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Lee C, Xu S, Samad T, Goodyer WR, Raissadati A, Heinrich P, Wu SM. The cardiac conduction system: History, development, and disease. Curr Top Dev Biol 2024; 156:157-200. [PMID: 38556422 DOI: 10.1016/bs.ctdb.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
The heart is the first organ to form during embryonic development, establishing the circulatory infrastructure necessary to sustain life and enable downstream organogenesis. Critical to the heart's function is its ability to initiate and propagate electrical impulses that allow for the coordinated contraction and relaxation of its chambers, and thus, the movement of blood and nutrients. Several specialized structures within the heart, collectively known as the cardiac conduction system (CCS), are responsible for this phenomenon. In this review, we discuss the discovery and scientific history of the mammalian cardiac conduction system as well as the key genes and transcription factors implicated in the formation of its major structures. We also describe known human diseases related to CCS development and explore existing challenges in the clinical context.
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Affiliation(s)
- Carissa Lee
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, United States
| | - Sidra Xu
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, United States
| | - Tahmina Samad
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, United States; Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States; Department of Pediatrics, Stanford University, Stanford, CA, United States
| | - William R Goodyer
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, United States; Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States
| | - Alireza Raissadati
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, United States; Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States
| | - Paul Heinrich
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, United States; Regenerative Medicine in Cardiovascular Diseases, First Department of Medicine, Cardiology, Klinikum Rechts der Isar, Technical University of Munich, School of Medicine and Health, Munich, Germany
| | - Sean M Wu
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, United States; Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, CA, United States; Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, United States.
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Wang W, Chen Q, Zhang F, Chen X, Xu Z, Sun X, Li J, Chen L, Chen J. Radiofrequency catheter ablation combined with spironolactone in the treatment of atrial fibrillation: A single-center randomized controlled study. Clin Cardiol 2021; 44:1120-1127. [PMID: 34076288 PMCID: PMC8364720 DOI: 10.1002/clc.23659] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 04/29/2021] [Accepted: 05/12/2021] [Indexed: 12/19/2022] Open
Abstract
At present, the question of whether radiofrequency ablation (RFA) combined with spironolactone can reduce the levels of plasma angiotensin II (AngII) and aldosterone (ALD) in patients with atrial fibrillation (AF) and reduce the recurrence of AF has not been reported.
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Affiliation(s)
- Weiwei Wang
- Department of Cardiology, Fujian Medical University Union Hospital & Fujian Provincial Institute of Coronary Disease, Fuzhou, China
| | - Quanhe Chen
- Union Clinic Medical College, Fujian Medical University, Fuzhou, China
| | - Feilong Zhang
- Department of Cardiology, Fujian Medical University Union Hospital & Fujian Provincial Institute of Coronary Disease, Fuzhou, China
| | - Xuehai Chen
- Department of Cardiology, Fujian Medical University Union Hospital & Fujian Provincial Institute of Coronary Disease, Fuzhou, China
| | - Zhe Xu
- Department of Cardiology, Fujian Medical University Union Hospital & Fujian Provincial Institute of Coronary Disease, Fuzhou, China
| | - Xudong Sun
- Department of Cardiology, Fujian Medical University Union Hospital & Fujian Provincial Institute of Coronary Disease, Fuzhou, China
| | - Jinguo Li
- Department of Cardiology, Fujian Medical University Union Hospital & Fujian Provincial Institute of Coronary Disease, Fuzhou, China
| | - Lianglong Chen
- Department of Cardiology, Fujian Medical University Union Hospital & Fujian Provincial Institute of Coronary Disease, Fuzhou, China
| | - Jianhua Chen
- Department of Cardiology, Fujian Medical University Union Hospital & Fujian Provincial Institute of Coronary Disease, Fuzhou, China
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Increased expression of NF-AT3 and NF-AT4 in the atria correlates with procollagen I carboxyl terminal peptide and TGF-β1 levels in serum of patients with atrial fibrillation. BMC Cardiovasc Disord 2014; 14:167. [PMID: 25422138 PMCID: PMC4251842 DOI: 10.1186/1471-2261-14-167] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 11/17/2014] [Indexed: 01/12/2023] Open
Abstract
