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Kharbanda RK, Ramdat Misier NL, van Schie MS, Zwijnenburg RD, Amesz JH, Knops P, Bogers AJJC, Taverne YJHJ, de Groot NMS. Insights Into the Effects of Low-Level Vagus Nerve Stimulation on Atrial Electrophysiology: Towards Patient-Tailored Cardiac Neuromodulation. JACC Clin Electrophysiol 2023; 9:1843-1853. [PMID: 37480858 DOI: 10.1016/j.jacep.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 05/10/2023] [Accepted: 05/10/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Low-level vagus nerve stimulation through the tragus (tLLVNS) is increasingly acknowledged as a therapeutic strategy to prevent and treat atrial fibrillation. However, a lack in understanding of the exact antiarrhythmic properties of tLLVNS has hampered clinical implementation. OBJECTIVES In this study, the authors aimed to study the effects of tLLVNS on atrial electrophysiology by performing intraoperative epicardial mapping during acute and chronic tLLVNS. METHODS Epicardial mapping of the superior right atrium was performed before and after arterial graft harvesting in patients undergoing coronary artery bypass grafting without a history of atrial fibrillation. The time needed for arterial graft harvesting was used to perform chronic tLLVNS. Electrophysiological properties were compared before and during chronic tLLVNS. RESULTS A total of 10 patients (median age 74 years [IQR: 69-78 years]) underwent tLLVNS for a duration of 56 minutes (IQR: 43-73 minutes). During acute and chronic tLLVNS, a shift of the sinoatrial node exit site toward a more cranial direction was observed in 5 (50%) patients. Unipolar potential voltage increased significantly during acute and chronic tLLVNS (3.9 mV [IQR: 3.1-4.8 mV] vs 4.7 mV [IQR: 4.0-5.3 mV] vs 5.2 mV [IQR: 4.8-7.0 mV]; P = 0.027, P = 0.02, respectively). Total activation time, slope of unipolar potentials, amount of fractionation, low-voltage areas and conduction velocity did not differ significantly between baseline measurements and tLLVNS. Two patients showed consistent "improvement" of all electrophysiological properties during tLLVNS, while 1 patient appeared to have no beneficial effect. CONCLUSIONS We demonstrated that tLLVNS resulted in a significant increase in unipolar potential voltage. In addition, we observed the following in selective patients: 1) reduction in total activation time; 2) steeper slope of unipolar potentials; 3) decrease in the amount of fractionation; and 4) change in sinoatrial node exit sites.
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Affiliation(s)
- Rohit K Kharbanda
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands; Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Mathijs S van Schie
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Roxanne D Zwijnenburg
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands; Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Jorik H Amesz
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Paul Knops
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Yannick J H J Taverne
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
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Khan AA, Lip GYH, Shantsila A. Heart rate variability in atrial fibrillation: The balance between sympathetic and parasympathetic nervous system. Eur J Clin Invest 2019; 49:e13174. [PMID: 31560809 DOI: 10.1111/eci.13174] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 09/23/2019] [Accepted: 09/24/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is the commonest abnormal heart rhythm with significant related morbidity and mortality. Several pathophysiologic mechanisms have been advocated to explain the onset of AF. There has been increasing evidence that abnormalities of the autonomic nervous system (ANS) that includes sympathetic, parasympathetic and intrinsic neural network are involved in the pathogenesis of AF. This review will consider the anatomical and pathophysiological concepts of the cardiac neuronal network and discuss how it can be investigated. DESIGN Relevant articles for this review were selected primarily from Ovid Medline and Embase databases (see appendix). We searched for key terms "atrial fibrillation," "AF," "autonomic dysfunction," "autonomic nervous system," "heart rate variability" and "HRV" to gather relevant studies. Duplicate papers were excluded. RESULTS Heart is richly innervated by autonomic nerves. Both sympathetic and parasympathetic systems interact in developing AF along with cardiac ganglionated plexi (GP). Thus autonomic dysfunction is present in AF. There are methods including selective ablation that reduce autonomic innervation and show to reduce the incidence of spontaneous or induced atrial arrhythmias. Heart rate variability (HRV) is a useful tool to assess sympathetic and parasympathetic influences on disease states. HRV can be improved following intervention and is thus a useful application in assessing autonomic dysfunction in patients with AF. CONCLUSION ANS plays a crucial role in the development, propagation and complexity of AF. Assessment of the autonomic involvement in the propagation of AF may help in explaining why certain patients with AF do not benefit from cardioversion or ablation.
