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Aksu T, Skeete JR, Huang HH. Ganglionic Plexus Ablation: A Step-by-step Guide for Electrophysiologists and Review of Modalities for Neuromodulation for the Management of Atrial Fibrillation. Arrhythm Electrophysiol Rev 2023; 12:e02. [PMID: 36845167 PMCID: PMC9945432 DOI: 10.15420/aer.2022.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 11/29/2022] [Indexed: 02/01/2023] Open
Abstract
As the most common sustained arrhythmia, AF is a complex clinical entity which remains a difficult condition to durably treat in the majority of patients. Over the past few decades, the management of AF has focused mainly on pulmonary vein triggers for its initiation and perpetuation. It is well known that the autonomic nervous system (ANS) has a significant role in the milieu predisposing to the triggers, perpetuators and substrate for AF. Neuromodulation of ANS - ganglionated plexus ablation, vein of Marshall ethanol infusion, transcutaneous tragal stimulation, renal nerve denervation, stellate ganglion block and baroreceptor stimulation - constitute an emerging therapeutic approach for AF. The purpose of this review is to summarise and critically appraise the currently available evidence for neuromodulation modalities in AF.
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Affiliation(s)
- Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, Istanbul, Turkey
| | | | - Henry H Huang
- Department of Cardiology, Rush Medical College, Chicago, IL, US
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Sawyer MKL, Gould PA, Ng ACT, Wang WYS. What is the Relationship Between Epicardial Adipose Tissue, Left Atrial Low Voltage Zones and Atrial Fibrillation? Heart Lung Circ 2022; 31:1429-1431. [PMID: 36436840 DOI: 10.1016/j.hlc.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Michael K L Sawyer
- Department of Cardiology, Princess Alexandra Hospital, Brisbane, Qld, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Qld, Australia
| | - Paul A Gould
- Department of Cardiology, Princess Alexandra Hospital, Brisbane, Qld, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Qld, Australia
| | - Arnold C T Ng
- Department of Cardiology, Princess Alexandra Hospital, Brisbane, Qld, Australia
| | - William Y S Wang
- Department of Cardiology, Princess Alexandra Hospital, Brisbane, Qld, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Qld, Australia.
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Hanna P, Ajijola OA. Afferents Nerves in Atrial Fibrillation: Going Beyond Fight or Flight. JACC Clin Electrophysiol 2022; 8:165-167. [PMID: 35210072 DOI: 10.1016/j.jacep.2022.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/08/2022] [Accepted: 01/10/2022] [Indexed: 10/19/2022]
Affiliation(s)
- Peter Hanna
- Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, Division of Cardiology, Department of Medicine, University of California-Los Angeles, Los Angeles, California, USA
| | - Olujimi A Ajijola
- Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, Division of Cardiology, Department of Medicine, University of California-Los Angeles, Los Angeles, California, USA; Molecular, Cellular and Integrative Physiology Program, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, California, USA.
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Malik V, Mishima R, D Elliott A, H Lau D, Sanders P. The "Road" to Atrial Fibrillation: The Role of the Cardiac Autonomic Nervous System. J Atr Fibrillation 2020; 13:2400. [PMID: 33024501 DOI: 10.4022/jafib.2400] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 02/16/2020] [Accepted: 03/18/2020] [Indexed: 01/04/2023]
Abstract
At the population level, there is a parallel escalation in the healthcare burden of both, atrial fibrillation (AF) as well its risk factors. Compounding this relationship, AF is associated with escalating burden at an individual level, due its self-perpetuating and progressive nature. The mechanisms by which these risk factors interact to produce atrial remodelling and subsequent AF are unclear. This intersection is critical to the development of strategies to combat this disease at both the individual and population-level. It is well known that AF can manifest from disturbances in autonomic activity. At the population level, there is growing data to suggest a role of the autonomic nervous system in the future incidence of AF. Here, we provide an overview of the association of cardiac autonomic dysfunction with the incidence of AF, review the role of the autonomic nervous system (ANS) as an intermediary between risk factors and the development of AF and finally, we discuss the bidirectional relationship between AF and cardiac autonomic nervous system dysfunction; to determine whether this is implicated in the progression of AF.