Background Atrial fibrillation (AF) is the most common cardiac arrhythmia in clinical practice. Unfortunately, the precise mechanisms and sensitive serum biomarkers of atrial remodeling in AF remain unclear. The aim of this study was to determine whether the expression of the transcription factors NF-AT3 and NF-AT4 correlate with atrial structural remodeling of atrial fibrillation and serum markers for collagen I and III synthesis. Methods Right and left atrial specimens were obtained from 90 patients undergoing valve replacement surgery. The patients were divided into sinus rhythm (n = 30), paroxysmal atrial fibrillation (n = 30), and persistent atrial fibrillation (n = 30) groups. NF-AT3, NF-AT4, and collagen I and III mRNA and protein expression in atria were measured. We also tested the levels of the carboxyl-terminal peptide from pro-collagen I, the N-terminal type I procollagen propeptides, the N-terminal type III procollagen propeptides, and TGF-β1 in serum using an enzyme immunosorbent assay. Results NF-AT3 and NF-AT4 mRNA and protein expression were increased in the AF groups, especially in the left atrium. NF-AT3 and NF-AT4 expression in the right atrium was increased in the persistent atrial fibrillation group compared the sinus rhythm group with similar valvular disease. In patients with AF, the expression levels of nuclear NF-AT3 and NF-AT4 correlated with those of collagens I and III in the atria and with PICP and TGF-β1 in blood. Conclusions These data support the hypothesis that nuclear NF-AT3 and NF-AT4 participates in atrial structural remodeling, and that PICP and TGF-β1 levels may be sensitive serum biomarkers to estimate atrial structural remodeling with atrial fibrillation.
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Wasmer K, Breithardt G, Eckardt L. The young patient with asymptomatic atrial fibrillation: what is the evidence to leave the arrhythmia untreated? Eur Heart J 2014; 35:1439-47. [DOI: 10.1093/eurheartj/ehu113] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Adlan AMA, Lip GYH. Benefit-risk assessment of dronedarone in the treatment of atrial fibrillation. Drug Saf 2013; 36:93-110. [PMID: 23329540 DOI: 10.1007/s40264-012-0012-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Rhythm control in atrial fibrillation (AF) can be achieved using pharmacological therapy. Amiodarone is the most efficacious anti-arrhythmic agent; however, its use is limited due to an unfavourable safety profile, including pro-arrhythmia, thyroid, liver, skin and pulmonary complications. Dronedarone, which is structurally similar to amiodarone, was developed to try and achieve a favourable balance of efficacy and risk. Dronedarone has been evaluated in several large clinical trials, which have shown reduced mortality and hospitalization rates in patients with non-permanent AF. In patients with permanent AF and/or heart failure, dronedarone has been shown to cause increased mortality and morbidity and should not be used in these groups. Compared with amiodarone, dronedarone has fewer toxic effects (thyroid, skin, pulmonary) and, although less efficacious, may be used as first-line therapy for maintenance of sinus rhythm in patients with non-permanent AF. Clinicians must be vigilant in monitoring their patients to ensure they do not develop permanent AF or heart failure.
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Affiliation(s)
- Ahmed M A Adlan
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Dudley Road, Birmingham B18 7QH, UK
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Zhao F, Zhang S, Shao Y, Wu Y, Qin J, Chen Y, Chen L, Gu H, Wang X, Huang C, Zhang W. Calreticulin overexpression correlates with integrin-α5 and transforming growth factor-β1 expression in the atria of patients with rheumatic valvular disease and atrial fibrillation. Int J Cardiol 2013; 168:2177-85. [PMID: 23465222 DOI: 10.1016/j.ijcard.2013.01.239] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 01/18/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVES The aim of this study was to determine whether altered calreticulin expression and distribution contribute to the pathogenesis of atrial fibrillation (AF) associated with valvular heart disease (VHD). BACKGROUND AF affects electrophysiological and structural changes that exacerbate AF. Atrial remodeling reportedly underlies AF generation, but the precise mechanism of atrial remodeling in AF remains unclear. METHODS Right and left atrial specimens were obtained from 68 patients undergoing valve replacement surgery. The patients were divided into sinus rhythm (SR; n=25), paroxysmal AF (PaAF; n=11), and persistent AF (PeAF; AF lasting >6 months; n=32) groups. Calreticulin, integrin-α5, and transforming growth factor-β1 (TGF-β1) mRNA and protein expression were measured. We also performed immunoprecipitation for calreticulin with either calcineurin B or integrin-α5. RESULTS Calreticulin, integrin-α5, and TGF-β1 mRNA and protein expression were increased in the AF groups, especially in the left atrium in patients with mitral valve disease. Calreticulin interacted with both calcineurin B and integrin-α5. Integrin-α5 expression correlated with TGF-β1 expression, while calreticulin expression correlated with integrin-α5 and TGF-β1 expression. Despite similar cardiac function classifications, calreticulin expression was greater in the PeAF group than in the SR group. CONCLUSIONS Calreticulin, integrin-α5, and TGF-β1 expression was increased in atrial tissue in patients with AF and was related to AF type, suggesting that calreticulin is involved in the pathogenesis of AF in VHD patients.
