Russia (E.P., A.R., A.S., S.B., D.S., A.B.-P., S.Z., V.V.L., A.K.); Institute of Cardiology, Siberian Division of Russian Academy of Medical Sciences, Tomsk, Russia (B.K., V.S.); Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City (S.S.P.); and University of Rochester School of Medicine & Dentistry and the Arrhythmia Institute, The Valley Health System, New York, NY and Ridgewood, NJ (J.S.S.)
| | - Boris Kozlov
- From the State Research Institute of Circulation Pathology, Novosibirsk, Russia (E.P., A.R., A.S., S.B., D.S., A.B.-P., S.Z., V.V.L., A.K.); Institute of Cardiology, Siberian Division of Russian Academy of Medical Sciences, Tomsk, Russia (B.K., V.S.); Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City (S.S.P.); and University of Rochester School of Medicine & Dentistry and the Arrhythmia Institute, The Valley Health System, New York, NY and Ridgewood, NJ (J.S.S.)
| | - Alexander Romanov
- From the State Research Institute of Circulation Pathology, Novosibirsk, Russia (E.P., A.R., A.S., S.B., D.S., A.B.-P., S.Z., V.V.L., A.K.); Institute of Cardiology, Siberian Division of Russian Academy of Medical Sciences, Tomsk, Russia (B.K., V.S.); Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City (S.S.P.); and University of Rochester School of Medicine & Dentistry and the Arrhythmia Institute, The Valley Health System, New York, NY and Ridgewood, NJ (J.S.S.)
| | - Artem Strelnikov
- From the State Research Institute of Circulation Pathology, Novosibirsk, Russia (E.P., A.R., A.S., S.B., D.S., A.B.-P., S.Z., V.V.L., A.K.); Institute of Cardiology, Siberian Division of Russian Academy of Medical Sciences, Tomsk, Russia (B.K., V.S.); Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City (S.S.P.); and University of Rochester School of Medicine & Dentistry and the Arrhythmia Institute, The Valley Health System, New York, NY and Ridgewood, NJ (J.S.S.)
| | - Sevda Bayramova
- From the State Research Institute of Circulation Pathology, Novosibirsk, Russia (E.P., A.R., A.S., S.B., D.S., A.B.-P., S.Z., V.V.L., A.K.); Institute of Cardiology, Siberian Division of Russian Academy of Medical Sciences, Tomsk, Russia (B.K., V.S.); Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City (S.S.P.); and University of Rochester School of Medicine & Dentistry and the Arrhythmia Institute, The Valley Health System, New York, NY and Ridgewood, NJ (J.S.S.)
| | - David Sergeevichev
- From the State Research Institute of Circulation Pathology, Novosibirsk, Russia (E.P., A.R., A.S., S.B., D.S., A.B.-P., S.Z., V.V.L., A.K.); Institute of Cardiology, Siberian Division of Russian Academy of Medical Sciences, Tomsk, Russia (B.K., V.S.); Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City (S.S.P.); and University of Rochester School of Medicine & Dentistry and the Arrhythmia Institute, The Valley Health System, New York, NY and Ridgewood, NJ (J.S.S.)
| | - Alexander Bogachev-Prokophiev
- From the State Research Institute of Circulation Pathology, Novosibirsk, Russia (E.P., A.R., A.S., S.B., D.S., A.B.-P., S.Z., V.V.L., A.K.); Institute of Cardiology, Siberian Division of Russian Academy of Medical Sciences, Tomsk, Russia (B.K., V.S.); Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City (S.S.P.); and University of Rochester School of Medicine & Dentistry and the Arrhythmia Institute, The Valley Health System, New York, NY and Ridgewood, NJ (J.S.S.)
