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Sato T, Hanna P, Mori S. Innervation of the coronary arteries and its role in controlling microvascular resistance. J Cardiol 2024:S0914-5087(24)00010-8. [PMID: 38346669 DOI: 10.1016/j.jjcc.2024.01.005] [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: 01/17/2024] [Accepted: 01/30/2024] [Indexed: 04/08/2024]
Abstract
The coronary circulation plays a crucial role in balancing myocardial perfusion and oxygen demand to prevent myocardial ischemia. Extravascular compressive forces, coronary perfusion pressure, and microvascular resistance are involved to regulate coronary blood flow throughout the cardiac cycle. Autoregulation of the coronary blood flow through dynamic adjustment of microvascular resistance is maintained by complex interactions among mechanical, endothelial, metabolic, neural, and hormonal mechanisms. This review focuses on the neural mechanism. Anatomy and physiology of the coronary arterial innervation have been extensively investigated using animal models. However, findings in the animal heart have limited applicability to the human heart as cardiac innervation is generally highly variable among species. So far, limited data are available on the human coronary artery innervation, rendering multiple questions unresolved. Recently, the clinical entity of ischemia with non-obstructive coronary arteries has been proposed, characterized by microvascular dysfunction involving abnormal vasoconstriction and impaired vasodilation. Thus, measurement of microvascular resistance has become a standard diagnostic for patients without significant stenosis in the epicardial coronary arteries. Neural mechanism is likely to play a pivotal role, supported by the efficacy of cardiac sympathetic denervation to control symptoms in patients with angina. Therefore, understanding the coronary artery innervation and control of microvascular resistance of the human heart is increasingly important for cardiologists for diagnosis and to select appropriate therapeutic options. Advancement in this field can lead to innovations in diagnostic and therapeutic approaches for coronary artery diseases.
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Affiliation(s)
- Takanori Sato
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Peter Hanna
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Shumpei Mori
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
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2
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Curran J, Ross-White A, Sibley S. Magnesium prophylaxis of new-onset atrial fibrillation: A systematic review and meta-analysis. PLoS One 2023; 18:e0292974. [PMID: 37883337 PMCID: PMC10602269 DOI: 10.1371/journal.pone.0292974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 10/03/2023] [Indexed: 10/28/2023] Open
Abstract
PURPOSE Atrial fibrillation (AF) is the most common cardiac arrhythmia in intensive care units (ICU) and is associated with increased morbidity and mortality. Magnesium prophylaxis has been shown to reduce incidence of AF in cardiac surgery patients, however, evidence outside this population is limited. The objective of this study is to summarize studies examining magnesium versus placebo in the prevention of NOAF outside the setting of cardiac surgery. SOURCE We performed a comprehensive search of MEDLINE, EMBASE, and Cochrane Library (CENTRAL) from inception until January 3rd, 2023. We included all interventional research studies that compared magnesium to placebo and excluded case reports and post cardiac surgery patients. We conducted meta-analysis using the inverse variance method with random effects modelling. PRINCIPAL FINDINGS Of the 1493 studies imported for screening, 87 full texts were assessed for eligibility and six citations, representing five randomized controlled trials (n = 4713), were included in the review, with four studies (n = 4654) included in the pooled analysis. Administration of magnesium did not significantly reduce the incidence of NOAF compared to placebo (OR 0.72, [95% CI 0.48 to 1.09]). CONCLUSION Use of magnesium did not reduce the incidence of NOAF, however these studies represent diverse groups and are hindered by significant bias. Further studies are necessary to determine if there is benefit to magnesium prophylaxis for NOAF in non-cardiac surgery patients.
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Affiliation(s)
- Jeffrey Curran
- Department of Critical Care Medicine, Queen’s University, Kingston, Canada
| | - Amanda Ross-White
- Bracken Health Sciences Library, Queen’s University, Kingston, Canada
| | - Stephanie Sibley
- Department of Critical Care Medicine, Queen’s University, Kingston, Canada
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3
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Intrinsic Cardiac Neuromodulation in the Management of Atrial Fibrillation- A Potential Missing Link? Life (Basel) 2023; 13:life13020383. [PMID: 36836740 PMCID: PMC9966489 DOI: 10.3390/life13020383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/14/2023] [Accepted: 01/26/2023] [Indexed: 01/31/2023] Open
Abstract
Atrial fibrillation (AF) is the most common supraventricular arrhythmia that is linked with higher cardiovascular morbidity and mortality. Recent evidence has demonstrated that catheter-based pulmonary vein isolation (PVI) is not only a viable alternative but may be superior to antiarrhythmic drug therapy for long-term freedom from symptomatic AF episodes, a reduction in the arrhythmia burden, and healthcare resource utilization with a similar risk of adverse events. The intrinsic cardiac autonomic nervous system (ANS) has a significant influence on the structural and electrical milieu, and imbalances in the ANS may contribute to the arrhythmogenesis of AF in some individuals. There is now increasing scientific and clinical interest in various aspects of neuromodulation of intrinsic cardiac ANS, including mapping techniques, ablation methods, and patient selection. In the present review, we aimed to summarize and critically appraise the currently available evidence for the neuromodulation of intrinsic cardiac ANS in AF.
