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Lenarczyk R, Zeppenfeld K, Tfelt-Hansen J, Heinzel FR, Deneke T, Ene E, Meyer C, Wilde A, Arbelo E, Jędrzejczyk-Patej E, Sabbag A, Stühlinger M, di Biase L, Vaseghi M, Ziv O, Bautista-Vargas WF, Kumar S, Namboodiri N, Henz BD, Montero-Cabezas J, Dagres N. Management of patients with an electrical storm or clustered ventricular arrhythmias: a clinical consensus statement of the European Heart Rhythm Association of the ESC-endorsed by the Asia-Pacific Heart Rhythm Society, Heart Rhythm Society, and Latin-American Heart Rhythm Society. Europace 2024; 26:euae049. [PMID: 38584423 PMCID: PMC10999775 DOI: 10.1093/europace/euae049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 02/07/2024] [Indexed: 04/09/2024] Open
Abstract
Electrical storm (ES) is a state of electrical instability, manifesting as recurrent ventricular arrhythmias (VAs) over a short period of time (three or more episodes of sustained VA within 24 h, separated by at least 5 min, requiring termination by an intervention). The clinical presentation can vary, but ES is usually a cardiac emergency. Electrical storm mainly affects patients with structural or primary electrical heart disease, often with an implantable cardioverter-defibrillator (ICD). Management of ES requires a multi-faceted approach and the involvement of multi-disciplinary teams, but despite advanced treatment and often invasive procedures, it is associated with high morbidity and mortality. With an ageing population, longer survival of heart failure patients, and an increasing number of patients with ICD, the incidence of ES is expected to increase. This European Heart Rhythm Association clinical consensus statement focuses on pathophysiology, clinical presentation, diagnostic evaluation, and acute and long-term management of patients presenting with ES or clustered VA.
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Affiliation(s)
- Radosław Lenarczyk
- Medical University of Silesia, Division of Medical Sciences, Department of Cardiology and Electrotherapy, Silesian Center for Heart Diseases, Skłodowskiej-Curie 9, 41-800 Zabrze, Poland
| | - Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jacob Tfelt-Hansen
- The Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- The Department of Forensic Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Frank R Heinzel
- Cardiology, Angiology, Intensive Care, Städtisches Klinikum Dresden Campus Friedrichstadt, Dresden, Germany
| | - Thomas Deneke
- Clinic for Interventional Electrophysiology, Heart Center RHÖN-KLINIKUM Campus Bad Neustadt, Bad Neustadt an der Saale, Germany
- Clinic for Electrophysiology, Klinikum Nuernberg, University Hospital of the Paracelsus Medical University, Nuernberg, Germany
| | - Elena Ene
- Clinic for Interventional Electrophysiology, Heart Center RHÖN-KLINIKUM Campus Bad Neustadt, Bad Neustadt an der Saale, Germany
| | - Christian Meyer
- Division of Cardiology/Angiology/Intensive Care, EVK Düsseldorf, Teaching Hospital University of Düsseldorf, Düsseldorf, Germany
| | - Arthur Wilde
- Department of Cardiology, Amsterdam UMC University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Heart Failure and arrhythmias, Amsterdam, the Netherlands
| | - Elena Arbelo
- Arrhythmia Section, Cardiology Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; IDIBAPS, Institut d'Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Ewa Jędrzejczyk-Patej
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Avi Sabbag
- The Davidai Center for Rhythm Disturbances and Pacing, Chaim Sheba Medical Center, Tel Hashomer, Israel
- School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Markus Stühlinger
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Luigi di Biase
- Albert Einstein College of Medicine at Montefiore Hospital, New York, NY, USA
| | - Marmar Vaseghi
- UCLA Cardiac Arrythmia Center, Division of Cardiology, Department of Medicine, University of California, Los Angeles, CA, USA
| | - Ohad Ziv
- Case Western Reserve University, Cleveland, OH, USA
- The MetroHealth System Campus, Cleveland, OH, USA
| | | | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Sydney, Australia
| | | | - Benhur Davi Henz
- Instituto Brasilia de Arritmias-Hospital do Coração do Brasil-Rede Dor São Luiz, Brasilia, Brazil
| | - Jose Montero-Cabezas
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
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Piccirillo G, Moscucci F, Mezzadri M, Caltabiano C, Cisaria G, Vizza G, De Santis V, Giuffrè M, Stefano S, Scinicariello C, Carnovale M, Corrao A, Lospinuso I, Sciomer S, Rossi P. Artificial Intelligence Applied to Electrical and Non-Invasive Hemodynamic Markers in Elderly Decompensated Chronic Heart Failure Patients. Biomedicines 2024; 12:716. [PMID: 38672072 PMCID: PMC11048014 DOI: 10.3390/biomedicines12040716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 03/16/2024] [Accepted: 03/18/2024] [Indexed: 04/28/2024] Open
Abstract
OBJECTIVES The first aim of this study was to assess the predictive power of Tend interval (Te) and non-invasive hemodynamic markers, based on bioimpedance in decompensated chronic heart failure (CHF). The second one was to verify the possible differences in repolarization and hemodynamic data between CHF patients grouped by level of left ventricular ejection fraction (LVEF). Finally, we wanted to check if repolarization and hemodynamic data changed with clinical improvement or worsening in CHF patients. METHODS Two hundred and forty-three decompensated CHF patients were studied by 5 min ECG recordings to determine the mean and standard deviation (TeSD) of Te (first study). In a subgroup of 129 patients (second study), non-invasive hemodynamic and repolarization data were recorded for further evaluation. RESULTS Total in-hospital and cardiovascular mortality rates were respectively 19 and 9%. Te was higher in the deceased than in surviving subjects (Te: 120 ± 28 vs. 100 ± 25 ms) and multivariable logistic regression analysis reported that Te was related to an increase of total (χ2: 35.45, odds ratio: 1.03, 95% confidence limit: 1.02-1.05, p < 0.001) and cardiovascular mortality (χ2: 32.58, odds ratio: 1.04, 95% confidence limit: 1.02-1.06, p < 0.001). Subjects with heart failure with reduced ejection fraction (HFrEF) reported higher levels of repolarization and lower non-invasive systolic hemodynamic data in comparison to those with preserved ejection fraction (HFpEF). In the subgroup, patients with the NT-proBNP reduction after therapy showed a lower rate of Te, heart rate, blood pressures, contractility index, and left ventricular ejection time in comparison with the patients without NT-proBNP reduction. CONCLUSION Electrical signals from ECG and bioimpedance were capable of monitoring the patients with advanced decompensated CHF. These simple, inexpensive, non-invasive, easily repeatable, and transmissible markers could represent a tool to remotely monitor and to intercept the possible worsening of these patients early by machine learning and artificial intelligence tools.
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Affiliation(s)
- Gianfranco Piccirillo
- Department of Internal and Clinical Medicine, Anesthesiology and Cardiovascular Sciences, Policlinico Umberto I, “Sapienza” University of Rome, 00185 Rome, Italy; (G.P.); (M.M.); (C.C.); (G.C.); (G.V.); (V.D.S.); (M.G.); (S.S.); (C.S.); (M.C.); (A.C.); (S.S.)
| | - Federica Moscucci
- Department of Internal Medicine and Medical Specialties, Policlinico Umberto I, Viale del Policlinico, 155, 00161 Rome, Italy;
| | - Martina Mezzadri
- Department of Internal and Clinical Medicine, Anesthesiology and Cardiovascular Sciences, Policlinico Umberto I, “Sapienza” University of Rome, 00185 Rome, Italy; (G.P.); (M.M.); (C.C.); (G.C.); (G.V.); (V.D.S.); (M.G.); (S.S.); (C.S.); (M.C.); (A.C.); (S.S.)
| | - Cristina Caltabiano
- Department of Internal and Clinical Medicine, Anesthesiology and Cardiovascular Sciences, Policlinico Umberto I, “Sapienza” University of Rome, 00185 Rome, Italy; (G.P.); (M.M.); (C.C.); (G.C.); (G.V.); (V.D.S.); (M.G.); (S.S.); (C.S.); (M.C.); (A.C.); (S.S.)
| | - Giovanni Cisaria
- Department of Internal and Clinical Medicine, Anesthesiology and Cardiovascular Sciences, Policlinico Umberto I, “Sapienza” University of Rome, 00185 Rome, Italy; (G.P.); (M.M.); (C.C.); (G.C.); (G.V.); (V.D.S.); (M.G.); (S.S.); (C.S.); (M.C.); (A.C.); (S.S.)
| | - Guendalina Vizza
- Department of Internal and Clinical Medicine, Anesthesiology and Cardiovascular Sciences, Policlinico Umberto I, “Sapienza” University of Rome, 00185 Rome, Italy; (G.P.); (M.M.); (C.C.); (G.C.); (G.V.); (V.D.S.); (M.G.); (S.S.); (C.S.); (M.C.); (A.C.); (S.S.)
| | - Valerio De Santis
- Department of Internal and Clinical Medicine, Anesthesiology and Cardiovascular Sciences, Policlinico Umberto I, “Sapienza” University of Rome, 00185 Rome, Italy; (G.P.); (M.M.); (C.C.); (G.C.); (G.V.); (V.D.S.); (M.G.); (S.S.); (C.S.); (M.C.); (A.C.); (S.S.)
| | - Marco Giuffrè
- Department of Internal and Clinical Medicine, Anesthesiology and Cardiovascular Sciences, Policlinico Umberto I, “Sapienza” University of Rome, 00185 Rome, Italy; (G.P.); (M.M.); (C.C.); (G.C.); (G.V.); (V.D.S.); (M.G.); (S.S.); (C.S.); (M.C.); (A.C.); (S.S.)
| | - Sara Stefano
- Department of Internal and Clinical Medicine, Anesthesiology and Cardiovascular Sciences, Policlinico Umberto I, “Sapienza” University of Rome, 00185 Rome, Italy; (G.P.); (M.M.); (C.C.); (G.C.); (G.V.); (V.D.S.); (M.G.); (S.S.); (C.S.); (M.C.); (A.C.); (S.S.)
| | - Claudia Scinicariello
- Department of Internal and Clinical Medicine, Anesthesiology and Cardiovascular Sciences, Policlinico Umberto I, “Sapienza” University of Rome, 00185 Rome, Italy; (G.P.); (M.M.); (C.C.); (G.C.); (G.V.); (V.D.S.); (M.G.); (S.S.); (C.S.); (M.C.); (A.C.); (S.S.)
| | - Myriam Carnovale
- Department of Internal and Clinical Medicine, Anesthesiology and Cardiovascular Sciences, Policlinico Umberto I, “Sapienza” University of Rome, 00185 Rome, Italy; (G.P.); (M.M.); (C.C.); (G.C.); (G.V.); (V.D.S.); (M.G.); (S.S.); (C.S.); (M.C.); (A.C.); (S.S.)
| | - Andrea Corrao
- Department of Internal and Clinical Medicine, Anesthesiology and Cardiovascular Sciences, Policlinico Umberto I, “Sapienza” University of Rome, 00185 Rome, Italy; (G.P.); (M.M.); (C.C.); (G.C.); (G.V.); (V.D.S.); (M.G.); (S.S.); (C.S.); (M.C.); (A.C.); (S.S.)
| | - Ilaria Lospinuso
- Department of Internal Medicine and Medical Specialties, Policlinico Umberto I, Viale del Policlinico, 155, 00161 Rome, Italy;
| | - Susanna Sciomer
- Department of Internal and Clinical Medicine, Anesthesiology and Cardiovascular Sciences, Policlinico Umberto I, “Sapienza” University of Rome, 00185 Rome, Italy; (G.P.); (M.M.); (C.C.); (G.C.); (G.V.); (V.D.S.); (M.G.); (S.S.); (C.S.); (M.C.); (A.C.); (S.S.)
| | - Pietro Rossi
- Arrhythmology Unit, Fatebenefratelli Hospital, Isola Tiberina-Gemelli Isola, 00186 Rome, Italy;
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Hoang JD, van Weperen VY, Kang KW, Jani NR, Swid MA, Chan CA, Lokhandwala ZA, Lux RL, Vaseghi M. Thoracic epidural blockade after myocardial infarction benefits from anti-arrhythmic pathways mediated in part by parasympathetic modulation. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.03.14.585127. [PMID: 38559001 PMCID: PMC10980055 DOI: 10.1101/2024.03.14.585127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Background Thoracic epidural anesthesia (TEA) has been shown to reduce the burden of ventricular tachyarrhythmias (VT) in small case-series of patients with refractory VT and cardiomyopathy. However, its electrophysiological and autonomic effects in diseased hearts remain unclear and its use after myocardial infarction (MI) is limited by concerns for potential RV dysfunction. Methods MI was created in Yorkshire pigs ( N =22) by LAD occlusion. Six weeks post-MI, an epidural catheter was placed at the C7-T1 vertebral level for injection of 2% lidocaine. RV and LV hemodynamics were recorded using Millar pressure-conductance catheters, and ventricular activation-recovery intervals (ARIs), a surrogate of action potential durations, by a 56-electrode sock and 64-electrode basket catheter. Hemodynamics and ARIs, baroreflex sensitivity (BRS) and intrinsic cardiac neural activity, and ventricular effective refractory periods (ERP) and slope of restitution (S max ) were assessed before and after TEA. VT/VF inducibility was assessed by programmed electrical stimulation. Results TEA reduced inducibility of VT/VF by 70%. TEA did not affect RV-systolic pressure or contractility, although LV-systolic pressure and contractility decreased modestly. Global and regional ventricular ARIs increased, including in scar and border zone regions post-TEA. TEA reduced ARI dispersion specifically in border zone regions. Ventricular ERPs prolonged significantly at critical sites of arrhythmogenesis, and S max was reduced. Interestingly, TEA significantly improved cardiac vagal function, as measured by both BRS and intrinsic cardiac neural activity. Conclusion TEA does not compromise RV function in infarcted hearts. Its anti-arrhythmic mechanisms are mediated by increases in ventricular ERP and ARIs, decreases in S max , and reductions in border zone heterogeneity. TEA improves parasympathetic function, which may independently underlie some of its observed anti-arrhythmic mechanisms. This study provides novel insights into the anti-arrhythmic mechanisms of TEA, while highlighting its applicability to the clinical setting. Abstract Illustration Myocardial infarction is known to cause cardiac autonomic dysfunction characterized by sympathoexcitation coupled with reduced vagal tone. This pathological remodeling collectively predisposes to ventricular arrhythmia. Thoracic epidural anesthesia not only blocks central efferent sympathetic outflow, but by also blocking ascending projections of sympathetic afferents, relieving central inhibition of vagal function. These complementary autonomic effects of thoracic epidural anesthesia may thus restore autonomic balance, thereby improving ventricular electrical stability and suppressing arrhythmogenesis. DRG=dorsal root ganglion, SG=stellate ganglion.
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Conti E, Cascio ND, Paluan P, Racca G, Longhitano Y, Savioli G, Tesauro M, Leo R, Racca F, Zanza C. Pregnancy Arrhythmias: Management in the Emergency Department and Critical Care. J Clin Med 2024; 13:1095. [PMID: 38398407 PMCID: PMC10888682 DOI: 10.3390/jcm13041095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 02/09/2024] [Accepted: 02/13/2024] [Indexed: 02/25/2024] Open
Abstract
Pregnancy is closely associated with an elevated risk of arrhythmias, constituting the predominant cardiovascular complication during this period. Pregnancy may induce the exacerbation of previously controlled arrhythmias and, in some instances, arrhythmias may present for the first time in pregnancy. The most important proarrhythmic mechanisms during pregnancy are the atrial and ventricular stretching, coupled with increased sympathetic activity. Notably, arrhythmias, particularly those originating in the ventricles, heighten the likelihood of syncope, increasing the potential for sudden cardiac death. The effective management of arrhythmias during the peripartum period requires a comprehensive, multidisciplinary approach from the prepartum to the postpartum period. The administration of antiarrhythmic drugs during pregnancy necessitates meticulous attention to potential alterations in pharmacokinetics attributable to maternal physiological changes, as well as the potential for fetal adverse effects. Electric cardioversion is a safe and effective intervention during pregnancy and should be performed immediately in patients with hemodynamic instability. This review discusses the pathophysiology of arrythmias in pregnancy and their management.