| | - Sergey Zheleznev
- From the State Research Institute of Circulation Pathology, Novosibirsk, Russia (E.P., A.R., A.S., S.B., D.S., A.B.-P., S.Z., V.V.L., A.K.); Institute of Cardiology, Siberian Division of Russian Academy of Medical Sciences, Tomsk, Russia (B.K., V.S.); Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City (S.S.P.); and University of Rochester School of Medicine & Dentistry and the Arrhythmia Institute, The Valley Health System, New York, NY and Ridgewood, NJ (J.S.S.)
| | - Vladimir Shipulin
- From the State Research Institute of Circulation Pathology, Novosibirsk, Russia (E.P., A.R., A.S., S.B., D.S., A.B.-P., S.Z., V.V.L., A.K.); Institute of Cardiology, Siberian Division of Russian Academy of Medical Sciences, Tomsk, Russia (B.K., V.S.); Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City (S.S.P.); and University of Rochester School of Medicine & Dentistry and the Arrhythmia Institute, The Valley Health System, New York, NY and Ridgewood, NJ (J.S.S.)
| | - Vladimir V Lomivorotov
- From the State Research Institute of Circulation Pathology, Novosibirsk, Russia (E.P., A.R., A.S., S.B., D.S., A.B.-P., S.Z., V.V.L., A.K.); Institute of Cardiology, Siberian Division of Russian Academy of Medical Sciences, Tomsk, Russia (B.K., V.S.); Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City (S.S.P.); and University of Rochester School of Medicine & Dentistry and the Arrhythmia Institute, The Valley Health System, New York, NY and Ridgewood, NJ (J.S.S.)
| | - Alexander Karaskov
- From the State Research Institute of Circulation Pathology, Novosibirsk, Russia (E.P., A.R., A.S., S.B., D.S., A.B.-P., S.Z., V.V.L., A.K.); Institute of Cardiology, Siberian Division of Russian Academy of Medical Sciences, Tomsk, Russia (B.K., V.S.); Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City (S.S.P.); and University of Rochester School of Medicine & Dentistry and the Arrhythmia Institute, The Valley Health System, New York, NY and Ridgewood, NJ (J.S.S.)
| | - Sunny S Po
- From the State Research Institute of Circulation Pathology, Novosibirsk, Russia (E.P., A.R., A.S., S.B., D.S., A.B.-P., S.Z., V.V.L., A.K.); Institute of Cardiology, Siberian Division of Russian Academy of Medical Sciences, Tomsk, Russia (B.K., V.S.); Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City (S.S.P.); and University of Rochester School of Medicine & Dentistry and the Arrhythmia Institute, The Valley Health System, New York, NY and Ridgewood, NJ (J.S.S.)
| | - Jonathan S Steinberg
- From the State Research Institute of Circulation Pathology, Novosibirsk, Russia (E.P., A.R., A.S., S.B., D.S., A.B.-P., S.Z., V.V.L., A.K.); Institute of Cardiology, Siberian Division of Russian Academy of Medical Sciences, Tomsk, Russia (B.K., V.S.); Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City (S.S.P.); and University of Rochester School of Medicine & Dentistry and the Arrhythmia Institute, The Valley Health System, New York, NY and Ridgewood, NJ (J.S.S.).
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Liu S, Jing Y, Zhang J, Bian C, Zhang YU, Zhang X. Does Anterior Fat Pad Removal Reduce the Incidence of Atrial Fibrillation after CABG? A Meta-Analysis of Randomized Controlled Trials. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 38:1363-8. [PMID: 26293995 DOI: 10.1111/pace.12740] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 08/12/2015] [Accepted: 08/03/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is a common complication after coronary artery bypass grafting (CABG). Several prospective randomized controlled trials (RCTs) have evaluated the effect of intact and removed anterior fat pads on the incidence of AF after CABG with conflicting results. We collected these RCTs and conducted a meta-analysis to determine whether anterior fat pad removal is effective in preventing the new onset of AF after CABG. METHODS AND RESULTS Prospective RCTs were collected for analysis and the main outcomes include the occurrence of AF after CABG, total hospital stay, and major complications. Statistical analysis was conducted using RevMan 5.0.18 software (The Cochrane Collaboration), and pooled estimates of the effect were reported as risk ratios (RRs) or mean differences (MDs) with their 95% confidence intervals (CIs). The results of this meta-analysis indicate that anterior fat pad removal was not associated with a decreased risk of occurrence of AF after CABG (RR = 1.34, 95% CI: 0.88-2.03; P = 0.18), and it also did not increase the risk of major complications (RR = 1.05, 95% CI: 0.75-1.47; P = 0.79) or lengthen total hospital stay (MD = 0.06, 95% CI: -0.46 to 0.58; P = 0.83) compared with the control group. CONCLUSION Anterior fat pad removal did not decrease the risk of the occurrence of AF after CABG despite its safety and convenience, and it should not be used to prevent new-onset AF after CABG unless new evidence is provided.
