Selective in situ parasympathetic control of the canine sinoatrial and atrioventricular nodes

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

INTRODUCTION

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

METHODS AND RESULTS

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

CONCLUSION

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

Persistent inappropriate sinus tachycardia after radiofrequency ablation of left lateral accessory pathway

A patient with palpitations and narrow QRS tachycardia was evaluated. In the EP study an atrioventricular reentrant tachycardia mediated by a left lateral accessory pathway was identified and catheter ablation was performed with success. A week later she returned with palpitations and pre-syncope. The resting ECG showed a sinus tachycardia with 110 bpm. After unsuccessful clinical treatment with beta-blockers, diltiazem and digoxin she underwent sinus node modification using radiofrequency catheter ablation with success. We postulated that RF application to ablate the lateral accessory pathway damaged the parasympathetic innervation in the left atrioventricular groove, causing inappropriate sinus tachycardia.

Electrical and hemodynamic function produced by stimulation of atropine sensitive right ventricular nerves in humans

In mammalian ventricles including humans, it is recognized that parasympathetic ganglia innervate the heart. Little is known about the location and function of right ventricular parasympathetic nerves in humans. We hypothesized that in humans: (1) there are parasympathetic ganglia that supply the right ventricle that can be stimulated via an endocardial catheter and (2) stimulation of these fibers will alter the electrical and hemodynamic function of the right ventricle. Parasympathetic nerve stimulation was performed via an endocardial catheter placed along several sites of the right ventricle, superior vena cava, and right internal jugular area in humans. The spatial extent of parasympathetic innervation was mapped in 1-cm zones across the right ventricle. Cardiac output, heart rate, and atrioventricular conduction were monitored to provide independent assessment of parasympathetic innervation. In all 22 patients, ventricular refractoriness shortened from 12 +/- 3 to 3 +/- 1 ms during parasympathetic nerve stimulation, and the greatest shortening of refractoriness was observed at the base of the right ventricle (p = 0.01). No significant shortening in ventricular refractoriness occurred in areas beyond 2 cm from the right ventricular base. These results were compared by using T table test. The parasympathetic nerve stimulation protocol decreased cardiac output, reaffirming the principle effect of parasympathetic ganglia. Atropine was administered in seven patients. All effects from nerve stimulation were abolished after atropine administration. These results were also compared by using T table test. These data provide the first demonstration of the electrical and hemodynamic function by stimulation of atropine sensitive nerves of the human right ventricle. Greater understanding of parasympathetic innervation may lead to novel therapies for arrhythmias.

Interactive atrial neural network: Determining the connections between ganglionated plexi

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

The neural basis of atrial fibrillation

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

CLINICAL STUDIES

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

BASIC STUDIES

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

The intrinsic cardiac nervous system and atrial fibrillation

PURPOSE OF REVIEW

Radiofrequency ablation techniques to cure cardiac arrhythmias have focused on destroying myocardial tissue involved in abnormal excitation or conduction. This review will address recent basic and clinical studies which suggest that targeting autonomic nerves and ganglia on the large vessels and the heart, within the pericardium, can result in cardiac arrhythmia suppression with little, if any, damage to healthy myocardium.

RECENT FINDINGS

Basic reports have shown that electrical stimulation of autonomic nerves on the heart itself can facilitate the induction of atrial fibrillation. The initial investigations found that the lowest threshold for inducing atrial fibrillation was at the entrances of the pulmonary veins. Moreover, beta-blockade blunted this response whereas atropine abolished atrial fibrillation inducibility. Subsequent studies found that ganglionated plexi clustered at the pulmonary vein entrances (within fat pads) could be stimulated without atrial excitation. Now, premature beats induced in the pulmonary veins could be converted to atrial fibrillation with a significantly greater propensity than without ganglionated plexi stimulation. Furthermore, ablation of these ganglionated plexi abolished atrial fibrillation inducibility. Clinical studies have been forthcoming clearly implicating these intrinsic cardiac ganglia in clinical atrial fibrillation.

SUMMARY

Previous ablation procedures have focused on destroying myocardial sites that participated in the initiation and perpetuation of various tachyarrhythmias. New basic and clinical findings may allow targeting autonomic elements at a few specific sites on the heart that are directly related to arrhythmia formation, thereby reducing extensive damage to healthy myocardium.

Ablation of Atrial Fibrillation

Due in large part to the growing dissatisfaction with traditional pharmacologic approaches to atrial fibrillation (AF) management, and fueled by both the fruits of basic and clinical investigation into the nature of AF initiation and maintenance and the explosive development in catheter-based technologies, AF ablation has matured from a purely investigational technique to a viable--and often preferred--strategy for treating patients suffering from this arrhythmia. Future insights and developments will help us refine our treatment strategies, making AF ablation safer, faster, and more effective. As the prevalence of AF in the general population continues to expand, the goal of optimizing our approach to AF becomes ever more important--and more pressing.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

EXPERIMENTAL STUDIES

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

CLINICAL STUDIES

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

CONCLUSIONS

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

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Experimental model of inappropriate sinus tachycardia: initiation and ablation

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Autonomically Induced Conversion of Pulmonary Vein Focal Firing Into Atrial Fibrillation

OBJECTIVES

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

"Cardioneuroablation"--new treatment for neurocardiogenic syncope, functional AV block and sinus dysfunction using catheter RF-ablation

Cardiac neuroablation is a new technique for management of patients with dominantly adverse parasympathetic autonomic influence. The technique is based on radiofrequency (RF) ablation of autonomic connections in the three main ganglia around the heart. Their connections are identified by Fast-Fourier Transforms (FFTs) of endocardial signals: sites of autonomic nervous connections show fractionated signals with FFTs shifted to the right. In contrast, normal myocardium without these connections does not show these features. RF-ablation is thought to inflict permanent damage on the parasympathetic autonomic influence because its cells are adjacent to the heart whereas sympathetic cells are remote. Twenty-one patients with a mean age of 48 years, neurally mediated reflex syncope in six, functional high grade atrioventricular block in seven and sinus node dysfunction in 13 (there is overlap between the second and third groups) were treated. Follow-up for a mean of 9.2 months demonstrated success in all cases with relief of symptoms. No complications occurred.

Time Course and Predictors of Autonomic Dysfunction After Ablation of the Slow Atrioventricular Nodal Pathway

Withdrawal of parasympathetic tone has been reported after ablation in the posteroseptal right atrium and has been attributed to injury of vagal efferent fibers. The purpose of this study was to assess the time course and predictors of autonomic dysfunction after slow pathway ablation. In 30 patients with AV nodal reentrant tachycardia, time- and frequency-domain measures of heart rate variability (HRV) were measured before, 30 minutes after, and 1 day after slow pathway ablation. There were significant reductions in mean RR interval (724 +/- 163 vs 836 +/- 164 ms, P < 0.05), SD of RR intervals (29 +/- 17 vs 40 +/- 18 ms, P < 0.05), root mean squared difference (15 +/- 8 vs 29 +/- 17 ms, P < 0.05), and high frequency power (4.1 +/- 0.4 vs 4.5 +/- 0.6 log10ms2, P < 0.05) 30 minutes after ablation. However, these parameters returned to baseline 1 day after ablation. Multivariate regression identified isoproterenol dose during the diagnostic study (P = 0.02) and radiofrequency duration (P = 0.02) as statistically significant predictors of heart rate change (R2= 0.45). These findings suggest that changes in autonomic tone after ablation in the posteroseptal right atrium are transitory and resolve within 1 day of the procedure. These short-term changes may be related to procedural variables rather than direct injury to vagal efferent fibers.

