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Abstract
Mitral isthmus ablation forms part of the electrophysiologist’s armoury in the catheter ablation treatment of atrial fibrillation. It is well recognised however, that mitral isthmus ablation is technically challenging and incomplete ablation may be pro-arrhythmic, leading some to question its role. This article first reviews the evidence for the use of adjunctive mitral isthmus ablation and its association with the development of macroreentrant perimitral flutter. It then describes the practical techniques of mitral isthmus ablation, with particular emphasis on the assessment of bi-directional mitral isthmus block. The anatomy of the mitral isthmus is also discussed in order to understand the possible obstacles to successful ablation. Finally, novel techniques which may facilitate mitral isthmus ablation are reviewed.
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Affiliation(s)
- Kelvin Ck Wong
- Oxford Heart Centre, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
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352
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2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. J Interv Card Electrophysiol 2012; 33:171-257. [PMID: 22382715 DOI: 10.1007/s10840-012-9672-7] [Citation(s) in RCA: 256] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
This is a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation, developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology and the European Cardiac Arrhythmia Society (ECAS), and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). This is endorsed by the governing bodies of the ACC Foundation, the AHA, the ECAS, the EHRA, the STS, the APHRS, and the HRS.
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353
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He B, Scherlag BJ, Nakagawa H, Lazzara R, Po SS. The intrinsic autonomic nervous system in atrial fibrillation: a review. ISRN CARDIOLOGY 2012; 2012:490674. [PMID: 22778995 PMCID: PMC3385664 DOI: 10.5402/2012/490674] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/24/2012] [Accepted: 04/22/2012] [Indexed: 11/23/2022]
Abstract
The procedure of catheter ablation for the treatment of drug resistant atrial fibrillation (AF) has evolved but still relies on lesion sets intended to isolate areas of focal firing, mainly the myocardial sleeves of the pulmonary veins (PVs), from the rest of the atria. However the success rates for this procedure have varied inversely with the type of AF. At best success rates have been 20 to 30% below that of other catheter ablation procedures for Wolff-Parkinson-White syndrome, atrioventricular junctional re-entrant tachycardia and atrial flutter. Basic and clinical evidence has emerged suggesting a critical role of the ganglionated plexi (GP) at the PV-atrial junctions in the initiation and maintenance of the focal form of AF. At present the highest success rates have been obtained with the combination of PV isolation and GP ablation both as catheter ablation or minimally invasive surgical procedures. Various lines of evidence from earlier and more recent reports provide that both neurally based and myocardially based forms of AF can separately dominate or coexist within the context of atrial remodeling. Future studies are focusing on non-pharmacological, non-ablative approaches for the prevention and treatment of AF in order to avoid the substantive complications of both these regimens.
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Affiliation(s)
- Bo He
- Department of Cardiology, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuchang, Wuhan, Hubei 430060, China
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354
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Makrides C. Transient ST Elevation in Vagally Mediated Atrial Fibrillation. J Atr Fibrillation 2012; 5:487. [PMID: 28496749 DOI: 10.4022/jafib.487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2011] [Revised: 12/31/2011] [Accepted: 03/09/2012] [Indexed: 11/10/2022]
Abstract
We report a case of vagally mediated atrial fibrillation on a young otherwise healthy man, with straight type ST-segment elevation in inferolateral leads that resolved a few hours after restoration of sinus rythm, a phenomenon that has never been previously reported. Even though no definite conclusion about the underlying mechanism of the ST-elevation can be made, this effect might probably be the result of intense parasympathetic tone and could be used to differentiate the causality.
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355
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The atrial neural network as a substrate for atrial fibrillation. J Interv Card Electrophysiol 2012; 35:3-9. [DOI: 10.1007/s10840-012-9692-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Accepted: 04/24/2012] [Indexed: 10/28/2022]
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356
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Lemery R. Trials and tribulations of stimulating human cardiac ganglia for autonomic intervention. Heart Rhythm 2012; 9:1393-4. [PMID: 22659212 DOI: 10.1016/j.hrthm.2012.05.025] [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: 05/23/2012] [Indexed: 11/18/2022]
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357
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HIGUCHI KOJI, MARROUCHE NASSIRF. Still Looking for the Right Mechanism as a Target During Ablation of Atrial Fibrillation. J Cardiovasc Electrophysiol 2012; 23:601-3. [DOI: 10.1111/j.1540-8167.2012.02303.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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358
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Lemery R. Autonomics and ablation of paroxysmal atrial fibrillation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 35:773-5. [PMID: 22486268 DOI: 10.1111/j.1540-8159.2012.03394.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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359
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Yao Y, Shi R, Wong T, Zheng L, Chen W, Yang L, Huang W, Bao J, Zhang S. Endocardial Autonomic Denervation of the Left Atrium to Treat Vasovagal Syncope. Circ Arrhythm Electrophysiol 2012; 5:279-86. [DOI: 10.1161/circep.111.966465] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Vasovagal syncope (VVS) is the most common cause of recurrent syncope that can be debilitating despite optimal conventional therapy. The aim of this study was to evaluate the feasibility and efficacy of selective endocardial autonomic denervation in left atrium (LA) as an alternative treatment strategy in patients with highly symptomatic VVS.
Methods and Results—
Ten consecutive patients (mean age, 50.4±6.4 years; 7 women) with a medium of 3.5 (range, 2–20) recurrent episodes of VVS during the preceding year and positive head-up tilt testing in whom standard therapies were ineffective or poorly tolerated were enrolled. Ganglionated plexi (GP) in the LA, identified by high-frequency stimulation, was targeted by radiofrequency catheter ablation. The patients were then followed up at 3, 6, 12, 24, and 36 months, including repeated head-up tilt testing and Holter at 3 and 12 months. Radiofrequency energy was applied at the left superior GP in 10 patients, right anterior GP in 5, and left inferior GP in 3, using an 8-mm ablation catheter. Vagal response, defined as transient ventricular asystole, atrioventricular block, or an increase in R-R interval by 50%, was observed during ablation in all GP sites. The end point of procedure was the inhibition of the vagal response at target sites. At 30±16 (range, 13–55) months of follow-up, no patient had any recurrence of syncope and all patients had significant improvement in symptoms, but 5 of 10 patients reported transient prodromes. No complications occurred.
Conclusions—
Comprehensive endocardial autonomic denervation of the LA demonstrates the feasibility of treating VVS in medium-term follow-up.
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Affiliation(s)
- Yan Yao
- From the Clinical Electrophysiological Laboratory and Arrhythmia Center, Fuwai Hospital and Cardiovascular Institute, Peking Union Medical College (PUMC)–Chinese Academy of Medical Sciences (CAMS), Beijing, China (Y.Y., R.S., L.Z., W.C., L.Y., W.H., J.B., S.Z.); and Heart Rhythm Centre, Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom (T.W.)
| | - Rui Shi
- From the Clinical Electrophysiological Laboratory and Arrhythmia Center, Fuwai Hospital and Cardiovascular Institute, Peking Union Medical College (PUMC)–Chinese Academy of Medical Sciences (CAMS), Beijing, China (Y.Y., R.S., L.Z., W.C., L.Y., W.H., J.B., S.Z.); and Heart Rhythm Centre, Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom (T.W.)
| | - Tom Wong
- From the Clinical Electrophysiological Laboratory and Arrhythmia Center, Fuwai Hospital and Cardiovascular Institute, Peking Union Medical College (PUMC)–Chinese Academy of Medical Sciences (CAMS), Beijing, China (Y.Y., R.S., L.Z., W.C., L.Y., W.H., J.B., S.Z.); and Heart Rhythm Centre, Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom (T.W.)