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Affiliation(s)
- Shanxin Liu
- Department of Cardiology, the Affiliated Hospital of Hangzhou Normal University, Hangzhou, Zhejiang Province, China
| | - Yunyan Jing
- Department of Cardiology, the Affiliated Hospital of Hangzhou Normal University, Hangzhou, Zhejiang Province, China
| | - Juhong Zhang
- Department of Cardiology, the Affiliated Hospital of Hangzhou Normal University, Hangzhou, Zhejiang Province, China
| | - Chang Bian
- Department of Cardiology, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Y U Zhang
- Department of Cardiology, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Xingwei Zhang
- Department of Cardiology, the Affiliated Hospital of Hangzhou Normal University, Hangzhou, Zhejiang Province, China
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93
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Rivarola E, Hardy C, Sosa E, Hachul D, Furlan V, Raimundi F, Scanavacca M. Selective atrial vagal denervation guided by spectral mapping to treat advanced atrioventricular block. Europace 2015; 18:445-9. [PMID: 26071235 DOI: 10.1093/europace/euv142] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 04/24/2015] [Indexed: 11/13/2022] Open
Abstract
AIMS Asymptomatic nocturnal long ventricular pauses are usually detected accidentally and it has been suggested that they may lead to sudden death. Identification of predisposing factors could prevent cardiovascular events. METHODS AND RESULTS We report the case of a patient with frequent asymptomatic nocturnal ventricular pauses of 3-11 s, characteristic of a vagally mediated atrioventricular (AV) block. Echocardiography, treadmill test, thyroid function test levels, and polysomnogram were normal. In an attempt to reduce the risk, it was decided that an atrial vagal denervation induced by radiofrequency (RF) ablation (cardioneuroablation) could be useful. Spectral mapping was used to localize endocardial vagal innervation in the right and left aspects of the inter-atrial septum, responsible for the sinus node and AV node modulation, and RF pulses were applied in those sites only. After finishing the procedure, significant changes were observed in the heart rate (66-90 b.p.m.), atrial-His interval (115-74 ms), Wenckebach cycle length (820-570 ms), and sinus node recovery time (1100-760 ms). Follow-up Holter recording demonstrated that the number of ventricular pauses had reduced from 438 to 0. Heart rate and time domain characteristics were compatible with vagal denervation. CONCLUSION Ablation of the endocardial vagal innervation sites seems to be safe and efficient in reducing the frequency and the length of the ventricular pauses. It was possible by identifying certain spectral components of the atrial electrogram, resulting in a conservative approach.