Ventricular rate control during atrial fibrillation and AV node modifications: past, present, and future

Atrial fibrillation (AF) is the most common arrhythmia. Currently there are two broad strategic treatment options for AF: rhythm control and rate control. For rhythm control, the treatment is directed toward restoring and maintaining the sinus rhythm. For rate control, the intention is to slow ventricular rate while allowing AF to continue. In both cases anticoagulation therapy is recommended. The results of currently available clinical trials demonstrated clearly that rate control is not inferior to rhythm control. Thus, rate control is an acceptable primary therapy for many AF patients. The rate control can be achieved essentially by depressing or modifying the filtering properties of the atrioventricular (AV) node. This can be attained by medications that depress the impulse transmission within the AV node, by anatomic modification of the AV communications, as well as by autonomic manipulations that produce AV node negative dromotropic effect. We are reviewing current clinical and newer experimental modalities aimed at enhancing the lifesaving function of this remarkable nodal structure.

Parasympathetic cardiac nerve stimulation with implanted coronary sinus lead

A patient with drug-refractory paroxysmal atrial fibrillation associated with rapid ventricular rate underwent biatrial pacemaker implantation. During elective replacement of the pacemaker, a significant voltage- and frequency-dependent decrease in ventricular rate was achieved by high-frequency electrical stimulation (17 Hz) of parasympathetic cardiac nerves innervating the AV node with the implanted bipolar coronary sinus electrode. The negative dromotropic effect of parasympathetic stimulation was eliminated by intravenous administration of 1-mg atropine.

Endovascular stimulation of autonomic neural elements in the superior vena cava using a flexible loop catheter

It has been previously shown that parasympathetic nerve stimulation (PNS) can be achieved via basket electrode catheters (BEC) positioned in the superior vena cava (SVC). Since questions have been raised regarding formation of thrombi between and/or on the splines of the BECs, we investigated the use of a flexible loop "Lasso" catheter (LC) to achieve autonomic nerve stimulation in the SVC without clot formation. In 5 dogs, anesthetized with Na-pentobarbital, standard ECG leads II and aVR, blood pressure and right atrial electrograms were continuously monitored. The LC is a 7-French catheter at the end of which is a circular ring, 25 mm in diameter, equipped with ten 1-mm electrodes. The circular loop is made of a flexible, shape retaining, covered metal, which can be straightened in order to be inserted transvenously. The catheter was inserted through a sheath in the external jugular vein and positioned in the SVC. Stimulation was performed sequentially across each of the five bipolar pairs of electrodes, and consisted of square wave stimuli, each 0.1 msec duration, frequency 20 Hz at voltages from 1-40 V. The average voltage required to produce a 50% decrease in heart rate was 15 +/- 7 V, compared to 22 +/- 12 V with the standard BEC and 10 +/- 5 V with a modified BEC. We did not observe any thrombus formation at the end of a four-hour period during which the catheter was stabilized in the SVC. PNS can be achieved safely and effectively by the LC in the SVC in dogs.

Optimal ventricular rate slowing during atrial fibrillation by feedback AV nodal-selective vagal stimulation

Although the beneficial effects of ventricular rate (VR) slowing during atrial fibrillation (AF) are axiomatic, the precise relationship between VR and hemodynamics has not been determined. We hypothesized that selective atrioventricular node (AVN) vagal stimulation (AVN-VS) by varying the nerve stimulation intensity could achieve precise graded slowing and permit evaluation of an optimal VR during AF. The aims of the present study were the following: 1) to develop a method for computerized vagally controlled VR slowing during AF, 2) to determine the hemodynamic changes at each level of VR slowing, and 3) to establish the optimal anterograde VR during AF. AVN-VS was delivered to the epicardial fat pad that projects parasympathetic nerve fibers to the AVN in 14 dogs. Four target average VR levels, corresponding to 75%, 100%, 125%, and 150% of the sinus cycle length (SCL), were achieved by computer feedback algorithm. VR slowing resulted in improved hemodynamics and polynomial fit analysis found an optimum for the cardiac output at VR slowing of 87% SCL. We conclude that this novel method can be used to maintain slow anterograde conduction with best hemodynamics during AF.

Selective AV nodal vagal stimulation improves hemodynamics during acute atrial fibrillation in dogs

Although the atrioventricular node (AVN) plays a vital role in blocking many of the atrial impulses from reaching the ventricles during atrial fibrillation (AF), a rapid irregular ventricular rate nevertheless persists. The goals of the present study were to explore the feasibility of novel epicardial selective vagal nerve stimulation for slowing of the ventricular rate during AF and to characterize the hemodynamic benefits in vivo. Electrophysiological-echocardiographic experiments were performed on 11 anesthetized open-chest dogs. Hemodynamic measurements were performed during three distinct periods: 1) sinus rate, 2) AF, and 3) AF with vagal nerve stimulation. AF was associated with significant deterioration of all measured parameters (P < 0.025). The vagal nerve stimulation produced slowing of the ventricular rate, significant reversal of the pressure and contractile indexes (P < 0.025), and a sharp reduction in one-half of the abortive ventricular contractions. The present study provides comprehensive evidence that slowing of the ventricular rate during AF by selective ganglionic stimulation of the vagal nerves that innervate the AVN successfully improved the hemodynamic responses.

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

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Transvenous parasympathetic nerve stimulation in the inferior vena cava and atrioventricular conduction

INTRODUCTION

In previous reports, we demonstrated a technique for parasympathetic nerve stimulation (PNS) within the superior vena cava, pulmonary artery, and coronary sinus to control rapid ventricular rates during atrial fibrillation (AF). In this report, we describe another vascular site, the inferior vena cava (IVC), at which negative dromotropic effects during AF could consistently be obtained. Moreover, stimulation at this site also induced dual AV nodal electrophysiology.

METHODS AND RESULTS

PNS was performed in ten dogs using rectangular stimuli (0.1 msec/20 Hz) delivered through a catheter with an expandable electrode basket at its tip. Within 3 minutes and without using fluoroscopy, the catheter was positioned at an effective PNS site in the IVC at the junction of the right atrium. AF was induced and maintained by rapid atrial pacing. During stepwise increase of the PNS voltage from 2 to 34 V, a graded response of ventricular rate slowing during AF was observed (266 +/- 79 msec without PNS vs 1,539 +/- 2,460 msec with PNS at 34 V; P = 0.005 by analysis of variance), which was abolished by atropine and blunted by hexamethonium. In three animals, PNS was performed during sinus rhythm. Dual AV nodal electrophysiology was present in 1 of 3 dogs in control, whereas with PNS, dual AV nodal electrophysiology was observed in all three dogs. PNS did not significantly change sinus rate or arterial blood pressure during ventricular pacing.

CONCLUSION

Stable and consistent transvenous electrical stimulation of parasympathetic nerves innervating the AV node can be achieved in the IVC, a transvenous site that is rapidly and readily accessible. The proposed catheter approach for PNS can be used to control ventricular rate during AF in this animal model.

Ventricular rate control during atrial fibrillation by cardiac parasympathetic nerve stimulation: a transvenous approach

OBJECTIVES

To identify intravascular sites for continuous, stable parasympathetic stimulation (PS) in order to control the ventricular rate during atrial fibrillation (AF).

