1
|
Zuhair M, Keene D, Kanagaratnam P, Lim PB. Percutaneous Neuromodulation for Atrial Fibrillation. Card Electrophysiol Clin 2024; 16:281-296. [PMID: 39084721 DOI: 10.1016/j.ccep.2023.09.001] [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: 08/02/2024]
Abstract
Percutaneous neuromodulation is emerging as a promising therapeutic approach for atrial fibrillation (AF). This article explores techniques such as ganglionated plexi (GP) ablation, and vagus nerve stimulation, pinpointing their potential in modulating AF triggers and maintenance. Noninvasive methods, such as transcutaneous low-level tragus stimulation, offer innovative treatment pathways, with early trials indicating a significant reduction in AF burden. GP ablation may address autonomic triggers, and the potential for GP ablation in neuromodulation is discussed. The article stresses the necessity for more rigorous clinical trials to validate the safety, reproducibility, and efficacy of these neuromodulation techniques in AF treatment.
Collapse
Affiliation(s)
- Mohamed Zuhair
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12, UK.
| | - Daniel Keene
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12, UK
| | - Prapa Kanagaratnam
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12, UK
| | - Phang Boon Lim
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12, UK
| |
Collapse
|
2
|
Zafeiropoulos S, Ahmed U, Bikou A, Mughrabi IT, Stavrakis S, Zanos S. Vagus nerve stimulation for cardiovascular diseases: Is there light at the end of the tunnel? Trends Cardiovasc Med 2024; 34:327-337. [PMID: 37506989 DOI: 10.1016/j.tcm.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/12/2023] [Accepted: 07/17/2023] [Indexed: 07/30/2023]
Abstract
Autonomic dysfunction and chronic inflammation contribute to the pathogenesis and progression of several cardiovascular diseases (CVD), such as heart failure with preserved ejection fraction, atherosclerotic CVD, pulmonary arterial hypertension, and atrial fibrillation. The vagus nerve provides parasympathetic innervation to the heart, vessels, and lungs, and is also implicated in the neural control of inflammation through a neuroimmune pathway involving the spleen. Stimulation of the vagus nerve (VNS) can in principle restore autonomic balance and suppress inflammation, with potential therapeutic benefits in these diseases. Although VNS ameliorated CVD in several animal models, early human studies have demonstrated variable efficacy. The purpose of this review is to discuss the rationale behind the use of VNS in the treatment of CVD, to critically review animal and human studies of VNS in CVD, and to propose possible means to overcome the challenges in the clinical translation of VNS in CVD.
Collapse
Affiliation(s)
- Stefanos Zafeiropoulos
- Elmezzi Graduate School of Molecular Medicine at Northwell Health, Manhasset, NY, USA; Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Umair Ahmed
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Alexia Bikou
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Ibrahim T Mughrabi
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Stavros Stavrakis
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Stavros Zanos
- Elmezzi Graduate School of Molecular Medicine at Northwell Health, Manhasset, NY, USA; Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY, USA.
| |
Collapse
|
3
|
Chakraborty P, Niewiadomska M, Farhat K, Morris L, Whyte S, Humphries KM, Stavrakis S. Effect of Low-Level Tragus Stimulation on Cardiac Metabolism in Heart Failure with Preserved Ejection Fraction: A Transcriptomics-Based Analysis. Int J Mol Sci 2024; 25:4312. [PMID: 38673896 PMCID: PMC11050145 DOI: 10.3390/ijms25084312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 04/10/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
Abnormal cardiac metabolism precedes and contributes to structural changes in heart failure. Low-level tragus stimulation (LLTS) can attenuate structural remodeling in heart failure with preserved ejection fraction (HFpEF). The role of LLTS on cardiac metabolism is not known. Dahl salt-sensitive rats of 7 weeks of age were randomized into three groups: low salt (0.3% NaCl) diet (control group; n = 6), high salt diet (8% NaCl) with either LLTS (active group; n = 8), or sham stimulation (sham group; n = 5). Both active and sham groups received the high salt diet for 10 weeks with active LLTS or sham stimulation (20 Hz, 2 mA, 0.2 ms) for 30 min daily for the last 4 weeks. At the endpoint, left ventricular tissue was used for RNA sequencing and transcriptomic analysis. The Ingenuity Pathway Analysis tool (IPA) was used to identify canonical metabolic pathways and upstream regulators. Principal component analysis demonstrated overlapping expression of important metabolic genes between the LLTS, and control groups compared to the sham group. Canonical metabolic pathway analysis showed downregulation of the oxidative phosphorylation (Z-score: -4.707, control vs. sham) in HFpEF and LLTS improved the oxidative phosphorylation (Z-score = -2.309, active vs. sham). HFpEF was associated with the abnormalities of metabolic upstream regulators, including PPARGC1α, insulin receptor signaling, PPARα, PPARδ, PPARGC1β, the fatty acid transporter SLC27A2, and lysine-specific demethylase 5A (KDM5A). LLTS attenuated abnormal insulin receptor and KDM5A signaling. HFpEF is associated with abnormal cardiac metabolism. LLTS, by modulating the functioning of crucial upstream regulators, improves cardiac metabolism and mitochondrial oxidative phosphorylation.
Collapse
Affiliation(s)
- Praloy Chakraborty
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, 800 Stanton L Young Blvd, Suite 5400, Oklahoma City, OK 73104, USA; (P.C.); (K.F.); (L.M.); (S.W.)
- Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, Toronto, ON M5G 2N2, Canada
| | - Monika Niewiadomska
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, 800 Stanton L Young Blvd, Suite 5400, Oklahoma City, OK 73104, USA; (P.C.); (K.F.); (L.M.); (S.W.)
| | - Kassem Farhat
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, 800 Stanton L Young Blvd, Suite 5400, Oklahoma City, OK 73104, USA; (P.C.); (K.F.); (L.M.); (S.W.)
| | - Lynsie Morris
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, 800 Stanton L Young Blvd, Suite 5400, Oklahoma City, OK 73104, USA; (P.C.); (K.F.); (L.M.); (S.W.)
| | - Seabrook Whyte
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, 800 Stanton L Young Blvd, Suite 5400, Oklahoma City, OK 73104, USA; (P.C.); (K.F.); (L.M.); (S.W.)
| | - Kenneth M. Humphries
- Aging and Metabolism Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK 73104, USA;
| | - Stavros Stavrakis
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, 800 Stanton L Young Blvd, Suite 5400, Oklahoma City, OK 73104, USA; (P.C.); (K.F.); (L.M.); (S.W.)
| |
Collapse
|
4
|
Rast J, Sohinki D, Warner A. Non-invasive Neuromodulation of Arrhythmias. J Innov Card Rhythm Manag 2024; 15:5757-5766. [PMID: 38444451 PMCID: PMC10911637 DOI: 10.19102/icrm.2024.15022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 08/28/2023] [Indexed: 03/07/2024] Open
Abstract
Dysfunction of the cardiac autonomic nervous system (CANS) is associated with various cardiac arrhythmias. Subsequently, invasive techniques have successfully targeted the CANS for the treatment of certain arrhythmias, such as sympathetic denervation for ventricular tachycardia storm. Non-invasive strategies capable of modulating the CANS for arrhythmia treatment have begun to gain interest due to their low-risk profile and applicability as an adjuvant therapy. This review provides an evidence-based overview of the currently studied technologies capable of non-invasively modulating CANS for the suppression of atrial fibrillation and ventricular arrhythmias.
Collapse
|
5
|
Chakraborty P, Farhat K, Morris L, Whyte S, Yu X, Stavrakis S. Non-invasive Vagus Nerve Simulation in Postural Orthostatic Tachycardia Syndrome. Arrhythm Electrophysiol Rev 2023; 12:e31. [PMID: 38173801 PMCID: PMC10762669 DOI: 10.15420/aer.2023.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/23/2023] [Indexed: 01/05/2024] Open
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a chronic debilitating condition of orthostatic intolerance, predominantly affecting young females. Other than postural tachycardia, symptoms of POTS include a spectrum of non-cardiac, systemic and neuropsychiatric features. Despite the availability of widespread pharmacological and non-pharmacological therapeutic options, the management of POTS remains challenging. Exaggerated parasympathetic withdrawal and sympathetic overdrive during postural stress are principal mechanisms of postural tachycardia in POTS. Non-invasive, transcutaneous, vagus nerve stimulation (tVNS) is known to restore sympathovagal balance and is emerging as a novel therapeutic strategy in cardiovascular conditions including arrhythmias and heart failure. Furthermore, tVNS also exerts immunomodulatory and anti-inflammatory effects. This review explores the effects of tVNS on the pathophysiology of POTS and its potential as an alternative non-pharmacological option in this condition.
Collapse
Affiliation(s)
- Praloy Chakraborty
- Heart Rhythm Institute, University of Oklahoma Health and Sciences Center Oklahoma City, OK, US
| | - Kassem Farhat
- Heart Rhythm Institute, University of Oklahoma Health and Sciences Center Oklahoma City, OK, US
| | - Lynsie Morris
- Heart Rhythm Institute, University of Oklahoma Health and Sciences Center Oklahoma City, OK, US
| | - Seabrook Whyte
- Heart Rhythm Institute, University of Oklahoma Health and Sciences Center Oklahoma City, OK, US
| | - Xichun Yu
- Heart Rhythm Institute, University of Oklahoma Health and Sciences Center Oklahoma City, OK, US
| | - Stavros Stavrakis
- Heart Rhythm Institute, University of Oklahoma Health and Sciences Center Oklahoma City, OK, US
| |
Collapse
|
6
|
Soltani D, Stavrakis S. Neuromodulation for the Management of Atrial Fibrillation—How to Optimize Patient Selection and the Procedural Approach. CURRENT CARDIOVASCULAR RISK REPORTS 2023. [DOI: 10.1007/s12170-023-00718-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
|
7
|
Sun Y, Chao S, Ouyang H, Zhang W, Luo W, Nie Q, Wang J, Luo C, Ni G, Zhang L, Yang J, Feng H, Mao G, Li Z. Hybrid nanogenerator based closed-loop self-powered low-level vagus nerve stimulation system for atrial fibrillation treatment. Sci Bull (Beijing) 2022; 67:1284-1294. [PMID: 36546158 DOI: 10.1016/j.scib.2022.04.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/23/2022] [Accepted: 03/28/2022] [Indexed: 01/07/2023]
Abstract
Atrial fibrillation is an "invisible killer" of human health. It often induces high-risk diseases, such as myocardial infarction, stroke, and heart failure. Fortunately, atrial fibrillation can be diagnosed and treated early. Low-level vagus nerve stimulation (LL-VNS) is a promising therapeutic method for atrial fibrillation. However, some fundamental challenges still need to be overcome in terms of flexibility, miniaturization, and long-term service of bioelectric stimulation devices. Here, we designed a closed-loop self-powered LL-VNS system that can monitor the patient's pulse wave status in real time and conduct stimulation impulses automatically during the development of atrial fibrillation. The implant is a hybrid nanogenerator (H-NG), which is flexible, light weight, and simple, even without electronic circuits, components, and batteries. The maximum output of the H-NG was 14.8 V and 17.8 μA (peak to peak). In the in vivo effect verification study, the atrial fibrillation duration significantly decreased by 90% after LL-VNS therapy, and myocardial fibrosis and atrial connexin levels were effectively improved. Notably, the anti-inflammatory effect triggered by mediating the NF-κB and AP-1 pathways in our therapeutic system is observed. Overall, this implantable bioelectronic device is expected to be used for self-powerability, intelligentization, portability for management, and therapy of chronic diseases.