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Affiliation(s)
- Varun Malik
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Ricardo Mishima
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Adrian D Elliott
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
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Linz D, Elliott AD, Hohl M, Malik V, Schotten U, Dobrev D, Nattel S, Böhm M, Floras J, Lau DH, Sanders P. Role of autonomic nervous system in atrial fibrillation. Int J Cardiol 2018; 287:181-188. [PMID: 30497894 DOI: 10.1016/j.ijcard.2018.11.091] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 11/01/2018] [Accepted: 11/14/2018] [Indexed: 01/08/2023]
Abstract
Atrial fibrillation is the most common sustained arrhythmia and is associated with significant morbidity and mortality. The autonomic nervous system has a significant role in the milieu predisposing to the triggers, perpetuators and substrate for atrial fibrillation. It has direct electrophysiological effects and causes alterations in atrial structure. In a significant portion of patients with atrial fibrillation, the autonomic nervous system activity is likely a composite of reflex excitation due to atrial fibrillation itself and contribution of concomitant risk factors such as hypertension, obesity and sleep-disordered breathing. We review the role of autonomic nervous system activation, with focus on changes in reflex control during atrial fibrillation and the role of combined sympatho-vagal activation for atrial fibrillation initiation, maintenance and progression. Finally, we discuss the potential impact of combined aggressive risk factor management as a strategy to modify the autonomic nervous system in patients with atrial fibrillation and to reverse the arrhythmogenic substrate.
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Affiliation(s)
- Dominik Linz
- Centre for Heart Rhythm Disorders (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia.
| | - Adrian D Elliott
- Centre for Heart Rhythm Disorders (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Mathias Hohl
- Saarland University, Klinik für Innere Medizin III (Cardiology, Angiology and Intensive Care Medicine), Homburg, Saar, Germany
| | - Varun Malik
- Centre for Heart Rhythm Disorders (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Ulrich Schotten
- University Maastricht, Dept. of Physiology, Maastricht, the Netherlands
| | - Dobromir Dobrev
- Institute of Pharmacology, West German Heart and Vascular Center, University Duisburg-Essen, Essen, Germany
| | - Stanley Nattel
- Institute of Pharmacology, West German Heart and Vascular Center, University Duisburg-Essen, Essen, Germany; Department of Medicine, Montreal Heart Institute, Université de Montréal, Montréal, Quebec, Canada; Department of Pharmacology and Therapeutics, McGill University, Montreal, Quebec, Canada
| | - Michael Böhm
- Saarland University, Klinik für Innere Medizin III (Cardiology, Angiology and Intensive Care Medicine), Homburg, Saar, Germany
| | - John Floras
- University Health Network and Sinai Health System Division of Cardiology, University of Toronto, Toronto, Ontario, Canada
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
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Field ME, Wasmund SL, Page RL, Hamdan MH. Restoring Sinus Rhythm Improves Baroreflex Function in Patients With Persistent Atrial Fibrillation. J Am Heart Assoc 2016; 5:e002997. [PMID: 26908410 PMCID: PMC4802450 DOI: 10.1161/jaha.115.002997] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 01/13/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Studies have suggested that patients with atrial fibrillation (AF) have impairment in the baroreflex. It is not clear whether these findings are the result of the associated comorbid conditions or the arrhythmia itself. We hypothesized that AF is associated with impairment in baroreflex function and that the arrhythmia itself is a contributing factor. METHODS AND RESULTS Twenty-four patients with persistent AF referred for cardioversion were enrolled. A second group of patients with no history of AF matched for age and left ventricular ejection fraction was identified and served as the control group. In the AF group, baroreflex gain (BRG) was measured on the day of cardioversion (Day 1) and again at 30 days post-cardioversion (Day 30) in patients who remained in sinus rhythm (SR). The clinical characteristics of patients with AF were not different than those of the control group. The mean BRG in the AF group on Day 1 was significantly lower than the mean BRG of the control group (5.2±3.6 versus 10.8±5.5 ms/mm Hg, P<0.05). Ten patients experienced AF recurrence before the 30-day follow-up and 14 patients remained in SR. In the group that remained in SR, BRG increased from 4.1±3.7 ms/mm Hg on Day 1 to 7.0±6.0 ms/mm Hg on Day 30 (P<0.01). CONCLUSION We have shown that AF is associated with impairment of the baroreflex and that restoration of SR improves BRG. Our data suggest that AF might be a contributing factor to the observed impairment in BRG and that restoring SR might help improve baroreflex function.