BACKGROUND

Ventricular rate control during AF in patients with congestive heart failure is a significant clinical problem because many drugs that slow the ventricular rate may depress ventricular function and cause hypotension. Parasympathetic stimulation can exert negative dromotropic effects without significantly affecting the ventricles.

METHODS

In 22 dogs, PS was performed using rectangular stimuli (0.05 ms duration, 20 Hz) delivered through a catheter with an expandable electrode-basket at its end. The catheter was positioned either in the superior vena cava (SVC, n = 6), coronary sinus (CS, n = 10) or right pulmonary artery (RPA, n = 6). The basket was then expanded to obtain long-term catheter stability. Atrial fibrillation was induced and maintained by rapid atrial pacing.

RESULTS

Nonfluoroscopic (SVC) and fluoroscopic (CS/RPA) identification of effective intravascular PS sites was achieved within 3 to 10 min. The ventricular rate slowing effect during AF started and ceased immediately after on-offset of PS, respectively, and could be maintained over 20 h. In the SVC, at least a 50% increase of ventricular rate (R-R) intervals occurred at 22 +/- 11 V (331 +/- 139 ms to 653 +/- 286 ms, p < 0.001), in the CS at 16 +/- 10 V (312 +/- 102 ms vs. 561 +/- 172 ms, p < 0.001) and in the RPA at 18 +/- 7 V (307 +/- 62 ms to 681 +/- 151 ms, p < 0.001). Parasympathetic stimulation did not change ventricular refractory periods.

CONCLUSIONS

Intravascular PS results in a significant ventricular rate slowing during AF in dogs. This may be beneficial in patients with AF and rapid ventricular response since many drugs that decrease atrioventricular conduction have negative inotropic effects which could worsen concomitant congestive heart failure.

Transvenous parasympathetic cardiac nerve stimulation: an approach for stable sinus rate control

INTRODUCTION

Epicardial electrical stimulation of parasympathetic nerves innervating the sinus node has been shown to decrease sinus rate. We investigated whether intravascular parasympathetic cardiac nerve stimulation (IPS) can be achieved over a relatively long-term period to slow the supraventricular rate.

METHODS AND RESULTS

Fifteen dogs were investigated. IPS was performed with rectangular stimuli (0.05-msec duration, 20 Hz) using a catheter with an expandable electrode basket. The catheter was positioned in the superior vena cava (SVC; n = 9) or right pulmonary artery (RPA; n = 6). The basket then was expanded to hold the catheter in place. Nonfluoroscopic identification of effective IPS sites was achieved within 5 minutes in the SVC. Increasing IPS voltage resulted in a graded response of supraventricular rate slowing. A 50% prolongation of the baseline atrial cycle length was achieved with 28 V in the SVC (1,056 +/- 355 msec vs 489 +/- 154 msec; P < 0.001) and 25 V in the RPA (1,181 +/- 306 msec vs 518 +/- 138 msec; P < 0.01). The rate slowing started immediately after IPS onset, terminated abruptly after IPS cessation, and could be maintained over 10 hours. A rate slowing effect also was observed when the sinus rate was increased by isoproterenol (SVC: 304 +/- 8 msec/RPA: 341 +/- 9 msec with isoproterenol vs SVC: 635 +/- 12 msec with isoproterenol + IPS at 39 V/ RPA: 584 +/- 16 msec with isoproterenol + IPS at 38 V; n = 6).

CONCLUSION

IPS results in a significant supraventricular rate slowing that is stable over a relatively long period and may be applied to slow undesirable sinus tachycardia in acute ischemic syndromes or to counteract undesirable chronotropic effects of catecholamines during treatment of cardiogenic or septic shock and acute congestive heart failure.

Characterization of sinoatrial parasympathetic innervation in humans

INTRODUCTION

The response to sinoatrial parasympathetic nerve stimulation (shortened atrial refractoriness) was used to determine the atrial distribution of these nerve fibers in humans. We hypothesized that, in humans, parasympathetic nerves that innervate the sinoatrial node also innervate the right atrium and that the greatest density of innervation is near the sinoatrial nodal fat pad.

METHODS AND RESULTS

Temporary epicardial wire electrodes were sutured in pairs in the sinoatrial nodal fat pad, high right atrium, and right ventricle by direct visualization during coronary artery bypass surgery in nine patients. Appropriate electrode placement was confirmed by electrically stimulating the fat pad in the operating room to prolong sinus cycle length by 50%. Experiments were performed in the electrophysiology laboratory 1 to 5 days after surgery. Programmed atrial stimulation was performed via an endocardial electrode catheter advanced to the right atrium. The catheter tip electrode was moved in 1-cm concentric zones around the epicardial wires by fluoroscopic guidance. Atrial refractoriness was determined in the presence and absence of sinoatrial parasympathetic nerve stimulation at each catheter site. In 8 of 9 patients, parasympathetic nerve stimulation reproducibly prolonged sinus cycle length by 50%. There was no effect on AV nodal conduction (no prolongation of PR interval) and no change in AV nodal refractoriness. Atrial effective refractory periods reproducibly shortened in response to parasympathetic nerve stimulation in 1-cm zones up to 3 cm surrounding the fat pad, by a mean (+/- SEM) of 26.6+/-4.3 msec (zone 1), 11.4+/-1.8 msec (zone 2), and 10.0+/-2.5 msec (zone 3), respectively (P = 0.0001). At distances > 3 cm from the fat pad, the effective refractory period did not shorten.

CONCLUSION

Stimulation of parasympathetic nerves that innervate the sinoatrial node shortened atrial refractoriness in humans.

Absence of significant changes in heart rate variability after slow pathway ablation of AV nodal reentrant tachycardia by using serial Holter recordings

BACKGROUND

Persistent inappropriate sinus tachycardia may evolve as a complication after radiofrequency (RF) fast pathway ablation of atrioventricular nodal reentrant tachycardia (AVNRT). Parasympathetic denervation may serve as one of the possible mechanisms. We performed a study to show the prevalence of this phenomenon in RF ablation of the slow pathway.

METHODS AND RESULTS

Thirty-three patients (25 women, 8 men) aged 53 +/- 16 years were investigated. A median of 3 pulses was used to selectively modify or ablate the slow pathway and render AVNRT noninducible. Heart rate (HR) and different indexes in the time and frequency domain of heart rate variability were evaluated in serial 24-hour Holter recordings. Data were obtained 1 day, 1 month, and 3 months after the procedure and compared with preablation values. Despite a trend of increasing HR and decreasing heart rate variability within the first month after RF ablation, no significant changes were detected.

CONCLUSIONS

RF ablation of the slow pathway in AVNRT does not change parameters of HR and heart rate variability significantly by means of serial 24-hour Holter recordings.

Intracardiac stimulation of human parasympathetic nerve fibers induces negative dromotropic effects: implication with the lesions of radiofrequency catheter ablation

INTRODUCTION

The dromotropic effects of intracardiac parasympathetic nerve stimulation have not been well studied; furthermore, the effects of radiofrequency ablation lesions on parasympathetic nerve stimulation are not clear.