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Demarchi A, Conte G, Chen SA, Lo LW, Chen WT, De Potter T, Geelen P, Sarkozy A, Spera FR, Reichlin T, Roten L, Defaye P, Carabelli A, Boveda S, Bourenane H, Riesinger L, Kochhäuser S, Caixal G, Mont L, Scherr D, Manninger M, Pentimalli F, Cornara S, Klersy C, Auricchio A. Catheter Ablation of Atrial Fibrillation in Patients with Previous Lobectomy or Partial Lung Resection: Long-Term Results of an International Multicenter Study. J Clin Med 2022; 11:jcm11061481. [PMID: 35329807 PMCID: PMC8955984 DOI: 10.3390/jcm11061481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 02/17/2022] [Accepted: 02/28/2022] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Data regarding the efficacy of catheter ablation in patients with atrial fibrillation (AF) and patients' previous history of pulmonary lobectomy/pneumonectomy are scanty. We sought to evaluate the efficacy and long-term follow-up of catheter ablation in this highly selected group of patients. MATERIAL AND METHODS Twenty consecutive patients (8 females, 40%; median age 65.2 years old) with a history of pneumonectomy/lobectomy and paroxysmal or persistent AF, treated by means of pulmonary vein isolation (PVI) at ten participating centers were included. Procedural success, intra-procedural complications, and AF recurrences were considered. RESULTS Fifteen patients had a previous lobectomy and five patients had a complete pneumonectomy. A large proportion (65%) of PV stumps were electrically active and represented a source of firing in 20% of cases. PVI was performed by radiofrequency ablation in 13 patients (65%) and by cryoablation in the remaining 7 cases. Over a median follow up of 29.7 months, a total of 7 (33%) AF recurrences were recorded with neither a difference between patients treated with cryoablation or radiofrequency ablation or between the two genders. CONCLUSIONS Catheter ablation by radiofrequency ablation or cryoablation in patients with pulmonary stumps is feasible and safe. Long-term outcomes are favorable, and a similar efficacy of catheter ablation has been noticed in both males and females.
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Affiliation(s)
- Andrea Demarchi
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland; (A.D.); (G.C.)
| | - Giulio Conte
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland; (A.D.); (G.C.)
| | - Shih-Ann Chen
- School of Medicine, National Yang Ming Chiao Tung University, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (S.-A.C.); (L.-W.L.); (W.-T.C.)
- Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
| | - Li-Wei Lo
- School of Medicine, National Yang Ming Chiao Tung University, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (S.-A.C.); (L.-W.L.); (W.-T.C.)
- Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
| | - Wei-Tso Chen
- School of Medicine, National Yang Ming Chiao Tung University, Taipei Veterans General Hospital, Taipei 11217, Taiwan; (S.-A.C.); (L.-W.L.); (W.-T.C.)
- Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
| | - Tom De Potter
- Cardiovascular Center, Department of Cardiology, Electrophysiology Section, Onze-Lieve-Vrouwziekenhuis (OLV) Hospital, 9300 Aalst, Belgium; (T.D.P.); (P.G.)
| | - Peter Geelen
- Cardiovascular Center, Department of Cardiology, Electrophysiology Section, Onze-Lieve-Vrouwziekenhuis (OLV) Hospital, 9300 Aalst, Belgium; (T.D.P.); (P.G.)
| | - Andrea Sarkozy
- Cardiology Department, Antwerp University Hospital, 2650 Edegem, Belgium; (A.S.); (F.R.S.)
- University of Antwerp, 2650 Edegem, Belgium
| | - Francesco R. Spera
- Cardiology Department, Antwerp University Hospital, 2650 Edegem, Belgium; (A.S.); (F.R.S.)
| | - Tobias Reichlin
- Inselspital, Bern University Hospital, University of Bern, 3012 Bern, Switzerland; (T.R.); (L.R.)
| | - Laurent Roten
- Inselspital, Bern University Hospital, University of Bern, 3012 Bern, Switzerland; (T.R.); (L.R.)
| | - Pascal Defaye
- Cardiology Department, University Hospital of Grenoble Alpes, Grenoble Alpes University, 38043 Grenoble, France; (P.D.); (A.C.)
| | - Adrien Carabelli
- Cardiology Department, University Hospital of Grenoble Alpes, Grenoble Alpes University, 38043 Grenoble, France; (P.D.); (A.C.)
| | - Serge Boveda
- Cardiology-Heart Rhythm Management Department, Clinique Pasteur, 31076 Toulouse, France; (S.B.); (H.B.)
- Vrije Universiteit Brussel (VUB), 1050 Brussels, Belgium
| | - Hamed Bourenane
- Cardiology-Heart Rhythm Management Department, Clinique Pasteur, 31076 Toulouse, France; (S.B.); (H.B.)
| | - Lisa Riesinger
- Klinik für Kardiologie und Angiologie, 45138 Essen, Germany; (L.R.); (S.K.)
| | - Simon Kochhäuser
- Klinik für Kardiologie und Angiologie, 45138 Essen, Germany; (L.R.); (S.K.)
| | - Gala Caixal
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (G.C.); (L.M.)
| | - Lluis Mont
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (G.C.); (L.M.)
| | - Daniel Scherr
- Division of Cardiology, Medical University of Graz, 8036 Graz, Austria; (D.S.); (M.M.)
| | - Martin Manninger
- Division of Cardiology, Medical University of Graz, 8036 Graz, Austria; (D.S.); (M.M.)
| | - Francesco Pentimalli
- S.S. di Elettrofisiologia Cardiaca, S.C. di Cardiologia, Ospedale San Paolo, 17100 Savona, Italy; (F.P.); (S.C.)
| | - Stefano Cornara
- S.S. di Elettrofisiologia Cardiaca, S.C. di Cardiologia, Ospedale San Paolo, 17100 Savona, Italy; (F.P.); (S.C.)
| | - Catherine Klersy
- Service of Clinical Epidemiology and Biometry, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Angelo Auricchio
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland; (A.D.); (G.C.)