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Affiliation(s)
- Ahsan A Khan
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Alena Shantsila
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
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3
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The autonomic nervous system and cardiac arrhythmias: current concepts and emerging therapies. Nat Rev Cardiol 2019; 16:707-726. [DOI: 10.1038/s41569-019-0221-2] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/07/2019] [Indexed: 12/19/2022]
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Han X, Li J. Catheter Ablation of Atrial Fibrillation: Where Are We? CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2017. [DOI: 10.15212/cvia.2016.0060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Krul SPJ, Berger WR, Veldkamp MW, Driessen AHG, Wilde AAM, Deneke T, de Bakker JMT, Coronel R, de Groot JR. Treatment of Atrial and Ventricular Arrhythmias Through Autonomic Modulation. JACC Clin Electrophysiol 2015; 1:496-508. [PMID: 29759403 DOI: 10.1016/j.jacep.2015.09.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 08/19/2015] [Accepted: 09/24/2015] [Indexed: 11/26/2022]
Abstract
This paper reviews the contribution of autonomic nervous system (ANS) modulation in the treatment of arrhythmias. Both the atria and ventricles are innervated by an extensive network of nerve fibers of parasympathetic and sympathetic origin. Both the parasympathetic and sympathetic nervous system exert arrhythmogenic electrophysiological effects on atrial and pulmonary vein myocardium, while in the ventricle the sympathetic nervous system plays a more dominant role in arrhythmogenesis. Identification of ANS activity is possible with nuclear imaging. This technique may provide further insight in mechanisms and treatment targets. Additionally, the myocardial effects of the intrinsic ANS can be identified through stimulation of the ganglionic plexuses. These can be ablated for the treatment of atrial fibrillation. New (non-) invasive treatment options targeting the extrinsic cardiac ANS, such as low-level tragus stimulation and renal denervation, provide interesting future treatment possibilities both for atrial fibrillation and ventricular arrhythmias. However, the first randomized trials have yet to be performed. Future clinical studies on modifying the ANS may not only improve the outcome of ablation therapy but may also advance our understanding of the manner in which the ANS interacts with the myocardium to modify arrhythmogenic triggers and substrate.
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Affiliation(s)
- Sébastien P J Krul
- Heart Center, Department of Clinical and Experimental Cardiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Wouter R Berger
- Heart Center, Department of Clinical and Experimental Cardiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Marieke W Veldkamp
- Heart Center, Department of Clinical and Experimental Cardiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Antoine H G Driessen
- Heart Center, Department of Clinical and Experimental Cardiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Arthur A M Wilde
- Heart Center, Department of Clinical and Experimental Cardiology, Academic Medical Center, Amsterdam, the Netherlands; Princess Al-Jawhara Al-Brahim Centre of Excellence in Research of Hereditary Disorders, Jeddah, Kingdom of Saudi Arabia
| | - Thomas Deneke
- Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Jacques M T de Bakker
- Heart Center, Department of Clinical and Experimental Cardiology, Academic Medical Center, Amsterdam, the Netherlands; Interuniversity Cardiology Institute of the Netherlands, Utrecht, the Netherlands
| | - Ruben Coronel
- Heart Center, Department of Clinical and Experimental Cardiology, Academic Medical Center, Amsterdam, the Netherlands; L'Institut de RYthmologie et de modélisation Cardiaque (LIRYC), Université Bordeaux Segalen, Bordeaux, France
| | - Joris R de Groot
- Heart Center, Department of Clinical and Experimental Cardiology, Academic Medical Center, Amsterdam, the Netherlands.