| | - Lihui Zheng
- From the Clinical Electrophysiological Laboratory and Arrhythmia Center, Fuwai Hospital and Cardiovascular Institute, Peking Union Medical College (PUMC)–Chinese Academy of Medical Sciences (CAMS), Beijing, China (Y.Y., R.S., L.Z., W.C., L.Y., W.H., J.B., S.Z.); and Heart Rhythm Centre, Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom (T.W.)
| | - Wensheng Chen
- From the Clinical Electrophysiological Laboratory and Arrhythmia Center, Fuwai Hospital and Cardiovascular Institute, Peking Union Medical College (PUMC)–Chinese Academy of Medical Sciences (CAMS), Beijing, China (Y.Y., R.S., L.Z., W.C., L.Y., W.H., J.B., S.Z.); and Heart Rhythm Centre, Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom (T.W.)
| | - Long Yang
- From the Clinical Electrophysiological Laboratory and Arrhythmia Center, Fuwai Hospital and Cardiovascular Institute, Peking Union Medical College (PUMC)–Chinese Academy of Medical Sciences (CAMS), Beijing, China (Y.Y., R.S., L.Z., W.C., L.Y., W.H., J.B., S.Z.); and Heart Rhythm Centre, Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom (T.W.)
| | - Wen Huang
- From the Clinical Electrophysiological Laboratory and Arrhythmia Center, Fuwai Hospital and Cardiovascular Institute, Peking Union Medical College (PUMC)–Chinese Academy of Medical Sciences (CAMS), Beijing, China (Y.Y., R.S., L.Z., W.C., L.Y., W.H., J.B., S.Z.); and Heart Rhythm Centre, Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom (T.W.)
| | - Jingru Bao
- From the Clinical Electrophysiological Laboratory and Arrhythmia Center, Fuwai Hospital and Cardiovascular Institute, Peking Union Medical College (PUMC)–Chinese Academy of Medical Sciences (CAMS), Beijing, China (Y.Y., R.S., L.Z., W.C., L.Y., W.H., J.B., S.Z.); and Heart Rhythm Centre, Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom (T.W.)
| | - Shu Zhang
- From the Clinical Electrophysiological Laboratory and Arrhythmia Center, Fuwai Hospital and Cardiovascular Institute, Peking Union Medical College (PUMC)–Chinese Academy of Medical Sciences (CAMS), Beijing, China (Y.Y., R.S., L.Z., W.C., L.Y., W.H., J.B., S.Z.); and Heart Rhythm Centre, Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom (T.W.)
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360
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Rebecchi M, de Ruvo E, Strano S, Sciarra L, Golia P, Martino A, Calò L. Ganglionated plexi ablation in right atrium to treat cardioinhibitory neurocardiogenic syncope. J Interv Card Electrophysiol 2012; 34:231-5. [DOI: 10.1007/s10840-012-9666-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2011] [Accepted: 01/06/2012] [Indexed: 11/25/2022]
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361
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Calkins H, Kuck KH, Cappato R, Brugada J, Camm AJ, Chen SA, Crijns HJG, Damiano RJ, Davies DW, DiMarco J, Edgerton J, Ellenbogen K, Ezekowitz MD, Haines DE, Haissaguerre M, Hindricks G, Iesaka Y, Jackman W, Jalife J, Jais P, Kalman J, Keane D, Kim YH, Kirchhof P, Klein G, Kottkamp H, Kumagai K, Lindsay BD, Mansour M, Marchlinski FE, McCarthy PM, Mont JL, Morady F, Nademanee K, Nakagawa H, Natale A, Nattel S, Packer DL, Pappone C, Prystowsky E, Raviele A, Reddy V, Ruskin JN, Shemin RJ, Tsao HM, Wilber D. 2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. Europace 2012; 14:528-606. [PMID: 22389422 DOI: 10.1093/europace/eus027] [Citation(s) in RCA: 1144] [Impact Index Per Article: 95.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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362
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Calkins H, Kuck KH, Cappato R, Brugada J, Camm AJ, Chen SA, Crijns HJG, Damiano RJ, Davies DW, DiMarco J, Edgerton J, Ellenbogen K, Ezekowitz MD, Haines DE, Haissaguerre M, Hindricks G, Iesaka Y, Jackman W, Jalife J, Jais P, Kalman J, Keane D, Kim YH, Kirchhof P, Klein G, Kottkamp H, Kumagai K, Lindsay BD, Mansour M, Marchlinski FE, McCarthy PM, Mont JL, Morady F, Nademanee K, Nakagawa H, Natale A, Nattel S, Packer DL, Pappone C, Prystowsky E, Raviele A, Reddy V, Ruskin JN, Shemin RJ, Tsao HM, Wilber D. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design: a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology (ESC) and the European Cardiac Arrhythmia Society (ECAS); and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). Endorsed by the governing bodies of the American College of Cardiology Foundation, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, the Asia Pacific Heart Rhythm Society, and the Heart Rhythm Society. Heart Rhythm 2012; 9:632-696.e21. [PMID: 22386883 DOI: 10.1016/j.hrthm.2011.12.016] [Citation(s) in RCA: 1299] [Impact Index Per Article: 108.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Indexed: 12/20/2022]
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363
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Affiliation(s)
- Siew Yen Ho
- From the Cardiac Morphology Unit, Royal Brompton Hospital, London, United Kingdom (S.Y.H.); Hospital Universitario Quirón-Madrid, European University of Madrid, Madrid, Spain (J.A.C.); and the Department of Anatomy and Cell Biology, Faculty of Medicine, University of Extremadura, Badajoz, Spain (D.S.-Q.)
| | - José Angel Cabrera
- From the Cardiac Morphology Unit, Royal Brompton Hospital, London, United Kingdom (S.Y.H.); Hospital Universitario Quirón-Madrid, European University of Madrid, Madrid, Spain (J.A.C.); and the Department of Anatomy and Cell Biology, Faculty of Medicine, University of Extremadura, Badajoz, Spain (D.S.-Q.)
| | - Damian Sanchez-Quintana
- From the Cardiac Morphology Unit, Royal Brompton Hospital, London, United Kingdom (S.Y.H.); Hospital Universitario Quirón-Madrid, European University of Madrid, Madrid, Spain (J.A.C.); and the Department of Anatomy and Cell Biology, Faculty of Medicine, University of Extremadura, Badajoz, Spain (D.S.-Q.)
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364
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Calò L, Rebecchi M, Sciarra L, De Luca L, Fagagnini A, Zuccaro LM, Pitrone P, Dottori S, Porfirio M, de Ruvo E, Lioy E. Catheter Ablation of Right Atrial Ganglionated Plexi in Patients With Vagal Paroxysmal Atrial Fibrillation. Circ Arrhythm Electrophysiol 2012; 5:22-31. [DOI: 10.1161/circep.111.964262] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Catheter ablation of ganglionated plexi (GP) in the left atrium has been proposed in different subgroup of patients with atrial fibrillation (AF). Anatomic studies found a high prevalence of GP in the posterior surface of the right atrium (RA). Experimental data suggested the potential role of right atrial GP in the AF initiation and maintenance. The aim of our study was to assess the efficacy of GP ablation in RA in patients with vagal AF.
Methods and Results—
Thirty-four patients without structural heart diseases were randomly assigned for a selective ablation procedure targeted on the elimination of vagal reflex evoked by high frequency stimulation or an extensive approach at anatomic sites of GP. All patients underwent Holter ECG and heart rate variability evaluation at baseline and at 3, 6, 12, and 18 months of follow-up. At a mean follow-up of 19.7±5.2 months, AF recurred in 5 of 17 patients with anatomic ablation and in 13 of 17 patients with a selective approach (
P
=0.01). No patient had major complications. After ablation, heart rate variability parameters showed a significant parasympathetic (and sympathetic) denervation in the first 6 months, which was more prominent in patients with anatomic GP ablation and in those without AF recurrence.