- Correspondence:
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Automatic Activity Arising in Cardiac Muscle Sleeves of the Pulmonary Vein. Biomolecules 2021; 12:biom12010023. [PMID: 35053171 PMCID: PMC8773798 DOI: 10.3390/biom12010023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 12/21/2021] [Accepted: 12/22/2021] [Indexed: 02/06/2023] Open
Abstract
Ectopic activity in the pulmonary vein cardiac muscle sleeves can both induce and maintain human atrial fibrillation. A central issue in any study of the pulmonary veins is their difference from the left atrial cardiac muscle. Here, we attempt to summarize the physiological phenomena underlying the occurrence of ectopic electrical activity in animal pulmonary veins. We emphasize that the activation of multiple signaling pathways influencing not only myocyte electrophysiology but also the means of excitation–contraction coupling may be required for the initiation of triggered or automatic activity. We also gather information regarding not only the large-scale structure of cardiac muscle sleeves but also recent studies suggesting that cellular heterogeneity may contribute to the generation of arrythmogenic phenomena and to the distinction between pulmonary vein and left atrial heart muscle.
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6
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Lemery R. Programmed Electrical (Nerve) Stimulation and Extensive LA Denervation in Patients with Paroxysmal Atrial Fibrillation. Heart Rhythm 2021; 19:525-526. [PMID: 34958939 DOI: 10.1016/j.hrthm.2021.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 12/23/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Robert Lemery
- AZ Heart Rhythm Center and St-Joseph Hospital, Dignity Health, Phoenix, Arizona.
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7
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Fang P, Wang J, Wei Y, Wang X, Yang H, Zhang M. Vagal response during circumferential pulmonary vein isolation decreases the recurrence of atrial fibrillation in the short-term in patients with paroxysmal atrial fibrillation: A prospective, observational study. J Electrocardiol 2021; 69:145-150. [PMID: 34763218 DOI: 10.1016/j.jelectrocard.2021.10.007] [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: 01/26/2021] [Revised: 06/02/2021] [Accepted: 10/20/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Vagal responses (VRs) are often seen in patients undergoing circumferential pulmonary vein isolation (CPVI). The possible mechanism of VR is that CPVI creates a coincidental modification of the cardiac ganglionated plexi (GP). AIM To investigate whether the presence of VR during CPVI impacts post-ablation recurrence in patients with paroxysmal atrial fibrillation (AF). METHODS A total of 112 consecutive patients with symptomatic paroxysmal AF who underwent CPVI for the first time from October 1, 2017 to April 30, 2019 were prospectively enrolled, of which two were lost the follow-up. Patients were divided into two groups based on whether VRs were experienced during CPVI. Electrophysiological parameters, including atrial effective refractory period (AERP) and mean heart rate (MHR), were measured before and post-ablation. The patients were then followed up for 12 months. RESULTS The 71 patients who had experienced VRs during CPVI were assigned to group B, and the remaing 39 patients who did not experience VR during CPVI were assigned to group A. The MHR (79.6 ± 8.3 vs 70.4 ± 7.8 b/min; p ≤ 0.001) was significantly higher; and the AERP (244 ± 22 vs 215 ± 27 ms; p ≤ 0.001) was prolonged in group B compared to respective pre-ablation values. There were no significant changes in the MHR (69.5 ± 7.9 vs 69.7 ± 8.7 b/min; p = 0.541) and AERP (224 ± 28 vs 225 ± 33 ms; p = 0.542) in group A. During the first four months of follow-up after ablation, the MHR gradually slowed down to pre-procedural levels in group B. The recurrence of AF (6/71 vs 7/39; p = 0.023) significantly decreased in group B relative to group A during the first 6 months after ablation, but there was no significant difference (14/71 vs 9/39; p = 0.598) at the end of the 12-month follow-up period. CONCLUSION Patients with paroxysmal AF who develop VRs during CPVI might have a decreased recurrence of AF and accelerated MHR in the short-term.
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Affiliation(s)
- Ping Fang
- Department of Cardiology, The First Affifiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, Anhui 241001, China.
| | - Jinfeng Wang
- Department of Cardiology, The First Affifiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, Anhui 241001, China
| | - Youquan Wei
- Department of Cardiology, The First Affifiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, Anhui 241001, China
| | - Xianghai Wang
- Department of Cardiology, The First Affifiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, Anhui 241001, China
| | - Hao Yang
- Department of Cardiology, The First Affifiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, Anhui 241001, China
| | - Meijun Zhang
- Department of Intensive Care Medicine, The First Affifiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, Anhui 241001, China.
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8
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Zandstra TE, Notenboom RGE, Wink J, Kiès P, Vliegen HW, Egorova AD, Schalij MJ, De Ruiter MC, Jongbloed MRM. Asymmetry and Heterogeneity: Part and Parcel in Cardiac Autonomic Innervation and Function. Front Physiol 2021; 12:665298. [PMID: 34603069 PMCID: PMC8481575 DOI: 10.3389/fphys.2021.665298] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 08/26/2021] [Indexed: 11/17/2022] Open
Abstract
The cardiac autonomic nervous system (cANS) regulates cardiac adaptation to different demands. The heart is an asymmetrical organ, and in the selection of adequate treatment of cardiac diseases it may be relevant to take into account that the cANS also has sidedness as well as regional differences in anatomical, functional, and molecular characteristics. The left and right ventricles respond differently to adrenergic stimulation. Isoforms of nitric oxide synthase, which plays an important role in parasympathetic function, are also distributed asymmetrically across the heart. Treatment of cardiac disease heavily relies on affecting left-sided heart targets which are thought to apply to the right ventricle as well. Functional studies of the right ventricle have often been neglected. In addition, many principles have only been investigated in animals and not in humans. Anatomical and functional heterogeneity of the cANS in human tissue or subjects is highly valuable for understanding left- and right-sided cardiac pathology and for identifying novel treatment targets and modalities. Within this perspective, we aim to provide an overview and synthesis of anatomical and functional heterogeneity of the cANS in tissue or subjects, focusing on the human heart.