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Affiliation(s)
- Esteban Rivarola
- Unidade Clínica de Arritmia, Heart Institute, University of São Paulo Medical School, Av Dr Eneas Carvalho de Aguiar 44, CEP 05403-000 São Paulo, Brazil Totalcor Hospital, São Paulo, Brazil
| | - Carina Hardy
- Unidade Clínica de Arritmia, Heart Institute, University of São Paulo Medical School, Av Dr Eneas Carvalho de Aguiar 44, CEP 05403-000 São Paulo, Brazil Totalcor Hospital, São Paulo, Brazil
| | - Eduardo Sosa
- Unidade Clínica de Arritmia, Heart Institute, University of São Paulo Medical School, Av Dr Eneas Carvalho de Aguiar 44, CEP 05403-000 São Paulo, Brazil Totalcor Hospital, São Paulo, Brazil
| | - Denise Hachul
- Unidade Clínica de Arritmia, Heart Institute, University of São Paulo Medical School, Av Dr Eneas Carvalho de Aguiar 44, CEP 05403-000 São Paulo, Brazil Totalcor Hospital, São Paulo, Brazil
| | | | - Fabrizio Raimundi
- Unidade Clínica de Arritmia, Heart Institute, University of São Paulo Medical School, Av Dr Eneas Carvalho de Aguiar 44, CEP 05403-000 São Paulo, Brazil
| | - Mauricio Scanavacca
- Unidade Clínica de Arritmia, Heart Institute, University of São Paulo Medical School, Av Dr Eneas Carvalho de Aguiar 44, CEP 05403-000 São Paulo, Brazil Totalcor Hospital, São Paulo, Brazil
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94
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Lim PB, Kanagaratnam P. The left atrial neural network: more complicated than we thought? Future Cardiol 2015; 11:251-4. [PMID: 26021626 DOI: 10.2217/fca.15.21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Phang Boon Lim
- 1Imperial College Healthcare NHS Trust and Imperial College London, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Prapa Kanagaratnam
- 1Imperial College Healthcare NHS Trust and Imperial College London, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
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95
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Sharma T, Scherlag BJ, Nakagawa H, Jackman WM, Lazzara R, Po SS. Catheter ablation for atrial fibrillation in a subset of patients with concomitant hypertension. World J Hypertens 2015; 5:98-103. [DOI: 10.5494/wjh.v5.i2.98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 01/11/2015] [Accepted: 02/12/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To study patients with atrial fibrillation and hypertension who had successful catheter ablation for changes in blood pressure 1 year later.
METHODS: A retrospective study was performed on patients who had catheter ablation for atrial fibrillation (AF) and hypertension (HTN) which included local autonomic ganglionated plexi denervation and pulmonary veins isolation. Of the records of 119 patients, follow-up data was found in order to determine the presence of sinus rhythm and data on systolic (SBP) and diastolic blood pressure at 2 wk, 3 mo, 6 mo and 1 year after the ablation procedure. Transthoracic echocardiograms were taken at the time of the catheter procedure to determine left atrial dimensions (LADs) and left ventricular size.
RESULTS: There was no significant difference in the pre-ablation mean blood pressures between the two groups (P = 0.08). After 1 year 33 of the 60 with AF and HTN were in sinus rhythm, of whom 12 had normal LADs, ≤ 4 cm Group 1, and 21 had enlarged left atria (LADs > 4 cm, Group 2). For Group 1, at 1 year of follow up, there was a significant difference in the SBP (119.2 ± 13 mmHg) compared to pre-ablation (142.6 ± 13.7 mmHg, P = 0.001). For Group 2, there was no significant difference in the SBP, pre-ablation (130.3 ± 17.5 mmHg) and at 1 year of follow up (130.4 ± 13.4 mmHg, P = 0.75). All patients were on similar anti-hypertensive medications. There was a trend for a greater left ventricular size in Group 2 compared to Group 1.
CONCLUSION: We suggest that Group 1 had HTN due to sympathetic hyperactivity, neurogenic HTN; whereas HTN in Group 2 was based on arterial vasoconstriction.