Conclusions—
This study demonstrates that in a selected population of vagal paroxysmal AF, the anatomic ablation of GPs in the RA is effective in about 70% of patients. These results confirm that atrial vagal denervation can abolish AF, as suggested by experimental and clinical data.
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Affiliation(s)
- Leonardo Calò
- From the Division of Cardiology, Policlinico Casilino (L.C., M.R., L.S., L.D.L., A.F., L.M., M.P., E.d.R., E.L.), ASL Roma B, Rome, Italy; and Biosense Webster Italy, Johnson & Johnson Medical (P.P., S.D.), Milan, Italy
| | - Marco Rebecchi
- From the Division of Cardiology, Policlinico Casilino (L.C., M.R., L.S., L.D.L., A.F., L.M., M.P., E.d.R., E.L.), ASL Roma B, Rome, Italy; and Biosense Webster Italy, Johnson & Johnson Medical (P.P., S.D.), Milan, Italy
| | - Luigi Sciarra
- From the Division of Cardiology, Policlinico Casilino (L.C., M.R., L.S., L.D.L., A.F., L.M., M.P., E.d.R., E.L.), ASL Roma B, Rome, Italy; and Biosense Webster Italy, Johnson & Johnson Medical (P.P., S.D.), Milan, Italy
| | - Lucia De Luca
- From the Division of Cardiology, Policlinico Casilino (L.C., M.R., L.S., L.D.L., A.F., L.M., M.P., E.d.R., E.L.), ASL Roma B, Rome, Italy; and Biosense Webster Italy, Johnson & Johnson Medical (P.P., S.D.), Milan, Italy
| | - Alessandro Fagagnini
- From the Division of Cardiology, Policlinico Casilino (L.C., M.R., L.S., L.D.L., A.F., L.M., M.P., E.d.R., E.L.), ASL Roma B, Rome, Italy; and Biosense Webster Italy, Johnson & Johnson Medical (P.P., S.D.), Milan, Italy
| | - Lorenzo Maria Zuccaro
- From the Division of Cardiology, Policlinico Casilino (L.C., M.R., L.S., L.D.L., A.F., L.M., M.P., E.d.R., E.L.), ASL Roma B, Rome, Italy; and Biosense Webster Italy, Johnson & Johnson Medical (P.P., S.D.), Milan, Italy
| | - Pietro Pitrone
- From the Division of Cardiology, Policlinico Casilino (L.C., M.R., L.S., L.D.L., A.F., L.M., M.P., E.d.R., E.L.), ASL Roma B, Rome, Italy; and Biosense Webster Italy, Johnson & Johnson Medical (P.P., S.D.), Milan, Italy
| | - Serena Dottori
- From the Division of Cardiology, Policlinico Casilino (L.C., M.R., L.S., L.D.L., A.F., L.M., M.P., E.d.R., E.L.), ASL Roma B, Rome, Italy; and Biosense Webster Italy, Johnson & Johnson Medical (P.P., S.D.), Milan, Italy
| | - Maurizio Porfirio
- From the Division of Cardiology, Policlinico Casilino (L.C., M.R., L.S., L.D.L., A.F., L.M., M.P., E.d.R., E.L.), ASL Roma B, Rome, Italy; and Biosense Webster Italy, Johnson & Johnson Medical (P.P., S.D.), Milan, Italy
| | - Ermenegildo de Ruvo
- From the Division of Cardiology, Policlinico Casilino (L.C., M.R., L.S., L.D.L., A.F., L.M., M.P., E.d.R., E.L.), ASL Roma B, Rome, Italy; and Biosense Webster Italy, Johnson & Johnson Medical (P.P., S.D.), Milan, Italy
| | - Ernesto Lioy
- From the Division of Cardiology, Policlinico Casilino (L.C., M.R., L.S., L.D.L., A.F., L.M., M.P., E.d.R., E.L.), ASL Roma B, Rome, Italy; and Biosense Webster Italy, Johnson & Johnson Medical (P.P., S.D.), Milan, Italy
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Abstract
Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, is an important contributor to population morbidity and mortality. An arrhythmia that is particularly common in the elderly, AF is growing in prevalence with the aging of the population. Our understanding of the basic mechanisms that govern AF occurrence and persistence has been increasing rapidly. This article reviews the basic pathophysiology of AF over a broad range of levels, touching on the tissue mechanisms that maintain the arrhythmia, the relationship between clinical presentation and basic mechanisms, ion channel and transporter abnormalities that lead to ectopic impulse formation, basic models and tissue determinants of reentry, ion channel determinants of reentry, the nature and roles of electric and structural remodeling, autonomic neural components, anatomic factors, interactions between atrial and ventricular functional consequences of AF, and the basic determinants of atrial thromboembolism. We then review the potential implications of the basic pathophysiology of the arrhythmia for its management. We first discuss consequences for improved rhythm control pharmacotherapy: targeting underlying conditions, new atrium-selective drug targets, new targets for focal ectopic source suppression, and upstream therapy aiming to prevent remodeling. We then review the implications of basic mechanistic considerations for rate control therapy, AF ablation, and the prevention of thromboembolic events. We conclude with some thoughts about the future of translational research related to AF mechanisms.
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Affiliation(s)
- Yu-ki Iwasaki
- Department of Medicine and Research Center, Montreal Heart Institute, Quebec, Canada
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366
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The training-induced changes on automatism, conduction and myocardial refractoriness are not mediated by parasympathetic postganglionic neurons activity. Eur J Appl Physiol 2011; 112:2185-93. [PMID: 21968799 DOI: 10.1007/s00421-011-2189-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Accepted: 09/19/2011] [Indexed: 10/17/2022]
Abstract
The purpose of this study is to test the role that parasympathetic postganglionic neurons could play on the adaptive electrophysiological changes produced by physical training on intrinsic myocardial automatism, conduction and refractoriness. Trained rabbits were submitted to a physical training protocol on treadmill during 6 weeks. The electrophysiological study was performed in an isolated heart preparation. The investigated myocardial properties were: (a) sinus automatism, (b) atrioventricular and ventriculoatrial conduction, (c) atrial, conduction system and ventricular refractoriness. The parameters to study the refractoriness were obtained by means of extrastimulus test at four different pacing cycle lengths (10% shorter than spontaneous sinus cycle length, 250, 200 and 150 ms) and (d) mean dominant frequency (DF) of the induced ventricular fibrillation (VF), using a spectral method. The electrophysiological protocol was performed before and during continuous atropine administration (1 μM), in order to block cholinergic receptors. Cholinergic receptor blockade did not modify either the increase in sinus cycle length, atrioventricular conduction and refractoriness (left ventricular and atrioventricular conduction system functional refractory periods) or the decrease of DF of VF. These findings reveal that the myocardial electrophysiological modifications produced by physical training are not mediated by intrinsic cardiac parasympathetic activity.