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Affiliation(s)
- Elena Conti
- Division of Anesthesia and Critical Care Medicine, Azienda Ospedaliera Ordine Mauriziano, 10128 Turin, Italy; (E.C.); (N.D.C.); (P.P.); (F.R.)
| | - Nunzio Dario Cascio
- Division of Anesthesia and Critical Care Medicine, Azienda Ospedaliera Ordine Mauriziano, 10128 Turin, Italy; (E.C.); (N.D.C.); (P.P.); (F.R.)
| | - Patrizia Paluan
- Division of Anesthesia and Critical Care Medicine, Azienda Ospedaliera Ordine Mauriziano, 10128 Turin, Italy; (E.C.); (N.D.C.); (P.P.); (F.R.)
| | - Giulia Racca
- Division of Anesthesia and Critical Care Medicine, Azienda Ospedaliera Ordine Mauriziano, 10128 Turin, Italy; (E.C.); (N.D.C.); (P.P.); (F.R.)
| | - Yaroslava Longhitano
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA
- Department of Emergency Medicine—Emergency Medicine Residency Program, Humanitas University-Research Hospital, 20089 Rozzano, Italy
| | - Gabriele Savioli
- Emergency Medicine and Surgery, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
| | - Manfredi Tesauro
- Geriatric Medicine Residency Program, University of Rome “Tor Vergata”, 00133 Rome, Italy
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Roberto Leo
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Fabrizio Racca
- Division of Anesthesia and Critical Care Medicine, Azienda Ospedaliera Ordine Mauriziano, 10128 Turin, Italy; (E.C.); (N.D.C.); (P.P.); (F.R.)
| | - Christian Zanza
- Geriatric Medicine Residency Program, University of Rome “Tor Vergata”, 00133 Rome, Italy
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Irfan A, Riggs DW, Koromia G, DeFilippis AP, Soliman EZ, Bhatnagar A, Carll AP. Smoking-associated Electrocardiographic Abnormalities Predict Cardiovascular Mortality: Insights from NHANES. RESEARCH SQUARE 2024:rs.3.rs-3615687. [PMID: 38260619 PMCID: PMC10802705 DOI: 10.21203/rs.3.rs-3615687/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Background— Smoking is associated with arrhythmia and sudden cardiac death, but the biological mechanisms remain unclear. Abnormal electrocardiogram (ECG) durations of ventricular repolarization (QT interval), atrial depolarization (P wave), and atrioventricular depolarization (PR interval and segment), predict cardiac arrhythmia and mortality. Objectives— To elucidate how smoking affects cardiac excitation, we assessed in a nationally representative sample (NHANES III) associations between cotinine, abnormalities in P duration, PR interval, PR segment, rate-corrected QT (QTc), QRS duration, and JT interval, and long-term mortality. Methods— We analyzed data from 5,633 adults using survey-weighted multinomial logistic regression to estimate associations between tobacco use (>15 ng/ml serum cotinine) and short (<5th percentile) or long (>95th percentile) ECG intervals, relative to reference (5 - 95th percentile). Results— After adjustment for demographics, risk factors, and conduction-altering medications, smoking was associated with a higher odds of short PR interval, PR segment, and QRS, and long JT. Broader ECG effects of smoking were also assessed by survey-weighted linear regression of continuous cotinine and ECG intervals, which revealed cotinine inversely associated with PR segment and QTc. Over a 22-year follow-up, many ECG abnormalities predicted cardiovascular mortality in smokers, including long JT, QRS, and QTc, and short QRS. Conclusions— Smoking increases likelihood for rapid atrioventricular conduction, rapid ventricular depolarization, and slow ventricular repolarization. The ventricular electrophysiologic abnormalities associated with smoking also predict cardiovascular mortality in smokers; however, traditional ECG measures of cardiac risk like QTc can overlook these ventricular defects and their independent predictive value in smokers.
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Xu BW, Zhang QY, Li XY, Tang CS, Du JB, Liu XQ, Jin HF. A predictive model of response to metoprolol in children and adolescents with postural tachycardia syndrome. World J Pediatr 2023; 19:390-400. [PMID: 36781629 PMCID: PMC10060270 DOI: 10.1007/s12519-022-00677-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 12/16/2022] [Indexed: 02/15/2023]
Abstract
BACKGROUND The present work was designed to explore whether electrocardiogram (ECG) index-based models could predict the effectiveness of metoprolol therapy in pediatric patients with postural tachycardia syndrome (POTS). METHODS This study consisted of a training set and an external validation set. Children and adolescents with POTS who were given metoprolol treatment were enrolled, and after follow-up, they were grouped into non-responders and responders depending on the efficacy of metoprolol. The difference in pre-treatment baseline ECG indicators was analyzed between the two groups in the training set. Binary logistic regression analysis was further conducted on the association between significantly different baseline variables and therapeutic efficacy. Nomogram models were established to predict therapeutic response to metoprolol. The receiver-operating characteristic curve (ROC), calibration, and internal validation were used to evaluate the prediction model. The predictive ability of the model was validated in the external validation set. RESULTS Of the 95 enrolled patients, 65 responded to metoprolol treatment, and 30 failed to respond. In the responders, the maximum value of the P wave after correction (Pcmax), P wave dispersion (Pd), Pd after correction (Pcd), QT interval dispersion (QTd), QTd after correction (QTcd), maximum T-peak-to-T-end interval (Tpemax), and T-peak-to-T-end interval dispersion (Tped) were prolonged (all P < 0.01), and the P wave amplitude was increased (P < 0.05) compared with those of the non-responders. In contrast, the minimum value of the P wave duration after correction (Pcmin), the minimum value of the QT interval after correction (QTcmin), and the minimum T-peak-to-T-end interval (Tpemin) in the responders were shorter (P < 0.01, < 0.01 and < 0.01, respectively) than those in the non-responders. The above indicators were screened based on the clinical significance and multicollinearity analysis to construct a binary logistic regression. As a result, pre-treatment Pcmax, QTcmin, and Tped were identified as significantly associated factors that could be combined to provide an accurate prediction of the therapeutic response to metoprolol among the study subjects, yielding good discrimination [area under curve (AUC) = 0.970, 95% confidence interval (CI) 0.942-0.998] with a predictive sensitivity of 93.8%, specificity of 90.0%, good calibration, and corrected C-index of 0.961. In addition, the calibration curve and standard curve had a good fit. The accuracy of internal validation with bootstrap repeated sampling was 0.902. In contrast, the kappa value was 0.769, indicating satisfactory agreement between the predictive model and the results from the actual observations. In the external validation set, the AUC for the prediction model was 0.895, and the sensitivity and specificity were 90.9% and 95.0%, respectively. CONCLUSIONS A high-precision predictive model was successfully developed and externally validated. It had an excellent predictive value of the therapeutic effect of metoprolol on POTS among children and adolescents.
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Affiliation(s)
- Bo-Wen Xu
- Department of Pediatrics, Peking University First Hospital, No. 1, Xi'an-Men Street, West District, Beijing, 100034, China
| | - Qing-You Zhang
- Department of Pediatrics, Peking University First Hospital, No. 1, Xi'an-Men Street, West District, Beijing, 100034, China
| | - Xue-Ying Li
- Department of Medical Statistics, Peking University First Hospital, Beijing, China
| | - Chao-Shu Tang
- Key Lab of Molecular Cardiovascular Sciences, Ministry of Education, Beijing, China
- Department of Physiology and Pathophysiology, Peking University Health Science Centre, Beijing, China
| | - Jun-Bao Du
- Department of Pediatrics, Peking University First Hospital, No. 1, Xi'an-Men Street, West District, Beijing, 100034, China.
- Key Lab of Molecular Cardiovascular Sciences, Ministry of Education, Beijing, China.
| | - Xue-Qin Liu
- Department of Pediatrics, Peking University First Hospital, No. 1, Xi'an-Men Street, West District, Beijing, 100034, China
| | - Hong-Fang Jin
- Department of Pediatrics, Peking University First Hospital, No. 1, Xi'an-Men Street, West District, Beijing, 100034, China.
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Killu AM, Yang M, Naksuk N, Tri J, Li X, Asirvatham R, Asirvatham SJ, Cha YM. Stellate ganglia stimulation counteracts vagal stimulation by significantly increasing heart rate and blood pressure. J Interv Card Electrophysiol 2023:10.1007/s10840-023-01516-w. [PMID: 36892802 DOI: 10.1007/s10840-023-01516-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 02/16/2023] [Indexed: 03/10/2023]
Abstract
BACKGROUND Vasovagal syncope (VVS) is the leading cause of syncope. The most frequent mechanism is that of a cardioinhibitory response, vasodepressor response, or mixture of both. Neural stimulation that negates or overcomes the effects of vagal tone may be used as a treatment strategy for VVS. METHODS Six male canines were studied. Stimulation (10-Hz, 2 ms pulse duration, 2 min duration) of the cervical vagus (CV), thoracic vagus (TV), and stellate ganglia (SG) was performed using needle electrodes at 3 V, 5 V, and 10 V output. SG stimulation at an output of 10 V overlaying TV stimulation at the same output was performed. Heart rate (HR), blood pressure (BP), and cardiac output (CO) were measured before, during, and after stimulation. RESULTS Right cervical vagal stimulation was associated with significant hemodynamic changes. HR, SBP, and DBP were reduced (107 ± 16 vs. 78 ± 15 bpm [P < 0.0001], 116 ± 24 vs. 107 ± 28 mmHg [P = 0.002] and 71 ± 18 vs. 58 ± 20 mmHg [P < 0.0001]), respectively, while left cervical vagal stimulation had minimal changes. CV stimulation was associated with greater hemodynamic changes than TV stimulation. Left and right SG stimulation significantly increased systolic blood pressure (SBP), diastolic blood pressure (DBP), and HR at 5 V and 10 V, which could be observed within 30 s after stimulation. An output-dependent increase in hemodynamic parameters was seen with both left and right SG stimulation. No difference between left and right SG stimulation was seen. SG stimulation overlay significantly increased HR, BP, and CO from baseline vagal stimulation bilaterally. CONCLUSIONS Stellate ganglia stimulation leads to increased HR and BP despite significant vagal stimulation. This may be exploited therapeutically in the management of vasovagal syncope.
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Affiliation(s)
- Ammar M Killu
- Department of Cardiovascular Disease, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Mei Yang
- Department of Cardiology, Xinhua Hospital, 1665 Kongjiang Rd, Yangpu Qu, Shanghai Shi, 200000, China
| | - Niyada Naksuk
- Department of Cardiovascular Disease, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Jason Tri
- Department of Cardiovascular Disease, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Xuping Li
- Department of Cardiovascular medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Roshini Asirvatham
- Department of Cardiovascular Disease, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Samuel J Asirvatham
- Department of Cardiovascular Disease, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Yong-Mei Cha
- Department of Cardiovascular Disease, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Markman TM, Gugger D, Arkles J, Riley MP, Dixit S, Guandalini GS, Frankel DS, Epstein AE, Callans DJ, Singhal S, Marchlinski FE, Nazarian S. Neuromodulation for the Treatment of Refractory Ventricular Arrhythmias. JACC Clin Electrophysiol 2023; 9:161-169. [PMID: 36858681 DOI: 10.1016/j.jacep.2022.08.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/25/2022] [Accepted: 08/29/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Neuromodulation is increasingly recognized as a therapeutic strategy for patients with refractory ventricular arrhythmias (VAs). Percutaneous stellate ganglion blockade (SGB), transcutaneous magnetic stimulation (TcMS), and surgical cardiac sympathetic denervation (CSD) have all been utilized in this setting. OBJECTIVES This study sought to characterize contemporary use and outcomes of these neuromodulation techniques for patients with refractory VA. METHODS This retrospective cohort study included all patients at the Hospital of the University of Pennsylvania with antiarrhythmic drug (AAD)-refractory VA from 2019 to 2021 who were treated with SGB, TcMS, or CSD. RESULTS A total of 34 patients (age 61 ± 14 years, 15 polymorphic VAs [44%], refractory to 1.8 ± 0.8 AADs) met inclusion criteria. SGB was performed on 11 patients (32%), TcMS on 19 (56%), and CSD on 7 (21%). Neuromodulation was associated with a reduction in the number of episodes of sustained VAs from 7 [IQR: 4-12] episodes in the 24 hours before the initial neuromodulation strategy to 0 [IQR: 0-1] episodes in the subsequent 24 hours (P < 0.001). During 1.2 ± 1.1 years of follow-up, 21 (62%) experienced recurrent VAs, and among those patients, the median time to recurrence was 3 [IQR: 1-25] days. Outcomes were similar among patients with monomorphic and polymorphic VAs. Among patients who had an acute myocardial infarction within 30 days before neuromodulation, the burden of VAs decreased from 11 [IQR: 7-12] episodes to 0 episodes in the 24 hours after treatment. CONCLUSIONS Autonomic neuromodulation with SGB, TcMS, or CSD in patients with AAD-refractory VAs is safe and results in substantial acute reduction of VA although recurrent arrhythmias are common, and not all patients experience a reduction in arrhythmia burden.
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Affiliation(s)
- Timothy M Markman
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Douglas Gugger
- Department of Anesthesia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeffrey Arkles
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael P Riley
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sanjay Dixit
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gustavo S Guandalini
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David S Frankel
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew E Epstein
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David J Callans
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sunil Singhal
- Thoracic Surgery Division, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francis E Marchlinski
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Saman Nazarian
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Kuwabara Y, Howard-Quijano K, Salavatian S, Yamaguchi T, Saba S, Mahajan A. Thoracic dorsal root ganglion stimulation reduces acute myocardial ischemia induced ventricular arrhythmias. Front Neurosci 2023; 17:1091230. [PMID: 36793544 PMCID: PMC9922704 DOI: 10.3389/fnins.2023.1091230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 01/09/2023] [Indexed: 02/03/2023] Open
Abstract
Background Dorsal root ganglion stimulation (DRGS) may serve as a novel neuromodulation strategy to reduce cardiac sympathoexcitation and ventricular excitability. Objective In this pre-clinical study, we investigated the effectiveness of DRGS on reducing ventricular arrhythmias and modulating cardiac sympathetic hyperactivity caused by myocardial ischemia. Methods Twenty-three Yorkshire pigs were randomized to two groups, which was control LAD ischemia-reperfusion (CONTROL) or LAD ischemia-reperfusion + DRGS (DRGS) group. In the DRGS group (n = 10), high-frequency stimulation (1 kHz) at the second thoracic level (T2) was initiated 30 min before ischemia and continued throughout 1 h of ischemia and 2 h of reperfusion. Cardiac electrophysiological mapping and Ventricular Arrhythmia Score (VAS) were assessed, along with evaluation of cFos expression and apoptosis in the T2 spinal cord and DRG. Results DRGS decreased the magnitude of activation recovery interval (ARI) shortening in the ischemic region (CONTROL: -201 ± 9.8 ms, DRGS: -170 ± 9.4 ms, p = 0.0373) and decreased global dispersion of repolarization (DOR) at 30 min of myocardial ischemia (CONTROL: 9546 ± 763 ms2, DRGS: 6491 ± 636 ms2, p = 0.0076). DRGS also decreased ventricular arrhythmias (VAS-CONTROL: 8.9 ± 1.1, DRGS: 6.3 ± 1.0, p = 0.038). Immunohistochemistry studies showed that DRGS decreased % cFos with NeuN expression in the T2 spinal cord (p = 0.048) and the number of apoptotic cells in the DRG (p = 0.0084). Conclusion DRGS reduced the burden of myocardial ischemia-induced cardiac sympathoexcitation and has a potential to be a novel treatment option to reduce arrhythmogenesis.