METHODS AND RESULTS

Group I: intracardiac electrical stimulation in the right posteroseptal and anteroseptal areas under different stimulation strengths; group II: intracardiac electrical stimulation before and 10 minutes after intravenous propranolol; group III: intracardiac electrical stimulation before and 5 minutes after intravenous atropine. Among the 10 patients with AV nodal reentrant tachycardia (group IV) and the 10 patients with atrial flutter (group V), atrial fibrillation was induced before and after successful ablation, and intracardiac electrical stimulation in the right posteroseptal area was performed before and after successful ablation. The maximal response and complete decay of the response occurred within 2 to 6 seconds of initiation or termination of parasympathetic nerve stimulation. This negative dromotropic effect disappeared after atropine was administered, but not after propranolol. After successful ablation, parasympathetic stimulation still induced negative dromotropic effects.

CONCLUSION

Electrical stimulation of parasympathetic nerve fibers near the posteroseptal and anteroseptal areas could induce a negative dromotropic effect, and this effect was preserved after successful radiofrequency ablation of slow pathway and isthmus conduction.

An increase in sinus rate following radiofrequency energy application in the posteroseptal space

An increase in sinus rate has been previously described in patients with AV node reentry (AVNRT) following successful AV node modification. This increase could either be a specific sign of elimination of slow pathway conduction or it could be a consequence of energy application in the posteroseptal area. Thus, we compared the changes in sinus cycle length following successful slow pathway ablation (defined as complete elimination of dual AV node physiology) in patients having AVNRT with those in patients undergoing successful ablation of a posteroseptal atrioventricular accessory connection. Twenty five patients (16 women and 9 men, mean age 41 +/- 4 years) with typical AVNRT (cycle length 378 +/- 12 ms) and 29 patients (16 women and 13 men, age 34 +/- 5 years) with an accessory connection (17 manifest and 12 concealed) were studied. The electrophysiology study was performed during sedation with Fentanyl and Midazolam. The mean number of energy applications was 3 +/- 1 for successful slow pathway ablation and 4 +/- 1 for successful ablation of the accessory connection (p:NS). Following the successful energy application, the sinus cycle length decreased significantly 776 ms at baseline to 691 ms in patients with AVNRT. Following successful ablation of the posteroseptal AC, sinus cycle length decreased from 755 ms at baseline to 664 ms (p < 0.05 in both groups [difference between groups not significant]). The decrease in sinus cycle length did not correlate with the number of RF energy applications required for successful ablation or the total energy delivered. In conclusion, ablation of the AV node slow pathway and a posteroseptal accessory connection results in similar increases in the sinus rate. Thus, the increase in sinus rate is probably due to energy application in the posteroseptal space, possibly due to concomitant destruction of vagal inputs, and it is not specific for elimination of slow pathway conduction.

Effects of ionic channel antagonists barium, cesium, and UL-FS-49 on vagal slowing of atrial rate in dogs

In response to a brief vagal stimulus, the atrial rate initially slows, then transiently accelerates, and slows a second time. We determined the effects of three antagonists to two ionic channels on this characteristic triphasic pacemaker response. Brief bursts of vagal stimulation were delivered to anesthetized dogs, and atrial cycle lengths were recorded. Either barium, cesium, or UL-FS-49 was administered. Barium, which primarily blocks the acetylcholine-sensitive potassium current (IK,ACh), attenuated the initial vagally induced bradycardia by > 50% without affecting the subsequent acceleration or the secondary slowing. Cesium and UL-FS-49 [both of which primarily block the pacemaker current (If)] did not affect the initial vagal slowing of atrial rate but abolished the acceleratory portion of the response. The secondary slowing was abolished by cesium but not by UL-FS-49. We conclude that the initial rapid atrial response to acetylcholine is mediated mainly by the IK,ACh, with little contribution from the If. The subsequent acceleration is mediated by activation of the If.

Increase in heart rate after radiofrequency catheter ablation is mediated by parasympathetic nervous withdrawal and related to site of ablation

To assess the mechanism for the increased sinus rate after radiofrequency catheter ablation performed for atrioventricular nodal reentrant tachycardia (AVNRT), we studied heart rate variability before and after radiofrequency catheter ablation in 17 patients with AVNRT and in 38 patients with an accessory pathway. The accessory pathway was located at the left ventricular free wall, the right ventricular free wall, or the posterior interventricular septum. An increased sinus rate was observed in patients with AVNRT or with the accessory pathway at the posterior septum or left free wall after radiofrequency ablation. In these groups, high-frequency power, root mean square of successive difference and percent of adjacent cycles that were more than 50 ms apart, all of which are indices reflecting parasympathetic nervous activity, were decreased. The ratio of low-frequency to high-frequency power reflecting sympathovagal balance, was increased in patients with AVNRT or with an accessory pathway at the posterior septum or left free wall. Increases in sinus rate were correlated with decreases in high-frequency power, and percent of adjacent cycles more than 50 ms apart that the increase in heart rate was due to parasympathetic nervous withdrawal.

Assessment of atrioventricular nodal electrophysiological characteristics after radiofrequency catheter ablation of the slow pathway in atrioventricular nodal reentrant tachycardia--3-month follow up

Radiofrequency catheter ablation of the slow pathway is commonly used to treat atrioventricular (AV) nodal reentrant tachycardia. However, there has been little study of the follow-up assessment of AV nodal physiology. We compared AV nodal electrophysiological characteristics before, immediately after, and again 3 months after successful catheter ablation in 17 patients (mean age 50 +/- 16 years). Sinus cycle length, Wenckebach cycle length, A-H interval at a paced cycle length of 600 ms, effective refractory period and functional refractory period of the fast pathway were significantly changed immediately after catheter ablation, but had recovered 3 months after the procedure. There were no significant differences between the electrophysiological parameters immediately after catheter ablation and those 3 months after the procedure under the intravenous injection of atropine sulfate. We conclude that, due to changes in autonomic nervous tone, AV nodal electrophysiological characteristics are influenced immediately after catheter ablation of the slow pathway in AV nodal reentrant tachycardia.

Regional distribution of atrial electrical changes induced by stimulation of extracardiac and intracardiac neural elements

Autonomic nerves and intrinsic cardiac neural elements are known to influence the electrophysiologic and dynamic properties of the heart. This study describes the regional distribution in the canine atria of electrophysiologic effects induced by stimulation of the right and left cervical vagosympathetic complexes, the right atrial ganglionated plexus, and the right and left stellate ganglia. Local atrial effects were determined from changes in QRST area of unipolar electrograms recorded from multiple sites with plaque electrodes sewn onto the atria in 16 anesthetized dogs.

RESULTS

(1) Although being very consistent in any given preparation, atrial changes varied between animals when similar neural structures were stimulated. (2) Among the common features identified between preparations, consistent effects were induced by neural stimulation in the region of the sinus node, indicating that this atrial region is the most richly innervated. (3) All other regions of the atria could be affected by stimulation of either right-sided or left-sided efferent nerves. (4) Responses to right atrial ganglionated plexus stimulation after atropine administration indicated that the corresponding fat pad contains both sympathetic and parasympathetic neural elements.

CONCLUSION

This study demonstrates that there is considerable overlapping of atrial innervation affecting all regions of the atria, as well as the sinus node region.

Elucidation of Prinzmetal's variant form of preexcitation

BACKGROUND

In 1952, Prinzmetal induced preexcitation in the normal dog heart using subthreshold stimulation (SS) delivered to the right ventricle.