Collapse
Affiliation(s)
- Yu Sun
- Department of Neurosurgery, General Hospital of Armed Police Forces, Anhui Medical University, Hefei 230032, China; Department of Neurosurgery, The Third Medical Centre, Chinese People's Liberation Army General Hospital, Beijing 100039, China
| | - Shengyu Chao
- Beijing Key Laboratory of Micro-nano Energy and Sensor, Beijing Institute of Nanoenergy and Nanosystems, Chinese Academy of Sciences, Beijing 101400, China; School of Nanoscience and Technology, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Han Ouyang
- School of Nanoscience and Technology, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Weiyi Zhang
- Beijing Key Laboratory of Micro-nano Energy and Sensor, Beijing Institute of Nanoenergy and Nanosystems, Chinese Academy of Sciences, Beijing 101400, China
| | - Weikang Luo
- Institute of Integrative Medicine, Department of Integrated Traditional Chinese and Western Medicine, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Qingbin Nie
- Department of Neurosurgery, The Third Medical Centre, Chinese People's Liberation Army General Hospital, Beijing 100039, China
| | - Jianing Wang
- Department of Neurosurgery, General Hospital of Armed Police Forces, Anhui Medical University, Hefei 230032, China; Department of Neurosurgery, The Third Medical Centre, Chinese People's Liberation Army General Hospital, Beijing 100039, China
| | - Changyi Luo
- Department of Neurosurgery, General Hospital of Armed Police Forces, Anhui Medical University, Hefei 230032, China; Department of Neurosurgery, The Third Medical Centre, Chinese People's Liberation Army General Hospital, Beijing 100039, China
| | - Gongang Ni
- Department of Neurosurgery, General Hospital of Armed Police Forces, Anhui Medical University, Hefei 230032, China; Department of Neurosurgery, The Third Medical Centre, Chinese People's Liberation Army General Hospital, Beijing 100039, China
| | - Lingyu Zhang
- Department of Neurosurgery, General Hospital of Armed Police Forces, Anhui Medical University, Hefei 230032, China; Department of Neurosurgery, The Third Medical Centre, Chinese People's Liberation Army General Hospital, Beijing 100039, China
| | - Jun Yang
- Department of Neurosurgery, Peking University Third Hospital, Beijing 100191, China.
| | - Hongqing Feng
- Beijing Key Laboratory of Micro-nano Energy and Sensor, Beijing Institute of Nanoenergy and Nanosystems, Chinese Academy of Sciences, Beijing 101400, China; School of Nanoscience and Technology, University of Chinese Academy of Sciences, Beijing 100049, China.
| | - Gengsheng Mao
- Department of Neurosurgery, General Hospital of Armed Police Forces, Anhui Medical University, Hefei 230032, China; Department of Neurosurgery, The Third Medical Centre, Chinese People's Liberation Army General Hospital, Beijing 100039, China.
| | - Zhou Li
- Beijing Key Laboratory of Micro-nano Energy and Sensor, Beijing Institute of Nanoenergy and Nanosystems, Chinese Academy of Sciences, Beijing 101400, China; School of Nanoscience and Technology, University of Chinese Academy of Sciences, Beijing 100049, China; School of Chemistry and Chemical Engineering, Center on Nanoenergy Research, Guangxi University, Nanning 530004, China; Institute for Stem Cell and Regeneration, Chinese Academy of Sciences, Beijing 100101, China.
| |
Collapse
|
8
|
Choline Protects the Heart from Doxorubicin-Induced Cardiotoxicity through Vagal Activation and Nrf2/HO-1 Pathway. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:4740931. [PMID: 35422894 PMCID: PMC9005275 DOI: 10.1155/2022/4740931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/14/2022] [Indexed: 12/15/2022]
Abstract
Choline is a precursor of the major neurotransmitter acetylcholine and has been demonstrated beneficial in diverse models of cardiovascular disease. Here, we sought to verify that choline protects the heart from DOX-induced cardiotoxicity and the underlying mechanisms. The results showed that DOX treatment decreased left ventricular ejection fraction and fractional shortening and increased serum cardiac markers and myocardial fibrosis, which were alleviated by cotreatment with choline. DOX-induced cardiotoxicity was accompanied by increases in oxidative stress, inflammation, and apoptosis, which were rectified by choline cotreatment. Levels of nuclear factor erythroid 2-related factor 2 (Nrf2) and heme-oxygenase-1 (HO-1), which are antioxidant markers, were lowered by DOX and upregulated by choline. Moreover, DOX significantly decreased serum acetylcholine levels and the high-frequency component of heart rate variability and increased serum norepinephrine levels and the low-frequency component; these effects were rescued by choline administration. Interestingly, the protective effects of choline could be partially reversed by administration of the muscarinic receptor antagonist atropine. This suggests that choline might be a promising adjunct therapeutic agent to alleviate DOX-induced cardiotoxicity.
Collapse
|
9
|
Kharbanda RK, van der Does WFB, van Staveren LN, Taverne YJHJ, Bogers AJJC, de Groot NMS. Vagus Nerve Stimulation and Atrial Fibrillation: Revealing the Paradox. Neuromodulation 2022; 25:356-365. [PMID: 35190246 DOI: 10.1016/j.neurom.2022.01.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 12/28/2021] [Accepted: 01/04/2022] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVE The cardiac autonomic nervous system (CANS) plays an important role in the pathophysiology of atrial fibrillation (AF). Cardiovascular disease can cause an imbalance within the CANS, which may contribute to the initiation and maintenance of AF. Increased understanding of neuromodulation of the CANS has resulted in novel emerging therapies to treat cardiac arrhythmias by targeting different circuits of the CANS. Regarding AF, neuromodulation therapies targeting the vagus nerve have yielded promising outcomes. However, targeting the vagus nerve can be both pro-arrhythmogenic and anti-arrhythmogenic. Currently, these opposing effects of vagus nerve stimulation (VNS) have not been clearly described. The aim of this review is therefore to discuss both pro-arrhythmogenic and anti-arrhythmogenic effects of VNS and recent advances in clinical practice and to provide future perspectives for VNS to treat AF. MATERIALS AND METHODS A comprehensive review of current literature on VNS and its pro-arrhythmogenic and anti-arrhythmogenic effects on atrial tissue was performed. Both experimental and clinical studies are reviewed and discussed separately. RESULTS VNS exhibits both pro-arrhythmogenic and anti-arrhythmogenic effects. The anatomical site and stimulation settings during VNS play a crucial role in determining its effect on cardiac electrophysiology. Since the last decade, there is accumulating evidence from experimental studies and randomized clinical studies that low-level VNS (LLVNS), below the bradycardia threshold, is an effective treatment for AF. CONCLUSION LLVNS is a promising novel therapeutic modality to treat AF and further research will further elucidate the underlying anti-arrhythmogenic mechanisms, optimal stimulation settings, and site to apply LLVNS.
Collapse
Affiliation(s)
- Rohit K Kharbanda
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands; 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
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | | |
Collapse
|
10
|
Rodríguez-Mañero M, Martínez-Sande JL, García-Seara J, González-Ferrero T, González-Juanatey JR, Schurmann P, Tavares L, Valderrábano M. Neuromodulatory Approaches for Atrial Fibrillation Ablation. Eur Cardiol 2022; 16:e53. [PMID: 35024055 PMCID: PMC8728882 DOI: 10.15420/ecr.2021.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 05/23/2021] [Indexed: 12/01/2022] Open
Abstract
In this review, the authors describe evolving alternative strategies for the management of AF, focusing on non-invasive and percutaneous autonomic modulation. This modulation can be achieved – among other approaches – via tragus stimulation, renal denervation, cardiac afferent denervation, alcohol injection in the vein of Marshall, baroreceptor activation therapy and endocardial ganglionated plexi ablation. Although promising, these therapies are currently under investigation but could play a role in the treatment of AF in combination with conventional pulmonary vein isolation in the near future.
Collapse
Affiliation(s)
- Moisés Rodríguez-Mañero
- Department of Cardiology, University Hospital of Santiago de Compostela, Santiago de Compostela, A Coruña Galicia, Spain.,Institute of Health Research, University of Santiago de Compostela, Santiago de Compostela, A Coruña Galicia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV) Spain
| | - Jose Luis Martínez-Sande
- Department of Cardiology, University Hospital of Santiago de Compostela, Santiago de Compostela, A Coruña Galicia, Spain.,Institute of Health Research, University of Santiago de Compostela, Santiago de Compostela, A Coruña Galicia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV) Spain
| | - Javier García-Seara
- Department of Cardiology, University Hospital of Santiago de Compostela, Santiago de Compostela, A Coruña Galicia, Spain.,Institute of Health Research, University of Santiago de Compostela, Santiago de Compostela, A Coruña Galicia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV) Spain
| | - Teba González-Ferrero
- Department of Cardiology, University Hospital of Santiago de Compostela, Santiago de Compostela, A Coruña Galicia, Spain
| | - José Ramón González-Juanatey
- Department of Cardiology, University Hospital of Santiago de Compostela, Santiago de Compostela, A Coruña Galicia, Spain.,Institute of Health Research, University of Santiago de Compostela, Santiago de Compostela, A Coruña Galicia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV) Spain
| | - Paul Schurmann
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research Institute, The Methodist Hospital Houston, TX, US
| | - Liliana Tavares
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research Institute, The Methodist Hospital Houston, TX, US
| | - Miguel Valderrábano
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research Institute, The Methodist Hospital Houston, TX, US
| |
Collapse
|
11
|
Stavrakis S, Kulkarni K, Singh JP, Katritsis DG, Armoundas AA. Autonomic Modulation of Cardiac Arrhythmias: Methods to Assess Treatment and Outcomes. JACC Clin Electrophysiol 2021; 6:467-483. [PMID: 32439031 DOI: 10.1016/j.jacep.2020.02.014] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 02/06/2020] [Accepted: 02/14/2020] [Indexed: 02/08/2023]
Abstract
The autonomic nervous system plays a central role in the pathogenesis of multiple cardiac arrhythmias, including atrial fibrillation and ventricular tachycardia. As such, autonomic modulation represents an attractive therapeutic approach in these conditions. Notably, autonomic modulation exploits the plasticity of the neural tissue to induce neural remodeling and thus obtain therapeutic benefit. Different forms of autonomic modulation include vagus nerve stimulation, tragus stimulation, renal denervation, baroreceptor activation therapy, and cardiac sympathetic denervation. This review seeks to highlight these autonomic modulation therapeutic modalities, which have shown promise in early preclinical and clinical trials and represent exciting alternatives to standard arrhythmia treatment. We also present an overview of the various methods used to assess autonomic tone, including heart rate variability, skin sympathetic nerve activity, and alternans, which can be used as surrogate markers and predictors of the treatment effect. Although the use of autonomic modulation to treat cardiac arrhythmias is supported by strong preclinical data and preliminary studies in humans, in light of the disappointing results of a number of recent randomized clinical trials of autonomic modulation therapies in heart failure, the need for optimization of the stimulation parameters and rigorous patient selection based on appropriate biomarkers cannot be overemphasized.