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Affiliation(s)
- Tjitske E Zandstra
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Robbert G E Notenboom
- Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, Netherlands
| | - Jeroen Wink
- Department of Anesthesiology, Leiden University Medical Center, Leiden, Netherlands
| | - Philippine Kiès
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Hubert W Vliegen
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Anastasia D Egorova
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Martin J Schalij
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Marco C De Ruiter
- Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, Netherlands
| | - Monique R M Jongbloed
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands.,Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, Netherlands
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9
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Nogami A, Kurita T, Abe H, Ando K, Ishikawa T, Imai K, Usui A, Okishige K, Kusano K, Kumagai K, Goya M, Kobayashi Y, Shimizu A, Shimizu W, Shoda M, Sumitomo N, Seo Y, Takahashi A, Tada H, Naito S, Nakazato Y, Nishimura T, Nitta T, Niwano S, Hagiwara N, Murakawa Y, Yamane T, Aiba T, Inoue K, Iwasaki Y, Inden Y, Uno K, Ogano M, Kimura M, Sakamoto S, Sasaki S, Satomi K, Shiga T, Suzuki T, Sekiguchi Y, Soejima K, Takagi M, Chinushi M, Nishi N, Noda T, Hachiya H, Mitsuno M, Mitsuhashi T, Miyauchi Y, Miyazaki A, Morimoto T, Yamasaki H, Aizawa Y, Ohe T, Kimura T, Tanemoto K, Tsutsui H, Mitamura H. JCS/JHRS 2019 guideline on non-pharmacotherapy of cardiac arrhythmias. J Arrhythm 2021; 37:709-870. [PMID: 34386109 PMCID: PMC8339126 DOI: 10.1002/joa3.12491] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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10
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The Electrophysiology of Atrial Fibrillation: From Basic Mechanisms to Catheter Ablation. Cardiol Res Pract 2021; 2021:4109269. [PMID: 34194824 PMCID: PMC8203364 DOI: 10.1155/2021/4109269] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 04/11/2021] [Accepted: 05/27/2021] [Indexed: 11/17/2022] Open
Abstract
The electrophysiology of atrial fibrillation (AF) has always been a deep mystery in understanding this complex arrhythmia. The pathophysiological mechanisms of AF are complex and often remain unclear despite extensive research. Therefore, the implementation of basic science knowledge to clinical practice is challenging. After more than 20 years, pulmonary vein isolation (PVI) remains the cornerstone ablation strategy for maintaining the sinus rhythm (SR). However, there is no doubt that, in many cases, especially in persistent and long-standing persistent AF, PVI is not enough, and eventually, the restoration of SR occurs after additional intervention in the rest of the atrial myocardium. Substrate mapping is a modern challenge as it can reveal focal sources or rotational activities that may be responsible for maintaining AF. Whether these areas are actually the cause of the AF maintenance is unknown. If this really happens, then the targeted ablation may be the solution; otherwise, more rough techniques such as atrial compartmentalization may prove to be more effective. In this article, we attempt a broad review of the known pathophysiological mechanisms of AF, and we present the recent efforts of advanced technology initially to reveal the electrical impulse during AF and then to intervene effectively with ablation.
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11
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Nogami A, Kurita T, Abe H, Ando K, Ishikawa T, Imai K, Usui A, Okishige K, Kusano K, Kumagai K, Goya M, Kobayashi Y, Shimizu A, Shimizu W, Shoda M, Sumitomo N, Seo Y, Takahashi A, Tada H, Naito S, Nakazato Y, Nishimura T, Nitta T, Niwano S, Hagiwara N, Murakawa Y, Yamane T, Aiba T, Inoue K, Iwasaki Y, Inden Y, Uno K, Ogano M, Kimura M, Sakamoto SI, Sasaki S, Satomi K, Shiga T, Suzuki T, Sekiguchi Y, Soejima K, Takagi M, Chinushi M, Nishi N, Noda T, Hachiya H, Mitsuno M, Mitsuhashi T, Miyauchi Y, Miyazaki A, Morimoto T, Yamasaki H, Aizawa Y, Ohe T, Kimura T, Tanemoto K, Tsutsui H, Mitamura H. JCS/JHRS 2019 Guideline on Non-Pharmacotherapy of Cardiac Arrhythmias. Circ J 2021; 85:1104-1244. [PMID: 34078838 DOI: 10.1253/circj.cj-20-0637] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Akihiko Nogami
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | - Haruhiko Abe
- Department of Heart Rhythm Management, University of Occupational and Environmental Health, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital
| | - Toshiyuki Ishikawa
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University
| | - Katsuhiko Imai
- Department of Cardiovascular Surgery, Kure Medical Center and Chugoku Cancer Center
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kaoru Okishige
- Department of Cardiology, Yokohama City Minato Red Cross Hospital
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Masahiko Goya
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | | | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School
| | - Morio Shoda
- Department of Cardiology, Tokyo Women's Medical University
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | - Yoshihiro Seo
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | - Hiroshi Tada
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui
| | | | - Yuji Nakazato
- Department of Cardiovascular Medicine, Juntendo University Urayasu Hospital
| | - Takashi Nishimura
- Department of Cardiac Surgery, Tokyo Metropolitan Geriatric Hospital
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School
| | - Shinichi Niwano
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | | | - Yuji Murakawa
- Fourth Department of Internal Medicine, Teikyo University Hospital Mizonokuchi
| | - Teiichi Yamane
- Department of Cardiology, Jikei University School of Medicine
| | - Takeshi Aiba
- Division of Arrhythmia, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Koichi Inoue