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Affiliation(s)
- Fei Zhao
- Cardiothoracic Surgery Department, First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Jiangsu Province, Nanjing 210029, China
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Camm J. Antiarrhythmic drugs for the maintenance of sinus rhythm: risks and benefits. Int J Cardiol 2012; 155:362-71. [PMID: 21708411 DOI: 10.1016/j.ijcard.2011.06.012] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 05/31/2011] [Accepted: 06/04/2011] [Indexed: 01/08/2023]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia seen in clinical practice, and its complications impose a significant economic burden. The development of more effective agents to manage patients with AF is essential. While clinical trials show no major differences in outcomes between rate and rhythm control strategies, some patients with AF require treatment with antiarrhythmic drugs (AADs) to maintain sinus rhythm, reduce symptoms, improve exercise tolerance, and improve quality of life. Currently available AADs, while effective, have limitations including limited efficacy, adverse events, toxicity, and proarrhythmic potential. The 6 most commonly used AADs (amiodarone, disopyramide, dofetilide [USA but not Europe], flecainide, propafenone, sotalol) have proarrhythmic effects (fewer with amiodarone). Amiodarone is the most effective AAD, but its safety profile limits its usefulness. Recent advances in AAD therapy include dronedarone and vernakalant. Dronedarone, approved by the United States Food and Drug Administration and the European Medicines Authority and others, has been proven efficacious in maintaining sinus rhythm and reducing the incidence of hospitalization due to cardiovascular events or death in patients with AF. The intravenous formulation of vernakalant is approved in the European Union, Iceland, and Norway. Oral vernakalant is currently undergoing evaluation for preventing AF recurrence and appears to be effective with an acceptable safety profile. Treatment should be individualized to the patient with consideration of pharmacologic risks and benefits according to AF management guidelines. Accumulating efficacy and safety data for new and emerging AADs holds promise for improved AF management and outcomes.
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Affiliation(s)
- John Camm
- British Heart Foundation, St. George's University of London, Department of Cardiological Sciences, London, United Kingdom.
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Wang JG, Li Y, Shi JH, Han J, Cui YQ, Luo TG, Meng X. Treatment of Long-Lasting Persistent Atrial Fibrillation Using Minimally Invasive Surgery Combined With Irbesartan. Ann Thorac Surg 2011; 91:1183-9. [PMID: 21440143 DOI: 10.1016/j.athoracsur.2010.11.063] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Revised: 11/11/2010] [Accepted: 11/23/2010] [Indexed: 11/30/2022]
Affiliation(s)
- Jian-Gang Wang
- Department of Atrial Fibrillation Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Risk of cardiac arrhythmias and conduction abnormalities in patients with acute myocardial infarction receiving packed red blood cell transfusions. J Crit Care 2010; 26:335-41. [PMID: 20869199 DOI: 10.1016/j.jcrc.2010.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Revised: 08/12/2010] [Accepted: 08/12/2010] [Indexed: 11/23/2022]
Abstract
PURPOSE Although transfusion has been linked to the development of atrial fibrillation (AF) in cardiac surgical patients, this association has not been investigated in patients with acute myocardial infarction (AMI). Evidence supports an inflammatory mechanism in the development of AF, and red cell transfusions also elicit an inflammatory response. We therefore sought to evaluate whether packed red blood cell transfusion increases the risk of AF, ventricular tachycardia (VT), and other arrhythmias and conduction abnormalities in patients with AMI. MATERIALS AND METHODS This is a retrospective study on patients with AMI and no prior history of AF, admitted to a critical care area and entered in Project Impact database from 08/2003-12/2007. Primary outcome measures were new-onset cardiac arrhythmias or conduction disturbances. RESULTS Transfused patients had significantly higher incidences of AF (4.7% vs 1.3%, P = .008), cardiac arrest (9.5% vs 1.7%, P < .001) and heart block (3.4% vs 0.1%, P < .001), and a trend toward a higher incidence of VT (3.4% vs 1.3%, P = .058). Multivariate regression analysis confirmed transfusion as an independent risk factor for "non-lethal" cardiac events (AF/heart block; odds ratio [OR], 4.7 [1.9-11.9]; P = .001), "lethal" events (VT/cardiac arrest; OR, 2.4 [1.1-5]; P = .016), and all cardiac events (OR, 2.8 [1.5-65.1]; P = .001). Transfused patients had significantly longer length of stay (P < .0001) and significantly higher mortality rates than nontransfused patients (OR, 3 [1.7-5.5]; P < .001). CONCLUSIONS Packed red blood cell transfusion is independently associated with an increased risk of new-onset cardiac arrhythmias and conduction abnormalities in the setting of AMI, even after controlling for traditional risk factors.