Collapse
Affiliation(s)
- Stavros Stavrakis
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA.
| | - Kanchan Kulkarni
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jagmeet P Singh
- Cardiology Division, Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Antonis A Armoundas
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA; Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA.
| |
Collapse
|
12
|
Cavalcante GL, Brognara F, Oliveira LVDC, Lataro RM, Durand MDT, Oliveira AP, Nóbrega ACL, Salgado HC, Sabino JPJ. Benefits of pharmacological and electrical cholinergic stimulation in hypertension and heart failure. Acta Physiol (Oxf) 2021; 232:e13663. [PMID: 33884761 DOI: 10.1111/apha.13663] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 03/12/2021] [Accepted: 04/06/2021] [Indexed: 12/11/2022]
Abstract
Systemic arterial hypertension and heart failure are cardiovascular diseases that affect millions of individuals worldwide. They are characterized by a change in the autonomic nervous system balance, highlighted by an increase in sympathetic activity associated with a decrease in parasympathetic activity. Most therapeutic approaches seek to treat these diseases by medications that attenuate sympathetic activity. However, there is a growing number of studies demonstrating that the improvement of parasympathetic function, by means of pharmacological or electrical stimulation, can be an effective tool for the treatment of these cardiovascular diseases. Therefore, this review aims to describe the advances reported by experimental and clinical studies that addressed the potential of cholinergic stimulation to prevent autonomic and cardiovascular imbalance in hypertension and heart failure. Overall, the published data reviewed demonstrate that the use of central or peripheral acetylcholinesterase inhibitors is efficient to improve the autonomic imbalance and hemodynamic changes observed in heart failure and hypertension. Of note, the baroreflex and the vagus nerve activation have been shown to be safe and effective approaches to be used as an alternative treatment for these cardiovascular diseases. In conclusion, pharmacological and electrical stimulation of the parasympathetic nervous system has the potential to be used as a therapeutic tool for the treatment of hypertension and heart failure, deserving to be more explored in the clinical setting.
Collapse
Affiliation(s)
- Gisele L. Cavalcante
- Graduate Program in Pharmaceutical Sciences Department of Biophysics and Physiology Federal University of Piaui Teresina PI Brazil
- Department of Pharmacology Ribeirão Preto Medical School University of São Paulo Ribeirão Preto SP Brazil
| | - Fernanda Brognara
- Department of Physiology Ribeirão Preto Medical School University of São Paulo Ribeirão Preto SP Brazil
| | - Lucas Vaz de C. Oliveira
- Graduate Program in Pharmaceutical Sciences Department of Biophysics and Physiology Federal University of Piaui Teresina PI Brazil
| | - Renata M. Lataro
- Department of Physiological Sciences Center of Biological Sciences Federal University of Santa Catarina Florianópolis SP Brazil
| | | | - Aldeidia P. Oliveira
- Graduate Program in Pharmacology Department of Biophysics and Physiology Federal University of Piaui Teresina PI Brazil
| | | | - Helio C. Salgado
- Department of Physiology Ribeirão Preto Medical School University of São Paulo Ribeirão Preto SP Brazil
| | - João Paulo J. Sabino
- Graduate Program in Pharmaceutical Sciences Department of Biophysics and Physiology Federal University of Piaui Teresina PI Brazil
| |
Collapse
|
13
|
Guo Y, Xiaokereti J, Meng Q, Cao G, Sun H, Zhou X, Zhang L, Tang B. Low-Level Vagus Nerve Stimulation Reverses Obstructive Sleep Apnea-Related Atrial Fibrillation by Ameliorating Sympathetic Hyperactivity and Atrial Myocyte Injury. Front Physiol 2021; 11:620655. [PMID: 33574766 PMCID: PMC7870686 DOI: 10.3389/fphys.2020.620655] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/21/2020] [Indexed: 12/29/2022] Open
Abstract
Background: Previous studies have proved that low-level vagus nerve stimulation (LLVS) could suppress acute obstructive sleep apnea (OSA), which is associated with atrial fibrillation (AF). Objective: This study investigates the underlying electrophysiological, neural, and cardiomyocyte injury mechanisms on acute OSA-induced AF, examining whether LLVS can attenuate or reverse this remodeling. Methods and Results: Eighteen mongrel dogs received endotracheal intubation under general anesthesia and were randomly divided into three groups: the OSA group (simulated OSA with clamping of the trachea cannula at the end of expiration for 2min followed ventilation 8min, lasting 6h, n=6), the OSA+LLVS group (simulated OSA plus LLVS, n=6), and a control group (sham clamping the trachea cannula without stimulation, n=6). In the OSA+LLVS group, the atrial effective refractory period was significantly lengthened while the sinus node recovery time and AF duration decreased after the 4th hour, and the expression level of Cx40 and Cx43 was significantly increased compared to the OSA group. Norepinephrine, TH, and ChAT were significantly decreased in the OSA+LLVS group compared with the OSA group. Mitochondrial swelling, cardiomyocyte apoptosis, and glycogen deposition, along with a higher concentration of TNF-α, IL-6 were observed in the OSA group, and the LLVS inhibited the structural remodeling and expression of inflammatory cytokines. Conclusion: LLVS decreased the inducibility of AF partly by ameliorating sympathetic hyperactivity and atrial myocyte injury after acute OSA-induced AF.
Collapse
Affiliation(s)
- Yankai Guo
- Department of Pacing and Electrophysiology, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang, China.,Xinjiang Key Laboratory of Cardiac Electrophysiology and Cardiac Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang, China.,Department of Cardiology, The Fifth Affiliated Hospital of Xinjiang Medical University, Xinjiang, China
| | - Jiasuoer Xiaokereti
- Department of Pacing and Electrophysiology, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang, China.,Xinjiang Key Laboratory of Cardiac Electrophysiology and Cardiac Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang, China
| | - Qingjun Meng
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Cardiac Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang, China
| | - Guiqiu Cao
- Department of Cardiology, The Fifth Affiliated Hospital of Xinjiang Medical University, Xinjiang, China
| | - Huaxin Sun
- Department of Pacing and Electrophysiology, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang, China.,Xinjiang Key Laboratory of Cardiac Electrophysiology and Cardiac Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang, China
| | - Xianhui Zhou
- Department of Pacing and Electrophysiology, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang, China.,Xinjiang Key Laboratory of Cardiac Electrophysiology and Cardiac Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang, China
| | - Ling Zhang
- Department of Pacing and Electrophysiology, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang, China.,Xinjiang Key Laboratory of Cardiac Electrophysiology and Cardiac Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang, China
| | - Baopeng Tang
- Department of Pacing and Electrophysiology, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang, China.,Xinjiang Key Laboratory of Cardiac Electrophysiology and Cardiac Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang, China
| |
Collapse
|
14
|
Manolis AA, Manolis TA, Apostolopoulos EJ, Apostolaki NE, Melita H, Manolis AS. The role of the autonomic nervous system in cardiac arrhythmias: The neuro-cardiac axis, more foe than friend? Trends Cardiovasc Med 2020; 31:290-302. [PMID: 32434043 DOI: 10.1016/j.tcm.2020.04.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 04/24/2020] [Accepted: 04/30/2020] [Indexed: 02/07/2023]
Abstract
The autonomic nervous system (ANS) with its two limbs, the sympathetic (SNS) and parasympathetic nervous system (PSNS), plays a critical role in the modulation of cardiac arrhythmogenesis. It can be both pro- and/or anti-arrhythmic at both the atrial and ventricular level of the myocardium. Intricate mechanisms, different for specific cardiac arrhythmias, are involved in this modulatory process. More data are available for the arrhythmogenic effects of the SNS, which, when overactive, can trigger atrial and/or ventricular "adrenergic" arrhythmias in susceptible individuals (e.g. in patients with paroxysmal atrial fibrillation-PAF, ventricular pre-excitation, specific channelopathies, ischemic heart disease or cardiomyopathies), while it can also negate the protective anti-arrhythmic drug effects. However, there is also evidence that PSNS overactivity may be responsible for triggering "vagotonic" arrhythmias (e.g. PAF, Brugada syndrome, idiopathic ventricular fibrillation). Thus, a fine balance is necessary to attain in these two limbs of the ANS in order to maintain eurhythmia, which is a difficult task to accomplish. Over the years, in addition to classical drug therapies, where beta-blockers prevail, several ANS-modulating interventions have been developed aiming at prevention and management of arrhythmias. Among them, techniques of cardiac sympathetic denervation, renal denervation, vagal stimulation, ganglionated plexi ablation and the newer experimental method of optogenetics have been employed. However, in many arrhythmogenic diseases, ANS modulation is still an investigative tool. Initial data are encouraging; however, further studies are needed to explore the efficacy of such interventions. These issues are herein reviewed and old and recent literature data are discussed, tabulated and pictorially illustrated.
Collapse
|
15
|
Qin D, Singh JP. Low-Level Tragus Stimulation for Atrial Fibrillation. JACC Clin Electrophysiol 2020; 6:292-294. [DOI: 10.1016/j.jacep.2020.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 01/09/2020] [Indexed: 12/20/2022]
|
16
|
TREAT AF (Transcutaneous Electrical Vagus Nerve Stimulation to Suppress Atrial Fibrillation): A Randomized Clinical Trial. JACC Clin Electrophysiol 2020; 6:282-291. [PMID: 32192678 DOI: 10.1016/j.jacep.2019.11.008] [Citation(s) in RCA: 111] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 11/13/2019] [Accepted: 11/14/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVES This study was a sham-controlled, double-blind, randomized clinical trial to examine the effect of chronic low level tragus stimulation (LLTS) in patients with paroxysmal AF. BACKGROUND Low-level transcutaneous electrical stimulation of the auricular branch of the vagus nerve at the tragus (LLTS) acutely suppresses atrial fibrillation (AF) in humans, but the chronic effect remains unknown. METHODS LLTS (20 Hz, 1 mA below the discomfort threshold) was delivered using an ear clip attached to the tragus (active arm) (n = 26) or the ear lobe (sham control arm) (n = 27) for 1 h daily over 6 months. AF burden over 2-week periods was assessed by noninvasive continuous electrocardiogram monitoring at baseline, 3 months, and 6 months. Five-minute electrocardiography and serum were obtained at each visit to measure heart rate variability and inflammatory cytokines, respectively. RESULTS Baseline characteristics were balanced between the 2 groups. Adherence to the stimulation protocol (≤4 sessions lost per month) was 75% in the active arm and 83% in the control arm (p > 0.05). At 6 months, the median AF burden was 85% lower in the active arm compared with the control arm (ratio of medians: 0.15; 95% confidence interval: 0.03 to 0.65; p = 0.011). Tumor necrosis factor-alpha was significantly decreased by 23% in the active group relative to the control group (ratio of medians: 0.77; 95% confidence interval: 0.63 to 0.94; p = 0.0093). Frequency domain indices of heart rate variability were significantly altered with active versus control stimulation (p < 0.01). No device-related side effects were observed. CONCLUSIONS Chronic, intermittent LLTS resulted in lower AF burden than did sham control stimulation, supporting its use to treat paroxysmal AF in selected patients. (Transcutaneous Electrical Vagus Nerve Stimulation to Suppress Atrial Fibrillation [TREAT-AF]; NCT02548754).