- Division of Arrhythmia, Cardiovascular Center, Sakurabashi Watanabe Hospital
| | - Yuki Iwasaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Kikuya Uno
- Arrhythmia Center, Chiba Nishi General Hospital
| | - Michio Ogano
- Department of Cardiovascular Medicine, Shizuoka Medical Center
| | - Masaomi Kimura
- Advanced Management of Cardiac Arrhythmias, Hirosaki University Graduate School of Medicine
| | | | - Shingo Sasaki
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine
| | | | - Tsuyoshi Shiga
- Department of Cardiology, Tokyo Women's Medical University
| | - Tsugutoshi Suzuki
- Departments of Pediatric Electrophysiology, Osaka City General Hospital
| | - Yukio Sekiguchi
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | - Kyoko Soejima
- Arrhythmia Center, Second Department of Internal Medicine, Kyorin University Hospital
| | - Masahiko Takagi
- Division of Cardiac Arrhythmia, Department of Internal Medicine II, Kansai Medical University
| | - Masaomi Chinushi
- School of Health Sciences, Faculty of Medicine, Niigata University
| | - Nobuhiro Nishi
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Takashi Noda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hitoshi Hachiya
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | | | | | - Yasushi Miyauchi
- Department of Cardiovascular Medicine, Nippon Medical School Chiba-Hokusoh Hospital
| | - Aya Miyazaki
- Department of Pediatric Cardiology, Congenital Heart Disease Center, Tenri Hospital
| | - Tomoshige Morimoto
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Hiro Yamasaki
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | | | - Takeshi Kimura
- Department of Cardiology, Graduate School of Medicine and Faculty of Medicine, Kyoto University
| | - Kazuo Tanemoto
- Department of Cardiovascular Surgery, Kawasaki Medical School
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12
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Aksu T, Yalin K, Bozyel S, Gopinathannair R, Gupta D. The anatomical basis behind the neuromodulation effects associated with pulmonary vein isolation. J Cardiovasc Electrophysiol 2021; 32:1733-1736. [PMID: 33844395 DOI: 10.1111/jce.15038] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/12/2021] [Accepted: 04/01/2021] [Indexed: 10/21/2022]
Abstract
The anatomical basis underlying the neuromodulation effects seen with pulmonary vein (PV) isolation (PVI) is not fully understood. Left atrial (LA) electro-anatomical maps of 38 patients who underwent catheter cardioneuroablation for vagally mediated bradycarrhythmias were studied. During the procedure, LA ganglionic plexi (GPs) were systematically identified and ablated. Design PVI lines were created on these maps by a blinded observer, and the degree of overlap between four GPs and individual PVs was assessed. Here, 1.7 ± 7 (35.5 ± 17.0%) of the total 31.6 ± 10 GP ablation sites per patient were found to overlap with the design PVI lines. The overlap was higher for the right-sided GPs, p < .001. The degree of GP-PV overlap varied: 1 PV in 5 (13.2%) patients, 2 PVs in 15 (39.2%), 3 PVs in 16 (42.1%), and all 4 PVs in 2 (5.3%). No patient had zero GP-PV overlap. A vagal response was most commonly observed during ablation at the left superior GP (89.5%), while a sympathetic response was observed most often during the right superior GP ablation (97.4%). Some degree of GP-PV antral overlap is the norm, and this is more pronounced for the right-sided PVs. There is significant individual variability in the degree of overlap which may explain why neuromodulation effects are not seen universally following PVI.
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Affiliation(s)
- Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, Istanbul, Turkey
| | - Kivanc Yalin
- Department of Cardiology, Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Serdar Bozyel
- Department of Cardiology, Kocaeli Derince Training and Research Hospital, University of Health Sciences, Kocaeli, Turkey
| | - Rakesh Gopinathannair
- Department of Cardiology, Kansas City Heart Rhythm Institute and Research Foundation, Overland Park, Kansas, USA
| | - Dhiraj Gupta
- Department of Cardiology, Liverpool Center for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
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13
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Vlachos K, Derval N, Pambrun T, Duchateau J, Martin CA, Bazoukis G, Frontera A, Takigawa M, Nakashima T, Efremidis M, Letsas KP, Bourier F, André C, Krisai P, Ramirez FD, Kamakura T, Takagi T, Nakatani Y, Tixier R, Chauvel R, Welte N, Kitamura T, Cheniti G, Sacher F, Jaïs P, Haïssaguerre M, Hocini M. Ligament of Marshall ablation for persistent atrial fibrillation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:782-791. [PMID: 33687764 DOI: 10.1111/pace.14208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 02/09/2021] [Accepted: 02/28/2021] [Indexed: 11/29/2022]
Abstract
Beyond pulmonary vein isolation, the two main additional strategies: Cox-Maze procedure or targeting of electrical signatures (focal bursts, rotational activities, meandering wavelets), remain controversial. High-density mapping of these arrhythmias has demonstrated firstly that a patchy lesion set is highly proarrhythmogenic, favoring macro-re-entry through conduction slowing and providing pivots for localized re-entry. Secondly, discrete anatomical structures such as the Vein or Ligament of Marshall (VOM/LOM) and the coronary sinus (CS) have epicardial muscular bundles that are more frequently involved in re-entry than previously thought. The Marshall Bundle can be ablated at any point along its course from the mid-to-distal coronary sinus to the left atrial appendage. If necessary, the VOM may be directly ablated using ethanol infusion to eliminate PV contributions and produce conduction block across the mistral isthmus. Ethanol ablation of the VOM, supplemented with RF ablation, may be more effective in producing conduction block at the mitral isthmus than repeat RF ablation alone.