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367
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Bissinger A, Grycewicz T, Grabowicz W, Lubinski A. The effect of diabetic autonomic neuropathy on P-wave duration, dispersion and atrial fibrillation. Arch Med Sci 2011; 7:806-12. [PMID: 22291825 PMCID: PMC3258812 DOI: 10.5114/aoms.2011.25555] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Revised: 11/05/2010] [Accepted: 12/13/2010] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Atrial fibrillation (AF) is the most common sustained arrhythmia. Diabetic autonomic neuropathy (DAN) is a frequent complication of diabetes mellitus and has a negative impact on the cardiovascular system. There are no data about the occurrence of paroxysmal atrial fibrillation (PAF) in the population with DAN. MATERIAL AND METHODS We analysed the data of 100 patients with PAF. The study population was divided into three groups: group I: 28 patients with diabetes mellitus (DM) and DAN, group II: 34 patients with DM without DAN, and group III: 38 patients without DM. P-wave duration (FPD) and dispersion (PWD) were measured during sinus rhythm and AF episodes were counted during 12 months of follow-up. RESULTS Recurrence of PAF was higher in group I (47 episodes/year) compared to groups II and III (26 and 22 episodes/year) - p<0.01. The FPD was longer in group I (137.4 ±12.0 ms vs. 126 ±23.0 ms in II group and 129 ±18.3 ms in group III; p<0.001). The PWD was longer in patients with DAN (53 ±19 ms vs. 36 ±18 ms and 34 ± 20 ms, p<0.001). CONCLUSIONS The results showed that the presence of DAN caused a significant increase in P-wave duration and dispersion, which might be responsible for the recurrence of AF.
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Affiliation(s)
- Andrzej Bissinger
- Corresponding author: Andrzej Bissinger MD, PhD, Department of Invasive Cardiology and Cardiodiabetology, Medical University, 113 Zeromskiego, 90-549 Lodz, Poland, Fax: +48426393563, Phone: +48426393563. E-mail:
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Chaldoupi SM, Linnenbank AC, Wittkampf FH, Boldt LH, VAN Wessel H, VAN Driel VJ, Doevendans PA, Hauer RN, DE Bakker JM, Loh P. Complex fractionated electrograms in the right atrial free wall and the superior/posterior wall of the left atrium are affected by activity of the autonomic nervous system. J Cardiovasc Electrophysiol 2011; 23:26-33. [PMID: 21815962 DOI: 10.1111/j.1540-8167.2011.02145.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Complex fractionated atrial electrograms (CFAEs) are supposed to be related to structural and electrical remodeling. Animal studies suggest a role of the autonomic nervous system (ANS). However, this has never been studied in humans. OBJECTIVE The goal of this study was to investigate the influence of ANS on CFAEs in patients with idiopathic atrial fibrillation (AF). METHODS Thirty-six patients (28 men, 55 ± 9 years) were included before undergoing catheter ablation. In the 24 hours preceding the procedure, 20 patients were in AF (group 1) and 16 were in sinus rhythm (SR, group 2). With 2 decapolar catheters, 1 in the right atrium (RA) and 1 in the left atrium (LA), 20 unipolar electrograms were simultaneously recorded during a 100-second AF-period (in group 2 after induction of AF). After atropine and metoprolol administration, a second 100-second AF-period was recorded 30 minutes later. Five patients of group 2 served as controls and did not receive atropine and metoprolol prior to the second recording. CFAEs were assessed and the prevalence of CFAEs was expressed as percentage of the recording time. RESULTS The prevalence of CFAEs was greater in group 1 than in group 2 in both RA and LA (P = 0.026, P < 0.001, respectively). Atropine and metoprolol significantly reduced CFAEs in group 1 (P < 0.001) and prevented the time-dependent increase of CFAEs in group 2. CONCLUSION The prevalence of CFAEs is greater in long-lasting AF episodes. Atropine and metoprolol administration reduces CFAEs in both atria. Thus, CFAEs are at least partly influenced by the ANS.
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Affiliation(s)
- Sevasti-Maria Chaldoupi
- Department of Cardiology, Division of Heart & Lungs, University Medical Center Utrecht, Utrecht, The Netherlands
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Oh S, Choi EK, Zhang Y, Mazgalev TN. Botulinum toxin injection in epicardial autonomic ganglia temporarily suppresses vagally mediated atrial fibrillation. Circ Arrhythm Electrophysiol 2011; 4:560-5. [PMID: 21659633 DOI: 10.1161/circep.111.961854] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Autonomic denervation may suppress atrial fibrillation (AF) vulnerability. This study was designed to assess the short- to mid-term effects of botulinum toxin, a cholinergic neurotransmission blocker, on AF inducibility. METHODS AND RESULTS A total of 23 mongrel dogs were studied. The sinus node and atrioventricular node epicardial fat pads were exposed through a right lateral thoracotomy. Botulinum toxin (Botox, 50 U per fat pad) or 0.9% normal saline (control) was injected into the center of each of the 2 fat pads. The electrophysiological effects were evaluated at 1, 2, and 3 weeks (7 to 8 animals at each time point) with and without cervical vagal stimulation. The vagal stimulation effects on the sinus and atrioventricular nodes were inhibited, and dispersion of atrial effective refractory period was lower at 1 week in the Botox group. Significant suppression of AF inducibility was observed at 1 week but disappeared at 2 and 3 weeks. These changes were not observed in the control group. CONCLUSIONS Temporary suppression of vagally mediated AF, for at least 1 week, was achieved with botulinum toxin injection in this canine model. This effect might be associated with reduced dispersion of effective refractory period. A temporary autonomic block using botulinum toxin might be a novel therapeutic option for several clinical conditions such as post-cardiac surgery AF.
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Affiliation(s)
- Seil Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.
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371
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Lim PB, Malcolme-Lawes LC, Stuber T, Koa-Wing M, Wright IJ, Tillin T, Sutton R, Davies DW, Peters NS, Francis DP, Kanagaratnam P. Feasibility of multiple short, 40-s, intra-procedural ECG recordings to detect immediate changes in heart rate variability during catheter ablation for arrhythmias. J Interv Card Electrophysiol 2011; 32:163-71. [PMID: 21647641 PMCID: PMC3204003 DOI: 10.1007/s10840-011-9580-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2011] [Accepted: 04/14/2011] [Indexed: 11/25/2022]
Abstract
PURPOSE This study aims to evaluate a method to detect heart rate variability (HRV) changes using short ECG segments during ablation for arrhythmias. METHODS HRV was averaged from sequentially shorter time windows from 5-min ECG recordings in 15 healthy volunteers. The 40-s window was identified as the shortest duration that yielded reproducible values in high frequency (HF) and low frequency (LF) HRV. This method was validated in patients undergoing tilt table testing to see if the expected modulation in HRV that occurs prior to syncope could be detected from multiple 40-s recordings. Lastly, this method was used to assess HRV changes in 75 patients undergoing ablation for atrial fibrillation (AF) and other arrhythmias, to see if autonomic modulation as a result of ablation could be detected. A further 14 patients had stepwise HRV measurements at different stages of the AF ablation procedure to determine whether intra-procedural HRV changes could be detected. RESULTS HRV, averaged from multiple 40-s recordings, demonstrated the expected increase immediately preceding syncope compared with baseline (LF: 341 ± 311-1,536 ± 1,368 ms(2), p< 0.05; HF: 342 ± 339-1,628 ± 1,755 ms(2), p < 0.05). AF ablation, particularly following right pulmonary vein circumferential ablation, produced immediately detectable reductions in LF (153 ± 251-50 + 116 ms(2), p < 0.001) and HF (86 ± 195-33 ± 83 ms(2), p < 0.001) without any change in RR interval (877 ± 191-843 ± 220 ms, p = 0.261). Ablation for atrial flutter did not change the mean RR interval, LF or HF HRV. CONCLUSION Averaging multiple 40-s windows give valid HF and LF HRV measurements that enable detection of intra-procedural changes. Left atrial ablation around the right-sided pulmonary veins is unique in producing reductions in HRV. This method has the potential for use as an endpoint marker for adjunctive autonomic ablation procedures.