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Stavrakis S, Nakagawa H, Po SS, Scherlag BJ, Lazzara R, Jackman WM. The role of the autonomic ganglia in atrial fibrillation. JACC Clin Electrophysiol 2015; 1:1-13. [PMID: 26301262 DOI: 10.1016/j.jacep.2015.01.005] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Recent experimental and clinical studies have shown that the epicardial autonomic ganglia play an important role in the initiation and maintenance of atrial fibrillation (AF). In this review, we present the current data on the role of the autonomic ganglia in the pathogenesis of AF and discuss potential therapeutic implications. Experimental studies have demonstrated that acute autonomic remodeling may play a crucial role in AF maintenance in the very early stages. The benefit of adding ablation of the autonomic ganglia to the standard pulmonary vein (PV) isolation procedure for patients with paroxysmal AF is supported by both experimental and clinical data. The interruption of axons from these hyperactive autonomic ganglia to the PV myocardial sleeves may be an important factor in the success of PV isolation procedures. The vagus nerve exerts an inhibitory control over the autonomic ganglia and attenuation or loss of this control may allow these ganglia to become hyperactive. Autonomic neuromodulation using low-level vagus nerve stimulation inhibits the activity of the autonomic ganglia and reverses acute electrical atrial remodeling during rapid atrial pacing and may provide an alternative non-ablative approach for the treatment of AF, especially in the early stages. This notion is supported by a preliminary human study. Further studies are warranted to confirm these findings.
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Affiliation(s)
- Stavros Stavrakis
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Hiroshi Nakagawa
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Sunny S Po
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Benjamin J Scherlag
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Ralph Lazzara
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Warren M Jackman
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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Xi Y, Cheng J. Dysfunction of the autonomic nervous system in atrial fibrillation. J Thorac Dis 2015; 7:193-8. [PMID: 25713736 DOI: 10.3978/j.issn.2072-1439.2015.01.12] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Accepted: 12/02/2014] [Indexed: 11/14/2022]
Affiliation(s)
- Yutao Xi
- 1 Texas Heart Institute, St. Luke's Hospital, Houston, TX 77030, USA ; 2 Section of Cardiology, University of Texas School of Medicine at Houston, Houston, TX 77030, USA
| | - Jie Cheng
- 1 Texas Heart Institute, St. Luke's Hospital, Houston, TX 77030, USA ; 2 Section of Cardiology, University of Texas School of Medicine at Houston, Houston, TX 77030, USA
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Kogawa R, Okumura Y, Watanabe I, Kofune M, Nagashima K, Mano H, Sonoda K, Sasaki N, Ohkubo K, Nakai T, Hirayama A. Spatial and temporal variability of the complex fractionated atrial electrogram activity and dominant frequency in human atrial fibrillation. J Arrhythm 2014; 31:101-7. [PMID: 26336540 DOI: 10.1016/j.joa.2014.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 07/30/2014] [Accepted: 08/05/2014] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND The presence of complex fractionated atrial electrograms (CFAEs) and high dominant frequencies (DFs) during atrial fibrillation (AF) have been demonstrated to be related to AF maintenance. Therefore, sequential mapping of CFAEs and DFs have been used for target sites of AF ablation. However, such mapping strategies are valid only if the CFAEs and DFs are spatiotemporally stable during the mapping procedure. We obtained spatially stable multi-electrode recordings to assess the spatiotemporal stability of CFAEs and DFs. METHODS We recorded electrical activity during AF for 10 min with a 64-electrode basket catheter (48 bipole electrode pairs) placed in the left atrium in 36 patients with AF (paroxysmal AF [PAF], n=16; persistent AF [PerAF], n=20). The spatial and temporal distribution of the CFAEs (fractionation interval <120 ms) and high DFs (>8 Hz) at 1-min intervals for 10 min were compared for each of the 48 bipoles. RESULTS The baseline CFAEs were located at 68.5±14.0% (32.9±6.7) of the 48 bipoles; however, the high DF sites were fewer (9.6±8.6% [4.6±4.1 bipoles]). The CFAEs sites did not change significantly during the 10-min recording period (kappa statistic: 0.71±0.24); however, the high DF sites changed significantly (kappa statistic: 0.07±0.19). These spatiotemporal changes in the CFAEs and high DFs did not differ between patients with PAF and PerAF. CONCLUSIONS Regardless of the AF type, CFAEs sites, but not high DF sites, showed a high degree of spatial and temporal stability.