Collapse
|
17
|
Huang B, Liu H, Scherlag BJ, Sun L, Xing S, Xu J, Luo M, Guo Y, Cao G, Jiang H. Atrial fibrillation in obstructive sleep apnea: Neural mechanisms and emerging therapies. Trends Cardiovasc Med 2020; 31:127-132. [PMID: 32008837 DOI: 10.1016/j.tcm.2020.01.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 12/23/2019] [Accepted: 01/15/2020] [Indexed: 02/07/2023]
Abstract
Obstructive sleep apnea (OSA) has been reproducibly identified as a risk factor for initiation and progression of atrial fibrillation (AF) and reduces the efficacy of antiarrhythmic drugs, electrical cardioversion, and catheter ablation in AF. It is still controversial whether continuous positive airway pressure ventilation (CPAP) could improve the successful rate of AF treatment in OSA patients. Besides, CPAP has shown relative low compliance in patients with OSA. Therefore, novel optional therapies might be needed to improve the control of AF associated with OSA. A growing body of evidence suggests that autonomic activation contributes to the pathogenesis of AF in OSA. Acute apneic episodes result in sympathovagal co-activation, shortening atrial refractoriness and promoting the initiation of AF. Chronic OSA-induced sympathetic activation plays a crucial role in atrial autonomic, structural, and electrical remodeling, thus providing substrates for AF maintenance and recurrence. Therefore, the autonomic nervous system may be a promising therapeutic target for OSA and AF. Autonomic modulation as a treatment for OSA-associated AF has been well established in several preclinical studies. Further clinical studies are needed to provide a more precise definition of the role of autonomic modulation in the treatment of AF in OSA.
Collapse
Affiliation(s)
- Bing Huang
- Department of Cardiology, Renmin Hospital of Wuhan University, No. 238 Jiefang Road, Wuchang District, Wuhan, Hubei 430060, PR China; Department of Cardiology, Fifth Affiliated Hospital of Xinjiang Medical University, No. 118 Henan Road, Xinshi District, Urumqi, Xinjiang 830000, PR China; Cardiovascular Research Institute, Wuhan University, Wuhan, Hubei, PR China; Hubei Key Laboratory of Cardiology, Wuhan, Hubei, PR China
| | - Huafen Liu
- Department of Cardiology, Renmin Hospital of Wuhan University, No. 238 Jiefang Road, Wuchang District, Wuhan, Hubei 430060, PR China; Cardiovascular Research Institute, Wuhan University, Wuhan, Hubei, PR China; Hubei Key Laboratory of Cardiology, Wuhan, Hubei, PR China
| | - Benjamin J Scherlag
- Heart Rhythm Institute and Department of Medicine, University of Oklahoma Health Science Center, Oklahoma City, OK, United States
| | - Lihua Sun
- Department of Cardiology, Fifth Affiliated Hospital of Xinjiang Medical University, No. 118 Henan Road, Xinshi District, Urumqi, Xinjiang 830000, PR China
| | - Shifeng Xing
- Department of Cardiology, Fifth Affiliated Hospital of Xinjiang Medical University, No. 118 Henan Road, Xinshi District, Urumqi, Xinjiang 830000, PR China
| | - Jie Xu
- Department of Cardiology, Fifth Affiliated Hospital of Xinjiang Medical University, No. 118 Henan Road, Xinshi District, Urumqi, Xinjiang 830000, PR China
| | - Mei Luo
- Department of Cardiology, Fifth Affiliated Hospital of Xinjiang Medical University, No. 118 Henan Road, Xinshi District, Urumqi, Xinjiang 830000, PR China
| | - Yankai Guo
- Department of Cardiology, Fifth Affiliated Hospital of Xinjiang Medical University, No. 118 Henan Road, Xinshi District, Urumqi, Xinjiang 830000, PR China
| | - Guiqiu Cao
- Department of Cardiology, Fifth Affiliated Hospital of Xinjiang Medical University, No. 118 Henan Road, Xinshi District, Urumqi, Xinjiang 830000, PR China.
| | - Hong Jiang
- Department of Cardiology, Renmin Hospital of Wuhan University, No. 238 Jiefang Road, Wuchang District, Wuhan, Hubei 430060, PR China; Cardiovascular Research Institute, Wuhan University, Wuhan, Hubei, PR China; Hubei Key Laboratory of Cardiology, Wuhan, Hubei, PR China.
| |
Collapse
|
18
|
Sohinki D, Stavrakis S. New approaches for treating atrial fibrillation: Focus on autonomic modulation. Trends Cardiovasc Med 2019; 30:433-439. [PMID: 31708408 DOI: 10.1016/j.tcm.2019.10.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 10/07/2019] [Accepted: 10/23/2019] [Indexed: 12/18/2022]
Abstract
Atrial fibrillation (AF) is a rapidly growing clinical problem in routine practice, both for cardiologists as well as general practitioners. Current therapies aimed at the management of AF include anti-arrhythmic drug therapy and catheter ablation. These therapies have a number of limitations and risks, and have disappointing long-term efficacy in maintaining sinus rhythm and improving hard clinical outcomes. Because of this, there is growing interest in pursuing alternative management strategies in patients with AF. This review seeks to highlight emerging AF therapies, with a specific focus on several modalities aimed at modulation of the autonomic nervous system. These therapies have shown promise in early pre-clinical and clinical trials, and represent exciting alternatives to standard AF treatment.
Collapse
Affiliation(s)
- Daniel Sohinki
- Department of Cardiology, Augusta University Medical Center, Augusta, GA, United States
| | - Stavros Stavrakis
- Department of Cardiology, University of Oklahoma Health Sciences Center, 800 Stanton L. Young Blvd., Suite 5400, Oklahoma, OK, United States; Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma, OK, United States.
| |
Collapse
|
19
|
Neuromodulation for Ventricular Tachycardia and Atrial Fibrillation: A Clinical Scenario-Based Review. JACC Clin Electrophysiol 2019; 5:881-896. [PMID: 31439288 DOI: 10.1016/j.jacep.2019.06.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 05/30/2019] [Accepted: 06/04/2019] [Indexed: 12/17/2022]
Abstract
Autonomic dysregulation in cardiovascular disease plays a major role in the pathogenesis of arrhythmias. Cardiac neural control relies on complex feedback loops consisting of efferent and afferent limbs, which carry sympathetic and parasympathetic signals from the brain to the heart and sensory signals from the heart to the brain. Cardiac disease leads to neural remodeling and sympathovagal imbalances with arrhythmogenic effects. Preclinical studies of modulation at central and peripheral levels of the cardiac autonomic nervous system have yielded promising results, leading to early stage clinical studies of these techniques in atrial fibrillation and refractory ventricular arrhythmias, particularly in patients with inherited primary arrhythmia syndromes and structural heart disease. However, significant knowledge gaps in basic cardiac neurophysiology limit the success of these neuromodulatory therapies. This review discusses the recent advances in neuromodulation for cardiac arrhythmia management, with a clinical scenario-based approach aimed at bringing neurocardiology closer to the realm of the clinical electrophysiologist.
Collapse
|
20
|
Wang Y, Po SS, Scherlag BJ, Yu L, Jiang H. The role of low-level vagus nerve stimulation in cardiac therapy. Expert Rev Med Devices 2019; 16:675-682. [PMID: 31306049 DOI: 10.1080/17434440.2019.1643234] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Introduction: Cardiovascular diseases are accompanied by autonomic nervous system (ANS) imbalance which is characterized by decreased vagal tone. Preclinical and clinical studies have revealed that increasing vagal activity via vagus nerve stimulation (VNS) could protect the heart. Based on these studies, VNS has emerged as a potential non-pharmaceutical treatment strategy. Although it's still difficult to find the optimal stimulus parameters, however, in arrhythmia model, it is reported that low-level VNS (LL-VNS) exacts paradoxical effects from the high-level VNS. Thus, the concept of LL-VNS is introduced. Areas covered: Animal and human studies have discussed the safety and efficacy of VNS and LL-VNS, and this review will discuss the research data in cardiovascular diseases, including atrial arrhythmia, ventricular arrhythmia, ischemia/reperfusion injury, heart failure, and hypertension. Expert opinion: In this regard, various clinical studies have been performed to verify the safety and efficacy of VNS. It is shown that VNS is well-tolerated and safe, but the results of its efficacy are conflicting, which may well block the translational process of VNS. The appearance of LL-VNS brings new idea and inspiration, suggesting an important role of subthreshold stimulation. A better understanding of the LL-VNS will contribute to translational research of VNS.
Collapse
Affiliation(s)
- Yuhong Wang
- a Department of Cardiology, Renmin Hospital of Wuhan University; Cardiovascular Research Institute, Wuhan University; Hubei Key Laboratory of Cardiology , Wuhan , Hubei , China.,b Key Laboratory of Myocardial Ischemia, Ministry of Education, Harbin Medical University , Harbin , China
| | - Sunny S Po
- c Heart Rhythm Institute and Department of Medicine, University of Oklahoma Health Sciences Center , Oklahoma City , OK , USA
| | - Benjamin J Scherlag
- c Heart Rhythm Institute and Department of Medicine, University of Oklahoma Health Sciences Center , Oklahoma City , OK , USA
| | - Lilei Yu
- a Department of Cardiology, Renmin Hospital of Wuhan University; Cardiovascular Research Institute, Wuhan University; Hubei Key Laboratory of Cardiology , Wuhan , Hubei , China
| | - Hong Jiang
- a Department of Cardiology, Renmin Hospital of Wuhan University; Cardiovascular Research Institute, Wuhan University; Hubei Key Laboratory of Cardiology , Wuhan , Hubei , China
| |
Collapse
|
21
|
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]
|
22
|
Autonomic Neuromodulation Acutely Ameliorates Left Ventricular Strain in Humans. J Cardiovasc Transl Res 2018; 12:221-230. [PMID: 30560316 DOI: 10.1007/s12265-018-9853-6] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Accepted: 12/05/2018] [Indexed: 12/13/2022]
Abstract
Low-level transcutaneous vagus nerve stimulation at the tragus (LLTS) is anti-adrenergic. We aimed to evaluate the acute effects of LLTS on left ventricular (LV) function and autonomic tone. Patients with diastolic dysfunction and preserved LV ejection fraction were enrolled in a prospective, randomized, double-blind, 2 × 2 cross-over study. Patients received two separate, 1-h sessions, at least 1 day apart, of active LLTS (20 Hz, 1 mA below the discomfort threshold) and sham stimulation. Echocardiography was performed after LLTS or sham stimulation to assess cardiac function. A 5-min ECG was performed to assess heart rate variability (HRV). Twenty-four patients were enrolled. LV global longitudinal strain improved by 1.8 ± 0.9% during active LLTS compared to sham stimulation (p = 0.001). Relative to baseline, HRV frequency domain components (low frequency, high frequency, and their ratio) were favorably altered after LLTS compared to sham stimulation (all p < 0.05). We concluded that LLTS acutely ameliorates cardiac mechanics by modulating the autonomic tone. Trial registration: NCT02983448.