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Affiliation(s)
- Phang Boon Lim
- Cardiology Department, Imperial College Healthcare NHS Trust, St Mary's Hospital, Praed Street, London, W2 1NY, UK.
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372
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Lim PB, Malcolme-Lawes LC, Stuber T, Kojodjojo P, Wright IJ, Francis DP, Wyn Davies D, Peters NS, Kanagaratnam P. Stimulation of the intrinsic cardiac autonomic nervous system results in a gradient of fibrillatory cycle length shortening across the atria during atrial fibrillation in humans. J Cardiovasc Electrophysiol 2011; 22:1224-31. [PMID: 21615814 DOI: 10.1111/j.1540-8167.2011.02097.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The intrinsic cardiac autonomic nervous system (ANS) is implicated in atrial fibrillation (AF) but little is known about its role in maintenance of the electrophysiological substrate during AF in humans. We hypothesized that ANS activation by high-frequency stimulation (HFS) of ganglionated plexi (GP) increases dispersion of atrial AF cycle lengths (AFCLs) via a parasympathetic effect. METHODS AND RESULTS During AF in 25 patients, HFS was delivered to presumed GP sites to provoke a bradycardic vagal response and AFCL was continuously monitored from catheters placed in the pulmonary vein (PV), coronary sinus (CS), and high right atrium (HRA). A total of 163 vagal responses were identified from 271 HFS episodes. With a vagal response, the greatest reduction in AFCL was seen in the PV adjacent to the site of HFS (16% reduction, 166 ± 28 to 139 ± 26 ms, P < 0.0001) followed by the PV-atrial junction (9% reduction, 173 ± 21 to 158 ± 20 ms, P < 0.0001), followed by the rest of the atrium (3-7% reduction recorded in HRA and CS). Without a vagal response, AFCL changes were not observed. In 10 patients, atropine was administered in between HFS episodes. Before atropine administration, HFS led to a vagal response and a reduction in PV AFCL (164 ± 28 to 147 ± 26 ms, P < 0.0001). Following atropine, HFS at the same GP sites no longer provoked a vagal response, and the PV AFCL remained unchanged (164 ± 30 to 166 ± 33 ms, P = 0.34). CONCLUSIONS Activation of the parasympathetic component of the cardiac ANS may cause heterogenous changes in atrial AFCL that might promote PV drivers.
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Yamamoto T, Hayashi M, Miyauchi Y, Murata H, Horie T, Igawa O, Kato T, Mizuno K. Respiratory cycle-dependent atrial tachycardia: prevalence, electrocardiographic and electrophysiologic characteristics, and outcome after catheter ablation. Heart Rhythm 2011; 8:1615-21. [PMID: 21699840 DOI: 10.1016/j.hrthm.2011.04.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Accepted: 04/27/2011] [Indexed: 11/17/2022]
Abstract
BACKGROUND Little is known about the tachyarrhythmias relating to respiration. Case reports presented patients with respiratory cycle-dependent atrial tachycardias (RCATs), which cyclically emerge after starting inspiration and cease during expiration. OBJECTIVE The aim of the present study was to elucidate the prevalence, characteristics, and long-term outcome after radiofrequency catheter ablation (RFCA) of RCATs. METHODS The electrocardiographic and electrophysiologic properties and results of RFCA were analyzed in 60 patients with a total of 71 focal atrial tachycardias (ATs). RESULTS Nine RCATs (13%) were observed in 7 patients (12%). RCATs were irregular, with a mean cycle length ranging from 220 to 650 ms, and developed incessantly accounting for 32% ± 14% of the 24-hour heartbeats. The P-wave morphology was positive or biphasic (positive to negative) in V1, and positive in I and II. The electroanatomical mapping demonstrated a centrifugal activation pattern, with the earliest site located at the antrum of the right superior pulmonary vein (RSPV), inside the RSPV, and inside the superior vena cava (SVC) in 4, 2, and 3 RCATs, respectively. Radiofrequency energy delivery at the earliest site or the electrical isolation of the RSPV and SVC suppressed all RCATs. During a follow-up of 25 ± 15 months, 1 RCAT recurred and was eliminated in a second procedure. CONCLUSION RCATs were observed in 13% of the focal ATs. As presumed from the P-wave morphologies, their foci converged around the RSPV or inside the SVC. RFCA was effective to eliminate RCATs.
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Affiliation(s)
- Teppei Yamamoto
- Department of Cardiology, Nippon Medical School, Tokyo, Japan
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374
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NAKATANI YOSUKE, MIZUMAKI KOICHI, NISHIDA KUNIHIRO, INOUE HIROSHI. Atrioventricular Node Ablation and Pacemaker Implantation for Recurrent Syncope in a Patient With Postural Tachycardia Syndrome (POTS). J Cardiovasc Electrophysiol 2011; 22:1284-7. [DOI: 10.1111/j.1540-8167.2011.02078.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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375
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Swallowing-induced multifocal atrial tachycardia originating from right pulmonary veins. J Electrocardiol 2011; 44:395.e1-5. [DOI: 10.1016/j.jelectrocard.2010.12.161] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Indexed: 11/19/2022]
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376
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Katritsis DG, Giazitzoglou E, Zografos T, Pokushalov E, Po SS, Camm AJ. Rapid pulmonary vein isolation combined with autonomic ganglia modification: A randomized study. Heart Rhythm 2011; 8:672-8. [PMID: 21199686 DOI: 10.1016/j.hrthm.2010.12.047] [Citation(s) in RCA: 171] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2010] [Accepted: 12/27/2010] [Indexed: 11/26/2022]
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377
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Cui B, Lu Z, He B, Hu X, Wu B, Xu S, Huang C, Jiang H. Acute effects of ganglionated plexi ablation on sinoatrial nodal and atrioventricular nodal functions. Auton Neurosci 2011; 161:87-94. [DOI: 10.1016/j.autneu.2011.01.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Revised: 12/19/2010] [Accepted: 01/13/2011] [Indexed: 11/16/2022]
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378
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Rivarola EWR, Scanavacca M, Ushizima M, Cestari I, Hardy C, Lara S, Pisani C, Sosa E. Spectral characteristics of atrial electrograms in sinus rhythm correlates with sites of ganglionated plexuses in patients with paroxysmal atrial fibrillation. Europace 2011; 13:1141-7. [PMID: 21454332 DOI: 10.1093/europace/eur074] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS To verify whether spectral components of atrial electrograms (AE) during sinus rhythm (SR) correlate with cardiac ganglionated plexus (GP) sites. METHODS AND RESULTS Thirteen patients undergoing atrial fibrillation (AF) ablation were prospectively enrolled. Prior to radio frequency application, endocardial AE were recorded with a sequential point-by-point approach. Electrical stimuli were delivered at 20 Hz, amplitude 100 V, and pulse width of 4 ms. A vagal response was defined as a high-frequency stimulation (HFS) evoked atrioventricular block or a prolongation of RR interval. Spectral analysis was performed on single AE during SR, sampling rate of 1000 Hz, Hanning window. Overall, 1488 SR electrograms were analysed from 186 different left atrium sites, 129 of them corresponding to negative vagal response sites, and 57 to positive response sites. The electrogram duration and the number of deflections were similar in positive and negative response sites. Spectral power density of sites with vagal response was lower between 26 and 83 Hz and higher between 107 and 200 Hz compared with negative response sites. The area between 120 and 170 Hz normalized to the total spectrum area was tested as a diagnostic parameter. Receiver operating characteristic curve analysis demonstrated that an area 120-170/area(total) value >0.14 identified vagal sites with 70.9% sensitivity and 72.1% specificity. CONCLUSION Spectral analysis of AE during SR in sites that correspond to the anatomical location of the GP is feasible and may be a simpler method of mapping the cardiac autonomic nervous system, compared with the HFS technique.