METHODS AND RESULTS

In 12 dogs we recorded ECG leads II, aVR, His (Hb) and proximal right bundle potentials with electrode catheters at the aortic root and a special electrode that was inserted through the right ventricular (RV) free wall. In 12 others, SS was delivered to the Hb area by a catheter placed under the septal leaflet of the tricuspid valve. During SS, the HV interval shortened from 35 +/- 4 milliseconds (mean +/- SD) to 19 +/- 7 milliseconds (P = .0001), but AH intervals were unchanged. The ECG showed delta waves with aberrant QRS complexes. Endocardial electrograms showed that the origin of activation in the preexcitation beats was localized to the muscle adjacent to the Hb or proximal right bundle. When vagal stimulation induced sudden AV block, no ventricular excitation was seen, confirming the subthreshold nature of the applied stimulation. By adjusting the levels of SS, latent forms of preexcitation could be induced, eg, early local septal muscle activation but no change in the ECG leads. Premature ventricular stimuli delivered to the RV apex or outflow tract could cause manifest preexcitation in the ECG leads or inhibit expression of latent preexcitation in endocardial recordings.

CONCLUSIONS

SS delivered to the RV apex or Hb area causes ventricular preexcitation, as shown previously by Prinzmetal et al. SS delivered at the insertion sites of an accessory pathway may facilitate localization of such abnormal connections, particularly when preexcitation is concealed.

Alterations of heart rate and of heart rate variability after radiofrequency catheter ablation of supraventricular tachycardia. Delineation of parasympathetic pathways in the human heart

BACKGROUND

Persistent inappropriate sinus tachycardia has been reported as a complication after radiofrequency (RF) ablation of the fast atrioventricular (AV) nodal pathway. The purpose of this study was to evaluate the prevalence of this complication and its mechanism using heart rate variability analysis.

METHODS AND RESULTS

Time and frequency domain analysis of heart rate was performed in the electrophysiology laboratory immediately before and immediately after RF ablation in 64 patients with supraventricular tachycardia. Ablation targets in these 64 patients included the fast AV nodal pathway (n = 3), the slow AV nodal pathway (n = 14), a posteroseptal accessory pathway (n = 23), and a left lateral accessory pathway (n = 24). A control group of 21 patients undergoing diagnostic study but not ablation underwent identical analysis immediately before and at the conclusion of their procedure. Patients undergoing ablation also had time and frequency domain analysis performed on ambulatory 24-hour Holter tapes recorded before ablation and at 1 day, 1 month, and 6 months after ablation. Compared with preablation values, time domain analysis immediately after ablation revealed a significant increase in mean heart rate and significant reductions in heart rate variability expressed as SD, MSSD, and PNN50 in patients undergoing AV nodal modification or posteroseptal accessory pathway ablation. Frequency domain analysis revealed marked attenuation of high frequency (0.15 to 0.40 Hz) components, indicating parasympathetic denervation. These acute changes were not seen after ablation of left lateral accessory pathways or after diagnostic study without ablation. Time and frequency domain analysis of 24-hour ambulatory Holter monitors performed serially after ablation revealed resolution of abnormalities of heart rate and of heart rate variability 1 to 6 months after ablation, with reappearance of the high frequency parasympathetic component suggestive of reinnervation.

CONCLUSIONS

RF ablation in the anterior, mid, and posterior regions of the low interatrial septum may disrupt preganglionic or postganglionic parasympathetic fibers located in these regions that are destined to innervate the sinus node. Such fibers become more scarce along the left AV groove with increasing distance from the posteroseptal space. Parasympathetic denervation may be one mechanism for persistent inappropriate sinus tachycardia after RF ablation.

Effects of intense antecedent sympathetic stimulation on sympathetic neurotransmission in the heart

We studied the effects of intense sympathetic stimulation on the chronotropic responses of the heart to subsequent test stimulations of the cardiac autonomic nerves in dogs anesthetized with alpha-chloralose. Such intense sympathetic stimulations (which we refer to as "release stimulations") are known to release neuropeptide Y as well as norepinephrine. The changes in cardiac cycle length evoked by vagal and sympathetic test stimulations were progressively more attenuated as we increased the frequency and duration of the antecedent sympathetic release stimulations. We found that 2.5 minutes after a maximal release stimulation (30 Hz for 5 minutes), the mean +/- SEM chronotropic responses to the vagal and sympathetic test stimulations were diminished to 36.5 +/- 1.6% and 54.7 +/- 1.3% respectively, of the prestimulation responses. The mean times for the chronotropic responses to the vagal and sympathetic test stimulations to recover to their control values were 52.0 +/- 1.3 and 63.2 +/- 2.9 minutes, respectively. This enduring effect suggests the action of a neuropeptide, such as neuropeptide Y. Phentolamine potentiated the inhibitory effects of the sympathetic release stimulations. The chronotropic responses to isoproterenol infusions were not affected appreciably by antecedent sympathetic release stimulation. We conclude, therefore, that the inhibitory effects of antecedent sympathetic release stimulation on cardiac sympathetic neurotransmission are mediated prejunctionally, probably via an inhibition of the neuronal release of norepinephrine by neuropeptide Y.

Sequence of excitation as a factor in sympathetic-parasympathetic interactions in the heart

We determined the influence of differences in the time of initiation of sympathetic and vagal stimulation (both at 10 Hz) on the cardiac autonomic interactions in 16 open-chest anesthetized dogs. We always ended the concurrent sympathetic and vagal stimulations simultaneously. Sympathetic stimulation alone for 1 minute increased heart rate by 90 +/- 7 (mean +/- SEM) beats per minute, and vagal stimulation alone for 1 minute decreased heart rate by 67 +/- 5 beats per minute; i.e., the algebraic sum of these responses was an increase of 23 beats per minute. However, combined sympathetic and vagal stimulation for 1 minute actually decreased heart rate by 35 beats per minute; i.e., the vagal effects predominated. When vagal stimulation was initiated first, the chronotropic responses to combined stimulation were not significantly affected by the duration of antecedent vagal stimulation. However, when sympathetic stimulation was initiated first, the vagal predominance (disparity between the summated individual responses and the combined response) progressively diminished as we increased the duration of antecedent sympathetic stimulation. The vagal predominance diminished from a value of 67 +/- 21 beats per minute when the stimulations were initiated simultaneously to a value of 37 +/- 21 beats per minute when the duration of antecedent sympathetic stimulation was 10 minutes. Sympathetic stimulation releases not only norepinephrine but also neuropeptide Y, and this neuropeptide inhibits vagal neurotransmission. Our data suggest, therefore, that the longer the antecedent sympathetic stimulation, the greater the inhibition of vagal neurotransmission (presumably by the neuropeptide Y) and, therefore, the less pronounced the vagal predominance.

Human cardiac nerve stimulation

Cardiovascular responses were elicited in 12 patients undergoing cardiac operations when cardiopulmonary neural elements between the aortic root and pulmonary artery or in the right atrial ganglionated plexus were stimulated. Heart rate and left ventricular intramyocardial systolic pressure were augmented when cardiopulmonary nerves between the aorta and pulmonary artery were stimulated in 11 of the 12 patients. Right ventricular intramyocardial systolic pressure was augmented in 7 of these 11 patients. Cardiodepressor responses were elicited when the right atrial ganglionated plexus (9 patients) or a cardiopulmonary nerve (2 patients) was stimulated. These results demonstrate that electrical stimulation of the human extrinsic and intrinsic cardiac nervous systems can alter cardiodynamics, different responses being elicited when different neural structures are stimulated. These data are in accord with those obtained from canine experiments and suggest that the human extrinsic and intrinsic cardiac nervous system contains functionally similar neural elements to those found in other mammals.