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Affiliation(s)
- Konstantinos Vlachos
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Nicolas Derval
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Thomas Pambrun
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Josselin Duchateau
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Claire A Martin
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France.,Cardiology Department, Royal Papworth Hospital, Cambridge, UK
| | - George Bazoukis
- Arrhythmia Unit, Laboratory of Cardiac Electrophysiology, Second Cardiology Department, Evangelismos General Hospital of Athens, Greece
| | - Antonio Frontera
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Masateru Takigawa
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Takashi Nakashima
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Michael Efremidis
- Arrhythmia Unit, Laboratory of Cardiac Electrophysiology, Second Cardiology Department, Evangelismos General Hospital of Athens, Greece.,Onassis Cardiac Surgery Centre, Athens, Greece
| | - Konstantinos P Letsas
- Arrhythmia Unit, Laboratory of Cardiac Electrophysiology, Second Cardiology Department, Evangelismos General Hospital of Athens, Greece
| | - Felix Bourier
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Clémentine André
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Philipp Krisai
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - F Daniel Ramirez
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Tsukasa Kamakura
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Takamitsu Takagi
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Yosuke Nakatani
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Romain Tixier
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Remi Chauvel
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Nicolas Welte
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Takeshi Kitamura
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Ghassen Cheniti
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Frédéric Sacher
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Pierre Jaïs
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Michel Haïssaguerre
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
| | - Mélèze Hocini
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux France, Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque (Centre Hospitalier Universtaire de Bordeaux), Talence, Aquitaine, France
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14
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Tonegawa-Kuji R, Yamagata K, Kusano K. Coughing as a potentially effective induction method of atrial tachycardia: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2021; 4:1-5. [PMID: 33442651 PMCID: PMC7793191 DOI: 10.1093/ehjcr/ytaa459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/05/2020] [Accepted: 11/05/2020] [Indexed: 11/25/2022]
Abstract
Background Cough-induced atrial tachycardia (AT) is extremely rare and its electrical origin remains largely unknown. Atrial tachycardias triggered by pharyngeal stimulation, such as swallowing or speech, appears to be more common and the majority of them originate from the superior vena cava or right superior pulmonary vein (PV). Only one case of swallow-triggered AT with right inferior pulmonary vein (RIPV) origin has been reported to date. Case summary We present a case of a 41-year-old man with recurring episodes of AT in the daytime. He underwent electrophysiology study without sedation. Atrial tachycardia was not observed when the patient entered the examination room and could not be induced with conventional induction procedures. By having the patient cough periodically on purpose, transient AT with P-wave morphology similar to the clinical AT was consistently induced. Activation mapping of the AT revealed a centrifugal pattern with the earliest activity localized inside the RIPV. After successful radiofrequency isolation of the right PV, AT was no longer inducible. Discussion In the rare case of cough-induced AT originating from the RIPV, the proximity of the inferior right ganglionated plexi (GP) suggests the role of GP in triggering tachycardia. This is the first report that demonstrates voluntary cough was used to induce AT. In such cases that induction of AT is difficult using conventional methods, having the patient cough may be an effective induction method that is easy to attempt.
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Affiliation(s)
- Reina Tonegawa-Kuji
- Division of Arrhythmia and Electrophysiology, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1, Kishibe-Shimmachi, Suita, 564-8565 Osaka, Japan
| | - Kenichiro Yamagata
- Division of Arrhythmia and Electrophysiology, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1, Kishibe-Shimmachi, Suita, 564-8565 Osaka, Japan
| | - Kengo Kusano
- Division of Arrhythmia and Electrophysiology, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 6-1, Kishibe-Shimmachi, Suita, 564-8565 Osaka, Japan
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15
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Dalmasso C, Leachman JR, Osborn JL, Loria AS. Sensory signals mediating high blood pressure via sympathetic activation: role of adipose afferent reflex. Am J Physiol Regul Integr Comp Physiol 2019; 318:R379-R389. [PMID: 31868518 DOI: 10.1152/ajpregu.00079.2019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Blood pressure regulation in health and disease involves a balance between afferent and efferent signals from multiple organs and tissues. Although there are numerous reviews focused on the role of sympathetic nerves in different models of hypertension, few have revised the contribution of afferent nerves innervating adipose tissue and their role in the development of obesity-induced hypertension. Both clinical and basic research support the beneficial effects of bilateral renal denervation in lowering blood pressure. However, recent studies revealed that afferent signals from adipose tissue, in an adipose-brain-peripheral pathway, could contribute to the increased sympathetic activation and blood pressure during obesity. This review focuses on the role of adipose tissue afferent reflexes and briefly describes a number of other afferent reflexes modulating blood pressure. A comprehensive understanding of how multiple afferent reflexes contribute to the pathophysiology of essential and/or obesity-induced hypertension may provide significant insights into improving antihypertensive therapeutic approaches.