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Affiliation(s)
- Esteban Wisnivesky Rocca Rivarola
- Heart Institute (InCor), University of São Paulo Medical School, Av. Dr Eneas de Carvalho Aguiar 44, CEP 05403-000, São Paulo, Brazil.
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379
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JIANG RUHONG, JIANG CHENYANG, LIU QIANG, PO SUNNYS. Regional Ganglionated Plexus Ablation Eliminated Rapid Firing in an Electrically Isolated Pulmonary Vein. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2011; 35:e316-9. [DOI: 10.1111/j.1540-8159.2011.03074.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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380
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Autonomic modulation of complex fractionated atrial electrograms in patients with paroxysmal atrial fibrillation. J Interv Card Electrophysiol 2011; 31:217-23. [DOI: 10.1007/s10840-011-9558-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Accepted: 02/18/2011] [Indexed: 11/25/2022]
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381
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Ware AL, Suri RM, Stulak JM, Sundt TM, Schaff HV. Left atrial ganglion ablation as an adjunct to atrial fibrillation surgery in valvular heart disease. Ann Thorac Surg 2011; 91:97-102. [PMID: 21172494 DOI: 10.1016/j.athoracsur.2010.08.037] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Revised: 08/18/2010] [Accepted: 08/19/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Our aim was to evaluate early results of ganglionic plexus (GP) ablation with modified Cox maze lesion sets for concomitant atrial fibrillation (AF) during corrective valve surgery. METHODS Between December 2006 and April 2008, 20 patients (7 men; median age, 65 years; range, 52 to 82 years) with valvular heart disease and AF (intermittent in 12 [60%]) underwent corrective valve surgery with maze and GP ablation. Patients were then compared with a case-matched control cohort who underwent radiofrequency ablation maze alone. RESULTS Procedures included mitral valve repair in 7 patients (35%), multivalve procedures in 5 (25%), mitral valve replacement in 4 (20%), aortic valve replacement in 3 (15%), and valve-sparing aortic root replacement in 1 (5%). All patients underwent concomitant AF ablation procedures (biatrial maze in 11 [55%], left-sided maze in 9 [45%]). Ganglionic plexus stimulation was performed in all patients. Sites at which the R-R interval doubled were considered active and were ablated. There were no early deaths. Freedom from AF at 1 year was significantly higher (90% versus 50%; p=0.01) and mean New York Heart Association functional class was better (1 versus 1.7; p<0.001) in the group that underwent maze and GP ablation compared with maze alone. CONCLUSIONS Active left atrial GP are frequently present in patients with AF and valvular heart disease, and GP ablation can be safely performed as an adjunct to AF ablation during valve surgery. Early results are promising and may yield higher freedom from AF compared with radiofrequency ablation maze alone.
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Affiliation(s)
- Adam L Ware
- Mayo Medical School, College of Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
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382
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Lim PB, Malcolme-Lawes LC, Stuber T, Wright I, Francis DP, Davies DW, Peters NS, Kanagaratnam P. Intrinsic cardiac autonomic stimulation induces pulmonary vein ectopy and triggers atrial fibrillation in humans. J Cardiovasc Electrophysiol 2011; 22:638-46. [PMID: 21235671 DOI: 10.1111/j.1540-8167.2010.01992.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
INTRODUCTION The induction of atrial fibrillation (AF) by pulmonary vein (PV) ectopy is well described. The triggers for these PV ectopy are not so well understood. The intrinsic cardiac autonomic nervous system (ANS) has been suggested as a potential upstream regulator that may cause PV ectopy and atrial fibrillation (AF). We hypothesized that activation of the ANS by high frequency stimulation (HFS) of atrial ganglionated plexi (GP) can initiate PV ectopy. METHODS AND RESULTS During sinus rhythm in 12 patients undergoing ablation for paroxysmal AF, short bursts of HFS, synchronized to the local atrial refractory period, were delivered at presumed GP sites. Electrograms were recorded from catheters placed in the PV, coronary sinus (CS) and high right atrium (HRA). A total of 112 episodes of HFS were recorded, producing ectopic activity in 91 of 112 (81%) episodes. Of these 91 episodes, there were 46 episodes of isolated single ectopic beats, 5 episodes of double ectopic responses, 24 episodes of ectopy/tachycardia lasting <30 s, and 16 episodes of AF lasting >30 s. In 63 of 91 episodes, the PV catheter was placed adjacent to the stimulated GP, resulting in ectopy recorded earliest in the PV catheter in 48 of 63 (76%) episodes. In one patient, reproducible ectopy was shown to occur following AV nodal conduction delay in response to HFS. Without HFS, neither AV nodal conduction delay nor ectopy occurred. CONCLUSIONS This study has demonstrated a direct link between activation of the intrinsic cardiac autonomic nervous system and pulmonary vein ectopy in humans.
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Affiliation(s)
- Phang Boon Lim
- Cardiology Department, Imperial College Healthcare NHS Trust, St. Mary's Hospital, Praed Street, London, UK.
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384
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Abstract
Atrial fibrillation is a common cardiac arrhythmia with rapid and irregular atrial activity. Instead of uniformly contracting as one chamber, the atrial compartment fibrillates. Several studies have demonstrated that this arrhythmia contributes substantially to cardiac morbidity and mortality. The purpose of this review is to describe the pathophysiology and clinical management of this arrhythmia.
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Affiliation(s)
- Shinsuke Miyazaki
- Hôpital Cardiologique du Haut-Lévêque and the Université Victor Segalen Bordeaux II, France.
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385
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LO LIWEI, CHEN SHIHANN. Superior Vena Cava-Aorta Ganglionated Plexus: An Arbitrator of the Heart or Just a Passer-By? J Cardiovasc Electrophysiol 2010; 21:1400-2. [DOI: 10.1111/j.1540-8167.2010.01822.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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386
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Lemery R. Actualités dans l’ablation de la fibrillation auriculaire. ARCHIVES OF CARDIOVASCULAR DISEASES SUPPLEMENTS 2010. [DOI: 10.1016/s1878-6480(10)70371-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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387
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Shen MJ, Choi EK, Tan AY, Han S, Shinohara T, Maruyama M, Chen LS, Shen C, Hwang C, Lin SF, Chen PS. Patterns of baseline autonomic nerve activity and the development of pacing-induced sustained atrial fibrillation. Heart Rhythm 2010; 8:583-9. [PMID: 21118728 DOI: 10.1016/j.hrthm.2010.11.040] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2010] [Accepted: 11/23/2010] [Indexed: 12/17/2022]
Abstract
BACKGROUND Whether autonomic nerve activity is important in the development of pacing-induced sustained atrial fibrillation (AF) is unclear. OBJECTIVE The purpose of this study was to test the hypothesis that patterns of baseline autonomic nerve activity are important in the development of pacing-induced sustained AF. METHODS Radiotransmitters were implanted in 12 ambulatory dogs to record left stellate ganglion nerve activity (SGNA) and vagal nerve activity (VNA). Sustained (>48 hours) AF was induced with intermittent rapid atrial pacing. RESULTS At baseline (before pacing), 1-minute integrated nerve activity between SGNA and VNA demonstrated either a single linear relationship with excellent correlation (group 1, N = 3, r = 0.816 ± 0.105) or nonlinear relationships with poor correlation (group 2, N = 9, r = 0.316 ± 0.162, P <.05 vs group 1). Group 1 dogs had higher VNA (97.0 ± 11.5 mV-s) compared to group 2 (33.4 ± 21.7 mV-s, P <.001). Group 1 dogs had more frequent sympathovagal co-activation episodes than did group 2 (50 ± 19 per day vs 15 ± 6 per day, P <.05) and more paroxysmal atrial tachycardia (PAT; 5 ± 1 per day vs 2 ± 1 per day, P <.05) at baseline. Sustained AF occurred after 16 ± 4 days (range 13-20 days) of pacing in group 1 and after 46 ± 18 days (range 23-72 days) of pacing in group 2 (P <.05). In the week before development of sustained AF, VNA of group 2 dogs was significantly increased compared to baseline (P <.05). CONCLUSION Ambulatory dogs with good linear sympathovagal correlation and higher vagal tone at baseline have more PAT episodes at baseline and faster induction of sustained AF by rapid pacing. Rapid atrial pacing increased the VNA of the remaining dogs before induction of sustained AF.