Selective stimulation of parasympathetic nerve fibers to the human sinoatrial node

BACKGROUND

In animals, parasympathetic nerve fibers that innervate the sinoatrial node can be selectively stimulated to increase atrial cycle length. These nerve fibers course through an epicardial fat pad at the margin of the right superior pulmonary vein, the superior vena cava, and the right atrium. We hypothesized that similar nerves exist and can be selectively stimulated in humans.

METHODS AND RESULTS

Microscopic examination of fat pads excised from the margin of the right superior pulmonary vein, the superior vena cava, and the right atrium during two human autopsies revealed the presence of nerve fibers and ganglia. We electrically stimulated this epicardial fat pad in 16 patients during cardiac surgery. The fat pads were stimulated with continuous-pulse trains for 15 seconds via a hand-held bipolar electrode using constant current (10-15 mA), constant pulse width (0.02-0.05 msec), and at 6.6, 10, 20, 25, and 30 Hz. The mean atrial cycle length +/- 1 SEM increased from 734 +/- 34 msec at baseline to a maximum of 823 +/- 61 msec at 6.6 Hz, 1,167 +/- 125 msec at 10 Hz, 1,734 +/- 281 msec at 20 Hz, 2,993 +/- 661 msec at 25 Hz, and 2,461 +/- 668 msec at 30 Hz during nerve stimulation. Linear regression analysis showed that the response of atrial cycle length to sinoatrial parasympathetic nerve stimulation was frequency dependent. The maximum response and complete decay of the response occurred within 4-8 seconds of initiation or termination of sinoatrial parasympathetic nerve stimulation. Atrioventricular conduction time and the PR interval did not change during sinoatrial parasympathetic nerve stimulation, even when the atria were paced at the baseline heart rate.

CONCLUSIONS

Electrical stimulation of parasympathetic nerve fibers in a fat pad near the sinoatrial node increased atrial cycle length without affecting atrioventricular nodal conduction. This is the first study in which such nerve fibers that innervate the sinoatrial node have been selectively stimulated in humans.

Rapid attenuation ("fade") of the chronotropic response during vagal stimulation in the canine newborn. Evidence for a prominent neuropeptide Y effect

We studied the time-dependent changes in the response of heart rate (sinus cycle length) to 30-second trains of vagal stimulation (8 Hz), repeated every 2 minutes, in canine neonates aged 7.1 +/- 2.5 (mean +/- SD) days. The first vagal train prolonged the sinus cycle length by 58 +/- 35%, but the response was attenuated during subsequent trains (98 +/- 5% inhibition of the vagal response after only 6.4 +/- 1.7 trains). After 40 minutes, complete restoration of the chronotropic response could be demonstrated. Receptor desensitization could be excluded as the reason for the attenuation by demonstrating preserved responses to exogenous acetylcholine. Neuropeptide Y, a sympathetic cotransmitter that has been shown to attenuate parasympathetic responses (thought to be the result of inhibition of the release of acetylcholine from parasympathetic nerve terminals), was administered (50 micrograms/kg) to eight newborns. Exogenous neuropeptide Y resulted in a complete inhibition of the chronotropic response to vagal stimulation, with restoration of the chronotropic response occurring after 60 minutes. Thus, exogenous neuropeptide Y mimicked the effect of repetitive vagosympathetic trunk stimulation; this finding suggested that neuropeptide Y release from sympathetic nerves during repetitive vagosympathetic trunk stimulation may have resulted in the observed attenuation of the vagal chronotropic response. To test this hypothesis, seven other newborns underwent chemical sympathectomy (50 mg/kg i.p. 6-hydroxydopamine for 3 days, tyramine verified), and in these newborns, stable chronotropic responses to repetitive vagosympathetic trunk stimulation were observed (inhibition of vagal response was 0 +/- 18% after 10 stimulus trains).(ABSTRACT TRUNCATED AT 250 WORDS)

Mapping in the atrioventricular junction

Ectopic conduction is defined as the premature exit of the cardiac impulse from the specialized conduction system across a damaged Purkinje-ventricular muscle interface. This anomalous form of atrioventricular (AV) conduction was induced in the dog heart by lidocaine injection of the His bundle-interventricular septum interface and by ischemic damage of the AV junction subsequent to anterior septal artery ligation in the dog heart. The electrocardiogram (ECG) manifestation of ectopic conduction is the loss of initial forces and replacement of the Q waves with delta waves. In order to verify these effects, the authors devised a multi-electrode, malleable plaque (63 electrode sites) that could be secured at the AV junction during venous occlusion in the open-chest, anesthetized dog. Preliminary maps indicated a dramatic change in activation that proceeded from apex to base of the heart in the control state and reversed after ischemic damage to the His bundle. In vitro, it was possible to induce ectopic conduction by lidocaine injection at the interface of the right bundle branch and septal muscle. Microelectrode studies demonstrated that foot potentials, for example, electrotonic, or subthreshold potentials mediated the connection from Purkinje to muscle in the damaged zone. In a recent set of experiments in vivo, subthreshold stimulation (STS) was delivered to simulate electrotonic potentials to the His bundle region, and right ventricular apex, using multipolar electrode catheters. In the normal heart, STS delivered as DC constant current or pulse trains (1000 Hz, 50 ms pulse duration) induced shortened P-R intervals and delta waves with or without bundle branch block patterns.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of the spatial dispersion of acetylcholine release on the chronotropic responses to vagal stimulation in dogs

We determined the effects of changing the spatial dispersion of acetylcholine release on the phase-dependent chronotropic responses to vagal stimulation in anesthetized dogs. We stimulated the vagus nerves with one brief burst of electrical pulses each cardiac cycle, and we changed the timing of the stimulus by a small, constant amount each cardiac cycle to scan the entire cycle. To vary the heterogeneity of acetylcholine release, we changed the voltage of the stimulus pulses over a range of submaximal values. To achieve the maximum homogeneity of acetylcholine release, we used supramaximal voltages, and we varied the level of acetylcholine release from each excited fiber by changing the number of pulses per burst. We used the average cardiac cycle length of the phase-response curve to assess the overall vagal effect, independent of its timing within the cardiac cycle. We found that the amplitude of the phase-response curve varied directly and the minimum-to-maximum phase difference varied inversely with the overall efficacy of vagal activity. However, for any given alteration in the overall efficacy, the specific changes in the characteristics of the phase-response curve did not depend on whether the alteration was achieved by varying the number of pulses per burst or by varying the stimulus voltage. Therefore, we conclude that although the cardiac chronotropic response is very sensitive to changes in the timing of vagal stimulation, it is not influenced appreciably by the spatial dispersion of acetylcholine release from the vagal nerve endings over a wide range of stimulation strengths.