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Affiliation(s)
- Yuki Kuwabara
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Kimberly Howard-Quijano
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Siamak Salavatian
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Tomoki Yamaguchi
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Samir Saba
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Aman Mahajan
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
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10
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Li YL. Stellate Ganglia and Cardiac Sympathetic Overactivation in Heart Failure. Int J Mol Sci 2022; 23:ijms232113311. [PMID: 36362099 PMCID: PMC9653702 DOI: 10.3390/ijms232113311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 10/28/2022] [Accepted: 10/29/2022] [Indexed: 11/06/2022] Open
Abstract
Heart failure (HF) is a major public health problem worldwide, especially coronary heart disease (myocardial infarction)-induced HF with reduced ejection fraction (HFrEF), which accounts for over 50% of all HF cases. An estimated 6 million American adults have HF. As a major feature of HF, cardiac sympathetic overactivation triggers arrhythmias and sudden cardiac death, which accounts for nearly 50–60% of mortality in HF patients. Regulation of cardiac sympathetic activation is highly integrated by the regulatory circuitry at multiple levels, including afferent, central, and efferent components of the sympathetic nervous system. Much evidence, from other investigators and us, has confirmed the afferent and central neural mechanisms causing sympathoexcitation in HF. The stellate ganglion is a peripheral sympathetic ganglion formed by the fusion of the 7th cervical and 1st thoracic sympathetic ganglion. As the efferent component of the sympathetic nervous system, cardiac postganglionic sympathetic neurons located in stellate ganglia provide local neural coordination independent of higher brain centers. Structural and functional impairments of cardiac postganglionic sympathetic neurons can be involved in cardiac sympathetic overactivation in HF because normally, many effects of the cardiac sympathetic nervous system on cardiac function are mediated via neurotransmitters (e.g., norepinephrine) released from cardiac postganglionic sympathetic neurons innervating the heart. This review provides an overview of cardiac sympathetic remodeling in stellate ganglia and potential mechanisms and the role of cardiac sympathetic remodeling in cardiac sympathetic overactivation and arrhythmias in HF. Targeting cardiac sympathetic remodeling in stellate ganglia could be a therapeutic strategy against malignant cardiac arrhythmias in HF.
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Affiliation(s)
- Yu-Long Li
- Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA; ; Tel.: +1-402-559-3016; Fax: +1-402-559-9659
- Department of Cellular & Integrative Physiology, University of Nebraska Medical Center, Omaha, NE 68198, USA
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11
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Ruedisueli I, Ma J, Nguyen R, Lakhani K, Gornbein J, Middlekauff HR. Optimizing ECG lead selection for detection of prolongation of ventricular repolarization as measured by the Tpeak-end interval. Ann Noninvasive Electrocardiol 2022; 27:e12958. [PMID: 35712805 PMCID: PMC9296803 DOI: 10.1111/anec.12958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/05/2022] [Accepted: 03/22/2022] [Indexed: 11/28/2022] Open
Abstract
Background The Tpeak‐end(Tp‐e) has not been compared in all 12 ECG leads in healthy adults to determine if the Tp‐e varies across leads. If there is variation, it remains uncertain, which lead(s) are preferred for recording in order to capture the maximal Tp‐e value. Objective The purpose of the current study was to determine the optimal leads, if any, to capture the maximal Tp‐e interval in healthy young adults. Methods In 88 healthy adults (ages 21–38 years), including derivation (n = 21), validation (n = 20), and smoker/vaper (n = 47) cohorts, the Tp‐e was measured using commercial computer software (LabChart Pro 8 with ECG module, ADInstruments) in all 12 leads at rest and following a provocative maneuver, abrupt standing. Tp‐e was compared to determine which lead(s) most frequently captured the maximal Tp‐e interval. Results In the rest and abrupt standing positions, the Tp‐e was not uniform among the 12 leads; the maximal Tp‐e was most frequently captured in the precordial leads. At rest, grouping leads V2–V4 resulted in detection of the maximum Tp‐e in 85.7% of participants (CI 70.7, 99.9%) versus all other leads (p < .001). Upon abrupt standing, grouping leads V2‐V6 together, resulted in detection of the maximum Tp‐e 85.0% of participants (CI 69.4, 99.9% versus all other leads; p < .001). These findings were confirmed in the validation cohort, and extended to the smoking/vaping cohort. Conclusion If only a subset of ECG leads will be recorded or analyzed for the Tp‐e interval, selection of the precordial leads is preferred since these leads are most likely to capture the maximal Tp‐e value.
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Affiliation(s)
- Isabelle Ruedisueli
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Joyce Ma
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Randy Nguyen
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Karishma Lakhani
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Jeffrey Gornbein
- Departments of Medicine and Computational Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Holly R Middlekauff
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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12
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Zhang D, Tu H, Hu W, Duan B, Zimmerman MC, Li YL. Hydrogen Peroxide Scavenging Restores N-Type Calcium Channels in Cardiac Vagal Postganglionic Neurons and Mitigates Myocardial Infarction-Evoked Ventricular Arrhythmias in Type 2 Diabetes Mellitus. Front Cardiovasc Med 2022; 9:871852. [PMID: 35548411 PMCID: PMC9082497 DOI: 10.3389/fcvm.2022.871852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/31/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveWithdrawal of cardiac vagal activity is associated with ventricular arrhythmia-related high mortality in patients with type 2 diabetes mellitus (T2DM). Our recent study found that reduced cell excitability of cardiac vagal postganglionic (CVP) neurons is involved in cardiac vagal dysfunction and further exacerbates myocardial infarction (MI)-evoked ventricular arrhythmias and mortality in T2DM. However, the mechanisms responsible for T2DM-impaired cell excitability of CVP neurons remain unclear. This study tested if and how elevation of hydrogen peroxide (H2O2) inactivates CVP neurons and contributes to cardiac vagal dysfunction and ventricular arrhythmogenesis in T2DM.Methods and ResultsRat T2DM was induced by a high-fat diet plus streptozotocin injection. Local in vivo transfection of adenoviral catalase gene (Ad.CAT) successfully induced overexpression of catalase and subsequently reduced cytosolic H2O2 levels in CVP neurons in T2DM rats. Ad.CAT restored protein expression and ion currents of N-type Ca2+ channels and increased cell excitability of CVP neurons in T2DM. Ad.CAT normalized T2DM-impaired cardiac vagal activation, vagal control of ventricular function, and heterogeneity of ventricular electrical activity. Additionally, Ad.CAT not only reduced the susceptibility to ventricular arrhythmias, but also suppressed MI-evoked lethal ventricular arrhythmias such as VT/VF in T2DM.ConclusionsWe concluded that endogenous H2O2 elevation inhibited protein expression and activation of N-type Ca2+ channels and reduced cell excitability of CVP neurons, which further contributed to the withdrawal of cardiac vagal activity and ventricular arrhythmogenesis in T2DM. Our current study suggests that the H2O2-N-type Ca2+ channel signaling axis might be an effective therapeutic target to suppress ventricular arrhythmias in T2DM patients with MI.
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Affiliation(s)
- Dongze Zhang
- Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE, United States
| | - Huiyin Tu
- Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE, United States
| | - Wenfeng Hu
- Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE, United States
| | - Bin Duan
- Mary and Dick Holland Regenerative Medicine Program, Division of Cardiology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, United States
| | - Matthew C. Zimmerman
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, NE, United States
| | - Yu-Long Li
- Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE, United States
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, NE, United States
- *Correspondence: Yu-Long Li
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13
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Malik V, Nguyen MT, Seeley MC, Thiyagarajah A, Elliott AD, Arnolda LF, Sanders P, Lau DH. Abnormal Cardiac Remodeling in Postural Orthostatic Tachycardia Syndrome. JACC Clin Electrophysiol 2022; 8:1044-1046. [DOI: 10.1016/j.jacep.2022.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 10/18/2022]
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Hoang JD, Yamakawa K, Rajendran PS, Chan CA, Yagishita D, Nakamura K, Lux RL, Vaseghi M. Proarrhythmic Effects of Sympathetic Activation Are Mitigated by Vagal Nerve Stimulation in Infarcted Hearts. JACC Clin Electrophysiol 2022; 8:513-525. [PMID: 35450607 PMCID: PMC9034056 DOI: 10.1016/j.jacep.2022.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 01/11/2022] [Accepted: 01/11/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The goal of this study was to evaluate whether intermittent VNS reduces electrical heterogeneities and arrhythmia inducibility during sympathoexcitation. BACKGROUND Sympathoexcitation increases the risk of ventricular tachyarrhythmias (VT). Vagal nerve stimulation (VNS) has been antiarrhythmic in the setting of ischemia-driven arrhythmias, but it is unclear if it can overcome the electrophysiological effects of sympathoexcitation in the setting of chronic myocardial infarction (MI). METHODS In Yorkshire pigs after chronic MI, a sternotomy was performed, a 56-electrode sock was placed over the ventricles (n = 17), and a basket catheter was positioned in the left ventricle (n = 6). Continuous unipolar electrograms from sock and basket arrays were obtained to analyze activation recovery interval (ARI), a surrogate of action potential duration. Bipolar voltage mapping was performed to define scar, border zone, or viable myocardium. Hemodynamic and electrical parameters and VT inducibility were evaluated during sympathoexcitation with bilateral stellate ganglia stimulation (BSS) and during combined BSS with intermittent VNS. RESULTS During BSS, global epicardial ARIs shortened from 384 ± 59 milliseconds to 297 ± 63 milliseconds and endocardial ARIs from 359 ± 36 milliseconds to 318 ± 40 milliseconds. Dispersion in ARIs increased in all regions, with the greatest increase observed in scar and border zone regions. VNS mitigated the effects of BSS on border zone ARIs (from -18.3% ± 6.3% to -2.1% ± 14.7%) and ARI dispersion (from 104 ms2 [1 to 1,108 ms2] to -108 ms2 [IQR: -588 to 30 ms2]). VNS reduced VT inducibility during sympathoexcitation (from 75%-40%; P < 0.05). CONCLUSIONS After chronic MI, VNS overcomes the detrimental effects of sympathoexcitation by reducing electrophysiological heterogeneities exacerbated by sympathetic stimulation, decreasing VT inducibility.
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Affiliation(s)
- Jonathan D Hoang
- UCLA Cardiac Arrhythmia Center, University of California, Los Angeles, California, USA; UCLA Neurocardiology Program of Excellence, University of California, Los Angeles, California, USA; Molecular, Cellular and Integrative Physiology Interdepartmental Program, University of California, Los Angeles, California, USA
| | - Kentaro Yamakawa
- UCLA Cardiac Arrhythmia Center, University of California, Los Angeles, California, USA
| | - Pradeep S Rajendran
- UCLA Cardiac Arrhythmia Center, University of California, Los Angeles, California, USA; UCLA Neurocardiology Program of Excellence, University of California, Los Angeles, California, USA
| | - Christopher A Chan
- UCLA Cardiac Arrhythmia Center, University of California, Los Angeles, California, USA; UCLA Neurocardiology Program of Excellence, University of California, Los Angeles, California, USA
| | - Daigo Yagishita
- UCLA Cardiac Arrhythmia Center, University of California, Los Angeles, California, USA
| | - Keijiro Nakamura
- UCLA Cardiac Arrhythmia Center, University of California, Los Angeles, California, USA
| | - Robert L Lux
- UCLA Cardiac Arrhythmia Center, University of California, Los Angeles, California, USA
| | - Marmar Vaseghi
- UCLA Cardiac Arrhythmia Center, University of California, Los Angeles, California, USA; UCLA Neurocardiology Program of Excellence, University of California, Los Angeles, California, USA; Molecular, Cellular and Integrative Physiology Interdepartmental Program, University of California, Los Angeles, California, USA.
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15
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Boukens BJD, Joyce W, Kristensen DL, Hooijkaas I, Jongejan A, Wang T, Jensen B. Catecholamines are key modulators of ventricular repolarization patterns in the ball python (Python regius). J Gen Physiol 2022; 154:212914. [PMID: 34910097 PMCID: PMC8679508 DOI: 10.1085/jgp.202012761] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/28/2021] [Accepted: 11/19/2021] [Indexed: 12/13/2022] Open
Abstract
Ectothermic vertebrates experience daily changes in body temperature, and anecdotal observations suggest these changes affect ventricular repolarization such that the T-wave in the ECG changes polarity. Mammals, in contrast, can maintain stable body temperatures, and their ventricular repolarization is strongly modulated by changes in heart rate and by sympathetic nervous system activity. The aim of this study was to assess the role of body temperature, heart rate, and circulating catecholamines on local repolarization gradients in the ectothermic ball python (Python regius). We recorded body-surface electrocardiograms and performed open-chest high-resolution epicardial mapping while increasing body temperature in five pythons, in all of which there was a change in T-wave polarity. However, the vector of repolarization differed between individuals, and only a subset of leads revealed T-wave polarity change. RNA sequencing revealed regional differences related to adrenergic signaling. In one denervated and Ringer's solution-perfused heart, heating and elevated heart rates did not induce change in T-wave polarity, whereas noradrenaline did. Accordingly, electrocardiograms in eight awake pythons receiving intra-arterial infusion of the β-adrenergic receptor agonists adrenaline and isoproterenol revealed T-wave inversion in most individuals. Conversely, blocking the β-adrenergic receptors using propranolol prevented T-wave change during heating. Our findings indicate that changes in ventricular repolarization in ball pythons are caused by increased tone of the sympathetic nervous system, not by changes in temperature. Therefore, ventricular repolarization in both pythons and mammals is modulated by evolutionary conserved mechanisms involving catecholaminergic stimulation.
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Affiliation(s)
- Bastiaan J D Boukens
- University of Amsterdam, Amsterdam UMC, Department of Medical Biology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - William Joyce
- Department of Biology, Zoophysiology, Aarhus University, Aarhus, Denmark
| | | | - Ingeborg Hooijkaas
- University of Amsterdam, Amsterdam UMC, Department of Medical Biology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Aldo Jongejan
- University of Amsterdam, Amsterdam UMC, Department of Epidemiology & Data Science, Amsterdam, The Netherlands
| | - Tobias Wang
- Department of Biology, Zoophysiology, Aarhus University, Aarhus, Denmark
| | - Bjarke Jensen
- University of Amsterdam, Amsterdam UMC, Department of Medical Biology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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Tamirisa KP, Elkayam U, Briller JE, Mason PK, Pillarisetti J, Merchant FM, Patel H, Lakkireddy DR, Russo AM, Volgman AS, Vaseghi M. Arrhythmias in Pregnancy. JACC Clin Electrophysiol 2022; 8:120-135. [PMID: 35057977 DOI: 10.1016/j.jacep.2021.10.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 10/06/2021] [Accepted: 10/13/2021] [Indexed: 12/18/2022]
Abstract
Increasing maternal mortality and incidence of arrhythmias in pregnancy have been noted over the past 2 decades in the United States. Pregnancy is associated with a greater risk of arrhythmias, and patients with a history of arrhythmias are at significant risk of arrhythmia recurrence during pregnancy. The incidence of atrial fibrillation in pregnancy is rising. This review discusses the management of tachyarrhythmias and bradyarrhythmias in pregnancy, including management of cardiac arrest. Management of fetal arrhythmias are also reviewed. For patients without structural heart disease, β-blocker therapy, especially propranolol and metoprolol, and antiarrhythmic drugs, such as flecainide and sotalol, can be safely used to treat tachyarrhythmias. As a last resort, catheter ablation with minimal fluoroscopy can be performed. Device implantation can be safely performed with minimal fluoroscopy and under echocardiographic or ultrasound guidance in patients with clear indications for devices during pregnancy. Because of rising maternal mortality in the United States, which is partly driven by increasing maternal age and comorbidities, a multidisciplinary and/or integrative approach to arrhythmia management from the prepartum to the postpartum period is needed.