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Affiliation(s)
- Mark J Shen
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA
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388
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Mikhaylov E, Kanidieva A, Sviridova N, Abramov M, Gureev S, Szili-Torok T, Lebedev D. Outcome of anatomic ganglionated plexi ablation to treat paroxysmal atrial fibrillation: a 3-year follow-up study. Europace 2010; 13:362-70. [DOI: 10.1093/europace/euq416] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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389
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Scherlag BJ, Nakagawa H, Jackman WM, Lazzara R, Po SS. Non-pharmacological, non-ablative approaches for the treatment of atrial fibrillation: experimental evidence and potential clinical implications. J Cardiovasc Transl Res 2010; 4:35-41. [PMID: 21057908 DOI: 10.1007/s12265-010-9231-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2010] [Accepted: 10/19/2010] [Indexed: 12/22/2022]
Abstract
In this review, we initially covered the basic and clinical reports that provided the prevalent concepts underlying the mechanisms for atrial fibrillation (AF). The clinical evolution of catheter ablation and its eventual application to AF has also been detailed. A critique of the results based on a review of the literature has shown that either or both drugs or catheter ablation therapy for preventing AF recurrences have significant limitations and even serious complications. Finally, we have presented recent experimental studies which suggest that an alternative approach to reducing AF inducibility can be achieved with low-level autonomic nerve stimulation. Specifically, electrical stimulation of the vago-sympathetic trunks, at levels well below that which slows the heart rate can significantly increase AF thresholds and suppress AF inducibility. Further studies will determine if this new method can be used as an effective means of treating some forms of clinical AF.
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Affiliation(s)
- Benjamin J Scherlag
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, 1200 Everett Drive, Rm 6E103, Oklahoma City, OK 73104, USA.
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391
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Nishida K, Maguy A, Sakabe M, Comtois P, Inoue H, Nattel S. The role of pulmonary veins vs. autonomic ganglia in different experimental substrates of canine atrial fibrillation. Cardiovasc Res 2010; 89:825-33. [DOI: 10.1093/cvr/cvq332] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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392
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Abstract
Atrial fibrillation is the most common clinical cardiac arrhythmia. It is often initiated by ectopic beats arising from the pulmonary veins and atria. While pulmonary vein myocytes most likely contribute to atrial ectopic beats initiating atrial fibrillation, emerging evidence suggests the existence of other cell populations that may also contribute to atrial arrhythmias. In addition to sinus node-like and intestinal Cajal-like cells, we recently characterized a novel, melanocyte-like cell population in murine and human hearts that may contribute to atrial arrhythmogenic triggers in mice. Murine cardiac melanocyte-like cells are electrically excitable, and express adrenergic and muscarinic receptors. Adult mice lacking the gene encoding dopachrome tautomerase (Dct) are susceptible to atrial arrhythmias, and Dct is expressed by both murine and human cardiac melanocytes. While Dct-expressing cells are present in human hearts in regions from which atrial arrhythmias often arise, the contribution of these cells to clinical atrial arrhythmias remains to be determined.
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Affiliation(s)
- Vickas V Patel
- Penn Cardiovascular Institute and Division of Cardiovascular Medicine, 905 BRB II/III, 421 Curie Boulevard, University of Pennsylvania, Philadelphia, PA 19104-6160, USA.
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Cardinal R, Armour JA, Bouchard C, Vermeulen M, Vinet A, Nadeau R, Pagé P. Atrial Tachyarrhythmias and Repolarization Changes Induced by Discrete Activation of Dorsal Mediastinal Cardiac Nerves in Canines. Circ Arrhythm Electrophysiol 2010; 3:511-20. [DOI: 10.1161/circep.110.938050] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Chronotropic “vagal responses” elicited by high-frequency stimulation have been used to identify atrial targets for ablative treatment of atrial tachyarrhythmias (AT), whereas an anatomic approach consisting of extensive ablation of the ganglionated plexus areas has been proposed as an alternative. Therefore, there is a need for precise delineation of juxtacardiac nerves involved in AT initiation and clarification of their regional influences throughout the atria in relation to AT sites of origin, beyond chronotropic effects related to sinus node modulation.
Methods and Results—
Unipolar electrograms were recorded from 191 biatrial epicardial sites in 13 anesthetized canines, with concomitant left atrial endocardial recording from 63 sites in 5 of 13 animals. When electric stimuli were delivered to dorsal mediastinal nerves during the atrial refractory period, atrial premature depolarizations initiating AT were elicited in all animals, most frequently without prior sinus cycle length modification. Among 63 episodes, the sites of origin of early AT beats were localized to (1) the posterolateral left atrial wall in the pulmonary vein region (33%), (2) superior left atrial loci along the Bachmann bundle (55%), and (3) the region of Bachmann bundle insertion into the superior right atrial wall (11%). Moreover, the AT sites of origin were spatially concordant with regional waveform changes during the repolarization phase of unipolar recordings. AT induction and repolarization changes were abolished after atropine administration.
Conclusions—
Activation of individual dorsal mediastinal nerves induces AT arising from distinct sites of origin which are spatially concordant with regional atrial repolarization changes.