Collapse
|
23
|
Annoni EM, Tolkacheva EG. Stochastic and periodic vagus nerve stimulation: how do they affect the heart? ACTA ACUST UNITED AC 2018. [DOI: 10.2217/bem-2019-0005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Elizabeth M Annoni
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN 55455, USA
| | - Elena G Tolkacheva
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN 55455, USA
| |
Collapse
|
24
|
Zhou L, Filiberti A, Humphrey MB, Fleming CD, Scherlag BJ, Po SS, Stavrakis S. Low-level transcutaneous vagus nerve stimulation attenuates cardiac remodelling in a rat model of heart failure with preserved ejection fraction. Exp Physiol 2018; 104:28-38. [PMID: 30398289 DOI: 10.1113/ep087351] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 11/02/2018] [Indexed: 12/17/2022]
Abstract
NEW FINDINGS What is the central question of this study? What is the effect of chronic intermittent low-level transcutaneous vagus nerve stimulation on cardiac inflammation, fibrosis and diastolic dysfunction in a rat model of heart failure with preserved ejection fraction? What is the main finding and its importance? In salt-sensitive rats fed with high salt diet, low-level transcutaneous vagus nerve stimulation significantly attenuated blood pressure elevation, ameliorated diastolic function, and attenuated left ventricular inflammation and fibrosis compared to the sham group. Further studies to examine the efficacy of this novel treatment in humans are warranted. ABSTRACT Inflammation and fibrosis play a central role in the development of heart failure with preserved ejection fraction (HFpEF). We previously showed that low-level, transcutaneous stimulation of the vagus nerve at the tragus (LLTS) is anti-inflammatory. We investigated the effect of chronic intermittent LLTS on cardiac inflammation, fibrosis and diastolic dysfunction in a rat model of HFpEF. Dahl salt-sensitive (DS) rats were randomized in three groups: low salt (LS, 0.3% NaCl; n = 12; control group without stimulation) and high salt (HS, 4% NaCl) with either active (n = 18) or sham (n = 18) LLTS at 7 weeks of age. After 6 weeks of diet (baseline), sham or active LLTS (20 Hz, 2 mA, 0.2 ms) was implemented for 30 min daily for 4 weeks. Echocardiography was performed at baseline and 4 weeks after treatment (endpoint). At endpoint, left ventricle (LV) histology and gene expression were examined. After 6 weeks of diets, HS rats developed hypertension and LV hypertrophy compared to LS rats. At endpoint, LLTS significantly attenuated blood pressure elevation, prevented the deterioration of diastolic function and improved LV circumferential strain, compared to the HS sham group. LV inflammatory cell infiltration and fibrosis were attenuated in the HS active compared to the HS sham group. Pro-inflammatory and pro-fibrotic genes (tumour necrosis factor, osteopontin, interleukin (IL)-11, IL-18 and IL-23A) were differentially altered in the two groups. Chronic intermittent LLTS ameliorates diastolic dysfunction, and attenuates cardiac inflammation and fibrosis in a rat model of HFpEF, suggesting that LLTS may be used clinically as a novel non-invasive neuromodulation therapy in HFpEF.
Collapse
Affiliation(s)
- Liping Zhou
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Adrian Filiberti
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Mary Beth Humphrey
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Christian D Fleming
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Benjamin J Scherlag
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.,Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Sunny S Po
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.,Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Stavros Stavrakis
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.,Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| |
Collapse
|
25
|
Abstract
The vagus nerve is a major component of the autonomic nervous system and plays a critical role in many body functions including for example, speech, swallowing, heart rate and respiratory control, gastric secretion, and intestinal motility. Vagus nerve stimulation (VNS) refers to any technique that stimulates the vagus nerve, with electrical stimulation being the most important. Implantable devices for VNS are approved therapy for refractory epilepsy and for treatment-resistant depression. In the case of heart disease applications, implantable VNS has been shown to be beneficial for treating heart failure in both preclinical and clinical studies. Adverse effects of implantable VNS therapy systems are generally associated with the implantation procedure or continuous on-off stimulation. The most serious implantation-associated adverse effect is infection. The effectiveness of non-invasive transcutaneous VNS for epilepsy, depression, primary headaches, heart failure, and other conditions remains under investigation. VNS merits further study for its potentially favorable effects on cardiovascular disease, especially heart failure.
Collapse
|
26
|
Zhou X, Wang Z, Huang B, Yuan S, Sheng X, Yu L, Meng G, Wang Y, Po SS, Jiang H. Regulation of the NRG1/ErbB4 Pathway in the Intrinsic Cardiac Nervous System Is a Potential Treatment for Atrial Fibrillation. Front Physiol 2018; 9:1082. [PMID: 30246788 PMCID: PMC6110946 DOI: 10.3389/fphys.2018.01082] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 07/20/2018] [Indexed: 12/02/2022] Open
Abstract
Background: The NRG1/ErbB4 signaling mechanism has been widely studied in the central nervous system for many years. However, the role of this pathway in modulating the intrinsic cardiac nervous system is largely unknown. Objective: The present study investigated whether the NRG1/ErbB4 signaling system affects the activity of major atrial ganglionated plexi (GP) in a paroxysmal atrial fibrillation (AF) model by 6-h rapid atrial pacing (RAP). Methods: Twenty-four dogs were randomly divided into (1) a control group (saline microinjections into GP), (2) RAP group (saline microinjections into GP plus 6 h-RAP), (3) NRG1 group (microinjections of neuregulin-1 into GP plus 6 h-RAP) and (4) NRG1 + ERA group (microinjections of neuregulin-1 and ErbB4 receptor antagonist-ERA into GP plus 6 h-RAP). The effective refractory period (ERP), window of vulnerability (WOV), anterior right GP (ARGP) function and neural activity were measured. ARGP tissues were excised for histological study and western blotting. Results: When compared to the control group, 6 h-RAP produced a significant (1) decrease in ERP, an increase in ΣWOV, (2) an increase in ARGP neural activity and neural function, and (3) an increase in c-fos and nerve growth factor protein expression in the ARGP. However, microinjection of NRG1 into the ARGP prior to RAP prevented ERP shortening and AGRP activity enhancement and inhibited the expression of c-Fos and NGF proteins. Furthermore, these changes were significantly attenuated by pretreatment with an ErbB4 receptor antagonist. Conclusion: The NRG1/ErbB4 signaling pathway may exist in the GP, and activation of this pathway suppressed RAP-induced GP activation, atrial electrical remodeling and AF.
Collapse
Affiliation(s)
- Xiaoya Zhou
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Zhuo Wang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Bing Huang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Shenxu Yuan
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xia Sheng
- Sir Run Run Shaw Institution of Clinical Medicine and Department of Cardiology, Sir Run Run Shaw Hospital Affiliated to Medical College of Zhejiang University, Hangzhou, China
| | - Lilei Yu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Guannan Meng
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yuhong Wang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Sunny S Po
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Hong Jiang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
| |
Collapse
|
27
|
Delfiner MS, Nofi C, Li Y, Gerdes AM, Zhang Y. Failing Hearts Are More Vulnerable to Sympathetic, but Not Vagal Stimulation-Induced, Atrial Fibrillation-Ameliorated with Dantrolene Treatment. J Card Fail 2018; 24:460-469. [PMID: 29885493 DOI: 10.1016/j.cardfail.2018.05.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 05/15/2018] [Accepted: 05/21/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Both vagal (VS) and sympathetic (SS) stimulations can increase atrial fibrillation (AF) inducibility, with VS being known as more arrhythmogenic in normal hearts. Heart failure (HF) results in autonomic dysfunction (characterized by sympathetic activation and vagal withdrawal) and is associated with an increased AF incidence. This study investigated whether failing hearts, compared with normal control hearts, respond differently to autonomic stimulation-induced AF arrhythmogenesis and the effect of dantrolene on SS-enhanced AF in HF. METHODS AND RESULTS A rat myocardial infarction (MI) HF model was used. In experiment 1, AF inducibility was compared in 9 MI-HF rats versus 10 sham-control animals at baseline, during VS, and during SS with isoproterenol infusion. In experiment 2, dantrolene treatment (n = 8) was compared with placebo-control (n = 9) on SS-induced AF inducibility in HF. Compared with the sham-control, baseline AF inducibility was higher in the MI-HF group. AF inducibility was augmented in both groups by autonomic stimulation. However, under VS the increased magnitude was less in the MI-HF group (49% ± 11% vs 80% ± 10%; P = .029), but under SS was significantly more (53% ± 8% vs 6% ± 7%; P < .001), compared with sham-control. Dantrolene significantly attenuated SS-enhanced AF in HF (69% ± 6% vs 29% ± 9%; P = .006). CONCLUSIONS Failing hearts are less sensitive to VS, but more vulnerable to SS-induced AF compared with normal-control hearts. Dantrolene can significantly attenuate SS-enhanced AF in HF, indicating that cardiac ryanodine receptor dysfunction may play a critical role in SS-enhanced AF in HF, and stabilizing leaky ryanodine receptor with the use of dantrolene may be a new treatment option in this condition.
Collapse
Affiliation(s)
- Matthew S Delfiner
- Department of Biomedical Sciences, New York Institute of Technology College of Osteopathic Medicine, Old Westbury, New York
| | - Colleen Nofi
- Department of Biomedical Sciences, New York Institute of Technology College of Osteopathic Medicine, Old Westbury, New York
| | - Ying Li
- Department of Biomedical Sciences, New York Institute of Technology College of Osteopathic Medicine, Old Westbury, New York
| | - A Martin Gerdes
- Department of Biomedical Sciences, New York Institute of Technology College of Osteopathic Medicine, Old Westbury, New York
| | - Youhua Zhang
- Department of Biomedical Sciences, New York Institute of Technology College of Osteopathic Medicine, Old Westbury, New York.
| |
Collapse
|
28
|
Atrial fibrillation: Neurogenic or myogenic? Arch Cardiovasc Dis 2018; 111:59-69. [DOI: 10.1016/j.acvd.2017.11.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 11/07/2017] [Accepted: 11/13/2017] [Indexed: 01/08/2023]
|
29
|
Reply: Parasympathetic Stimulation in Acute Myocardial Infarction: Is There a Role for a Pharmacologic Alternative Beyond Vagal Electrical Stimulation? JACC Cardiovasc Interv 2017; 10:2466-2467. [PMID: 29217011 DOI: 10.1016/j.jcin.2017.10.002] [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: 09/18/2017] [Accepted: 10/03/2017] [Indexed: 11/21/2022]
|
30
|
Low-Level Vagus Nerve Stimulation Suppresses Post-Operative Atrial Fibrillation and Inflammation: A Randomized Study. JACC Clin Electrophysiol 2017; 3:929-938. [PMID: 29759717 DOI: 10.1016/j.jacep.2017.02.019] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 02/27/2017] [Accepted: 02/28/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVES This study sought to examine the efficacy of low-level vagus nerve stimulation (LLVNS) in suppressing post-operative atrial fibrillation (POAF) and inflammatory cytokines in patients undergoing cardiac surgery. BACKGROUND POAF often complicates cardiac surgery. METHODS Patients undergoing cardiac surgery were randomized to active or sham LLVNS. In all patients, a bipolar wire was sutured to the vagus nerve pre-ganglionic fibers alongside the lateral aspect of the superior vena cava. High-frequency (20 Hz) stimulation, 50% below the threshold for slowing the heart rate, was delivered for 72 h in the LLVNS group. The development of POAF was monitored continuously during the entire hospital stay by use of telemetry. Blood was collected on arrival in the intensive care unit and at 24 and 72 h for measurement of inflammatory cytokines. Patients were followed up within 1 month after cardiac surgery. RESULTS A total of 54 patients were randomized to either active LLVNS (n = 26) or sham control (n = 28). The baseline characteristics of the patients were balanced in the 2 groups. POAF occurred in 3 patients (12%) in the LLVNS group and 10 patients (36%) in the control group (hazard ratio: 0.28; 95% confidence interval: 0.10 to 0.85; p = 0.027). None of the patients developed any complications as a result of wire placement. At 72 h, serum tumor necrosis factor-α and interleukin-6 levels were significantly lower in the LLVNS group than in the control group. CONCLUSIONS These data suggest that LLVNS suppresses POAF and attenuates inflammation in patients undergoing cardiac surgery. Further studies are warranted.