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Affiliation(s)
| | - Uri Elkayam
- Keck School of Medicine, University of Southern California, California; Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, California, USA
| | - Joan E Briller
- Division of Cardiology, University of Illinois, Chicago, Illinois, USA
| | - Pamela K Mason
- Division of Cardiology/Electrophysiology, University of Virginia, Charlottesville, Virginia
| | | | - Faisal M Merchant
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Hena Patel
- University of Chicago, Chicago, Illinois, USA
| | | | | | | | - Marmar Vaseghi
- UCLA Cardiac Arrhythmia Center, University of California, Los Angeles, California, USA.
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17
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Odening KE, van der Linde HJ, Ackerman MJ, Volders PGA, ter Bekke RMA. OUP accepted manuscript. Eur Heart J 2022; 43:3018-3028. [PMID: 35445703 PMCID: PMC9443984 DOI: 10.1093/eurheartj/ehac135] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 02/23/2022] [Accepted: 03/03/2022] [Indexed: 11/13/2022] Open
Abstract
An abundance of literature describes physiological and pathological determinants of cardiac performance, building on the principles of excitation–contraction coupling. However, the mutual influencing of excitation–contraction and mechano-electrical feedback in the beating heart, here designated ‘electromechanical reciprocity’, remains poorly recognized clinically, despite the awareness that external and cardiac-internal mechanical stimuli can trigger electrical responses and arrhythmia. This review focuses on electromechanical reciprocity in the long-QT syndrome (LQTS), historically considered a purely electrical disease, but now appreciated as paradigmatic for the understanding of mechano-electrical contributions to arrhythmogenesis in this and other cardiac conditions. Electromechanical dispersion in LQTS is characterized by heterogeneously prolonged ventricular repolarization, besides altered contraction duration and relaxation. Mechanical alterations may deviate from what would be expected from global and regional repolarization abnormalities. Pathological repolarization prolongation outlasts mechanical systole in patients with LQTS, yielding a negative electromechanical window (EMW), which is most pronounced in symptomatic patients. The electromechanical window is a superior and independent arrhythmia-risk predictor compared with the heart rate-corrected QT. A negative EMW implies that the ventricle is deformed—by volume loading during the rapid filling phase—when repolarization is still ongoing. This creates a ‘sensitized’ electromechanical substrate, in which inadvertent electrical or mechanical stimuli such as local after-depolarizations, after-contractions, or dyssynchrony can trigger abnormal impulses. Increased sympathetic-nerve activity and pause-dependent potentiation further exaggerate electromechanical heterogeneities, promoting arrhythmogenesis. Unraveling electromechanical reciprocity advances the understanding of arrhythmia formation in various conditions. Real-time image integration of cardiac electrophysiology and mechanics offers new opportunities to address challenges in arrhythmia management.
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Affiliation(s)
| | - Henk J van der Linde
- Janssen Research & Development, Division of Janssen Pharmaceutica N.V., Beerse, Belgium
| | - Michael J Ackerman
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services (Windland Smith Rice Genetic Heart Rhythm Clinic), Mayo Clinic, Rochester, MN, USA
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN, USA
- Department of Molecular Pharmacology & Experimental Therapeutics (Windland Smith Rice Sudden Death Genomics Laboratory), Mayo Clinic, Rochester, MN, USA
| | - Paul G A Volders
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
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18
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van Weperen VYH, Vos MA, Ajijola OA. Autonomic modulation of ventricular electrical activity: recent developments and clinical implications. Clin Auton Res 2021; 31:659-676. [PMID: 34591191 PMCID: PMC8629778 DOI: 10.1007/s10286-021-00823-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/12/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE This review aimed to provide a complete overview of the current stance and recent developments in antiarrhythmic neuromodulatory interventions, focusing on lifethreatening vetricular arrhythmias. METHODS Both preclinical studies and clinical studies were assessed to highlight the gaps in knowledge that remain to be answered and the necessary steps required to properly translate these strategies to the clinical setting. RESULTS Cardiac autonomic imbalance, characterized by chronic sympathoexcitation and parasympathetic withdrawal, destabilizes cardiac electrophysiology and promotes ventricular arrhythmogenesis. Therefore, neuromodulatory interventions that target the sympatho-vagal imbalance have emerged as promising antiarrhythmic strategies. These strategies are aimed at different parts of the cardiac neuraxis and directly or indirectly restore cardiac autonomic tone. These interventions include pharmacological blockade of sympathetic neurotransmitters and neuropeptides, cardiac sympathetic denervation, thoracic epidural anesthesia, and spinal cord and vagal nerve stimulation. CONCLUSION Neuromodulatory strategies have repeatedly been demonstrated to be highly effective and very promising anti-arrhythmic therapies. Nevertheless, there is still much room to gain in our understanding of neurocardiac physiology, refining the current neuromodulatory strategic options and elucidating the chronic effects of many of these strategic options.
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Affiliation(s)
- Valerie Y H van Weperen
- Department of Medical Physiology, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
- UCLA Cardiac Arrhythmia Center, UCLA Neurocardiology Research Center, UCLA Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, University of California, 100 Medical Plaza, Suite 660, Westwood Blvd, Los Angeles, CA, 90095-1679, USA
| | - Marc A Vos
- Department of Medical Physiology, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - Olujimi A Ajijola
- UCLA Cardiac Arrhythmia Center, UCLA Neurocardiology Research Center, UCLA Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, University of California, 100 Medical Plaza, Suite 660, Westwood Blvd, Los Angeles, CA, 90095-1679, USA.
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19
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Hu W, Zhang D, Tu H, Li YL. Reduced Cell Excitability of Cardiac Postganglionic Parasympathetic Neurons Correlates With Myocardial Infarction-Induced Fatal Ventricular Arrhythmias in Type 2 Diabetes Mellitus. Front Neurosci 2021; 15:721364. [PMID: 34483832 PMCID: PMC8416412 DOI: 10.3389/fnins.2021.721364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 07/30/2021] [Indexed: 01/09/2023] Open
Abstract
Objective Withdrawal of cardiac vagal activity is considered as one of the important triggers for acute myocardial infarction (MI)-induced ventricular arrhythmias in type 2 diabetes mellitus (T2DM). Our previous study demonstrated that cell excitability of cardiac parasympathetic postganglionic (CPP) neurons was reduced in T2DM rats. This study investigated whether cell excitability of CPP neurons is associated with cardiac vagal activity and MI-induced ventricular arrhythmias in T2DM rats. Methods Rat T2DM was induced by a high-fat diet plus streptozotocin injection. MI-evoked ventricular arrhythmia was achieved by surgical ligation of the left anterior descending coronary artery. Twenty-four-hour, continuous ECG recording was used to quantify ventricular arrhythmic events and heart rate variability (HRV) in conscious rats. The power spectral analysis of HRV was used to evaluate autonomic function. Cell excitability of CPP neurons was measured by the whole-cell patch-clamp technique. Results Twenty-four-hour ECG data demonstrated that MI-evoked fatal ventricular arrhythmias are more severe in T2DM rats than that in sham rats. In addition, the Kaplan-Meier analysis demonstrated that the survival rate over 2 weeks after MI is significantly lower in T2DM rats (15% in T2DM+MI) compared to sham rats (75% in sham+MI). The susceptibility to ventricular tachyarrhythmia elicited by programmed electrical stimulation was higher in anesthetized T2DM+MI rats than that in rats with MI or T2DM alone (7.0 ± 0.58 in T2DM+MI group vs. 3.5 ± 0.76 in sham+MI). Moreover, as an index for vagal control of ventricular function, changes of left ventricular systolic pressure (LVSP) and the maximum rate of increase of left ventricular pressure (LV dP/dtmax) in response to vagal efferent nerve stimulation were blunted in T2DM rats. Furthermore, T2DM increased heterogeneity of ventricular electrical activities and reduced cardiac parasympathetic activity and cell excitability of CPP neurons (current threshold-inducing action potentials being 62 ± 3.3 pA in T2DM rats without MI vs. 27 ± 1.9 pA in sham rats without MI). However, MI did not alter vagal control of the ventricular function and CPP neuronal excitability, although it also induced cardiac autonomic dysfunction and enhanced heterogeneity of ventricular electrical activities. Conclusion The reduction of CPP neuron excitability is involved in decreased cardiac vagal function, including cardiac parasympathetic activity and vagal control of ventricular function, which is associated with MI-induced high mortality and malignant ventricular arrhythmias in T2DM.
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Affiliation(s)
- Wenfeng Hu
- Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE, United States
| | - Dongze Zhang
- Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE, United States
| | - Huiyin Tu
- Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE, United States
| | - Yu-Long Li
- Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, NE, United States.,Department of Cellular & Integrative Physiology, University of Nebraska Medical Center, Omaha, NE, United States
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20
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Crotti L, Odening KE, Sanguinetti MC. Heritable arrhythmias associated with abnormal function of cardiac potassium channels. Cardiovasc Res 2021; 116:1542-1556. [PMID: 32227190 DOI: 10.1093/cvr/cvaa068] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/24/2020] [Accepted: 03/26/2020] [Indexed: 12/16/2022] Open
Abstract
Cardiomyocytes express a surprisingly large number of potassium channel types. The primary physiological functions of the currents conducted by these channels are to maintain the resting membrane potential and mediate action potential repolarization under basal conditions and in response to changes in the concentrations of intracellular sodium, calcium, and ATP/ADP. Here, we review the diversity and functional roles of cardiac potassium channels under normal conditions and how heritable mutations in the genes encoding these channels can lead to distinct arrhythmias. We briefly review atrial fibrillation and J-wave syndromes. For long and short QT syndromes, we describe their genetic basis, clinical manifestation, risk stratification, traditional and novel therapeutic approaches, as well as insights into disease mechanisms provided by animal and cellular models.
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Affiliation(s)
- Lia Crotti
- Center for Cardiac Arrhythmias of Genetic Origin, Istituto Auxologico Italiano, IRCCS, Milan, Italy.,Laboratory of Cardiovascular Genetics, Istituto Auxologico Italiano, IRCCS, Milan, Italy.,Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, San Luca Hospital, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Katja E Odening
- Department of Cardiology and Angiology I, Heart Center University of Freiburg, Medical Faculty, Freiburg, Germany.,Institute of Experimental Cardiovascular Medicine, Heart Center University of Freiburg, Medical Faculty, Freiburg, Germany.,Department of Cardiology, Translational Cardiology, Inselspital, Bern University Hospital, and Institute of Physiology, University of Bern, Bern, Switzerland
| | - Michael C Sanguinetti
- Department of Internal Medicine, Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, USA
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21
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Kusuki H, Mizutani Y, Tsuchiya Y, Nishio M, Oikawa S, Nagata R, Kiriyanagi Y, Horio K, Hosoi M, Matsuura H, Sadanaga T, Hata T. Myocardial repolarization time, J-point to T-peak and T-peak to T-end intervals, have different heart rate dependency and autonomic nerve interference in healthy prepubertal children. J Electrocardiol 2021; 67:119-123. [PMID: 34174541 DOI: 10.1016/j.jelectrocard.2021.05.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/10/2021] [Accepted: 05/25/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The JT interval of the myocardial repolarization time can be divided into Jpoint to T-peak interval (JTp) and T-peak to T-end interval (Tpe). It is well known that the JT interval is dependent on the heart rate, but little is known regarding heart rate dependence for JTp and Tpe. The aim of the present study was to clarify the heart rate dependence of JTp and Tpe and to elucidate the interference of autonomic nervous activity with these parameters. METHODS We evaluated 50 prepubertal children (mean age: 6.4 ± 0.5 years; male:female, 22:28) without heart disease. JTp, Tpe, and the preceding RR intervals were measured using 120 consecutive beats (lead CM5). First, the relationships between the RR interval and JTp and Tpe were evaluated by Pearson's correlation coefficient. Second, to evaluate autonomic interference with JTp and Tpe, the degree of coherence between RR interval variability and JTp or Tpe variability was calculated using spectral analysis. RESULTS Significant positive correlations were observed between the RR interval and JTp (y = 0.116x + 105.5; r = 0.594, p < 0.001) and between the RR interval and Tpe (y = 0.037x + 44.7; r = 0.432, p < 0.001). Tpe variability had a lower degree of coherence with RR interval variability (range: 0.039-0.5 Hz) than with JTp variability (0.401 [interquartile range, 0.352-0.460] vs. 0.593 [0.503-0.664], respectively; p < 0.001). CONCLUSIONS Tpe had lower heart rate dependence and a lower degree of autonomic nervous interference than did JTp.
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Affiliation(s)
- Hirofumi Kusuki
- Graduate school of Health Science, Fujita Health University, Toyoake, Japan.
| | - Yuri Mizutani
- Clinical Laboratory Division, Fujita Health University Hospital, Toyoake, Japan
| | - Yuka Tsuchiya
- Graduate school of Health Science, Fujita Health University, Toyoake, Japan
| | - Miki Nishio
- Graduate school of Health Science, Fujita Health University, Toyoake, Japan
| | - Shota Oikawa
- Clinical Laboratory Division, Fujita Health University Hospital, Toyoake, Japan
| | - Rina Nagata
- Clinical Laboratory Division, Fujita Health University Hospital, Toyoake, Japan
| | - Yumi Kiriyanagi
- Clinical Laboratory Division, Fujita Health University Hospital, Toyoake, Japan
| | - Kayo Horio
- Department of Physiology, School of Medicine, Fujita Health University, Toyoake, Japan
| | - Misa Hosoi
- Clinical Laboratory Division, Fujita Health University Hospital, Toyoake, Japan
| | - Hideaki Matsuura
- Graduate school of Health Science, Fujita Health University, Toyoake, Japan; Clinical Laboratory Division, Fujita Health University Hospital, Toyoake, Japan
| | | | - Tadayoshi Hata
- Graduate school of Health Science, Fujita Health University, Toyoake, Japan; Clinical Laboratory Division, Fujita Health University Hospital, Toyoake, Japan
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22
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Zekios KC, Mouchtouri ET, Lekkas P, Nikas DN, Kolettis TM. Sympathetic Activation and Arrhythmogenesis after Myocardial Infarction: Where Do We Stand? J Cardiovasc Dev Dis 2021; 8:jcdd8050057. [PMID: 34063477 PMCID: PMC8156099 DOI: 10.3390/jcdd8050057] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/30/2021] [Accepted: 05/12/2021] [Indexed: 12/11/2022] Open
Abstract
Myocardial infarction often leads to progressive structural and electrophysiologic remodeling of the left ventricle. Despite the widespread use of β-adrenergic blockade and implantable defibrillators, morbidity and mortality from chronic-phase ventricular tachyarrhythmias remains high, calling for further investigation on the underlying pathophysiology. Histological and functional studies have demonstrated extensive alterations of sympathetic nerve endings at the peri-infarct area and flow-innervation mismatches that create a highly arrhythmogenic milieu. Such accumulated evidence, along with the previously well-documented autonomic dysfunction as an important contributing factor, has stirred intense research interest for pharmacologic and non-pharmacologic neuromodulation in post-infarction heart failure. In this regard, aldosterone inhibitors, sacubitril/valsartan and sodium-glucose cotransporter type 2 inhibitors have shown antiarrhythmic effects. Non-pharmacologic modalities, currently tested in pre-clinical and clinical trials, include transcutaneous vagal stimulation, stellate ganglion modulation and renal sympathetic denervation. In this review, we provide insights on the pathophysiology of ventricular arrhythmogenesis post-myocardial infarction, focusing on sympathetic activation.