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Key Words
- 3D, 3-dimensional
- AF, atrial fibrillation
- Atrial fibrillation
- Basket catheter
- CFAE, complex fractionated atrial electrogram
- Complex fractionated atrial electrogram
- DF, dominant frequency
- Dominant frequency
- FI, fractionation interval
- LA, left atrium
- LAA, left atrial appendage
- LV, left ventricle
- MAP, monophasic action potential
- PV, pulmonary vein
- PVI, pulmonary vein isolation
- PerAF, persistent AF
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Affiliation(s)
- Rikitake Kogawa
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Ichiro Watanabe
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Masayoshi Kofune
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Koichi Nagashima
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Hiroaki Mano
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Kazumasa Sonoda
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Naoko Sasaki
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Kimie Ohkubo
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Toshiko Nakai
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Atsushi Hirayama
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
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Waks JW, Josephson ME. Mechanisms of Atrial Fibrillation - Reentry, Rotors and Reality. Arrhythm Electrophysiol Rev 2014; 3:90-100. [PMID: 26835073 DOI: 10.15420/aer.2014.3.2.90] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 08/08/2014] [Indexed: 01/02/2023] Open
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice, yet our understanding of the mechanisms that initiate and sustain this arrhythmia remains quite poor. Over the last 50 years, various mechanisms of AF have been proposed, yet none has been consistently observed in both experimental studies and in humans. Recently, there has been increasing interest in understanding how spiral waves or rotors - which are specific, organised forms of functional reentry - sustain human AF and how they might be therapeutic targets for catheter-based ablation. The following review describes the historical understanding of reentry and AF mechanisms from earlier in the 20th century, advances in our understanding of mechanisms that are able to sustain AF with a focus on rotors and complex fractionated atrial electrograms (CFAEs), and how the study of AF mechanisms has resulted in new strategies for treating AF with novel forms of catheter ablation.
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Affiliation(s)
- Jonathan W Waks
- Clinical Fellow in Cardiac Electrophysiology, Harvard Medical School, Harvard-Thorndike Electrophysiology Institute and Arrhythmia Service, Beth Israel Deaconess Medical Center, Boston, US
| | - Mark E Josephson
- Herman C. Dana Professor of Medicine, Harvard Medical School, Chief of the Cardiovascular Division, Beth Israel Deaconess Medical Center and Director, Harvard-Thorndike Electrophysiology Institute and Arrhythmia Service, Beth Israel Deaconess Medical Center, Boston, US
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10
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Lau DH, Zeemering S, Maesen B, Kuklik P, Verheule S, Schotten U. Catheter Ablation Targeting Complex Fractionated Atrial Electrogram in Atrial Fibrillation. J Atr Fibrillation 2013; 6:907. [PMID: 28496893 PMCID: PMC5153035 DOI: 10.4022/jafib.907] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 10/08/2013] [Accepted: 10/15/2013] [Indexed: 11/10/2022]
Abstract
The relatively low success rates seen with pulmonary vein ablation in non-paroxysmal atrial fibrillation (AF) patients as compared to those with the paroxysmal form of the arrhythmia have prompted electrophysiologists to search for newer ablative strategies. A decade has passed since the initial description of complex fractionated atrial electrogram (CFAE) ablation aimed at targeting the electrophysiological substrate in atrial fibrillation. Despite intensive research, superiority of CFAE-based ablation over other contemporary approaches could not be demonstrated. Nevertheless, the technique has an adjunctive role to pulmonary vein ablation in non-paroxysmal AF patients. Perhaps our incomplete understanding of the complex AF pathophysiology and inadequate characterization or determination of CFAE has limited our success so far. This review aims to highlight the current challenges and future role of CFAE ablation. .