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Affiliation(s)
- Carolina Dalmasso
- Department of Pharmacology and Nutritional Sciences, College of Medicine, University of Kentucky, Lexington, Kentucky
| | - Jacqueline R Leachman
- Department of Pharmacology and Nutritional Sciences, College of Medicine, University of Kentucky, Lexington, Kentucky
| | - Jeffrey L Osborn
- Department of Biology, College of Arts and Sciences, University of Kentucky, Lexington, Kentucky
| | - Analia S Loria
- Department of Pharmacology and Nutritional Sciences, College of Medicine, University of Kentucky, Lexington, Kentucky
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16
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Yan F, Zhao S, Wu W, Xie Z, Guo Q. Different effects of additional ganglion plexus ablation on catheter and surgical ablation for atrial fibrillation: a systemic review and meta‐analysis. J Cardiovasc Electrophysiol 2019; 30:3039-3049. [PMID: 31670479 DOI: 10.1111/jce.14258] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 10/08/2019] [Accepted: 10/26/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Fangbing Yan
- Laboratory of Cardiovascular Diseases, Regenerative Medicine Research Center, West China HospitalSichuan UniversityChengdu China
| | - Shuyan Zhao
- Department of Cardiology, Yunnan Fuwai Cardiovascular HospitalKunming Medical UniversityKunming China
| | - Wenchao Wu
- Laboratory of Cardiovascular Diseases, Regenerative Medicine Research Center, West China HospitalSichuan UniversityChengdu China
| | - Zhuxinyue Xie
- Department of Cardiology, Yunnan Fuwai Cardiovascular HospitalKunming Medical UniversityKunming China
| | - Qiuzhe Guo
- Laboratory of Cardiovascular Diseases, Regenerative Medicine Research Center, West China HospitalSichuan UniversityChengdu China
- Department of Cardiac Surgery, Yunnan Fuwai Cardiovascular HospitalKunming Medical UniversityKunming China
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Valderrábano M, Peterson LE, Bunge R, Prystash M, Dave AS, Nagueh S, Kleiman NS. Vein of Marshall ethanol infusion for persistent atrial fibrillation: VENUS and MARS clinical trial design. Am Heart J 2019; 215:52-61. [PMID: 31279972 DOI: 10.1016/j.ahj.2019.04.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 04/29/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Although pulmonary vein isolation (PVI) is effective in the treatment of paroxysmal atrial fibrillation (AF), its success rates in persistent AF are suboptimal. Ablation strategies to improve outcomes including additional lesions beyond PVI have not consistently shown benefit. Recurrence as perimitral flutter (PMF) is a common form of ablation failure. The vein of Marshall (VOM) contains myocardial connections and abundant sympathetic and parasympathetic innervation implicated in the genesis and maintenance of AF, and is anatomically co-localized with the mitral isthmus, the ablation target of PMF. VOM ethanol infusion is effective in targeting these arrhythmia substrates. OBJECTIVE To test the safety and efficacy of VOM ethanol infusion when added to PVI in patients undergoing either de novo ablation of persistent AF or after a previous ablation failure. STUDY DESIGN VENUS-AF and MARS-AF are prospective, multicenter, randomized, controlled trials. VENUS-AF will enroll patients undergoing their first catheter ablation of persistent AF. MARS-AF will enroll patients undergoing ablation after previous ablation failure(s). Patients (n = 405) will be randomized to PVI alone or in combination with VOM ethanol infusion. The primary endpoints include procedural safety and freedom from AF or atrial tachycardia (AT) of more than 30 seconds on 30-day continuous event monitors at 6 and 12 months after randomization procedure (single-procedure success), off antiarrhythmic drugs. Key secondary endpoints include AF burden, freedom from AF/AT after repeat procedures and quality of life. CONCLUSIONS The VENUS-AF and MARS-AF will determine the safety and potential rhythm control benefit of VOM ethanol infusion when added to PVI in patients with persistent AF undergoing de novo or repeat ablation, respectively.
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18
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Grandi E, Ripplinger CM. Antiarrhythmic mechanisms of beta blocker therapy. Pharmacol Res 2019; 146:104274. [PMID: 31100336 DOI: 10.1016/j.phrs.2019.104274] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 05/04/2019] [Accepted: 05/13/2019] [Indexed: 02/07/2023]
Abstract
Sympathetic activity plays an important role in modulation of cardiac rhythm. Indeed, while exerting positive tropic effects in response to physiologic and pathologic stressors, β-adrenergic stimulation influences cardiac electrophysiology and can lead to disturbances of the heart rhythm and potentially lethal arrhythmias, particularly in pathological settings. For this reason, β-blockers are widely utilized clinically as antiarrhythmics. In this review, the molecular mechanisms of β-adrenergic action in the heart, the cellular and tissue level cardiac responses to β-adrenergic stimulation, and the clinical use of β-blockers as antiarrhythmic agents are reviewed. We emphasize the complex interaction between cardiomyocyte signaling, contraction, and electrophysiology occurring over multiple time- and spatial-scales during pathophysiological responses to β-adrenergic stimulation. An integrated understanding of this complex system is essential for optimizing therapies aimed at preventing arrhythmias.
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Affiliation(s)
- Eleonora Grandi
- Department of Pharmacology, University of California Davis, United States.
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Abstract
Purpose of Review An overview of recent literature regarding pathophysiology, risk factors, prophylaxis, and treatment of new-onset atrial fibrillation (AF) in post-cardiac surgical patients. Recent Findings AF is the most frequent adverse event after cardiac surgery with significant associated morbidity, mortality, and financial cost. Its causes are multifactorial, and models to stratify patients into risk categories are progressing but a consistent, evidence-based system has not yet been developed. Pharmacologic and surgical interventions to prevent and treat this complication have been an area of ongoing research and recent societal guidelines reflect this. Summary Inconsistencies remain surrounding how to best identify higher-risk AF patients, which interventions should be used to prevent and treat AF, and which patient groups should receive these interventions. The evidence for these available strategies and their place in contemporary guidelines are summarized.