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Christiansen CB, Torp-Pedersen C, Køber L. Efficacy and safety of dronedarone: a review of randomized trials. Expert Opin Drug Saf 2009; 9:189-99. [DOI: 10.1517/14740330903514105] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Burashnikov A, Antzelevitch C. New pharmacological strategies for the treatment of atrial fibrillation. Ann Noninvasive Electrocardiol 2009; 14:290-300. [PMID: 19614642 DOI: 10.1111/j.1542-474x.2009.00305.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Atrial fibrillation (AF) is a growing clinical problem, increasing in prevalence as the population of the United States and countries around the world ages. Intensive research aimed at improving prevention, diagnosis, and treatment of AF is ongoing. Although the use and efficacy of catheter ablation-based approaches in AF treatment have increased significantly in the last decade, pharmacological agents remain the first-line therapy for rhythm management of AF. Currently available anti-AF agents are generally only moderately effective and associated with extracardiac toxicity and/or a risk for development of life-threatening ventricular arrhythmias. Included among current investigational strategies for improving the effectiveness and safety of anti-AF drugs is the development of (1) Agents that produce atrial-specific or predominant inhibition of I(Kur), I(K-ACh), or I(Na); (2) "Upstream therapies" that effect nonion channel targets that reduce atrial structural remodeling, hypertrophy, dilatation, inflammation, oxidative injury, etc; (3) Derivatives of "old" anti-AF drugs with an improved safety pharmacological profile; and (4) Gap junction therapy aimed at improving conduction without affecting sodium channels. This review focuses on new pharmacological approaches under investigation for the treatment of AF.
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Pellman J, Lyon RC, Sheikh F. Extracellular matrix remodeling in atrial fibrosis: mechanisms and implications in atrial fibrillation. J Mol Cell Cardiol 2009; 48:461-7. [PMID: 19751740 DOI: 10.1016/j.yjmcc.2009.09.001] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2009] [Revised: 08/29/2009] [Accepted: 09/02/2009] [Indexed: 12/28/2022]
Abstract
Atrial fibrosis has been strongly associated with the presence of heart diseases/arrhythmias, including congestive heart failure (CHF) and atrial fibrillation (AF). Inducibility of AF as a result of atrial fibrosis has been the subject of intense recent investigation since it is the most commonly encountered arrhythmia in adults and can substantially increase the risk of premature death. Rhythm and rate control drugs as well as surgical interventions are used as therapies for AF; however, increased attention has been diverted to mineralocorticoid receptor (MR) antagonists including spironolactone as potential therapies for human AF because of their positive effects on reducing atrial fibrosis and associated AF in animal models. Spironolactone has been shown to exert positive effects in human patients with heart failure; however, the mechanisms and effects in human atrial fibrosis and AF remain undetermined. This review will discuss and highlight developments on (i) the relationship between atrial fibrosis and AF, (ii) spironolactone, as a drug targeted to atrial fibrosis and AF, as well as (iii) the distinct and common mechanisms important for regulating atrial and ventricular fibrosis, inclusive of the key extracellular matrix regulatory proteins involved.
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Affiliation(s)
- Jason Pellman
- Department of Medicine, University of California-San Diego, 9500 Gilman Drive, La Jolla, CA 92093-0613, USA
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