Collapse
|
31
|
He B, Lu Z, He W, Huang B, Jiang H. Autonomic Modulation by Electrical Stimulation of the Parasympathetic Nervous System: An Emerging Intervention for Cardiovascular Diseases. Cardiovasc Ther 2017; 34:167-71. [PMID: 26914959 DOI: 10.1111/1755-5922.12179] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
The cardiac autonomic nervous system has been known to play an important role in the development and progression of cardiovascular diseases. Autonomic modulation by electrical stimulation of the parasympathetic nervous system, which increases the parasympathetic activity and suppresses the sympathetic activity, is emerging as a therapeutic strategy for the treatment of cardiovascular diseases. Here, we review the recent literature on autonomic modulation by electrical stimulation of the parasympathetic nervous system, including vagus nerve stimulation, transcutaneous auricular vagal stimulation, spinal cord stimulation, and ganglionated plexi stimulation, in the treatment of heart failure, atrial fibrillation, and ventricular arrhythmias.
Collapse
Affiliation(s)
- Bo He
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China.,Cardiovascular Research Institute of Wuhan University, Wuhan, China.,Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Zhibing Lu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China.,Cardiovascular Research Institute of Wuhan University, Wuhan, China.,Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Wenbo He
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China.,Cardiovascular Research Institute of Wuhan University, Wuhan, China.,Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Bing Huang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China.,Cardiovascular Research Institute of Wuhan University, Wuhan, China.,Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Hong Jiang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China.,Cardiovascular Research Institute of Wuhan University, Wuhan, China.,Hubei Key Laboratory of Cardiology, Wuhan, China
| |
Collapse
|
32
|
Abstract
Ganglionated plexi (GP), consisting of conglomerations of autonomic ganglia on the epicardial surface of the heart, have been shown to play a significant role in different arrhythmias, including atrial fibrillation. GP ablation has become an adjunctive procedure in the treatment of atrial fibrillation, while it has been used successfully in preliminary studies in vasovagal syncope. This review will present the current data on the physiology and clinical applications of GP ablation in the treatment of atrial fibrillation and other diseases.
Collapse
Affiliation(s)
- Stavros Stavrakis
- University of Oklahoma Health Sciences Center,Oklahoma City, Oklahoma, USA
| | - Sunny Po
- University of Oklahoma Health Sciences Center,Oklahoma City, Oklahoma, USA
| |
Collapse
|
33
|
Shivkumar K, Ajijola OA, Anand I, Armour JA, Chen PS, Esler M, De Ferrari GM, Fishbein MC, Goldberger JJ, Harper RM, Joyner MJ, Khalsa SS, Kumar R, Lane R, Mahajan A, Po S, Schwartz PJ, Somers VK, Valderrabano M, Vaseghi M, Zipes DP. Clinical neurocardiology defining the value of neuroscience-based cardiovascular therapeutics. J Physiol 2016; 594:3911-54. [PMID: 27114333 PMCID: PMC4945719 DOI: 10.1113/jp271870] [Citation(s) in RCA: 212] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 04/08/2016] [Indexed: 12/13/2022] Open
Abstract
The autonomic nervous system regulates all aspects of normal cardiac function, and is recognized to play a critical role in the pathophysiology of many cardiovascular diseases. As such, the value of neuroscience-based cardiovascular therapeutics is increasingly evident. This White Paper reviews the current state of understanding of human cardiac neuroanatomy, neurophysiology, pathophysiology in specific disease conditions, autonomic testing, risk stratification, and neuromodulatory strategies to mitigate the progression of cardiovascular diseases.
Collapse
Affiliation(s)
- Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Center of Excellence, Los Angeles, CA, USA
| | - Olujimi A Ajijola
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Center of Excellence, Los Angeles, CA, USA
| | - Inder Anand
- Department of Cardiology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - J Andrew Armour
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Center of Excellence, Los Angeles, CA, USA
| | - Peng-Sheng Chen
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Murray Esler
- Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | | | - Michael C Fishbein
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Jeffrey J Goldberger
- Division of Cardiology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ronald M Harper
- Department of Neurobiology and the Brain Research Institute, University of California, Los Angeles, CA, USA
| | - Michael J Joyner
- Division of Cardiovascular Diseases, Mayo Clinic and Mayo Foundation, Rochester, MN, USA
| | | | - Rajesh Kumar
- Departments of Anesthesiology and Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Richard Lane
- Department of Psychiatry, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Aman Mahajan
- Department of Anesthesia, UCLA, Los Angeles, CA, USA
| | - Sunny Po
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- University of Tulsa Oxley College of Health Sciences, Tulsa, OK, USA
| | - Peter J Schwartz
- Center for Cardiac Arrhythmias of Genetic Origin, IRCCS Instituto Auxologico Italiano, c/o Centro Diagnostico e di Ricerrca San Carlo, Milan, Italy
| | - Virend K Somers
- Division of Cardiovascular Diseases, Mayo Clinic and Mayo Foundation, Rochester, MN, USA
| | - Miguel Valderrabano
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research Institute, Houston Methodist Hospital, Houston, TX, USA
| | - Marmar Vaseghi
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Center of Excellence, Los Angeles, CA, USA
| | - Douglas P Zipes
- Indiana University School of Medicine, Indianapolis, IN, USA
| |
Collapse
|
34
|
Leftheriotis D, Flevari P, Kossyvakis C, Katsaras D, Batistaki C, Arvaniti C, Giannopoulos G, Deftereos S, Kostopanagiotou G, Lekakis J. Acute effects of unilateral temporary stellate ganglion block on human atrial electrophysiological properties and atrial fibrillation inducibility. Heart Rhythm 2016; 13:2111-2117. [PMID: 27353237 DOI: 10.1016/j.hrthm.2016.06.025] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Indexed: 01/04/2023]
Abstract
BACKGROUND In experimental models, stellate ganglion block (SGB) reduces the induction of atrial fibrillation (AF), while data in humans are limited. OBJECTIVE The aim of this study was to assess the effect of unilateral SGB on atrial electrophysiological properties and AF induction in patients with paroxysmal AF. METHODS Thirty-six patients with paroxysmal AF were randomized in a 2:1 order to temporary, transcutaneous, pharmaceutical SGB with lidocaine or placebo before pulmonary vein isolation. Lidocaine was 1:1 randomly infused to the right or left ganglion. Before and after randomization, atrial effective refractory period (ERP) of each atrium, difference between right and left atrial ERP, intra- and interatrial conduction time, AF inducibility, and AF duration were assessed. RESULTS After SGB, right atrial ERP was prolonged from a median (1st-3rd quartile) of 240 (220-268) ms to 260 (240-300) ms (P < .01) and left atrial ERP from 235 (220-260) ms to 245 (240-280) ms (P < .01). AF was induced by atrial pacing in all 24 patients before SGB, but only in 13 patients (54%) after the intervention (P < .01). AF duration was shorter after SGB: 1.5 (0.0-5.8) minutes from 5.5 (3.0-12.0) minutes (P < .01). Intra- and interatrial conduction time was not significantly prolonged. No significant differences were observed between right and left SGB. No changes were observed in the placebo group. CONCLUSION Unilateral temporary SGB prolonged atrial ERP, reduced AF inducibility, and decreased AF duration. An equivalent effect of right and left SGB on both atria was observed. These findings may have a clinical implication in the prevention of drug refractory and postsurgery AF and deserve further clinical investigation.
Collapse
Affiliation(s)
| | - Panayota Flevari
- Department of Cardiology, Attikon University Hospital of Athens, Athens, Greece
| | - Charalampos Kossyvakis
- Department of Cardiology, Georgios Genimmatas General Hospital of Athens, Athens, Greece
| | - Dimitrios Katsaras
- Department of Cardiology, Attikon University Hospital of Athens, Athens, Greece
| | - Chrysanthi Batistaki
- Department of Anesthesiology, Attikon University Hospital of Athens, Athens, Greece
| | - Chrysa Arvaniti
- Department of Neurology, Attikon University Hospital of Athens, Athens, Greece
| | | | - Spyridon Deftereos
- Department of Cardiology, Attikon University Hospital of Athens, Athens, Greece
| | | | - John Lekakis
- Department of Cardiology, Attikon University Hospital of Athens, Athens, Greece
| |
Collapse
|
35
|
Effect of Low-level Vagus Nerve Stimulation on Cardiac Remodeling in a Rapid Atrial Pacing–induced Canine Model of Atrial Fibrillation. J Cardiovasc Pharmacol 2016; 67:218-24. [DOI: 10.1097/fjc.0000000000000338] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
36
|
Wang Z, Yu L, Huang B, Wang S, Liao K, Saren G, Zhou X, Jiang H. Low-level transcutaneous electrical stimulation of the auricular branch of vagus nerve ameliorates left ventricular remodeling and dysfunction by downregulation of matrix metalloproteinase 9 and transforming growth factor β1. J Cardiovasc Pharmacol 2016; 65:342-8. [PMID: 25502306 DOI: 10.1097/fjc.0000000000000201] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Vagus nerve stimulation improves left ventricular (LV) remodeling by downregulation of matrix metalloproteinase 9 (MMP-9) and transforming growth factor β1 (TGF-β1). Our previous study found that low-level transcutaneous electrical stimulation of the auricular branch of the vagus nerve (LL-TS) could be substituted for vagus nerve stimulation to reverse cardiac remodeling. So, we hypothesize that LL-TS could ameliorate LV remodeling by regulation of MMP-9 and TGF-β1 after myocardial infarction (MI). Twenty-two beagle dogs were randomly divided into a control group (MI was induced by permanent ligation of the left coronary artery, n = 8), an LL-TS group (MI with long-term intermittent LL-TS, n = 8), and a normal group (sham ligation without stimulation, n = 6). At the end of 6 weeks follow-up, LL-TS significantly reduced LV end-systolic and end-diastolic dimensions, improved ejection fraction and ratio of early (E) to late (A) peak mitral inflow velocity. LL-TS attenuated interstitial fibrosis and collagen degradation in the noninfarcted myocardium compared with the control group. Elevated level of MMP-9 and TGF-β1 in LV tissue and peripheral plasma were diminished in the LL-TS treated dogs. LL-TS improves cardiac function and prevents cardiac remodeling in the late stages after MI by downregulation of MMP-9 and TGF-β1 expression.