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Affiliation(s)
- Konstantinos C. Zekios
- 1st Department of Cardiology, University Hospital of Ioannina, 1 St. Niarxou Avenue, 45500 Ioannina, Greece; (K.C.Z.); (D.N.N.)
- Department of Cardiology, University of Ioannina, 1 St. Niarxou Avenue, 45500 Ioannina, Greece;
| | - Eleni-Taxiarchia Mouchtouri
- Department of Cardiology, University of Ioannina, 1 St. Niarxou Avenue, 45500 Ioannina, Greece;
- Cardiovascular Research Institute, 1 St. Niarxou Avenue, 45500 Ioannina, Greece;
| | - Panagiotis Lekkas
- Cardiovascular Research Institute, 1 St. Niarxou Avenue, 45500 Ioannina, Greece;
| | - Dimitrios N. Nikas
- 1st Department of Cardiology, University Hospital of Ioannina, 1 St. Niarxou Avenue, 45500 Ioannina, Greece; (K.C.Z.); (D.N.N.)
| | - Theofilos M. Kolettis
- 1st Department of Cardiology, University Hospital of Ioannina, 1 St. Niarxou Avenue, 45500 Ioannina, Greece; (K.C.Z.); (D.N.N.)
- Department of Cardiology, University of Ioannina, 1 St. Niarxou Avenue, 45500 Ioannina, Greece;
- Cardiovascular Research Institute, 1 St. Niarxou Avenue, 45500 Ioannina, Greece;
- Correspondence:
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23
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Koracevic G, Stojanovic M, Lovic D, Zdravkovic M, Sakac D. Certain beta blockers (e.g., bisoprolol) may be reevaluated in hypertension guidelines for patients with left ventricular hypertrophy to diminish the ventricular arrhythmic risk. J Hum Hypertens 2021; 35:564-576. [PMID: 33654234 DOI: 10.1038/s41371-021-00505-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 01/29/2021] [Accepted: 02/04/2021] [Indexed: 12/18/2022]
Abstract
Hypertensive left ventricular hypertrophy (HTN LVH) is associated with almost threefold increased risk of ventricular tachycardia (VT)/ventricular fibrillation (VF). Furthermore, HTN LVH increases the risk of sudden cardiac death (SCD). The reverse LV remodeling due to efficient antihypertensive therapy lowers the incidence rates of cardiovascular events and SCD and the vast majority of available arterial hypertension (HTN) guidelines recommend renin angiotensin system (RAS) blockers and calcium channel blockers (CCBs) for HTN LVH aiming for LVH regression. On the other hand, beta blockers (BBs) as a class are not recommended in HTN LVH due to their insufficient capacity to reverse LVH remodeling even though they are recommended as the first-line drugs for prevention/treatment of VT/VF (in general, unrelated to HTN LVH). Moreover, BBs are the best antiarrhythmic (against VT/VF) among antihypertensive drugs. Despite that, BBs are currently not recommended for LVH treatment in HTN Guidelines. It is important to prevent VT/VF in patients at high risk, such as those with HTN LVH. Therefore, certain BBs (such as Bisoprolol) may be reevaluated in guidelines for HTN (in the section of HTN LVH).
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Affiliation(s)
- Goran Koracevic
- Department for Cardiovascular Diseases, Clinical Center Nis, Nis, Serbia.,Faculty of Medicine, University of Nis, Nis, Serbia
| | | | - Dragan Lovic
- Clinic for Internal Diseases Inter Medica, Nis, Serbia.,Singidunum University, School of Medicine, Belgrade, Serbia
| | - Marija Zdravkovic
- University Hospital Medical Center Bezanijska Kosa, Belgrade, Serbia
| | - Dejan Sakac
- Institute for Cardiovascular Diseases of Vojvodina, Sremska Kamenica & Medical Faculty Novi Sad, Novi Sad, Serbia
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24
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Vila BCP, Camacho AA, Sousa MG. T-wave peak-end interval and ratio of T-wave peak-end and QT intervals: novel arrhythmogenic and survival markers for dogs with myxomatous mitral valve disease. J Vet Cardiol 2021; 35:25-41. [PMID: 33812131 DOI: 10.1016/j.jvc.2021.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 02/12/2021] [Accepted: 02/18/2021] [Indexed: 01/22/2023]
Abstract
INTRODUCTION/OBJECTIVES In the past few years, novel markers such as the interval between the peak and the end of T-wave (Tpte) and Tpte/QT ratio have been shown to have high sensitivity for ventricular arrhythmias and mortality. We analyzed these and other parameters of ventricular repolarization, such as QT interval, QT interval corrected for heart rate (QTc), and QT dispersion (QTd) in dogs with myxomatous mitral valve disease (MMVD). Additionally, we investigated their relationship with the progression of the disease, echocardiographic parameters, and ventricular arrhythmias and assessed their prognostic value with development of clinical signs or mortality as the final outcome. ANIMALS, MATERIALS AND METHODS Epidemiological, clinical, echocardiographic, and electrocardiographic data were obtained from 236 dogs with MMVD and 15 healthy dogs. Prognostic and survival information was also recorded for the MMVD group. All ventricular repolarization indices were measured in 10 lead electrocardiographic recordings. RESULTS With the exception of the QT interval, most repolarization markers increased along with the frequency of arrhythmias and with the progression of MMVD. The parameters that best identified ventricular arrhythmias (AUC > 0.7) were Tpte (aVR, rV2, average rV2-V10, average rV2-V4) and Tpte/QT (II, aVR, rV2). In survival analysis, statistically significant markers with the highest differences in median survival were Tpte (maximum of any lead, maximum rV2-V10), QTc aVR, and Tpte rV2. CONCLUSION Tpte and Tpte/QT are good non-invasive markers for clinical risk stratification in dogs with MMVD.
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Affiliation(s)
- B C P Vila
- Laboratory of Comparative Cardiology, Department of Veterinary Medicine, Federal University of Paraná, Curitiba, PR, 80035-050, Brazil.
| | - A A Camacho
- Department of Veterinary Clinic and Surgery, São Paulo State University, Jaboticabal, SP, 14884-900, Brazil
| | - M G Sousa
- Laboratory of Comparative Cardiology, Department of Veterinary Medicine, Federal University of Paraná, Curitiba, PR, 80035-050, Brazil
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25
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Zhang D, Tu H, Wang C, Cao L, Hu W, Hackfort BT, Muelleman RL, Wadman MC, Li YL. Inhibition of N-type calcium channels in cardiac sympathetic neurons attenuates ventricular arrhythmogenesis in heart failure. Cardiovasc Res 2021; 117:137-148. [PMID: 31995173 PMCID: PMC7797209 DOI: 10.1093/cvr/cvaa018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/13/2019] [Accepted: 01/21/2020] [Indexed: 02/07/2023] Open
Abstract
AIMS Cardiac sympathetic overactivation is an important trigger of ventricular arrhythmias in patients with chronic heart failure (CHF). Our previous study demonstrated that N-type calcium (Cav2.2) currents in cardiac sympathetic post-ganglionic (CSP) neurons were increased in CHF. This study investigated the contribution of Cav2.2 channels in cardiac sympathetic overactivation and ventricular arrhythmogenesis in CHF. METHODS AND RESULTS Rat CHF was induced by surgical ligation of the left coronary artery. Lentiviral Cav2.2-α shRNA or scrambled shRNA was transfected in vivo into stellate ganglia (SG) in CHF rats. Final experiments were performed at 14 weeks after coronary artery ligation. Real-time polymerase chain reaction and western blot data showed that in vivo transfection of Cav2.2-α shRNA reduced the expression of Cav2.2-α mRNA and protein in the SG in CHF rats. Cav2.2-α shRNA also reduced Cav2.2 currents and cell excitability of CSP neurons and attenuated cardiac sympathetic nerve activities (CSNA) in CHF rats. The power spectral analysis of heart rate variability (HRV) further revealed that transfection of Cav2.2-α shRNA in the SG normalized CHF-caused cardiac sympathetic overactivation in conscious rats. Twenty-four-hour continuous telemetry electrocardiogram recording revealed that this Cav2.2-α shRNA not only decreased incidence and duration of ventricular tachycardia/ventricular fibrillation but also improved CHF-induced heterogeneity of ventricular electrical activity in conscious CHF rats. Cav2.2-α shRNA also decreased susceptibility to ventricular arrhythmias in anaesthetized CHF rats. However, Cav2.2-α shRNA failed to improve CHF-induced cardiac contractile dysfunction. Scrambled shRNA did not affect Cav2.2 currents and cell excitability of CSP neurons, CSNA, HRV, and ventricular arrhythmogenesis in CHF rats. CONCLUSIONS Overactivation of Cav2.2 channels in CSP neurons contributes to cardiac sympathetic hyperactivation and ventricular arrhythmogenesis in CHF. This suggests that discovering purely selective and potent small-molecule Cav2.2 channel blockers could be a potential therapeutic strategy to decrease fatal ventricular arrhythmias in CHF.
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MESH Headings
- Action Potentials
- Animals
- Calcium/metabolism
- Calcium Channels, N-Type/genetics
- Calcium Channels, N-Type/metabolism
- Calcium Signaling
- Cells, Cultured
- Disease Models, Animal
- Heart/innervation
- Heart Failure/genetics
- Heart Failure/metabolism
- Heart Failure/physiopathology
- Heart Rate
- Male
- RNA Interference
- RNA, Small Interfering/genetics
- RNA, Small Interfering/metabolism
- Rats, Sprague-Dawley
- Stellate Ganglion/metabolism
- Stellate Ganglion/physiopathology
- Sympathetic Fibers, Postganglionic/metabolism
- Sympathetic Fibers, Postganglionic/physiopathology
- Tachycardia, Ventricular/genetics
- Tachycardia, Ventricular/metabolism
- Tachycardia, Ventricular/physiopathology
- Tachycardia, Ventricular/prevention & control
- Ventricular Fibrillation/genetics
- Ventricular Fibrillation/metabolism
- Ventricular Fibrillation/physiopathology
- Ventricular Fibrillation/prevention & control
- Rats
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Affiliation(s)
- Dongze Zhang
- Department of Emergency Medicine, University of Nebraska Medical Center, 985850 Nebraska Medical Center, Omaha, NE 68198-5850, USA
| | - Huiyin Tu
- Department of Emergency Medicine, University of Nebraska Medical Center, 985850 Nebraska Medical Center, Omaha, NE 68198-5850, USA
| | - Chaojun Wang
- Department of Emergency Medicine, University of Nebraska Medical Center, 985850 Nebraska Medical Center, Omaha, NE 68198-5850, USA
- Department of Cardiovascular Disease, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, 710061, China
| | - Liang Cao
- Department of Emergency Medicine, University of Nebraska Medical Center, 985850 Nebraska Medical Center, Omaha, NE 68198-5850, USA
- Department of Cardiac Surgery, Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Wenfeng Hu
- Department of Emergency Medicine, University of Nebraska Medical Center, 985850 Nebraska Medical Center, Omaha, NE 68198-5850, USA
| | - Bryan T Hackfort
- Department of Cellular & Integrative Physiology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Robert L Muelleman
- Department of Emergency Medicine, University of Nebraska Medical Center, 985850 Nebraska Medical Center, Omaha, NE 68198-5850, USA
| | - Michael C Wadman
- Department of Emergency Medicine, University of Nebraska Medical Center, 985850 Nebraska Medical Center, Omaha, NE 68198-5850, USA
| | - Yu-Long Li
- Department of Emergency Medicine, University of Nebraska Medical Center, 985850 Nebraska Medical Center, Omaha, NE 68198-5850, USA
- Department of Cellular & Integrative Physiology, University of Nebraska Medical Center, Omaha, NE 68198, USA
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26
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Kuwabara Y, Salavatian S, Howard-Quijano K, Yamaguchi T, Lundquist E, Mahajan A. Neuromodulation With Thoracic Dorsal Root Ganglion Stimulation Reduces Ventricular Arrhythmogenicity. Front Physiol 2021; 12:713717. [PMID: 34690795 PMCID: PMC8528951 DOI: 10.3389/fphys.2021.713717] [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] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/31/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Sympathetic hyperactivity is strongly associated with ventricular arrhythmias and sudden cardiac death. Neuromodulation provides therapeutic options for ventricular arrhythmias by modulating cardiospinal reflexes and reducing sympathetic output at the level of the spinal cord. Dorsal root ganglion stimulation (DRGS) is a recent neuromodulatory approach; however, its role in reducing ventricular arrhythmias has not been evaluated. The aim of this study was to determine if DRGS can reduce cardiac sympathoexcitation and the indices for ventricular arrhythmogenicity induced by programmed ventricular extrastimulation. We evaluated the efficacy of thoracic DRGS at both low (20 Hz) and high (1 kHz) stimulation frequencies. Methods: Cardiac sympathoexcitation was induced in Yorkshire pigs (n = 8) with ventricular extrastimulation (S1/S2 pacing), before and after DRGS. A DRG-stimulating catheter was placed at the left T2 spinal level, and animals were randomized to receive low-frequency (20 Hz and 0.4 ms) or high-frequency (1 kHz and 0.03 ms) DRGS for 30 min. High-fidelity cardiac electrophysiological recordings were performed with an epicardial electrode array measuring the indices of ventricular arrhythmogenicity-activation recovery intervals (ARIs), electrical restitution curve (Smax), and Tpeak-Tend interval (Tp-Te interval). Results: Dorsal root ganglion stimulation, at both 20 Hz and 1 kHz, decreased S1/S2 pacing-induced ARI shortening (20 Hz DRGS -21±7 ms, Control -50±9 ms, P = 0.007; 1 kHz DRGS -13 ± 2 ms, Control -46 ± 8 ms, P = 0.001). DRGS also reduced arrhythmogenicity as measured by a decrease in Smax (20 Hz DRGS 0.5 ± 0.07, Control 0.7 ± 0.04, P = 0.006; 1 kHz DRGS 0.5 ± 0.04, Control 0.7 ± 0.03, P = 0.007), and a decrease in Tp-Te interval/QTc (20 Hz DRGS 2.7 ± 0.13, Control 3.3 ± 0.12, P = 0.001; 1 kHz DRGS 2.8 ± 0.08, Control; 3.1 ± 0.03, P = 0.007). Conclusions: In a porcine model, we show that thoracic DRGS decreased cardiac sympathoexcitation and indices associated with ventricular arrhythmogenicity during programmed ventricular extrastimulation. In addition, we demonstrate that both low-frequency and high-frequency DRGS can be effective neuromodulatory approaches for reducing cardiac excitability during sympathetic hyperactivity.
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Affiliation(s)
- Yuki Kuwabara
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Siamak Salavatian
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Kimberly Howard-Quijano
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Tomoki Yamaguchi
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Eevanna Lundquist
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Aman Mahajan
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
- *Correspondence: Aman Mahajan
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Saadeh K, Shivkumar K, Jeevaratnam K. Targeting the β-adrenergic receptor in the clinical management of congenital long QT syndrome. Ann N Y Acad Sci 2020; 1474:27-46. [PMID: 32901453 DOI: 10.1111/nyas.14425] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/10/2020] [Accepted: 06/09/2020] [Indexed: 01/01/2023]
Abstract
The long QT syndrome (LQTS) is largely treated pharmacologically with β-blockers, despite the role of sympathetic activity in LQTS being poorly understood. Using the trigger-substrate model of cardiac arrhythmias in this review, we amalgamate current experimental and clinical data from both animal and human studies to explain the mechanism of adrenergic stimulation and blockade on LQT arrhythmic risk and hence assess the efficacy of β-adrenoceptor blockade in the management of LQTS. In LQTS1 and LQTS2, sympathetic stimulation increases arrhythmic risk by enhancing early afterdepolarizations and transmural dispersion of repolarization. β-Blockers successfully reduce cardiac events by reducing these triggers and substrates; however, these effects are less marked in LQTS2 compared with LQTS1. In LQTS3, clinical and experimental investigations of the effects of sympathetic stimulation and β-blocker use have produced contradictory findings, resulting in significant clinical uncertainty. We offer explanations for these contradicting results relating to study sample size, the dose of the β-blocker administered associated with its off-target Na+ channel effects, as well as the type of β-blocker used. We conclude that the antiarrhythmic efficacy of β-blockers is a genotype-specific phenomenon, and hence the use of β-blockers in clinical practice should be genotype dependent.