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Affiliation(s)
- Dennis H Lau
- Department of Physiology, Maastricht University,Medical Center; Maastricht, The Netherlands
| | - Stef Zeemering
- Department of Physiology, Maastricht University,Medical Center; Maastricht, The Netherlands
| | - Bart Maesen
- Department of Physiology, Maastricht University,Medical Center; Maastricht, The Netherlands
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Center; Maastricht, The Netherlands
| | - Pawel Kuklik
- Department of Physiology, Maastricht University,Medical Center; Maastricht, The Netherlands
| | - Sander Verheule
- Department of Physiology, Maastricht University,Medical Center; Maastricht, The Netherlands
| | - Ulrich Schotten
- Department of Physiology, Maastricht University,Medical Center; Maastricht, The Netherlands
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11
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Katritsis DG, Pokushalov E, Romanov A, Giazitzoglou E, Siontis GCM, Po SS, Camm AJ, Ioannidis JPA. Autonomic denervation added to pulmonary vein isolation for paroxysmal atrial fibrillation: a randomized clinical trial. J Am Coll Cardiol 2013; 62:2318-25. [PMID: 23973694 DOI: 10.1016/j.jacc.2013.06.053] [Citation(s) in RCA: 303] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 05/27/2013] [Accepted: 06/02/2013] [Indexed: 12/16/2022]
Abstract
OBJECTIVES The aim of this study was to investigate whether the combination of conventional pulmonary vein isolation (PVI) by circumferential antral ablation with ganglionated plexi (GP) modification in a single ablation procedure, yields higher success rates than PVI or GP ablation alone, in patients with paroxysmal atrial fibrillation (PAF). BACKGROUND Conventional PVI transects the major left atrial GP, and it is possible that autonomic denervation by inadvertent GP ablation plays a central role in the efficacy of PVI. METHODS A total of 242 patients with symptomatic PAF were recruited and randomized as follows: 1) circumferential PVI (n = 78); 2) anatomic ablation of the main left atrial GP (n = 82); or 3) circumferential PVI followed by anatomic ablation of the main left atrial GP (n = 82). The primary endpoint was freedom from atrial fibrillation (AF) or other sustained atrial tachycardia (AT), verified by monthly visits, ambulatory electrocardiographic monitoring, and implantable loop recorders, during a 2-year follow-up period. RESULTS Freedom from AF or AT was achieved in 44 (56%), 39 (48%), and 61 (74%) patients in the PVI, GP, and PVI+GP groups, respectively (p = 0.004 by log-rank test). PVI+GP ablation strategy compared with PVI alone yielded a hazard ratio of 0.53 (95% confidence interval: 0.31 to 0.91; p = 0.022) for recurrence of AF or AT. Fluoroscopy duration was 16 ± 3 min, 20 ± 5 min, and 23 ± 5 min for PVI, GP, and PVI+GP groups, respectively (p < 0.001). Post-ablation atrial flutter did not differ between groups: 5.1% in PVI, 4.9% in GP, and 6.1% in PVI+GP. No serious adverse procedure-related events were encountered. CONCLUSIONS Addition of GP ablation to PVI confers a significantly higher success rate compared with either PVI or GP alone in patients with PAF.