Collapse
Affiliation(s)
- Zhuo Wang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
| | | | | | | | | | | | | | | |
Collapse
|
37
|
Sheng X, Chen M, Huang B, Liu J, Zhou L, Bao M, Li S. Cardioprotective effects of low-level carotid baroreceptor stimulation against myocardial ischemia-reperfusion injury in canine model. J Interv Card Electrophysiol 2016; 45:131-40. [DOI: 10.1007/s10840-015-0094-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 12/22/2015] [Indexed: 12/26/2022]
|
38
|
Zhang L, Lu Y, Sun J, Zhou X, Tang B. Subthreshold vagal stimulation suppresses ventricular arrhythmia and inflammatory response in a canine model of acute cardiac ischaemia and reperfusion. Exp Physiol 2015; 101:41-9. [PMID: 26553757 DOI: 10.1113/ep085518] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 11/05/2015] [Indexed: 12/24/2022]
Affiliation(s)
- Ling Zhang
- Department of Cardiology, First Affiliated Hospital; Xinjiang Medical University; Urumqi 830054 China
| | - Yanmei Lu
- Department of Cardiology, First Affiliated Hospital; Xinjiang Medical University; Urumqi 830054 China
| | - Juan Sun
- Department of Cardiology, First Affiliated Hospital; Xinjiang Medical University; Urumqi 830054 China
| | - Xianhui Zhou
- Department of Cardiology, First Affiliated Hospital; Xinjiang Medical University; Urumqi 830054 China
| | - Baopeng Tang
- Department of Cardiology, First Affiliated Hospital; Xinjiang Medical University; Urumqi 830054 China
| |
Collapse
|
39
|
Chinda K, Tsai WC, Chan YH, Lin AYT, Patel J, Zhao Y, Tan AY, Shen MJ, Lin H, Shen C, Chattipakorn N, Rubart-von der Lohe M, Chen LS, Fishbein MC, Lin SF, Chen Z, Chen PS. Intermittent left cervical vagal nerve stimulation damages the stellate ganglia and reduces the ventricular rate during sustained atrial fibrillation in ambulatory dogs. Heart Rhythm 2015; 13:771-80. [PMID: 26607063 DOI: 10.1016/j.hrthm.2015.11.031] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND The effects of intermittent open-loop vagal nerve stimulation (VNS) on the ventricular rate (VR) during atrial fibrillation (AF) remain unclear. OBJECTIVE The purpose of this study was to test the hypothesis that VNS damages the stellate ganglion (SG) and improves VR control during persistent AF. METHODS We performed left cervical VNS in ambulatory dogs while recording the left SG nerve activity (SGNA) and vagal nerve activity. Tyrosine hydroxylase (TH) staining and terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining were used to assess neuronal cell death in the SG. RESULTS We induced persistent AF by atrial pacing in 6 dogs, followed by intermittent VNS with short ON-time (14 seconds) and long OFF-time (66 seconds). The integrated SGNA and VR during AF were 4.84 mV·s (95% confidence interval [CI] 3.08-6.60 mV·s) and 142 beats/min (95% CI 116-168 beats/min), respectively. During AF, VNS reduced the integrated SGNA and VR, respectively, to 3.74 mV·s (95% CI 2.27-5.20 mV·s; P = .021) and 115 beats/min (95% CI 96-134 beats/min; P = .016) during 66-second OFF-time and to 4.07 mV·s (95% CI 2.42-5.72 mV·s; P = .037) and 114 beats/min (95% CI 83-146 beats/min; P = .039) during 3-minute OFF-time. VNS increased the frequencies of prolonged (>3 seconds) pauses during AF. TH staining showed large confluent areas of damage in the left SG, characterized by pyknotic nuclei, reduced TH staining, increased percentage of TH-negative ganglion cells, and positive TUNEL staining. Occasional TUNEL-positive ganglion cells were also observed in the right SG. CONCLUSION VNS damaged the SG, leading to reduced SGNA and better rate control during persistent AF.
Collapse
Affiliation(s)
- Kroekkiat Chinda
- The Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; Department of Physiology, Faculty of Medical Science, Naresuan University, Phitsanulok, Thailand
| | - Wei-Chung Tsai
- The Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Hsin Chan
- The Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Division of Cardiology, The First Department of Medicine, Chang-Gung Memorial Hospital, Taipei, Taiwan
| | - Andrew Y-T Lin
- The Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jheel Patel
- The Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ye Zhao
- The Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Department of Cardiac Surgery, The First Affiliated Hospital of China Medical University, Shenyang, People's Republic of China
| | - Alex Y Tan
- Division of Cardiology, Hunter Holmes McGuire VA Medical Center, Virginia Commonwealth University, Richmond, Virginia
| | - Mark J Shen
- The Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Hongbo Lin
- Department of Biostatistics, Indiana University School of Medicine and the Fairbanks School of Public Health, Indianapolis, Indiana
| | - Changyu Shen
- Department of Biostatistics, Indiana University School of Medicine and the Fairbanks School of Public Health, Indianapolis, Indiana
| | - Nipon Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | | | - Lan S Chen
- The Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Michael C Fishbein
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Shien-Fong Lin
- The Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Institute of Biomedical Engineering, National Chiao-Tung University, Hsin-Chu, Taiwan
| | - Zhenhui Chen
- The Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Peng-Sheng Chen
- The Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.
| |
Collapse
|
40
|
ZHOU XIAOYA, ZHOU LIPING, WANG SONGYUN, YU LILEI, WANG ZHUO, HUANG BING, CHEN MINGXIAN, WAN JUN, JIANG HONG. The Use of Noninvasive Vagal Nerve Stimulation to Inhibit Sympathetically Induced Sinus Node Acceleration: A Potential Therapeutic Approach for Inappropriate Sinus Tachycardia. J Cardiovasc Electrophysiol 2015; 27:217-23. [PMID: 26467778 DOI: 10.1111/jce.12859] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 09/27/2015] [Accepted: 10/08/2015] [Indexed: 11/27/2022]
Affiliation(s)
- XIAOYA ZHOU
- Department of Cardiology, Renmin Hospital of Wuhan University; Cardiovascular Research Institute of Wuhan University; Wuhan Hubei China
| | - LIPING ZHOU
- Department of Cardiology, Renmin Hospital of Wuhan University; Cardiovascular Research Institute of Wuhan University; Wuhan Hubei China
| | - SONGYUN WANG
- Department of Cardiology, Renmin Hospital of Wuhan University; Cardiovascular Research Institute of Wuhan University; Wuhan Hubei China
| | - LILEI YU
- Department of Cardiology, Renmin Hospital of Wuhan University; Cardiovascular Research Institute of Wuhan University; Wuhan Hubei China
| | - ZHUO WANG
- Department of Cardiology, Renmin Hospital of Wuhan University; Cardiovascular Research Institute of Wuhan University; Wuhan Hubei China
| | - BING HUANG
- Department of Cardiology, Renmin Hospital of Wuhan University; Cardiovascular Research Institute of Wuhan University; Wuhan Hubei China
| | - MINGXIAN CHEN
- Department of Cardiology; the Second Xiangya Hospital of Central South, University; Changsha Hunan China
| | - JUN WAN
- Department of Cardiology, Renmin Hospital of Wuhan University; Cardiovascular Research Institute of Wuhan University; Wuhan Hubei China
| | - HONG JIANG
- Department of Cardiology, Renmin Hospital of Wuhan University; Cardiovascular Research Institute of Wuhan University; Wuhan Hubei China
| |
Collapse
|
41
|
CHEN MINGXIAN, ZHOU XIAOYA, YU LILEI, LIU QIMING, SHENG XIA, WANG ZHUO, WANG SONGYUN, JIANG HONG, ZHOU SHENGHUA. Low-Level Vagus Nerve Stimulation Attenuates Myocardial Ischemic Reperfusion Injury by Antioxidative Stress and Antiapoptosis Reactions in Canines. J Cardiovasc Electrophysiol 2015; 27:224-31. [PMID: 26546374 DOI: 10.1111/jce.12850] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 09/18/2015] [Accepted: 09/22/2015] [Indexed: 11/30/2022]
Affiliation(s)
- MINGXIAN CHEN
- Department of Cardiology; The Second Xiangya Hospital of Central South University; Changsha Hunan China
| | - XIAOYA ZHOU
- Department of Cardiology, Renmin Hospital; Wuhan University; Wuhan Hubei China
| | - LILEI YU
- Department of Cardiology, Renmin Hospital; Wuhan University; Wuhan Hubei China
| | - QIMING LIU
- Department of Cardiology; The Second Xiangya Hospital of Central South University; Changsha Hunan China
| | - XIA SHENG
- Sir Run Run Shaw Hospital; Affiliated to Medical College of Zhejiang University; Hangzhou Zhejiang China
| | - ZHUO WANG
- Department of Cardiology, Renmin Hospital; Wuhan University; Wuhan Hubei China
| | - SONGYUN WANG
- Department of Cardiology, Renmin Hospital; Wuhan University; Wuhan Hubei China
| | - HONG JIANG
- Department of Cardiology, Renmin Hospital; Wuhan University; Wuhan Hubei China
| | - SHENGHUA ZHOU
- Department of Cardiology; The Second Xiangya Hospital of Central South University; Changsha Hunan China
| |
Collapse
|
42
|
Spinal cord stimulation suppresses focal rapid firing-induced atrial fibrillation by inhibiting atrial ganglionated plexus activity. J Cardiovasc Pharmacol 2015; 64:554-9. [PMID: 25165998 DOI: 10.1097/fjc.0000000000000154] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study was designed to demonstrate that spinal cord stimulation (SCS) could suppress high-frequency stimulation (HFS)-induced focal atrial fibrillation (AF) at atrial and pulmonary vein (PV) sites by inhibiting atrial ganglionated plexus (GP) activity. METHODS Multielectrode catheters were attached to atria and all PV sites. SCS was performed at the T1-T5 spinal region for 1 hour. At the baseline state and the end of 1 hour of SCS, 40 milliseconds of HFS was delivered 2 milliseconds after atrial pacing to determine the AF threshold at each site. One electrode was attached to the superior left GP so that HFS to this site induced sinus rate slowing. Microelectrodes inserted into the anterior right GP recorded neural firing. RESULTS SCS induced a significant increase in AF threshold at all sites (all P < 0.05). The sinus rate slowing response induced by superior left GP stimulation was blunted by SCS (17% ± 3.6% vs. 39% ± 3.8%, P < 0.05). The frequency (32 ± 4 vs. 87 ± 6 impulses per minute, P < 0.05) and amplitude (0.16 ± 0.02 vs. 0.42 ± 0.04 mv, P < 0.05) of the neural activity recorded from the anterior right GP were markedly inhibited by SCS. CONCLUSIONS SCS may prevent episodic AF caused by rapid PV and non-PV firing through modulating GP activity.
Collapse
|
43
|
Aging and magnetism: Presenting a possible new holistic paradigm for ameliorating the aging process and the effects thereof, through externally applied physiologic PicoTesla magnetic fields. Med Hypotheses 2015; 85:276-86. [PMID: 26092501 DOI: 10.1016/j.mehy.2015.05.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Revised: 05/03/2015] [Accepted: 05/27/2015] [Indexed: 11/20/2022]
Abstract
A new holistic paradigm is proposed for slowing our genomic-based biological clocks (e.g. regulation of telomere length), and decreasing heat energy exigencies for maintenance of physiologic homeostasis. Aging is considered the result of a progressive slow burn in small volumes of tissues with increase in the quantum entropic states; producing desiccation, microscopic scarring, and disruption of cooperative coherent states. Based upon piezoelectricity, i.e. photon-phonon transductions, physiologic PicoTesla range magnetic fields may decrease the production of excessive heat energy through target specific, bio molecular resonant interactions, renormalization of intrinsic electromagnetic tissue profiles, and autonomic modulation. Prospectively, we hypothesize that deleterious effects of physical trauma, immunogenic microbiological agents, stress, and anxiety may be ameliorated. A particle-wave equation is cited to ascertain magnetic field parameters for application to the whole organism thereby achieving desired homeostasis; secondary to restoration of structure and function on quantum levels. We hypothesize that it is at the atomic level that physical events shape the flow of signals and the transmission of energy in bio molecular systems. References are made to experimental data indicating the aspecific efficacy of non-ionizing physiologic magnetic field profiles for treatment of various pathologic states.