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96
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Gelsomino S, Lozekoot P, La Meir M, Lorusso R, Lucà F, Rostagno C, Renzulli A, Parise O, Matteucci F, Gensini GF, Crjins HJGM, Maessen JG. Is ganglionated plexi ablation during Maze IV procedure beneficial for postoperative long-term stable sinus rhythm? Int J Cardiol 2015; 192:40-8. [PMID: 25985014 DOI: 10.1016/j.ijcard.2015.04.259] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 04/15/2015] [Accepted: 04/30/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND We investigated the role of surgical ablation targeting the autonomous nervous system during a Cox-Maze IV procedure in the maintenance of sinus rhythm at long-term follow-up. METHODS The patient population consisted of 519 subjects with persistent or long-standing persistent atrial fibrillation (AF) undergoing radiofrequency Maze IV during open heart surgery between January 2006 and July 2013 at three institutions without (Group 1) or with (Group 2) ganglionated plexi (GP) ablation. Recurrence of atrial fibrillation off-antiarrhythmic drugs was the primary outcome. Predictors of AF recurrence were evaluated by means of competing risk regression. Median follow-up was 36.7 months. RESULTS The percentage of patients in normal sinus rhythm (NSR) off-antiarrhythmic drugs did not differ between groups (Group 1-75.5%, Group 2-67.8%, p = 0.08). Duration of AF ≥ 38 months (p = 0.01), left atrial diameter ≥ 54 mm (0.001), left atrial area ≥ 33 cm(2) (p = 0.005), absence of connecting lesions (p= 0.04), and absence of right atrial ablation (p < 0.001) were independently associated with high incidence of AF recurrence. In contrast the absence of GP ablation was not a significant factor (p = 0.12). CONCLUSIONS GP ablation did not prove to be beneficial for postoperative stable NSR. A complete left atrial lesion set and biatrial ablation are advisable for improving rhythm outcomes. Randomized controlled trials are necessary to confirm our findings.
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Affiliation(s)
- Sandro Gelsomino
- University Hospital Maastricht, The Netherlands; Careggi Hospital, Florence Italy.
| | | | | | | | - Fabiana Lucà
- University Hospital Maastricht, The Netherlands; Careggi Hospital, Florence Italy
| | | | | | - Orlando Parise
- University Hospital Maastricht, The Netherlands; Careggi Hospital, Florence Italy
| | - Francesco Matteucci
- University Hospital Maastricht, The Netherlands; Careggi Hospital, Florence Italy
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97
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Radio frequency responsive nano-biomaterials for cancer therapy. J Control Release 2015; 204:85-97. [DOI: 10.1016/j.jconrel.2015.02.036] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 02/27/2015] [Accepted: 02/28/2015] [Indexed: 12/25/2022]
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98
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Krummen DE, Hebsur S, Salcedo J, Narayan SM, Lalani GG, Schricker AA. Mechanisms Underlying AF: Triggers, Rotors, Other? CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015; 17:371. [PMID: 25778423 DOI: 10.1007/s11936-015-0371-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OPINION STATEMENT There is ongoing debate regarding the precise mechanisms underlying atrial fibrillation (AF). An improved understanding of these mechanisms is urgently needed to improve interventional strategies to suppress and eliminate AF, since the success of current strategies is suboptimal. At present, guidelines for AF ablation focus on pulmonary vein (PV) isolation for the prevention of arrhythmia. Additional targets are presently unclear, and include additional linear ablation and electrogram-guided substrate modification, without clear mechanistic relevance. PV and non-PV triggers are likely central in the first few seconds of AF initiation. Rapid activation from such triggers interacts with transitional mechanisms including conduction velocity slowing, action potential duration (APD) alternans, and steep APD restitution to cause conduction block and initiate functional reentry. However, complete suppression of potential triggers has proven elusive, and the intra-procedural mapping and targeting of transitional mechanisms has not been reported. A growing body of research implicates electrical rotors and focal sources as central mechanisms for the maintenance of AF. In several recent series, they were observed in nearly all patients with sustained arrhythmia. Ablation of rotor and focal source sites, prior to pulmonary vein isolation, substantially modulated atrial fibrillation in a high proportion of patients, and improved ablation outcomes versus pulmonary vein isolation alone. These results have subsequently been confirmed in multicenter series, and the improved outcomes have been found to persist to a mean follow-up of 3 years. Recently, rotors have been observed by multiple groups using diverse technologies. These findings represent a paradigm shift in AF, focusing on sustaining mechanisms, as is currently done with other arrhythmias such as atrioventricular node reentrant tachycardia. Studies are currently underway to assess the optimal strategy for the application of rotor-based ablation in AF management, including clinical trials on the relative efficacy of rotor-only ablation versus PVI-only ablation, which will inform future practice guidelines.