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Affiliation(s)
| | - Evgeny Pokushalov
- Arrhythmia Department, State Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Alexander Romanov
- Arrhythmia Department, State Research Institute of Circulation Pathology, Novosibirsk, Russia
| | | | - George C M Siontis
- Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Sunny S Po
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - A John Camm
- Cardiac and Vascular Sciences, St. George's, University of London, London, United Kingdom
| | - John P A Ioannidis
- Stanford Prevention Research Center, Department of Medicine, and Department of Health Research and Policy, Stanford University School of Medicine, and Department of Statistics, Stanford University School of Humanities and Sciences, Stanford, California
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Pantos I, Katritsis G, Zografos T, Camm AJ, Katritsis DG. Temporal stability of atrial electrogram fractionation in patients with paroxysmal atrial fibrillation. Am J Cardiol 2013; 111:863-8. [PMID: 23276474 DOI: 10.1016/j.amjcard.2012.11.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2012] [Revised: 11/27/2012] [Accepted: 11/27/2012] [Indexed: 11/19/2022]
Abstract
The atrial sites associated with fractionated activity and/or high-frequency signals are commonly considered as targets of ablation for atrial fibrillation (AF); however, their temporal stability has not been established. A total of 21 patients with paroxysmal AF were studied. Left atrial (LA) ganglionated plexi (GP) were identified by high-frequency stimulation, and prolonged (3-minute) electrogram sampling from the GP and the posterior wall of the left atrium during AF was acquired. Fast Fourier transformation was used to determine the dominant frequencies (DFs) of the recorded electrogram signals and to study their temporal variability. The DF at the identified GP was 5.34 ± 0.78 Hz and at the posterior LA wall was 5.58 ± 0.87 Hz. Fractionation, expressed as electrograms exhibiting consecutive DFs deferring >20%, was detected at 21 of the studied GP (84%) and 7 of the posterior LA wall sites (44%). Fractionation, expressed as electrograms exhibiting DFs >8 Hz, was detected at 6 GP (24%) and 1 posterior LA wall site (6%). During the 3-minute recordings, the derived DFs were temporally variable, exhibiting an average coefficient of variation of 15.2 ± 12.0%. Fractionation, expressed by significant consecutive DF variability (>20%), was detected only for 18.0 ± 19.0% of the recording period at GP and for 12.7 ± 13.4% at the posterior LA wall. In conclusion, atrial electrograms are temporarily variable, and fractionation is transient at atrial sites associated with fractionated electrical activity during AF. Our results question the clinical validity of fractionated atrial electrograms for ablation purposes.
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13
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Arora R. Recent insights into the role of the autonomic nervous system in the creation of substrate for atrial fibrillation: implications for therapies targeting the atrial autonomic nervous system. Circ Arrhythm Electrophysiol 2012; 5:850-9. [PMID: 22895601 DOI: 10.1161/circep.112.972273] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Rishi Arora
- Northwestern Memorial Hospital, Chicago, IL 60611, USA.
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14
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Habel N, Müller JG, Znojkiewicz P, Thompson N, Calame J, Calame S, Noori A, Gallo A, Lustgarten DL, Sobel BE, Spector PS. The impact of pharmacologic sympathetic and parasympathetic blockade on atrial electrogram characteristics in patients with atrial fibrillation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 34:1460-7. [PMID: 21883315 DOI: 10.1111/j.1540-8159.2011.03212.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Ablation of atrial autonomic inputs exerts antifibrillatory effects. However, because ablation destroys both myocardium and nerve cells, the effect of autonomic withdrawal alone remains unclear. We therefore examined the effects of pharmacologic autonomic blockade (PAB) on frequency and fractionation in patients with atrial fibrillation (AF). METHODS Esmolol and atropine were administered and electrograms were recorded simultaneously from both atria and the coronary sinus. In 17 patients, AF was recorded for 5 minutes and dominant frequency (DF) and continuous activity (CA) were compared before and during PAB. RESULTS Examination of the pooled data (537 sites, 17 patients) revealed a statistically significant decrease in mean DF (5.61–5.43Hz, P < 0.001) during PAB. Site-by-site analysis showed that 67% of sites slowed (0.45 ± 0.59 Hz), whereas 32% accelerated (0.49 ± 0.59Hz). Fractionation was reduced: median CA decreased from 31% to 26% (P < 0.001). In patient-by-patient analysis, mean DF/median CA decreased in 13 of 17 patients and increased in four. The spatial heterogeneity of DF decreased in nine of 17 patients (spatial coefficient of variation of DF at "nondriver sites" decreased by a mean of 2%). CONCLUSION PAB decreases DF and CA in the majority of sites. Given the complexity of interactions between atrial cells during AF, the effects of PAB on DF and fractionation are more heterogeneous than the effects of PAB on isolated cells.
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Affiliation(s)
- Nicole Habel
- Department of Medicine, University of Vermont College of Medicine, Burlington, Vermont, USA
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