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Affiliation(s)
- Michael E Field
- Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Stephen L Wasmund
- Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Richard L Page
- Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Mohamed H Hamdan
- Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Yoshida K, Kaneshiro T, Ito Y, Kimata A, Koda N, Hiraya D, Baba M, Misaki M, Takeyasu N, Yamaguchi I, Aonuma K. Elevated plasma norepinephrine level and sick sinus syndrome in patients with lone atrial fibrillation. Heart 2015; 101:1133-8. [DOI: 10.1136/heartjnl-2014-307334] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 04/16/2015] [Indexed: 11/04/2022] Open
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Yu Y, Liu L, Jiang JY, Qu XF, Yu G. Parasympathetic and substance P-immunoreactive nerve denervation in atrial fibrillation models. Cardiovasc Pathol 2011; 21:39-45. [PMID: 21353601 DOI: 10.1016/j.carpath.2011.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2010] [Revised: 10/17/2010] [Accepted: 01/11/2011] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Recent studies demonstrated that atrial fibrillation (AF) induced heterogeneous sympathetic hyperinnervation and baroreflex impartation, but the changes of vagal and afferent nerve are not clear. METHODS Six dogs underwent atrial pacing at 600 beats/min (AF group). All paced dogs developed sustained AF by 5 weeks of pacing. Tissues from six healthy dogs were used as controls. Immunohistochemistry staining of cardiac nerves was performed using anti-growth-associated protein 43 (anti-GAP43), anti-tyrosine hydroxylase, antiacetylcholine (anti-ACh), and anti-substance P (anti-SP) antibodies. RESULTS In AF group, the density of GAP43-positive in the right atrium (RA), atrial septum (AS), and left atrium (LA) was 5590.24±1417.51, 8083.22±1271.39, and 10854.56±1877.56 μm(2)/mm(2), respectively, which was significantly (P<.01) higher than the control group. Most of the newly sprouting nerves are sympathetic nerve. Sympathetic nerve density in AF group was significantly higher than that of control group (P<.001). Whereas denervation of parasympathetic and SP-immunoreactive nerve occurred in AF group. In the dogs with AF, the density of ACh-positive nerve in the RA, AS, and LA was 506.04±104.44, 317.72±84.10, and 114.9±29. 62 μm(2)/mm(2), respectively, which was lower than the control group (P<.01). At the same time, the density of SP-positive nerve in the atria of AF dogs was also significantly lower than the control tissues (P<.01). CONCLUSION AF led to significant nerve sprouting and sympathetic hyperinnervation in the canine models, but the newly sprouting nerve did not include parasympathetic and SP-immunoreactive nerve. Heterogeneous parasympathetic and SP-immunoreactive nerve denervation occurred in the AF dogs.
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Affiliation(s)
- Yang Yu
- Department of Cardiovascular Diseases, First Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, China
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Gould PA, Esler MD, Kaye DM. Atrial fibrillation is associated with decreased cardiac sympathetic response to isometric exercise in CHF in comparison to sinus rhythm. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2009; 31:1125-9. [PMID: 18834463 DOI: 10.1111/j.1540-8159.2008.01152.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The presence of atrial fibrillation (AF) in congestive heart failure (CHF) is accompanied by increased mortality, although the exact mechanism is unclear. In previous studies, we have demonstrated cardiac baroreceptor abnormalities in association with AF and CHF. In this study, we sought to examine the effect of cardiac rhythm on the cardiac sympathetic response to exercise in CHF. METHODS In 13 CHF patients (six AF, seven SR, left ventricular ejection fraction 31 +/- 2%, age 61 +/- 1 years), we measured the hemodynamic and cardiac sympathetic response isometric handgrip (IHG) exercise. RESULTS At baseline the groups were well matched. Baseline hemodynamics and cardiac sympathetic activity did not significantly differ between the cohorts. In response to IHG exercise, both groups demonstrated significant hemodynamic responses. In conjunction, the sinus rhythm (SR) group demonstrated a significant increase in cardiac sympathetic response to exercise (P = 0.04) while in contrast the AF group did not (P = 0.6). CONCLUSION In this study, we demonstrate for the first time that the combination of AF and CHF is accompanied by a marked attenuation of the cardiac sympathetic response to acute hemodynamic stress. This implies AF is associated with a further impairment of baroreceptor response in CHF compared to SR. These findings present possible insights to the associated increased mortality and pathogenesis of AF with CHF.