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Affiliation(s)
- Khalil Saadeh
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom.,School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Centre, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Kamalan Jeevaratnam
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
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28
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Cosgun A, Oren H. Variation of Tpeak-end, corrected Tpeak-end, QT, and corrected QT intervals, Tpeak-end/QT, Tpeak-end/corrected QT ratios and heart rate variability according to decades in the healthy male subjects aged between 30 and 79 years. J Arrhythm 2020; 36:508-517. [PMID: 32528579 PMCID: PMC7279968 DOI: 10.1002/joa3.12339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 03/15/2020] [Accepted: 03/23/2020] [Indexed: 11/05/2022] Open
Abstract
Background Heart rate variability (HRV) is a predictor of cardiac autonomic functions. Ventricular repolarization markers can indicate ventricular arrhythmias. We aimed to evaluate variations of HRV and these repolarization markers in five healthy male groups between age 30 and 79 years according to decades. Materials and Methods The study group consisted of 500 healthy male subjects between October 2018 and May 2019. The male subjects were divided into five categories according to their ages. Then, electrocardiograms (ECG), transthoracic echocardiograms (TTE), and treadmill exercise test (TET) were performed. T-wave peak-end (Tp-e) interval was defined as the time between the peak point and end of T-wave. Tp-e, corrected Tp-e (cTp-e), QT, and corrected QT (QTc) were measured from the resting ECGs and HRV temporal parameters (SDNN, SDNN Index, SDANN Index, RMSSD, sNN50, and pNN50), and HRV frequency parameters (VLF, LF, HF, and LF/HF) were obtained from 24-hour Holter monitorization recordings. One-way ANOVA test was used for the differences between the groups. Pearson correlation test was used to determine the correlations between the values of all groups. Results Considering the repolarization parameters, there are significant differences in five groups in terms of Tp-e interval, but not Tp-e/QT and Tp-e/QTc ratios. Considering the HRV parameters, there were statistically significant differences between the five male healthy groups in terms of HRV temporal parameters and there are no significant differences in terms of HRV frequency parameters. Conclusion As the age increases, basal Tp-e interval increases and HRV temporal parameters decrease significantly in the male subjects aged between 30 and 79 years, but HRV frequency parameters do not change.
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Affiliation(s)
- Ayhan Cosgun
- Cardiology Department Sincan State Hospital Ankara Turkey
| | - Huseyin Oren
- Cardiology Department Ankara City Hospital Ankara Turkey
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29
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Hoang JD, Salavatian S, Yamaguchi N, Swid MA, David H, Vaseghi M. Cardiac sympathetic activation circumvents high-dose beta blocker therapy in part through release of neuropeptide Y. JCI Insight 2020; 5:135519. [PMID: 32493842 DOI: 10.1172/jci.insight.135519] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 04/30/2020] [Indexed: 01/14/2023] Open
Abstract
The sympathetic nervous system plays an important role in the occurrence of ventricular tachycardia (VT). Many patients, however, experience VT despite maximal doses of beta blocker therapy, possibly due to the effects of sympathetic cotransmitters such as neuropeptide Y (NPY). The purpose of this study was to determine, in a porcine model, whether propranolol at doses higher than clinically recommended could block ventricular electrophysiological effects of sympathoexcitation via stellate ganglia stimulation, and if any residual effects are mediated by NPY. Greater release of cardiac NPY was observed at higher sympathetic stimulation frequencies (10 and 20 vs. 4 Hz). Despite treatment with even higher doses of propranolol (1.0 mg/kg), electrophysiological effects of sympathetic stimulation remained, with residual shortening of activation recovery interval (ARI), a surrogate of action potential duration (APD). Adjuvant treatment with the NPY Y1 receptor antagonist BIBO 3304, however, reduced these electrophysiological effects while augmenting inotropy. These data demonstrate that high-dose beta blocker therapy is insufficient to block electrophysiological effects of sympathoexcitation, and a portion of these electrical effects in vivo are mediated by NPY. Y1 receptor blockade may represent a promising adjuvant therapy to beta-adrenergic receptor blockade.
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Affiliation(s)
- Jonathan D Hoang
- UCLA Cardiac Arrhythmia Center.,Neurocardiology Center for Excellence, and.,UCLA Molecular Cellular and Integrative Physiology Interdepartmental Program, UCLA, Los Angeles, California, USA
| | - Siamak Salavatian
- UCLA Cardiac Arrhythmia Center.,Neurocardiology Center for Excellence, and
| | - Naoko Yamaguchi
- UCLA Cardiac Arrhythmia Center.,Neurocardiology Center for Excellence, and
| | - Mohammed Amer Swid
- UCLA Cardiac Arrhythmia Center.,Neurocardiology Center for Excellence, and
| | - Hamon David
- UCLA Cardiac Arrhythmia Center.,Neurocardiology Center for Excellence, and
| | - Marmar Vaseghi
- UCLA Cardiac Arrhythmia Center.,Neurocardiology Center for Excellence, and.,UCLA Molecular Cellular and Integrative Physiology Interdepartmental Program, UCLA, Los Angeles, California, USA
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30
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L Nguyen H, Vaseghi M. Sympathetic Denervation for Treatment of Ventricular Arrhythmias. J Atr Fibrillation 2020; 13:2404. [PMID: 33024504 DOI: 10.4022/jafib.2404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/22/2020] [Accepted: 03/20/2020] [Indexed: 12/16/2022]
Abstract
Ventricular arrhythmias are a major cause of morbidity and mortality in patients with heart disease. A growing understanding of the cardiac autonomic nervous system's crucial role in the pathogenesis of ventricular arrhythmias has led to the development of several neuromodulation therapies. Sympathetic neuromodulation is being increasingly utilized to treat ventricular arrhythmias refractory to medical therapy and catheter ablation. There is a growing body of preclinical and clinical evidence supporting the use of thoracic epidural anesthesia, stellate ganglion blockade, cardiac sympathetic denervation, and renal denervation in the treatment of recurrent ventricular arrhythmias. This review summarizes the relevant literature and discusses approaches to sympathetic neuromodulation, particularly in the management of scar-related ventricular arrhythmias.
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Affiliation(s)
- Heajung L Nguyen
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Marmar Vaseghi
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
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31
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Scholman KT, Meijborg VMF, Gálvez-Montón C, Lodder EM, Boukens BJ. From Genome-Wide Association Studies to Cardiac Electrophysiology: Through the Maze of Biological Complexity. Front Physiol 2020; 11:557. [PMID: 32536879 PMCID: PMC7267057 DOI: 10.3389/fphys.2020.00557] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 05/04/2020] [Indexed: 12/19/2022] Open
Abstract
Genome Wide Association Studies (GWAS) have provided an enormous amount of data on genomic loci associated with cardiac electrophysiology and arrhythmias. Clinical relevance, however, remains unclear since GWAS do not provide a mechanistic explanation for this association. Determining the electrophysiological relevance of variants for arrhythmias would aid development of risk stratification models for patients with arrhythmias. In this review, we give an overview of genetic variants related to ECG intervals and arrhythmogenic pathologies and discuss how these variants may influence cardiac electrophysiology and the occurrence of arrhythmias.
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Affiliation(s)
- Koen T Scholman
- Department of Medical Biology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Veronique M F Meijborg
- Department of Experimental Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands.,Netherlands Heart Institute, Utrecht, Netherlands
| | - Carolina Gálvez-Montón
- ICREC Research Program, Germans Trias i Pujol Health Science Research Institute, Badalona, Spain.,CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
| | - Elisabeth M Lodder
- Department of Experimental Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Bastiaan J Boukens
- Department of Medical Biology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands.,Department of Experimental Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
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32
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Evaluation of Tp-e interval and Tp-e/QT ratio in major burn patients. J Electrocardiol 2020; 60:67-71. [PMID: 32304902 DOI: 10.1016/j.jelectrocard.2020.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/14/2020] [Accepted: 04/03/2020] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Major burn injury is an acute stress reaction with systemic effects. Major burn injury has been associated with a number of cardiovascular dysfunctions, including ventricular arrhythmias. The mechanism of increased ventricular arrhythmias in burn patients uncertain. The aim of the present study was to evaluate the ventricular repolarization by using the Tp-e interval, Tp-e/QT ratio, and Tp-e/QTc ratio as candidate markers of ventricular arrhythmias in patients with major burn patients. In addition, the relationship between the repolarization parameters and the CRP(C-reactive protein) and ABSI(Abbreviated Burn Severity Index) score was investigated. METHODS 55 major burn patients, 55 age and sex matched healthy subjects were included in the study between January 2017 and September 2019. The risk of ventricular arrhythmias was evaluated by calculating the electrocardiographic Tp-e and QT interval, corrected QT(QTc), Tp-e/QT and Tp-e/QTc ratios. ABSI score was calculated in burn patients. Left ventricular functions were evaluated by echocardiography. RESULTS Tp-e interval (80.7 ± 5.7 vs. 67.4 ± 5.7; p < 0.001), Tp-e/QT ratio (0.21 ± 0.01 vs. 0.18 ± 0.01; p < 0.001) and Tp-e/QTc ratio (0.20 ± 0.01 vs.0.17 ± 0.01; p < 0.001) were significantly higher in major burn patients than the control group. There was a significant positive correlation between Tp-e interval, Tp-e/QTc ratio and ABSI score in major burn patients (r = 0.870, p < 0.001, r = 0.312, p = 0.020 consecutively). CONCLUSION Our study showed for the first time in literature that the Tp-e interval, Tp-e/QT ratio, and Tp-e/QTc ratio, which were evaluated electrocardiographically in major burn patients, were prolonged compared with normal healthy individuals. A positive correlation was determined between repolarization parameters and ABSI score. Whether these changes increase the risk of ventricular arrhythmia deserve further studies. TAKE-HOME MESSAGE Tp-e interval, Tp-e/QT ratio, and Tp-e/QTc ratio, which were evaluated electrocardiographically in major burn patients, were prolonged compared with normal healthy individuals and a positive correlation was found between these repolarization parameters and burn severity.
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33
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Ip M, Diamantakos E, Haptonstall K, Choroomi Y, Moheimani RS, Nguyen KH, Tran E, Gornbein J, Middlekauff HR. Tobacco and electronic cigarettes adversely impact ECG indexes of ventricular repolarization: implication for sudden death risk. Am J Physiol Heart Circ Physiol 2020; 318:H1176-H1184. [PMID: 32196360 DOI: 10.1152/ajpheart.00738.2019] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Tobacco cigarette smoking is associated with increased sudden death risk, perhaps through adverse effects on ventricular repolarization. The effect of electronic (e-)cigarettes on ventricular repolarization is unknown. The objective of the study was to test the hypothesis that tobacco cigarettes and e-cigarettes have similar adverse effects on electrocardiogram (ECG) indexes of ventricular repolarization and these effects are attributable to nicotine. ECG recordings were obtained in 37 chronic tobacco cigarette smokers, 43 chronic e-cigarette users, and 65 nonusers. Primary outcomes, Tpeak to Tend (Tp-e), Tp-e/QT ratio, and Tp-e/QTc ratio, were measured in tobacco cigarette smokers pre-/post-straw control and smoking one tobacco cigarette and in e-cigarette users and nonusers pre-/post-straw control and using an e-cigarette with and without nicotine (different days). Mean values of the primary outcomes were not different among the three groups at baseline. In chronic tobacco cigarette smokers, all primary outcomes, including the Tp-e (12.9 ± 5.0% vs. 1.5 ± 5%, P = 0.017), Tp-e/QT (14.9 ± 5.0% vs. 0.7 ± 5.1%, P = 0.004), and Tp-e/QTc (11.9 ± 5.0% vs. 2.1 ± 5.1%, P = 0.036), were significantly increased pre-/post-smoking one tobacco cigarette compared with pre-/post-straw control. In chronic e-cigarette users, the Tp-e/QT (6.3 ± 1.9%, P = 0.046) was increased only pre/post using an e-cigarette with nicotine but not pre/post the other exposures. The changes relative to the changes after straw control were greater after smoking the tobacco cigarette compared with using the e-cigarette with nicotine for Tp-e (11.4 ± 4.4% vs. 1.1 ± 2.5%, P < 0.05) and Tp-e/QTc (9.8 ± 4.4% vs. -1.6 ± 2.6%, P = 0.05) but not Tp-e/QT(14.2 ± 4.5% vs. 4.2 ± 2.6%, P = 0.061) . Heart rate increased similarly after the tobacco cigarette and e-cigarette with nicotine. Baseline ECG indexes of ventricular repolarization were not different among chronic tobacco cigarette smokers, electronic cigarette users and nonusers. An adverse effect of acute tobacco cigarette smoking on ECG indexes of ventricular repolarization was confirmed. In chronic e-cigarette users, an adverse effect of using an e-cigarette with nicotine, but not without nicotine, on ECG indexes of ventricular repolarization was also observed.NEW & NOTEWORTHY Abnormal ventricular repolarization, as indicated by prolonged Tpeak-end (Tp-e), is associated with increased sudden death risk. Baseline ECG indexes of repolarization, Tp-e, Tp-e/QT, and Tp-e/QTc, were not different among tobacco cigarette (TC) smokers, electronic cigarette (EC) users, and nonsmokers at baseline, but when TC smokers smoked one TC, all parameters were prolonged. Using an electronic cigarette with nicotine, but not without nicotine, increased the Tp-e/QT. Smoking induces changes in ECG indexes of ventricular repolarization associated with increased sudden death risk.
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Affiliation(s)
- Michelle Ip
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, California
| | - Evangelos Diamantakos
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, California
| | - Kacey Haptonstall
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, California
| | - Yasmine Choroomi
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, California
| | - Roya S Moheimani
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, California
| | - Kevin Huan Nguyen
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, California
| | - Elizabeth Tran
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, California
| | - Jeffrey Gornbein
- Departments of Medicine and Computational Medicine, David Geffen School of Medicine at the University of California, Los Angeles, California
| | - Holly R Middlekauff
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, California
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Wu P, Vaseghi M. The autonomic nervous system and ventricular arrhythmias in myocardial infarction and heart failure. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:172-180. [PMID: 31823401 DOI: 10.1111/pace.13856] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 11/25/2019] [Accepted: 12/05/2019] [Indexed: 12/20/2022]
Abstract
Ventricular arrhythmias (VA) can range in presentation from asymptomatic to cardiac arrest and sudden cardiac death (SCD). Sustained ventricular tachycardias/ventricular fibrillation (VT/VF) are a common cause of SCD in the setting of myocardial infarction (MI) and heart failure. A particularly arrhythmogenic cardiac syncytia in these conditions can be attributed to both sympathetic activation and parasympathetic dysfunction, while appropriate neuromodulation has the potential to reduce occurrence of VT/VF. In this review, we outline the components of the autonomic nervous system that play an important role in normal cardiac electrophysiology and function. In addition, we discuss changes that occur in the setting of cardiac disease including adverse neural remodeling and neurohormonal activation which significantly contribute to propensity for VT/VF. Finally, we review neuromodulation strategies to mitigate VT/VF which predominantly rely on increasing parasympathetic drive and blockade of sympathetic neurotransmission.