Insignificant bilateral convergence of preganglionic vagal fibers on postganglionic neurons to the canine heart

We determined the extent of convergence of preganglionic fibers from the right and left vagus nerves on postganglionic neurons that supply the sinoatrial node in chloralose-anesthetized dogs. We administered hemicholinium-3 and stimulated the right vagus nerve at a high frequency to deplete acetylcholine from the postganglionic parasympathetic neurons supplied by that nerve. We compared the effects of this "depletion regimen" with the responses in two control groups: a stimulation control group, which was subjected to high-frequency right vagus stimulation only, and a drug control group, which received a hemicholinium-3 infusion only. The effects of right vagus stimulation did not differ from those of left vagus stimulation in either of the control groups. In the animals subjected to the depletion regimen, the responses to right vagus stimulation were almost abolished. However, the left vagus nerve retained its ability to prolong cardiac cycle length in these animals. Thus, our experiments indicate that left vagus preganglionic fibers do not converge with right vagus preganglionic fibers on a substantial pool of postganglionic neurons that innervate the canine sinoatrial node.

Modification of supraventricular tachyarrhythmias by stimulating atrial neurons

The effects of stimulating the right atrial ventral ganglionated plexus on ventricular performance during atrial tachycardia was studied in 8 lightly sedated (pentobarbital, 2.5 mg/kg intravenously) dogs with sterile pericarditis. Atrial arrhythmias were induced by electrical stimulation (10 V, 4 ms, 100 Hz) of the right atrium through previously inserted temporary bipolar pacemaker wires. Various types of supraventricular tachycardias were produced. Atrial fibrillation was produced in 3 dogs, atrial tachycardia in all 8 dogs, different atrioventricular nodal ectopic rhythms in 6 dogs, and atrial flutter in 1 dog. These arrhythmias were associated with irregular ventricular contractions that resulted in low ventricular pressures during many cardiac cycles such that low or no aortic pressure was generated. Right atrial ventral ganglionated plexus stimulation induced slowing of ventricular rate so that every ventricular contraction resulted in aortic pressure generation, thus increasing mean aortic pressure. Responses elicited by atrial ganglionated plexus stimulation were eliminated after atropine administration. We conclude that electrical stimulation of the right atrial ventral ganglionated plexus results in slowing of ventricular contractile rate during supraventricular tachycardia, presumably by activating efferent vagal neuronal elements, thereby improving ventricular performance. If applicable in humans, this technique may be of use in management of postoperative atrial arrhythmias after cardiac operations.

Prolongation of cardiac cycle length attenuates negative dromotropic response to selective vagal stimuli

We stimulated intracardiac parasympathetic nerve fibers that selectively innervated the atrioventricular (AV) nodal area (AV parasympathetic stimulation), and the sinoatrial (SA) nodal area (SA parasympathetic stimulation), in autonomically decentralized, anesthetized dogs. We then compared these responses to those elicited by stimulation of the cervical vagus nerves. We investigated the interactions between the dromotropic and chronotropic responses to simultaneous AV and SA parasympathetic stimulation. AV parasympathetic stimulation increased the AV interval (AV conduction time) but did not alter the interval between atrial depolarizations (sinus cycle length). SA parasympathetic stimulation increased the sinus cycle length and evoked small changes in the AV interval. Simultaneous AV and SA parasympathetic stimulation, at different combinations of frequencies, induced negative dromotropic and chronotropic responses that were similar to those evoked by cervical vagal stimulation. The greater the increase in sinus cycle length, the less did a given parasympathetic stimulation prolong the AV interval. The prolongation of the AV interval by parasympathetic stimulation did not affect the sinus cycle length. These results suggest that the direct pure negative dromotropic response to parasympathetic nerve stimulation is attenuated by the prolongation of the sinus cycle length, e.g. a concomitant negative chronotropic effect of the parasympathetic stimulation, in the dog heart. This attenuation reflects a mechanism that does not depend on the relative timing of the stimulus impulses in the cardiac cycle, i.e. a phase-independent, as well as the previously reported phase-dependent, mechanism.

Autonomic nervous stimulation affects left ventricular relaxation more than left ventricular contraction

We studied the effects of stimulation of the vagal and also the sympathetic efferent cardiac nerves on left ventricular (LV) relaxation and contraction in 11 anesthetized, open-chest dogs. In each dog, we paced the ventricles at a fixed rate of 120 beats.min-1 and kept the systemic arterial pressure constant. The maximum rate of LV pressure decline, (dP/dt)min, and the time constant of LV isovolumic pressure decline, tau, were used as our indexes of LV relaxation. The maximum rate of LV pressure rise, (dP/dt)max, was used as our measure of LV contractility. Vagal stimulation decreased (dP/dt)min more than (dP/dt)max (P less than 0.01) when examined at frequencies that ranged from 2 to 12 Hz. Vagal stimulation at 12 Hz reduced (dP/dt)min by 26% (P less than 0.001) and increased tau by 57% (P less than 0.0001) but decreased (dP/dt)max by only 20%. Sympathetic stimulation, at frequencies that ranged from 2 to 12 Hz, increased (dP/dt)min more than (dP/dt)max (P less than 0.001). Sympathetic stimulation at 12 Hz increased (dP/dt)min by 130% (P less than 0.0001) whereas it increased (dP/dt)max by 60% (P less than 0.0001). Sympathetic stimulation at 12 Hz decreased tau by 74% (P less than 0.0001). Our studies suggest that cardiac autonomic nerve stimulation affects left ventricular relaxation more than left ventricular contraction.

QTU prolongation and polymorphic ventricular tachyarrhythmias due to bradycardia-dependent early afterdepolarizations. Afterdepolarizations and ventricular arrhythmias

Polymorphic ventricular tachyarrhythmias occurred spontaneously during bradycardia in dogs given the inotropic polypeptide anthopleurin-A (AP-A). The arrhythmia was investigated in in vitro and in vivo experiments. In in vitro experiments, AP-A (50 micrograms/l) produced bradycardia-dependent prolongation of action potential duration that was more pronounced in Purkinje than in muscle fibers. Only Purkinje fibers developed early afterdepolarizations (EAD) and triggered activity. These effects could be abolished by rapid pacing, lidocaine (4 mg/l), or tetrodotoxin (1 mg/l). In vivo experiments were conducted in anesthetized healthy dogs with simultaneous recording of surface ECG, monophasic action potentials from the endocardial and epicardial surface of the left ventricle by contact electrode catheter technique, and transmembrane action potentials from the epicardial surface of the left ventricle with a floating microelectrode technique. AP-A in a dose comparable to that used in vitro (4 micrograms/kg, i.v. bolus) resulted in bradycardia-dependent marked prolongation of both monophasic and transmembrane action potentials. An EAD gradually appeared on both recordings but was more marked in endocardial monophasic action potentials. Eventually, a premature ventricular depolarization arose from or very close to the peak of the EAD. The prolongation of action potentials was associated with similar prolongation of the QTU interval in surface ECG, and in some experiments, the EAD corresponded to a distinct prominent U wave. A ventricular premature depolarization arose from the U or TU complex and initiated polymorphic ventricular tachyarrhythmias that terminated spontaneously or degenerated into ventricular fibrillation. These effects were reversed by rapid pacing or lidocaine (1 mg/kg). The present study provides evidence in support of the hypothesis that AP-A-induced ventricular tachyarrhythmias are due to bradycardia-dependent EAD and triggered activity.