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Affiliation(s)
- David E Krummen
- University of California San Diego and VA San Diego Healthcare System, 3350 La Jolla Village Drive, Cardiology Section 111A, San Diego, CA, 92161, USA,
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Stavrakis S, Nakagawa H, Po SS, Scherlag BJ, Lazzara R, Jackman WM. The role of the autonomic ganglia in atrial fibrillation. JACC Clin Electrophysiol 2015; 1:1-13. [PMID: 26301262 DOI: 10.1016/j.jacep.2015.01.005] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Recent experimental and clinical studies have shown that the epicardial autonomic ganglia play an important role in the initiation and maintenance of atrial fibrillation (AF). In this review, we present the current data on the role of the autonomic ganglia in the pathogenesis of AF and discuss potential therapeutic implications. Experimental studies have demonstrated that acute autonomic remodeling may play a crucial role in AF maintenance in the very early stages. The benefit of adding ablation of the autonomic ganglia to the standard pulmonary vein (PV) isolation procedure for patients with paroxysmal AF is supported by both experimental and clinical data. The interruption of axons from these hyperactive autonomic ganglia to the PV myocardial sleeves may be an important factor in the success of PV isolation procedures. The vagus nerve exerts an inhibitory control over the autonomic ganglia and attenuation or loss of this control may allow these ganglia to become hyperactive. Autonomic neuromodulation using low-level vagus nerve stimulation inhibits the activity of the autonomic ganglia and reverses acute electrical atrial remodeling during rapid atrial pacing and may provide an alternative non-ablative approach for the treatment of AF, especially in the early stages. This notion is supported by a preliminary human study. Further studies are warranted to confirm these findings.
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Affiliation(s)
- Stavros Stavrakis
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Hiroshi Nakagawa
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Sunny S Po
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Benjamin J Scherlag
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Ralph Lazzara
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Warren M Jackman
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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Park J, Pak HN. Elimination Of Triggers Without An Additional Substrate Modification Is Not Sufficient In Patients With Persistent Atrial Fibrillation. J Atr Fibrillation 2015; 7:1207. [PMID: 27957155 DOI: 10.4022/jafib.1207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 01/30/2015] [Accepted: 01/30/2015] [Indexed: 11/10/2022]
Abstract
Atrial fibrillation (AF) is a multifactorial disease with complex pathophysiology. Although restoring sinus rhythm delays the progression of atrial remodeling, non-pharmacologic intervention, such as radiofrequency catheter ablation (RFCA), should be done based on the background pathophysiology of the disease. While circumferential pulmonary vein isolation (CPVI) has been known to be the cornerstone of AF catheter ablation, a clinical recurrence rate after CPVI is high in patients with persistent AF (PeAF). Step-wise linear ablation, complex fractionate atrial electrogram (CFAE)-guided ablation, rotor ablation, ganglionate plexus ablation, and left atrial appendage isolation may improve the ablation success rate after CPVI. But, there are still substantial AF recurrences after such liberal atrial substrate ablation, and current ablation techniques regarding substrate modification still have limitations. Therefore, more understanding about AF pathophysiology and early precise intervention may improve clinical outcome of AF management. Keeping in mind "more touch, more scar," operators should generate most efficient substrate modification to achieve better long-term clinical outcome.
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Affiliation(s)
- Junbeom Park
- Yonsei University Health System, Seoul, Republic of Korea
| | - Hui-Nam Pak
- Yonsei University Health System, Seoul, Republic of Korea
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