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Affiliation(s)
- Perry Wu
- UCLA Cardiac Arrhythmia Center and UCLA Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Marmar Vaseghi
- UCLA Cardiac Arrhythmia Center and UCLA Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California
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35
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Fong CY, Law WHC, Uka T, Koike S. Auditory Mismatch Negativity Under Predictive Coding Framework and Its Role in Psychotic Disorders. Front Psychiatry 2020; 11:557932. [PMID: 33132932 PMCID: PMC7511529 DOI: 10.3389/fpsyt.2020.557932] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 08/18/2020] [Indexed: 12/13/2022] Open
Abstract
Traditional neuroscience sees sensory perception as a simple feedforward process. This view is challenged by the predictive coding model in recent years due to the robust evidence researchers had found on how our prediction could influence perception. In the first half of this article, we reviewed the concept of predictive brain and some empirical evidence of sensory prediction in visual and auditory processing. The predictive function along the auditory pathway was mainly studied by mismatch negativity (MMN)-a brain response to an unexpected disruption of regularity. We summarized a range of MMN paradigms and discussed how they could contribute to the theoretical development of the predictive coding neural network by the mechanism of adaptation and deviance detection. Such methodological and conceptual evolution sharpen MMN as a tool to better understand the structural and functional brain abnormality for neuropsychiatric disorder such as schizophrenia.
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Affiliation(s)
- Chun Yuen Fong
- Center for Evolutionary Cognitive Sciences, Graduate School of Art and Sciences, The University of Tokyo, Meguro-ku, Japan
| | - Wai Him Crystal Law
- Center for Evolutionary Cognitive Sciences, Graduate School of Art and Sciences, The University of Tokyo, Meguro-ku, Japan
| | - Takanori Uka
- Department of Integrative Physiology, Graduate School of Medicine, University of Yamanashi, Chuo, Yamanashi, Japan
| | - Shinsuke Koike
- Center for Evolutionary Cognitive Sciences, Graduate School of Art and Sciences, The University of Tokyo, Meguro-ku, Japan.,University of Tokyo Institute for Diversity & Adaptation of Human Mind (UTIDAHM), Meguro-ku, Japan.,University of Tokyo Center for Integrative Science of Human Behavior (CiSHuB), 3-8-1 Komaba, Meguro-ku, Japan.,The International Research Center for Neurointelligence (WPI-IRCN), Institutes for Advanced Study (UTIAS), University of Tokyo, Bunkyo-ku, Japan
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36
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Winbo A, Paterson DJ. The Brain-Heart Connection in Sympathetically Triggered Inherited Arrhythmia Syndromes. Heart Lung Circ 2019; 29:529-537. [PMID: 31959550 DOI: 10.1016/j.hlc.2019.11.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 10/25/2019] [Accepted: 11/11/2019] [Indexed: 12/31/2022]
Abstract
Sympathetically triggered inherited arrhythmia syndromes, including the long QT syndrome (LQTS) and catecholaminergic polymorphic ventricular tachycardia (CPVT), can cause sudden cardiac death in young individuals with structurally normal hearts. With cardiac events typically triggered by physical or emotional stress, not surprisingly, two of the most common treatments are neuromodulators, including mainstay beta blocker pharmacotherapy, and surgical sympathetic cardiac denervation. This review updates the clinician on the relevant anatomy and physiology of the cardiac autonomic nervous system, outlines neurocardiac arrhythmia mechanisms, and discusses the latest rationale for a neurocardiac therapeutic approach to manage sympathetic-induced arrhythmia in patients with inherited cardiac disease.
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Affiliation(s)
- Annika Winbo
- Department of Physiology, University of Auckland, Auckland, New Zealand; Department of Paediatric and Congenital Cardiac Services, Starship Children's Hospital, Auckland, New Zealand.
| | - David J Paterson
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK
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37
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Zhou M, Liu Y, He Y, Xie K, Quan D, Tang Y, Huang H, Huang C. Selective chemical ablation of transient receptor potential vanilloid 1 expressing neurons in the left stellate ganglion protects against ischemia-induced ventricular arrhythmias in dogs. Biomed Pharmacother 2019; 120:109500. [PMID: 31600641 DOI: 10.1016/j.biopha.2019.109500] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 09/12/2019] [Accepted: 09/26/2019] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Findings from prior investigations show that left stellate ganglion (LSG) inhibitory approaches protect the heart from ventricular arrhythmias (VAs) caused by acute myocardial infarction (AMI), which still remain many side effects. Targeted transient receptor potential vanilloid 1/tyrosine hydroxylase (TRPV-1/TH) expressing sympathetic neurons ablation is a novel neuro-ablative strategy. The aim of this investigation was to explore if targeted molecular neuro-ablative strategy by resiniferatoxin (RTX) stellate microinjection could protect against ischemia-induced VAs. METHODS Twenty-four anesthetized beagles were assigned to a control group (n = 12) and RTX group (n = 12) in a random manner. Targeted molecular neuro-ablative was produced by RTX stellate microinjection and DMSO was microinjected into LSG in the same way as control. Plasma norepinephrine (NE) level, heart rate variability (HRV), Tpeak-Tend interval (Tp-Te), LSG neural activity and function, ventricular effective refractory period (ERP), beat-to-beat variability of repolarization (BVR) and ventricular action potential duration (APD) were measured at baseline and 60 min after RTX or DMSO microinjection. AMI model was established by the ligation of left anterior descending coronary artery and 60-minute electrocardiography was continuously recorded for VAs analysis. Subsequently, HRV, Tp-Te, plasma NE level from jugular vein and coronary sinus, LSG neural activity and function, ventricular ERP, ventricular APD, BVR, action potential duration alternans (APDA) cycle length and ventricular fibrillation threshold (VFT) were evaluated after AMI. Finally, tissue collection of LSG was performed for examining the TRPV-1, nerve growth factor (NGF) protein and c-fos protein. RESULTS TRPV-1 was highly expressed in the TH-expressing neurons and RTX injection significantly ablated TRPV-1/TH-positive neurons in LSG. Compared with baseline, RTX stellate microinjection significantly reduced plasma NE level, the sympathetic component of HRV, LSG neural activity and LSG function, shortened Tp-Te, prolonged ventricular ERP and APD, but there were no remarkable differences existed for control group. AMI resulted in the significant raise in plasma NE level from jugular vein and coronary sinus, the sympathetic component of HRV, LSG neural activity and LSG function, the marked prolongation in Tp-Te and BVR, the significant decrease in ERP and APD from ischemia area, and the increase in APDA cycle length in the ischemic region of the control group, which were remarkably attenuated in the RTX group. RTX pretreatment markedly rose the VFT in the RTX group. Furthermore, the AMI-triggered VAs was significantly prevented by RTX injection in the RTX group. RTX microinjection down-regulated significantly TRPV-1, NGF and c-fos expression in the LSG compared with the control group. CONCLUSION Targeted ablation of TRPV-1/TH positive sympathetic neurons induced by RTX stellate microinjection could suppress ischemia-induced cardiac autonomic imbalances and cardiac electrophysiology instability to protect against AMI-induced VAs.
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Affiliation(s)
- Mingmin Zhou
- 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
| | - Yu Liu
- 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.
| | - Yan 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
| | - Ke Xie
- 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
| | - Dajun Quan
- 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
| | - Yanhong Tang
- 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
| | - He 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
| | - Congxin 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
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Cardiac sympathetic denervation for refractory ventricular arrhythmias in patients with structural heart disease: A systematic review. Heart Rhythm 2019; 16:1499-1505. [DOI: 10.1016/j.hrthm.2019.06.018] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Indexed: 01/04/2023]
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39
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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.
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Meng L, Tseng CH, Shivkumar K, Ajijola O. Efficacy of Stellate Ganglion Blockade in Managing Electrical Storm: A Systematic Review. JACC Clin Electrophysiol 2019; 3:942-949. [PMID: 29270467 DOI: 10.1016/j.jacep.2017.06.006] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The efficacy of percutaneous stellate ganglion block (SGB) for managing electrical storm (ES) is not well understood. OBJECTIVE To characterize the efficacy of SGB as a treatment for ES. METHODS We conducted literature searches using PubMed/Medline and Google Scholar, for mixed combinations of terms including "stellate ganglion block", *ganglion block (ade)", "sympathetic block (ade)" and "arrhythmia", "ventricular arrhythmia (VA)" or "tachycardia" (VT), "ventricular fibrillation" (VF), "electrical storm". Inclusion criteria were presentation with guideline-defined ES and treatment with SGB. Exclusion criteria: presentation with any supraventricular arrhythmia, VA without ES, or surgical sympathectomy. Studies lacking basic demographic data, arrhythmia description, and outcomes were excluded. RESULTS Of 3,374 publications reviewed, 38 patients from 23 studies met study criteria (52 ± 19.1 years, 11 F, 17 with ischemic cardiomyopathy). Anti-arrhythmics were used in all patients. Mean Left ventricular ejection fraction was 31 ± 10%. ES was triggered by acute myocardial infarction in 15 patients and QT prolongation in 7 patients. The most common local anesthetic used for SGB was bupivacaine (0.25-0.5%). SGB resulted in a significant decrease in VA burden (12.4±8.8 vs. 1.04±2.12 episodes/day, p< 0.001) and number of external and ICD shocks (10.0±9.1 vs. 0.05±0.22 shocks/day, p< 0.01). Following SGB, 80.6% of patients survived to discharge. CONCLUSION SGB is an effective acute treatment for ES. However, larger prospective randomized studies are needed to better understand the role of SGB in ES and other VAs.
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Affiliation(s)
- Lingjin Meng
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Center of Excellence, University of California, Los Angeles, CA
| | - Chi-Hong Tseng
- Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, CA
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Center of Excellence, University of California, Los Angeles, CA
| | - Olujimi Ajijola
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Center of Excellence, University of California, Los Angeles, CA
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Wang L, Morotti S, Tapa S, Francis Stuart SD, Jiang Y, Wang Z, Myles RC, Brack KE, Ng GA, Bers DM, Grandi E, Ripplinger CM. Different paths, same destination: divergent action potential responses produce conserved cardiac fight-or-flight response in mouse and rabbit hearts. J Physiol 2019; 597:3867-3883. [PMID: 31215643 DOI: 10.1113/jp278016] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 06/17/2019] [Indexed: 12/22/2022] Open
Abstract
KEY POINTS Cardiac electrophysiology and Ca2+ handling change rapidly during the fight-or-flight response to meet physiological demands. Despite dramatic differences in cardiac electrophysiology, the cardiac fight-or-flight response is highly conserved across species. In this study, we performed physiological sympathetic nerve stimulation (SNS) while optically mapping cardiac action potentials and intracellular Ca2+ transients in innervated mouse and rabbit hearts. Despite similar heart rate and Ca2+ handling responses between mouse and rabbit hearts, we found notable species differences in spatio-temporal repolarization dynamics during SNS. Species-specific computational models revealed that these electrophysiological differences allowed for enhanced Ca2+ handling (i.e. enhanced inotropy) in each species, suggesting that electrophysiological responses are fine-tuned across species to produce optimal cardiac fight-or-flight responses. ABSTRACT Sympathetic activation of the heart results in positive chronotropy and inotropy, which together rapidly increase cardiac output. The precise mechanisms that produce the electrophysiological and Ca2+ handling changes underlying chronotropic and inotropic responses have been studied in detail in isolated cardiac myocytes. However, few studies have examined the dynamic effects of physiological sympathetic nerve activation on cardiac action potentials (APs) and intracellular Ca2+ transients (CaTs) in the intact heart. Here, we performed bilateral sympathetic nerve stimulation (SNS) in fully innervated, Langendorff-perfused rabbit and mouse hearts. Dual optical mapping with voltage- and Ca2+ -sensitive dyes allowed for analysis of spatio-temporal AP and CaT dynamics. The rabbit heart responded to SNS with a monotonic increase in heart rate (HR), monotonic decreases in AP and CaT duration (APD, CaTD), and a monotonic increase in CaT amplitude. The mouse heart had similar HR and CaT responses; however, a pronounced biphasic APD response occurred, with initial prolongation (50.9 ± 5.1 ms at t = 0 s vs. 60.6 ± 4.1 ms at t = 15 s, P < 0.05) followed by shortening (46.5 ± 9.1 ms at t = 60 s, P = NS vs. t = 0). We determined the biphasic APD response in mouse was partly due to dynamic changes in HR during SNS and was exacerbated by β-adrenergic activation. Simulations with species-specific cardiac models revealed that transient APD prolongation in mouse allowed for greater and more rapid CaT responses, suggesting more rapid increases in contractility; conversely, the rabbit heart requires APD shortening to produce optimal inotropic responses. Thus, while the cardiac fight-or-flight response is highly conserved between species, the underlying mechanisms orchestrating these effects differ significantly.
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Affiliation(s)
- Lianguo Wang
- Department of Pharmacology, School of Medicine, University of California, Davis, USA
| | - Stefano Morotti
- Department of Pharmacology, School of Medicine, University of California, Davis, USA
| | - Srinivas Tapa
- Department of Pharmacology, School of Medicine, University of California, Davis, USA
| | | | - Yanyan Jiang
- Department of Pharmacology, School of Medicine, University of California, Davis, USA
| | - Zhen Wang
- Department of Pharmacology, School of Medicine, University of California, Davis, USA
| | - Rachel C Myles
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK
| | - Kieran E Brack
- Department of Cardiovascular Sciences, University of Leicester, NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - G André Ng
- Department of Cardiovascular Sciences, University of Leicester, NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Donald M Bers
- Department of Pharmacology, School of Medicine, University of California, Davis, USA
| | - Eleonora Grandi
- Department of Pharmacology, School of Medicine, University of California, Davis, USA
| | - Crystal M Ripplinger
- Department of Pharmacology, School of Medicine, University of California, Davis, USA
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Matsumoto T, Ohnishi H, Sato T, Miki T, Akasaka H, Hanawa N, Koyama M, Saitoh S, Miura T. Insulin Resistance is Associated with Longitudinal Changes of Cardiac Repolarization Heterogeneity in Apparently Healthy Subjects. Cardiol Ther 2019; 8:239-251. [PMID: 31273651 PMCID: PMC6828911 DOI: 10.1007/s40119-019-0140-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Increased heterogeneity in ventricular repolarization is a risk factor of sudden cardiac death, but its natural history is unclear. Here we examined whether insulin resistance is associated with longitudinal change in ventricular repolarization heterogeneity in apparently healthy subjects. METHODS The study subjects were participants in health checkups in cohort 1 and cohort 2, which were followed up for 6 years and 5 years, respectively. Subjects with diabetes, cardiovascular disease, or renal disease at baseline were excluded from the analyses. As indices of insulin resistance, the homeostasis model assessment of insulin resistance (HOMA-IR) and triglyceride to HDL-cholesterol ratio (TG/HDL-C) were used in cohort 1 and cohort 2, respectively. Heterogeneity in ventricular repolarization was assessed by heart rate-corrected Tpeak-Tend interval in V5 (cTpTe), QT interval, and QT dispersion. In regression analyses, parameters with a skewed distribution were normalized by logarithmic transformation or by Box-Cox transformation. RESULTS In longitudinal analyses, Box-Cox-transformed cTpTe at the end of follow-up was weakly correlated with log HOMA-IR at baseline in cohort 1 (n = 153, r = - 0.207, 95% CI - 0.354 to - 0.050, p = 0.010) and with log TG/HDL-C at baseline in cohort 2 (n = 738, r = - 0.098, 95% CI - 0.169 to - 0.026, p = 0.008). Multiple regression analysis showed that indices of insulin resistance, but not glycosylated hemoglobin (HbA1c) or plasma glucose, at baseline were significant explanatory variables for cTpTe at the end of follow-up. Neither QT interval nor QT dispersion was correlated with metabolic parameters. CONCLUSION Insulin resistance may be involved in the longitudinal increase of ventricular repolarization heterogeneity in apparently healthy subjects.