Differential effects of sympathetic activity on AV junctional automaticity and AV conduction

Rapid ventricular response during episodes of supraventricular tachycardia are often followed, on abrupt cessation of the tachycardia, by prolonged pauses terminated by a sluggish and sometimes erratic escape of a supraventricular pacemaker. Such chronotropic-dromotropic paradoxes are readily reproduced in the animal laboratory following elimination of the sinus node and bilateral decentralization of the stellate ganglia and vagi. This study examined whether left stellate stimulation (0.5, 1, 2, 4, 8 and 16 Hz) or lack thereof differentially affected AV junctional automaticity and AV conduction. In the absence of any sympathetic neural activity (maximal sympathetic deficit), the AV junctional rate averaged a mere 22 +/- 2 percent of its peak performance, whereas under the same conditions, anterograde AV conduction averaged 73 +/- 5 percent and retrograde VA conduction 56 +/- 13 percent of their respective peak performances. On comparing the response curve (normalized responses) for AV junctional automaticity with that obtained for anterograde AV conduction the differences were significant at all frequencies between 0 and 4 Hz. Retrograde VA conduction (as assessed by the fastest ventricular pacing rate still conducted 1:1 to the atria) was always significantly less than anterograde AV conduction (as assessed by the fastest atrial pacing still conducted 1:1 to the ventricles). These results indicate that AV junctional automaticity is considerably more affected by sympathetic deficit than are either anterograde or retrograde AV conduction. In other words, AV junctional automaticity is far more dependent upon sympathetic input than AV conduction. While sympathetic influence is critical to the escape and maintenance of AV junctional automaticity both anterograde and retrograde AV conduction are remarkably resilient even under conditions of severe sympathetic deficit.

Circadian variations in the electrical properties of the human heart assessed by sequential bedside electrophysiologic testing

To assess the variability of the currently used electrophysiologic parameters and their possible circadian rhythm, sequential bedside electrophysiologic testing was performed during a 24-hour period, at intervals of 1 to 2 hours, in 12 patients who had normal atrioventricular (AV) conduction times and normal sinus node function. The coefficients of variation during the 24-hour period were: +/- 10.4% for the R-R interval, +/- 10.6% for the sinus node recovery time (SRT) at atrial pacing of 100 bpm, +/- 32.5% for the corrected SRT, +/- 15.1% for the ventriculoatrial (VA) effective refractory period (ERP), +/- 8.3% for the AV nodal ERP, +/- 5.7% for the AH interval, +/- 5.2% for the HV interval, +/- 5.5% for the atrial ERP, +/- 3.3% for the right ventricular ERP, +/- 2.8% for the QT interval, +/- 4% for the VA interval, and +/- 3.4% for the retrograde Kent bundle ERP. Between 12:00 midnight and 7:00 AM, there was significant lengthening of: the sinus node rate (p less than 0.0005), the SRT at atrial paced rates of 100 and 120 bpm (p less than 0.025), the QT interval duration (p less than 0.025), and the ERP of the atria (p less than 0.025), AV node (p less than 0.01), and right ventricle (p less than 0.05). Thus conventional electrophysiologic parameters are subject to daily variability and, like sinus node function, AV nodal and myocardial refractoriness follow a circadian rhythm with an acrophase between 12:00 midnight and 7:00 AM. In addition, prolonged bedside recording of the His bundle potential can be reliably obtained.

Differential modulation of autonomic activity by ethmozin and ethacizin (analog of ethmozin) on the canine sinus node and atrioventricular junction

The chronotropic and dromotropic actions of ethmozin and its diethylamine analog ethacizin were studied in the presence and absence of combined muscarinic, beta- and alpha-adrenoreceptor blockade in the intact canine heart in situ (n = 38). Injections of ethacizin, 5, 10 and 25 micrograms/ml, into the sinus node artery caused an immediate and significant (p less than 0.001) sinus bradycardia of 2, 6 and 11%, respectively. Injection of 25 and 50 micrograms/ml of ethacizin into the atrioventricular (AV) node artery significantly (p less than 0.001) prolonged AV conduction time with occasional second degree heart block. Conduction delay was located exclusively during the AH interval of the His bundle electrogram. Autonomic blockade did not alter the negative chronotropic or negative dromotropic effects of ethacizin. Ethacizin, 25 micrograms/ml, injected into the sinus node artery immediately reduced the sinus node response to vagal stimulations by 30% and the effect of acetylcholine, 0.1 micrograms/ml, injected into the sinus node artery by 50%. Ethacizin, 25 micrograms/ml, injected into the AV node artery immediately reduced the duration of complete AV block elicited by vagal stimulation or intranodal acetylcholine, 0.5 micrograms/ml, by 90%. Ethacizin caused a minor reduction in sinus node response to right stellate stimulations without, however, altering the sinus node response to intranodal norepinephrine. Ethmozin injections of up to 50 micrograms/ml into the sinus and AV node arteries had no chronotropic or dromotropic effects. Ethmozin had a minor and variable vagolytic action but significantly (p less than 0.05) reduced the sinus node response to sympathetic nerve stimulation. Hence, ethacizin, in contrast to ethmozin, has a direct depressing action on both the sinus node and the AV junction.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of sympathetic tone on vagally induced phasic changes in heart rate and atrioventricular node conduction in the anesthetized dog

We examined the effects of stellate ganglia stimulation on the phase-dependent chronotropic and dromotropic responses to brief vagal bursts in open-chest anesthetized dogs. Stellate stimulation affected the phasic vagal effects on heart rate by shortening the latent period, shifting the phase at which maximum decrease in heart rate occurred to earlier phases, and reducing the maximum decrease in heart rate. These effects were due primarily to an increase in the basic heart rate. No significant sympathetic-parasympathetic interaction occurred for heart rate, indicating that accentuated antagonism did not occur with brief vagal bursts. Stellate stimulation primarily decreased the amplitude of the phasic vagal effects on atrioventricular nodal conduction, regardless of the underlying heart rate, and a significant sympathetic-parasympathetic interaction was associated with this effect. The peak of the phase-dependent vagal effects on heart rate and atrioventricular nodal conduction were phase-shifted with one another. From these findings, we postulate the small changes in sympathetic tone might shift the predominant phase-dependent vagal effect from one on heart rate to one on atrioventricular nodal conduction. Furthermore, our results suggest that dynamic vagal control of heart rate and atrioventricular node conduction involves both phase-dependent and phase-independent factors. Sympathetic activity appears to affect only the phase-independent factor(s) in the control of heart rate, whereas it affects both phase-dependent and phase-independent factors in the control of atrioventricular node conduction.

Ectopic ventricular tachycardia sensitive to calcium antagonists in acute myocardial infarction in dogs

The effects of antiarrhythmic agents on automatic ventricular tachycardia (VT), which emerged in the early stage of acute myocardial infarction (AMI), were examined in 30 closed-chest mongrel dogs. Antiarrhythmic agents were administered intravenously when the rate of VT became almost equal to sinus rate (5.6 +/- 1.4 hours). VT was slowed significantly by verapamil (0.15 or 0.3 mg/kg), diltiazem (0.2 or 0.4 mg/kg), propranolol (0.1 mg/kg) and amiodarone (5 mg/kg), but not by procainamide (20 mg/kg), lidocaine (2 or 4 mg/kg), nifedipine (0.01 mg/kg) and nicorandil (0.03 mg/kg). The number of ventricular premature complexes was reduced most effectively by verapamil. The significant suppressive effects of calcium antagonist drugs (verapamil and diltiazem) and propranolol indicate that an inward calcium current during diastole may play a critical role in the abnormal enhancement of ventricular automaticity in the early stage (4 to 8 hours) of AMI.