Collapse
|
44
|
Stavrakis S, Humphrey MB, Scherlag BJ, Hu Y, Jackman WM, Nakagawa H, Lockwood D, Lazzara R, Po SS. Low-level transcutaneous electrical vagus nerve stimulation suppresses atrial fibrillation. J Am Coll Cardiol 2015; 65:867-75. [PMID: 25744003 DOI: 10.1016/j.jacc.2014.12.026] [Citation(s) in RCA: 221] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 12/07/2014] [Accepted: 12/13/2014] [Indexed: 01/11/2023]
Abstract
BACKGROUND Transcutaneous low-level tragus electrical stimulation (LLTS) suppresses atrial fibrillation (AF) in canines. OBJECTIVES This study examined the antiarrhythmic and anti-inflammatory effects of LLTS in humans. METHODS Patients with paroxysmal AF who presented for AF ablation were randomized to either 1 h of LLTS (n = 20) or sham control (n = 20). Attaching a flat metal clip onto the tragus produced LLTS (20 Hz) in the right ear (50% lower than the voltage slowing the sinus rate). Under general anesthesia, AF was induced by burst atrial pacing at baseline and after 1 h of LLTS or sham treatment. Blood samples from the coronary sinus and the femoral vein were collected at those time points and then analyzed for inflammatory cytokines, including tumor necrosis factor alpha and C-reactive protein, using a multiplex immunoassay. RESULTS There were no differences in baseline characteristics between the 2 groups. Pacing-induced AF duration decreased significantly by 6.3 ± 1.9 min compared with baseline in the LLTS group, but not in the control subjects (p = 0.002 for comparison between groups). AF cycle length increased significantly from baseline by 28.8 ± 6.5 ms in the LLTS group, but not in control subjects (p = 0.0002 for comparison between groups). Systemic (femoral vein) but not coronary sinus tumor necrosis factor (TNF)-alpha and C-reactive protein levels decreased significantly only in the LLTS group. CONCLUSIONS LLTS suppresses AF and decreases inflammatory cytokines in patients with paroxysmal AF. Our results support the emerging paradigm of neuromodulation to treat AF.
Collapse
Affiliation(s)
- Stavros Stavrakis
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Mary Beth Humphrey
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Benjamin J Scherlag
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Yanqing Hu
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Warren M Jackman
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Hiroshi Nakagawa
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Deborah Lockwood
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Ralph Lazzara
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Sunny S Po
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.
| |
Collapse
|
45
|
Huang WA, Shivkumar K, Vaseghi M. Device-based autonomic modulation in arrhythmia patients: the role of vagal nerve stimulation. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015; 17:379. [PMID: 25894588 DOI: 10.1007/s11936-015-0379-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OPINION STATEMENT Vagal nerve stimulation (VNS) has shown promise as an adjunctive therapy for management of cardiac arrhythmias by targeting the cardiac parasympathetic nervous system. VNS has been evaluated in the setting of ischemia-driven ventricular arrhythmias and atrial arrhythmias, as well as a treatment option for heart failure. As better understanding of the complexities of the cardiac autonomic nervous system is obtained, vagal nerve stimulation will likely become a powerful tool in the current cardiovascular therapeutic armamentarium.
Collapse
Affiliation(s)
- William A Huang
- UCLA Cardiac Arrhythmia Center, University of California, 100 Medical Plaza, Suite 660, Los Angeles, CA, 90095, USA
| | | | | |
Collapse
|
46
|
Jammes Y, Joulia F, Steinberg JG, Ravailhe S, Delpierre S, Condo J, Guieu R, Delliaux S. Endogenous adenosine release is involved in the control of heart rate in rats. Can J Physiol Pharmacol 2015. [PMID: 26222197 DOI: 10.1139/cjpp-2015-0042] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Intravenous (i.v.) injections of adenosine exert marked effects on heart rate (HR) and arterial blood pressure (BP), but the role of an endogenous adenosine release by vagal stimulation has not been evaluated. In anaesthetized rats, we examined HR and BP changes induced by 1 min electrical vagal stimulation in the control condition, and then after i.v. injections of (i) atropine, (ii) propranolol, (iii) caffeine, (iv) 8 cyclopentyl-1,3-dipropylxanthine (DPCPX), or (v) dipyridamole to increase the plasma concentration of adenosine (APC). APC was measured by chromatography in the arterial blood before and at the end of vagal stimulation. The decrease in HR in the controls during vagal stimulation was markedly attenuated, but persisted after i.v. injections of atropine and propranolol. When first administered, DPCPX modestly but significantly reduced the HR response to vagal stimulation, but this disappeared after i.v. caffeine administration. Both the HR and BP responses were significantly accentuated after i.v. injection of dipyridamole. Vagal stimulation induced a significant increase in APC, proportional to the magnitude of HR decrease. Our data suggest that the inhibitory effects of electrical vagal stimulations on HR and BP were partly mediated through the activation of A1 and A2 receptors by an endogenous adenosine release. Our experimental data could help to understand the effects of ischemic preconditioning, which are partially mediated by adenosine.
Collapse
Affiliation(s)
- Yves Jammes
- Aix-Marseille University, UMR MD2, 13015 Marseille, France.,Aix-Marseille University, UMR MD2, 13015 Marseille, France
| | - Fabrice Joulia
- Aix-Marseille University, UMR MD2, 13015 Marseille, France.,Aix-Marseille University, UMR MD2, 13015 Marseille, France
| | - Jean Guillaume Steinberg
- Aix-Marseille University, UMR MD2, 13015 Marseille, France.,Aix-Marseille University, UMR MD2, 13015 Marseille, France
| | - Sylvie Ravailhe
- Aix-Marseille University, UMR MD2, 13015 Marseille, France.,Aix-Marseille University, UMR MD2, 13015 Marseille, France
| | - Stéphane Delpierre
- Aix-Marseille University, UMR MD2, 13015 Marseille, France.,Aix-Marseille University, UMR MD2, 13015 Marseille, France
| | - Jocelyne Condo
- Aix-Marseille University, UMR MD2, 13015 Marseille, France.,Aix-Marseille University, UMR MD2, 13015 Marseille, France
| | - Regis Guieu
- Aix-Marseille University, UMR MD2, 13015 Marseille, France.,Aix-Marseille University, UMR MD2, 13015 Marseille, France
| | - Stéphane Delliaux
- Aix-Marseille University, UMR MD2, 13015 Marseille, France.,Aix-Marseille University, UMR MD2, 13015 Marseille, France
| |
Collapse
|
47
|
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.
Collapse
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
| |
Collapse
|
48
|
Low-level baroreceptor stimulation suppresses atrial fibrillation by inhibiting ganglionated plexus activity. Can J Cardiol 2015; 31:767-74. [PMID: 26022989 DOI: 10.1016/j.cjca.2015.01.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 01/13/2015] [Accepted: 01/17/2015] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The autonomic nervous system (ANS) plays an important role in the initiation and maintenance of atrial fibrillation (AF), and modulation of the ANS function may contribute to AF control. METHODS Anesthetized dogs received either sham treatment (SHAM group, n = 8) or low-level carotid baroreceptor stimulation (LL-CBS) treatment (LL-CBS group, n = 8). The stimulation voltage was set at 80% below the threshold. To simulate focal AF, high-frequency stimulation (HFS) was applied to local nerves during the atrial refractory period. Multielectrode catheters were attached to the atria and all the pulmonary veins to determine the changes in the AF threshold (AF-TH), the atrial effective refractory period (AERP), and the window of vulnerability (WOV) during HFS in both groups. Microelectrodes were inserted into the anterior right ganglionated plexus (ARGP) to record neural firing. RESULTS HFS induced sinus rate (SR) slowing in the superior left ganglionated plexus (SLGP). LL-CBS induced a progressive increase in AF-TH and AERP at all sites and a significant decrease in the sum of WOV at 2 hours (all P < 0.05). LL-CBS inhibited the ability of SLGP stimulation to slow the SR and the mean values of frequency and amplitude of ARGP neural activity compared with the SHAM group (all P < 0.05). CONCLUSIONS LL-CBS suppressed AF inducibility by inhibiting the neural activity of ganglionated plexuses. LL-CBS may serve as a novel therapeutic modality to treat AF.
Collapse
|
49
|
Huang B, Yu L, Scherlag BJ, Wang S, He B, Yang K, Liao K, Lu Z, He W, Zhang L, Po SS, Jiang H. Left renal nerves stimulation facilitates ischemia-induced ventricular arrhythmia by increasing nerve activity of left stellate ganglion. J Cardiovasc Electrophysiol 2014; 25:1249-56. [PMID: 25066536 DOI: 10.1111/jce.12498] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 07/14/2014] [Accepted: 07/21/2014] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Renal sympathetic nerve (RSN) activity plays a key role in systemic sympathetic hyperactivity. Previous studies have shown that cardiac sympathetic hyperactivity, especially the left stellate ganglion (LSG), contributes to the pathogenesis of ventricular arrhythmias (VAs) after acute myocardial infarction (AMI). METHODS AND RESULTS Twenty-eight dogs received 3 hours of continuous left-sided electrical stimulation of RSN (LRS; Group-1, n = 9), sham RSN stimulation (Group-2, n = 9), or LSG ablation plus 3 hours of LRS (Group-3, n = 10) were included. AMI was induced by ligating the proximal left anterior descending coronary artery. LRS was performed using electrical stimulation on the adventitia of left renal artery at the voltage increasing the systolic blood pressure (BP) by 10%. BP, heart rate variability (HRV), serum norepinephrine (NE) level, and LSG function were measured at baseline and the end of each hour of LRS. C-fos and nerve growth factor (NGF) protein expressed in the LSG were examined in Group-1 and Group-2. Compared with baseline, 3 hours of LRS induced a significant increase in BP, sympathetic indices of HRV, serum NE level, and LSG function. The incidence of VAs in Group-1 was significantly higher than other groups. The expression of c-fos and NGF protein in the LSG was significantly higher in Group-1 than Group-2. CONCLUSION Three hours of LRS induces both systemic and cardiac sympathetic hyperactivity and increases the incidence of ischemia-induced VAs.
Collapse
Affiliation(s)
- Bing Huang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Hucker WJ, Singh JP, Parks K, Armoundas AA. Device-Based Approaches to Modulate the Autonomic Nervous System and Cardiac Electrophysiology. Arrhythm Electrophysiol Rev 2014; 3:30-5. [PMID: 26835062 PMCID: PMC4711497 DOI: 10.15420/aer.2011.3.1.30] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 04/04/2014] [Indexed: 01/29/2023] Open
Abstract
Alterations in resting autonomic tone can be pathogenic in many cardiovascular disease states, such as heart failure and hypertension. Indeed, autonomic modulation by way of beta-blockade is a standard treatment of these conditions. There is a significant interest in developing non-pharmacological methods of autonomic modulation as well. For instance, clinical trials of vagal stimulation and spinal cord stimulation in the treatment of heart failure are currently underway, and renal denervation has been studied recently in the treatment of resistant hypertension. Notably, autonomic stimulation is also a potent modulator of cardiac electrophysiology. Manipulating the autonomic nervous system in studies designed to treat heart failure and hypertension have revealed that autonomic modulation may have a role in the treatment of common atrial and ventricular arrhythmias as well. Experimental data on vagal nerve and spinal cord stimulation suggest that each technique may reduce ventricular arrhythmias. Similarly, renal denervation may play a role in the treatment of atrial fibrillation, as well as in controlling refractory ventricular arrhythmias. In this review, we present the current experimental and clinical data on the effect of these therapeutic modalities on cardiac electrophysiology and their potential role in arrhythmia management.
Collapse
Affiliation(s)
- William J Hucker
- Fellow in Cardiovascular Medicine, Division of Cardiology, Massachusetts General Hospital, US;
| | - Jagmeet P Singh
- Associate Professor of Medicine, Harvard Medical School, Director, Resynchronization and Advanced Cardiac Therapeutics Program, Massachusetts General Hospital, US
| | - Kimberly Parks
- Instructor in Medicine, Harvard Medical School, Advanced Heart Failure and Transplantation, Massachusetts General Hospital, US
| | - Antonis A Armoundas
- Assistant Professor of Medicine, Harvard Medical School Cardiovascular Research Center, Massachusetts General Hospital, US
| |
Collapse
|