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Affiliation(s)
- Tamaki Matsumoto
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Hirofumi Ohnishi
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
- Department of Public Health, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Tatsuya Sato
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
- Department of Cellular Physiology and Signal Transduction, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Takayuki Miki
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Hiroshi Akasaka
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | | | - Masayuki Koyama
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Shigeyuki Saitoh
- Division of Medical and Behavioral Subjects, Department of Nursing, Sapporo Medical University School of Health Sciences, Sapporo, Japan
| | - Tetsuji Miura
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan.
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Cai C, Dai MY, Tian Y, Zhang P, Wittwer ED, Rho RH, Kapa S, McLeod CJ, Mulpuru SK, Lee HC, Ackerman MJ, Asirvatham SJ, Munger TM, Chen ML, Friedman PA, Cha YM. Electrophysiologic effects and outcomes of sympatholysis in patients with recurrent ventricular arrhythmia and structural heart disease. J Cardiovasc Electrophysiol 2019; 30:1499-1507. [PMID: 31199536 DOI: 10.1111/jce.14030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/29/2019] [Accepted: 05/31/2019] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Autonomic modulation has been used as a therapy to control recurrent ventricular arrhythmia (VA). This study was to explore stellate ganglion block (SGB) effect on cardiac electrophysiologic properties and evaluate the long-term outcome of cardiac sympathetic denervation (CSD) for patients with recurrent VA and structural heart disease (SHD). MATERIALS AND METHODS Patients who had recurrent VA due to SHD were enrolled prospectively. Electrophysiologic study and ventricular tachycardia (VT) induction were performed before and after left and right SGB. VA burden and long-term outcomes were assessed for a separate patient group who underwent left or bilateral CSD for drug-refractory VA due to SHD. RESULTS Electrophysiologic study of nine patients showed that baseline mean (SD) corrected sinus node recovery time (cSNRT) increased from 320.4 (73.3) ms to 402.9 (114.2) ms after left and 482.4 (95.7) ms after bilateral SGB (P = .03). SGB did not significantly change P-R, QRS, and Q-T intervals and ventricular effective refractory period, nor did the inducibility of VA. Nineteen patients underwent left (n = 14) or bilateral (n = 5) CSD. CSD reduced VA burden and appropriate ICD therapies from a median (interquartile range) of 2.5 (0.4-11.6) episodes weekly to 0.1 (0.0-2.4) episodes weekly at 6-month follow-up (P = .002). Three-year freedom from orthotopic heart transplant (OHT) and death was 52.6%. New York Heart Association functional class III/IV and VT rate less than 160 beats per minute were predictors of recurrent VA, OHT, and death. CONCLUSION SGB increased cSNRT without changing heart rate. CSD was more beneficial for patients with mild-to-moderate heart failure and faster VA.
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Affiliation(s)
- Cheng Cai
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ming-Yan Dai
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.,Hubei Key Laboratory of Cardiology, Department of Cardiology, Renmin Hospital of Wuhan University, Cardiovascular Research Institute, Wuhan University, Wuhan, China
| | - Ying Tian
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.,Department of Cardiovascular Diseases, Beijing Chaoyang Hospital, Beijing, China
| | - Pei Zhang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.,Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Erica D Wittwer
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Richard H Rho
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Suraj Kapa
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Siva K Mulpuru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Hon-Chi Lee
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Michael J Ackerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Thomas M Munger
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ming-Long Chen
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Paul A Friedman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Yong-Mei Cha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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The autonomic nervous system and cardiac arrhythmias: current concepts and emerging therapies. Nat Rev Cardiol 2019; 16:707-726. [DOI: 10.1038/s41569-019-0221-2] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/07/2019] [Indexed: 12/19/2022]
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Left cardiac sympathetic denervation for recurrent ventricular tachyarrhythmias in children with congenital heart disease. HeartRhythm Case Rep 2019; 5:392-394. [PMID: 31341785 PMCID: PMC6630183 DOI: 10.1016/j.hrcr.2019.04.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Tomek J, Hao G, Tomková M, Lewis A, Carr C, Paterson DJ, Rodriguez B, Bub G, Herring N. β-Adrenergic Receptor Stimulation and Alternans in the Border Zone of a Healed Infarct: An ex vivo Study and Computational Investigation of Arrhythmogenesis. Front Physiol 2019; 10:350. [PMID: 30984029 PMCID: PMC6450465 DOI: 10.3389/fphys.2019.00350] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 03/14/2019] [Indexed: 12/21/2022] Open
Abstract
Background: Following myocardial infarction (MI), the myocardium is prone to calcium-driven alternans, which typically precedes ventricular tachycardia and fibrillation. MI is also associated with remodeling of the sympathetic innervation in the infarct border zone, although how this influences arrhythmogenesis is controversial. We hypothesize that the border zone is most vulnerable to alternans, that β-adrenergic receptor stimulation can suppresses this, and investigate the consequences in terms of arrhythmogenic mechanisms. Methods and Results: Anterior MI was induced in Sprague-Dawley rats (n = 8) and allowed to heal over 2 months. This resulted in scar formation, significant (p < 0.05) dilation of the left ventricle, and reduction in ejection fraction compared to sham operated rats (n = 4) on 7 T cardiac magnetic resonance imaging. Dual voltage/calcium optical mapping of post-MI Langendorff perfused hearts (using RH-237 and Rhod2) demonstrated that the border zone was significantly more prone to alternans than the surrounding myocardium at longer cycle lengths, predisposing to spatially heterogeneous alternans. β-Adrenergic receptor stimulation with norepinephrine (1 μmol/L) attenuated alternans by 60 [52–65]% [interquartile range] and this was reversed with metoprolol (10 μmol/L, p = 0.008). These results could be reproduced by computer modeling of the border zone based on our knowledge of β-adrenergic receptor signaling pathways and their influence on intracellular calcium handling and ion channels. Simulations also demonstrated that β-adrenergic receptor stimulation in this specific region reduced the formation of conduction block and the probability of premature ventricular activation propagation. Conclusion: While high levels of overall cardiac sympathetic drive are a negative prognostic indicator of mortality following MI and during heart failure, β-adrenergic receptor stimulation in the infarct border zone reduced spatially heterogeneous alternans, and prevented conduction block and propagation of extrasystoles. This may help explain recent clinical imaging studies using meta-iodobenzylguanidine (MIBG) and 11C-meta-hydroxyephedrine positron emission tomography (PET) which demonstrate that border zone denervation is strongly associated with a high risk of future arrhythmia.
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Affiliation(s)
- Jakub Tomek
- Department of Computer Science, British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, United Kingdom
| | - Guoliang Hao
- Department of Physiology, Anatomy and Genetics, British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, United Kingdom
| | - Markéta Tomková
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Andrew Lewis
- Department of Physiology, Anatomy and Genetics, British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, United Kingdom
| | - Carolyn Carr
- Department of Physiology, Anatomy and Genetics, British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, United Kingdom
| | - David J Paterson
- Department of Physiology, Anatomy and Genetics, British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, United Kingdom
| | - Blanca Rodriguez
- Department of Computer Science, British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, United Kingdom
| | - Gil Bub
- Department of Physiology, McGill University, Montreal, QC, Canada
| | - Neil Herring
- Department of Physiology, Anatomy and Genetics, British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, United Kingdom
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Dusi V, De Ferrari GM, Pugliese L, Schwartz PJ. Cardiac Sympathetic Denervation in Channelopathies. Front Cardiovasc Med 2019; 6:27. [PMID: 30972341 PMCID: PMC6443634 DOI: 10.3389/fcvm.2019.00027] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 03/01/2019] [Indexed: 12/24/2022] Open
Abstract
Left cardiac sympathetic denervation (LCSD) is a surgical antiadrenergic intervention with a strong antiarrhythmic effect, supported by preclinical as well as clinical data. The mechanism of action of LCSD in structurally normal hearts with increased arrhythmic susceptibility (such as those of patients with channelopathies) is not limited to the antagonism of acute catecholamines release in the heart. LCSD also conveys a strong anti-fibrillatory action that was first demonstrated over 40 years ago and provides the rationale for its use in almost any cardiac condition at increased risk of ventricular fibrillation. The molecular mechanisms involved in the final antiarrhythmic effect of LCSD turned out to be much broader than anticipated. Beside the vagotonic effect at different levels of the neuraxis, other new mechanisms have been recently proposed, such as the antagonism of neuronal remodeling, the antagonism of neuropeptide Y effects, and the correction of neuronal nitric oxide synthase (nNOS) imbalance. The beneficial effects of LCSD have never been associated with a detectable deterioration of cardiac performance. Finally, patients express a high degree of satisfaction with the procedure. In this review, we focus on the rationale, results and our personal approach to LCSD in patients with channelopathies such as long QT syndrome and catecholaminergic polymorphic ventricular tachycardia.
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Affiliation(s)
- Veronica Dusi
- Department of Molecular Medicine, Section of Cardiology, University of Pavia, Pavia, Italy.,Cardiac Intensive Care Unit, Arrhythmia and Electrophysiology and Experimental Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Gaetano Maria De Ferrari
- Department of Molecular Medicine, Section of Cardiology, University of Pavia, Pavia, Italy.,Cardiac Intensive Care Unit, Arrhythmia and Electrophysiology and Experimental Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Luigi Pugliese
- Unit of General Surgery 2, Department of Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Peter J Schwartz
- Center for Cardiac Arrhythmias of Genetic Origin and Laboratory of Cardiovascular Genetics, Istituto Auxologico Italiano, IRCCS, Milan, Italy
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Abstract
PURPOSE OF REVIEW This review aims to describe the latest advances in autonomic neuromodulation approaches to treating cardiac arrhythmias, with a focus on ventricular arrhythmias. RECENT FINDINGS The increasing understanding of neuronal remodeling in cardiac diseases has led to the development and improvement of novel neuromodulation therapies targeting multiple levels of the autonomic nervous system. Thoracic epidural anesthesia, spinal cord stimulation, stellate ganglion modulatory therapies, vagal stimulation, renal denervation, and interventions on the intracardiac nervous system have all been studied in preclinical models, with encouraging preliminary clinical data. The autonomic nervous system regulates all the electrical processes of the heart and plays an important role in the pathophysiology of cardiac arrhythmias. Despite recent advances in the clinical application of cardiac neuromodulation, our comprehension of the anatomy and function of the cardiac autonomic nervous system is still limited. Hopefully in the near future, more preclinical data combined with larger clinical trials will lead to further improvements in neuromodulatory treatment for heart rhythm disorders.
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Ahmed TAN, Abdel-Nazeer AA, Hassan AKM, Hasan-Ali H, Youssef AA. Electrocardiographic measures of ventricular repolarization dispersion and arrhythmic outcomes among ST elevation myocardial infarction patients with pre-infarction angina undergoing primary percutaneous coronary intervention. Ann Noninvasive Electrocardiol 2019; 24:e12637. [PMID: 30737993 DOI: 10.1111/anec.12637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 12/06/2018] [Accepted: 12/28/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Arrhythmias are considered one of the major causes of death in ST elevation myocardial infarction (STEMI), particularly in the early in-hospital phase. Pre-infarction angina (PIA) has been suggested to have a protective role. OBJECTIVES To study the difference in acute electrocardiographic findings between STEMI patients with and without PIA and to assess the in-hospital arrhythmias in both groups. MATERIAL AND METHODS We prospectively enrolled 238 consecutive patients with STEMI. Patients were divided into two groups: those with or without PIA. ECG data recorded and analyzed included ST-segment resolution (STR) at 90 min, corrected QT interval (QTc) and dispersion (QTD), T-peak-to-T-end interval (Tp-Te), and dispersion and Tp-Te/QT ratio. In-hospital ventricular arrhythmias encountered in both groups were recorded. Predictors of in-hospital arrhythmias were assessed among different clinical and electrocardiographic parameters. RESULTS Of the 238 patients included, 42 (17%) had PIA and 196 (83%) had no PIA. Patients with PIA had higher rates of STR (p < 0.0001), while patients with no PIA had higher values of QTc (p = 0.006), QTD (p = 0.001), Tp-Te interval (p = 0.001), Tp-Te dispersion (p < 0.0001), and Tp-Te/QT ratio (p = 0.01) compared to those with angina preceding their incident infarction (PIA). This was reflected into significantly higher rates of in-hospital arrhythmias among patients with no PIA (20% vs. 7%, p = 0.04). Furthermore, longer Tp-Te interval and higher Tp-Te/QT ratio independently predicted in-hospital ventricular arrhythmias. CONCLUSION Pre-infarction angina patients had better electrocardiographic measures of repolarization dispersion and encountered significantly less arrhythmic events compared to patients who did not experience PIA.
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Affiliation(s)
- Tarek A N Ahmed
- Department of Cardiovascular Medicine, Asyut University Hospital, Asyut, Egypt
| | - Amr A Abdel-Nazeer
- Department of Cardiovascular Medicine, Asyut University Hospital, Asyut, Egypt
| | - Ayman K M Hassan
- Department of Cardiovascular Medicine, Asyut University Hospital, Asyut, Egypt
| | - Hosam Hasan-Ali
- Department of Cardiovascular Medicine, Asyut University Hospital, Asyut, Egypt
| | - Amr A Youssef
- Department of Cardiovascular Medicine, Asyut University Hospital, Asyut, Egypt
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Chadda KR, Ajijola OA, Vaseghi M, Shivkumar K, Huang CLH, Jeevaratnam K. Ageing, the autonomic nervous system and arrhythmia: From brain to heart. Ageing Res Rev 2018; 48:40-50. [PMID: 30300712 DOI: 10.1016/j.arr.2018.09.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 08/21/2018] [Accepted: 09/30/2018] [Indexed: 02/08/2023]
Abstract
An ageing myocardium possesses significant electrophysiological alterations that predisposes the elderly patient to arrhythmic risk. Whilst these alterations are intrinsic to the cardiac myocytes, they are modulated by the cardiac autonomic nervous system (ANS) and consequently, ageing of the cardiac ANS is fundamental to the development of arrhythmias. A systems-based approach that incorporates the influence of the cardiac ANS could lead to better mechanistic understanding of how arrhythmogenic triggers and substrates interact spatially and temporally to produce sustained arrhythmia and why its incidence increases with age. Despite the existence of physiological oscillations of ANS activity on the heart, pathological oscillations can lead to defective activation and recovery properties of the myocardium. Such changes can be attributable to the decrease in functionality and structural alterations to ANS specific receptors in the myocardium with age. These altered ANS adaptive responses can occur either as a normal ageing process or accelerated in the presence of specific cardiac pathologies, such as genetic mutations or neurodegenerative conditions. Targeted intervention that seek to manipulate the ageing ANS influence on the myocardium may prove to be an efficacious approach for the management of arrhythmia in the ageing population.
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Affiliation(s)
- Karan R Chadda
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, GU2 7AL, United Kingdom; Physiological Laboratory, University of Cambridge, Downing Street, Cambridge, CB2 3EG, United Kingdom
| | - Olujimi A Ajijola
- UCLA Cardiac Arrhythmia Center, UCLA Health System/David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Marmar Vaseghi
- UCLA Cardiac Arrhythmia Center, UCLA Health System/David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, UCLA Health System/David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Christopher L-H Huang
- Physiological Laboratory, University of Cambridge, Downing Street, Cambridge, CB2 3EG, United Kingdom; Department of Biochemistry, Hopkins Building, University of Cambridge, Cambridge, CB2 1QW, United Kingdom
| | - Kamalan Jeevaratnam
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, GU2 7AL, United Kingdom; Physiological Laboratory, University of Cambridge, Downing Street, Cambridge, CB2 3EG, United Kingdom.
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