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Affiliation(s)
- Paul A Gould
- Wynn Department of Metabolic Cardiology, Baker Heart Research Institute, Melbourne, Australia
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Pichlmaier M, Bagaev E, Lichtenberg A, Teebken O, Klein G, Niehaus M, Haverich A. Four-chamber pacing in patients with poor ejection fraction but normal QRS durations undergoing open heart surgery. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2008; 31:184-91. [PMID: 18233971 DOI: 10.1111/j.1540-8159.2007.00967.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Poor ejection fraction (EF) comprises a critical risk factor in cardiac bypass surgery (CABG). It has been unclear, whether biventricular or four-chamber pacing confers benefit upon patients with intact atrioventricular and interventricular conduction especially following surgery. METHODS Twenty-one consecutive patients with an EF <or= 35% underwent hemodynamic evaluation (continuous pressures and thermodilution) 3, 6, and 18 hours post-CABG and biatrial (AA), biatrial-right ventricular (AAV), and biatrial-biventricular (AAVV) pacing were compared. RESULTS Patients (65 +/- 9 years) presented with an average EF of 29.5% (15-35%). 514 measurements of cardiac index (CI) were taken. Nineteen patients (91%) showed highly significant increases in CI with AAVV as compared to AA pacing (P < 0,001) at all times post surgery. The increase in CI with pacing mode varied from 6% to 25% and decreased with time following surgery. No consistent difference in CI was seen between four-chamber (AAVV) and biventricular pacing (AVV). The QRS-widths prior to surgery never exceeded 120 ms; postoperatively QRS-complexes widened in all patients on average by 15.9 ms +/-6 and returned to starting values by 48 hours. CONCLUSIONS Biventricular pacing improves CI in patients with poor EF following cardiac surgery in the absence of preoperative atrioventricular- or interventricular conduction block. This benefit decreases with time after surgery as the QRS width returns to preoperative values. Four-chamber pacing did not confer additional benefit as compared to biventricular pacing in this series. Biventricular pacing should be considered as an adjunct in patients with critically low EF undergoing cardiac surgery.
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Affiliation(s)
- Maximilian Pichlmaier
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
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Karayannis G, Kitsios G, Kotidis H, Triposkiadis F. Left atrial remodelling contributes to the progression of asymptomatic left ventricular systolic dysfunction to chronic symptomatic heart failure. Heart Fail Rev 2007; 13:91-8. [PMID: 17450425 DOI: 10.1007/s10741-007-9021-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2007] [Accepted: 03/30/2007] [Indexed: 11/28/2022]
Abstract
Systolic heart failure (HF) is a progressive disorder that often begins with asymptomatic left ventricular (LV) systolic dysfunction and culminates in symptoms from fluid overload and poor end-organ perfusion. The progression to symptomatic HF is accompanied by marked activation of neurohormonal and cytokine systems, as well as a series of adaptive LV anatomical and functional changes, collectively referred to as LV remodelling. However, the mechanisms underlying symptom appearance have not been delineated and the weight of experimental and clinical evidence suggests that the development of symptomatic HF occurs independently of the haemodynamic status of the patient. The left atrium is a muscular chamber strategically located between the left ventricle and the pulmonary circulation with important mechanical function (modulation of LV filling), which is closely coupled with its endocrine (atrial natriuretic peptide synthesis and secretion) and regulatory (contribution to the control of sympathetic activity and vasopressin release) functions. In this narrative review we provide evidence supporting the concept that left atrial dilation and systolic dysfunction (left atrial remodelling) contributes to the progression of asymptomatic LV dysfunction to chronic symptomatic systolic HF as it is a prerequisite for the development of the pulmonary congestion and marked neuronhormoral activity that characterize the symptomatic state.
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Affiliation(s)
- George Karayannis
- Department of Cardiology, University of Thessaly Medical School, Larissa University Hospital, P.O. Box 1425, 411 10 Larissa, Greece
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Floras JS. Atrial fibrillation and cardiac sympathetic reflexes in heart failureThe opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology. Eur Heart J 2005; 26:2490-2. [PMID: 16230309 DOI: 10.1093/eurheartj/ehi598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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