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Affiliation(s)
- René Cardinal
- From the Centre de recherche (R.C., A.A., C.B., M.V., A.V., R.N., P.P.), Hôpital du Sacré-Cœur de Montréal, and the Departments of Pharmacology (R.C., A.A., C.B., M.V.) and Surgery (P.P.), Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - J. Andrew Armour
- From the Centre de recherche (R.C., A.A., C.B., M.V., A.V., R.N., P.P.), Hôpital du Sacré-Cœur de Montréal, and the Departments of Pharmacology (R.C., A.A., C.B., M.V.) and Surgery (P.P.), Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Caroline Bouchard
- From the Centre de recherche (R.C., A.A., C.B., M.V., A.V., R.N., P.P.), Hôpital du Sacré-Cœur de Montréal, and the Departments of Pharmacology (R.C., A.A., C.B., M.V.) and Surgery (P.P.), Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Michel Vermeulen
- From the Centre de recherche (R.C., A.A., C.B., M.V., A.V., R.N., P.P.), Hôpital du Sacré-Cœur de Montréal, and the Departments of Pharmacology (R.C., A.A., C.B., M.V.) and Surgery (P.P.), Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Alain Vinet
- From the Centre de recherche (R.C., A.A., C.B., M.V., A.V., R.N., P.P.), Hôpital du Sacré-Cœur de Montréal, and the Departments of Pharmacology (R.C., A.A., C.B., M.V.) and Surgery (P.P.), Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Réginald Nadeau
- From the Centre de recherche (R.C., A.A., C.B., M.V., A.V., R.N., P.P.), Hôpital du Sacré-Cœur de Montréal, and the Departments of Pharmacology (R.C., A.A., C.B., M.V.) and Surgery (P.P.), Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Pierre Pagé
- From the Centre de recherche (R.C., A.A., C.B., M.V., A.V., R.N., P.P.), Hôpital du Sacré-Cœur de Montréal, and the Departments of Pharmacology (R.C., A.A., C.B., M.V.) and Surgery (P.P.), Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
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394
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Oh S, Choi EK, Choi YS. Short-term autonomic denervation of the atria using botulinum toxin. Korean Circ J 2010; 40:387-90. [PMID: 20830252 PMCID: PMC2933463 DOI: 10.4070/kcj.2010.40.8.387] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2009] [Revised: 01/26/2010] [Accepted: 02/16/2010] [Indexed: 11/15/2022] Open
Abstract
Background and Objectives Major epicardial fat pads contain cardiac ganglionated plexi (GP) of the autonomic nervous system. Autonomic denervation may improve the success rate of atrial fibrillation (AF) ablation. This study was designed to elucidate the acute effects of blocking the right atrium-pulmonary vein (RA-PV) and left atrium-inferior vena cava (LA-IVC) fat pads on the electrophysiologic characteristics of the atrium and AF inducibility with a botulinum toxin injection. Materials and Methods Eight mongrel dogs were studied. The RA-PV and LA-IVC fat pads were exposed through a median thoracotomy. Botulinum toxin (BT, 50 U to each fat pad, n=6) or normal saline (NS, n=2) was injected in the entire area of two fat pads. The study protocol was applied before injection and repeated at 1, 2, 3, 4, and 5 hours thereafter. The sinus rate, ventricular rate during rapid atrial pacing with a cycle length of 50 ms, and AF inducibility were measured with and without vagal stimulation (VS). Bilateral cervical VS was applied (20 Hz, 0.2 ms, 5.6±2.0 V). AF inducibility was evaluated with burst pacing with 200 impulses at a 50-ms cycle length. Results VS effects on the sinus node and AF inducibility were eliminated a few hours after injection of BT; these changes were not observed after injection of NS. Conclusion Short-term autonomic denervation of the atria was achieved by blocking the major epicardial GP with BT.
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Affiliation(s)
- Seil Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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395
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Remembrances of time past, or À la recherche du temps perdu. Heart Rhythm 2010; 7:951-2. [DOI: 10.1016/j.hrthm.2010.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Indexed: 11/21/2022]
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396
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397
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POKUSHALOV EVGENY, ROMANOV ALEXANDER, ARTYOMENKO SERGEY, TUROV ALEX, SHIROKOVA NATALYA, KATRITSIS DEMOSTHENESG. Left Atrial Ablation at the Anatomic Areas of Ganglionated Plexi for Paroxysmal Atrial Fibrillation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2010; 33:1231-8. [DOI: 10.1111/j.1540-8159.2010.02800.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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398
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Choi EK, Shen MJ, Han S, Kim D, Hwang S, Sayfo S, Piccirillo G, Frick K, Fishbein MC, Hwang C, Lin SF, Chen PS. Intrinsic cardiac nerve activity and paroxysmal atrial tachyarrhythmia in ambulatory dogs. Circulation 2010; 121:2615-23. [PMID: 20529998 DOI: 10.1161/circulationaha.109.919829] [Citation(s) in RCA: 189] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Little is known about the relationship between intrinsic cardiac nerve activity (ICNA) and spontaneous arrhythmias in ambulatory animals. METHODS AND RESULTS We implanted radiotransmitters to record extrinsic cardiac nerve activity (ECNA; including stellate ganglion nerve activity and vagal nerve activity) and ICNA (including superior left ganglionated plexi nerve activity and ligament of Marshall nerve activity) in 6 ambulatory dogs. Intermittent rapid left atrial pacing was performed to induce paroxysmal atrial fibrillation or atrial tachycardia. The vast majority (94%) of ligament of Marshall nerve activity were preceded by or coactivated with ECNA (stellate ganglion nerve activity or vagal nerve activity), whereas 6% of episodes were activated alone without concomitant stellate ganglion nerve activity or vagal nerve activity. Paroxysmal atrial fibrillation and atrial tachycardia were invariably (100%) preceded (<5 seconds) by ICNA. Most paroxysmal atrial tachycardia events (89%) were preceded by ICNA and sympathovagal coactivation, whereas 11% were preceded by ICNA and stellate ganglion nerve activity-only activation. Most paroxysmal atrial fibrillation events were preceded only by ICNA (72%); the remaining 28% were preceded by ECNA and ICNA together. Complex fractionated atrial electrograms were observed during ICNA discharges that preceded the onset of paroxysmal atrial tachycardia and atrial fibrillation. Immunostaining confirmed the presence of both adrenergic and cholinergic nerve at ICNA sites. CONCLUSIONS There is a significant temporal relationship between ECNA and ICNA. However, ICNA can also activate alone. All paroxysmal atrial tachycardia and atrial fibrillation episodes were invariably preceded by ICNA. These findings suggest that ICNA (either alone or in collaboration with ECNA) is an invariable trigger of paroxysmal atrial tachyarrhythmias. ICNA might contaminate local atrial electrograms, resulting in complex fractionated atrial electrogram-like activity.
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Affiliation(s)
- Eue-Keun Choi
- Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine,1801 N Capitol Avenue, Indianapolis, IN 46202, USA
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399
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Satellite glial cells in sympathetic and parasympathetic ganglia: in search of function. ACTA ACUST UNITED AC 2010; 64:304-27. [PMID: 20441777 DOI: 10.1016/j.brainresrev.2010.04.009] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2009] [Revised: 04/14/2010] [Accepted: 04/27/2010] [Indexed: 01/08/2023]
Abstract
Glial cells are established as essential for many functions of the central nervous system, and this seems to hold also for glial cells in the peripheral nervous system. The main type of glial cells in most types of peripheral ganglia - sensory, sympathetic, and parasympathetic - is satellite glial cells (SGCs). These cells usually form envelopes around single neurons, which create a distinct functional unit consisting of a neuron and its attending SGCs. This review presents the knowledge on the morphology of SGCs in sympathetic and parasympathetic ganglia, and the (limited) available information on their physiology and pharmacology. It appears that SGCs carry receptors for ATP and can thus respond to the release of this neurotransmitter by the neurons. There is evidence that SGCs have an uptake mechanism for GABA, and possibly other neurotransmitters, which enables them to control the neuronal microenvironment. Damage to post- or preganglionic nerve fibers influences both the ganglionic neurons and the SGCs. One major consequence of postganglionic nerve section is the detachment of preganglionic nerve terminals, resulting in decline of synaptic transmission. It appears that, at least in sympathetic ganglia, SGCs participate in the detachment process, and possibly in the subsequent recovery of the synaptic connections. Unlike sensory neurons, neurons in autonomic ganglia receive synaptic inputs, and SGCs are in very close contact with synaptic boutons. This places the SGCs in a position to influence synaptic transmission and information processing in autonomic ganglia, but this topic requires much further work.
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400
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Katritsis D, Merchant FM, Mela T, Singh JP, Heist EK, Armoundas AA. Catheter Ablation of Atrial Fibrillation. J Am Coll Cardiol 2010; 55:2293-8. [PMID: 20488298 DOI: 10.1016/j.jacc.2010.03.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2009] [Revised: 01/21/2010] [Accepted: 03/01/2010] [Indexed: 11/18/2022]
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