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Suwalski G, Suwalski P. Successful surgical ablation of atrial fibrillation does not disturb long-term sinus rhythm variability. Interact Cardiovasc Thorac Surg 2018; 27:520-524. [DOI: 10.1093/icvts/ivy117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 03/19/2018] [Indexed: 02/04/2023] Open
Affiliation(s)
- Grzegorz Suwalski
- Department of Cardiac Surgery, Military Institute of Medicine, Warsaw, Poland
| | - Piotr Suwalski
- Department of Cardiac Surgery, Central Clinical Hospital of Ministry of Interior, Warsaw, Poland
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Radiofrequency Catheter Ablation For Atrial Fibrillation: Approaches And Outcomes. Heart Lung Circ 2017; 26:941-949. [DOI: 10.1016/j.hlc.2017.05.125] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 05/16/2017] [Indexed: 01/27/2023]
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Maurer T, Kuck KH. The quest for durable lesions in catheter ablation of atrial fibrillation - technological advances in radiofrequency catheters and balloon devices. Expert Rev Med Devices 2017; 14:621-631. [PMID: 28723304 DOI: 10.1080/17434440.2017.1358086] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Atrial fibrillation is the most common cardiac arrhythmia and represents a growing clinical, social and economic challenge. Catheter ablation for symptomatic atrial fibrillation has evolved from an experimental procedure into a widespread therapy and offers a safe and effective treatment option. A prerequisite for durable PVI are transmural and contiguous circumferential lesions around the pulmonary veins. However, electrical reconnection of initially isolated pulmonary veins remains a primary concern and is a dominant factor for arrhythmia recurrence during long-term follow up. Areas covered: This article discusses the physiology of lesion formation using radiofrequency-, cryo- or laser- energy for pulmonary vein isolation and provides a detailed review of recent technological advancements in the field of radiofrequency catheters and balloon devices. Finally, future directions and upcoming developments for the interventional treatment of atrial fibrillation are discussed. Expert commentary: Durable conduction block across deployed myocardial lesions is mandatory not only for PVI but for any other cardiac ablation strategy as well. A major improvement urgently expected is the intraprocedural real-time distinction of durable lesions from interposed gaps with only transiently impaired electrical conduction. Furthermore, a simplification of ablation tools used for PVI is required to reduce the high technical complexity of the procedure.
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Affiliation(s)
- Tilman Maurer
- a Department of Cardiology , Asklepios Klinik St. Georg , Hamburg , Germany
| | - Karl-Heinz Kuck
- a Department of Cardiology , Asklepios Klinik St. Georg , Hamburg , Germany
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Kawashima T, Sato F. Anatomical visualization of neural course and distribution of anterior ascending aortic plexus. Heart Vessels 2017; 32:1262-1270. [PMID: 28516212 DOI: 10.1007/s00380-017-0993-4] [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: 02/11/2017] [Accepted: 05/12/2017] [Indexed: 11/30/2022]
Abstract
The aim of this study was to document the detailed anatomy of neural course and distribution on the anterior ascending aorta, to identify the high and low density areas of the anterior ascending aortic plexus for further understandings in cardiovascular surgery. The embalmed hearts of 42 elderly individuals were submacroscopically and microscopically examined, after excluding any that were macroscopically abnormal. With its origins in the anterior ascending aortic plexus, the right coronary plexus substantially innervated the right coronary artery, the right atrium and ventricle, and the sinus node. The intensive neural area extending from 10 mm lateral to the interatrial groove below the pericardial reflection as far as the right coronary artery opening contained almost all the right coronary plexus in 61.3% of patients, and more than 40.9% of the total nerve volume of the anterior ascending aortic plexus. Our findings suggest that the most superior and lateral area on the ascending aorta show the lowest neural density of right coronary component in the anterior ascending aortic plexus and the high density areas are invisible in right lateral field of view as seen in the right trans-axillary MICS approach.
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Affiliation(s)
- Tomokazu Kawashima
- Department of Anatomy, School of Medicine, Toho University, 5-21-16 Omori-Nish, Ota-ku, Tokyo, 143-8540, Japan.
| | - Fumi Sato
- Department of Anatomy, School of Medicine, Toho University, 5-21-16 Omori-Nish, Ota-ku, Tokyo, 143-8540, Japan
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24
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Suwalski G, Marczewska MM, Kaczejko K, Mróz J, Gryszko L, Cwetsch A, Skrobowski A. Left Atrial Ganglionated Plexi Detection is Related to Heart Rate and Early Recurrence of Atrial Fibrillation after Surgical Ablation. Braz J Cardiovasc Surg 2017; 32:118-124. [PMID: 28492793 PMCID: PMC5409258 DOI: 10.21470/1678-9741-2016-0059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 12/26/2016] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION: Left atrial ganglionated plexi ablation is an adjuvant technique used to increase the success rate of surgical ablation of atrial fibrillation. Ganglionated plexi ablation requires previous detection. We aimed to assess determinants of successful ganglionated plexi detection and to correlate range of ganglionated plexi ablation with risk of early atrial fibrillation recurrence. METHODS: The study involved 34 consecutive patients referred for surgical coronary revascularization with concomitant atrial fibrillation ablation. Ganglionated plexi detection was done by inducing vagal reflexes in the area of the pulmonary veins and left atrial fat pads. RESULTS: Detection of GP was successful in 85% of the patients. There was no difference in preoperative characteristics nor in atrial fibrillation type between patients in whom ganglionated plexi detection was successful and others. The number of detected ganglionated plexi correlated significantly only with preoperative resting heart rate. Significant negative correlation was found in patients with preoperative heart rate>75 beat/min in terms of total number of detected ganglionated plexi (P=0.04). Average number of detected ganglionated plexi was significantly higher in patients with in-hospital atrial fibrillation recurrence requiring electrical cardioversion (3.8±3) in comparison to rest of the study population (2±1.3; P=0.02). In patients in whom 4 or more ganglionated plexi were detected, significantly increased risk of in-hospital atrial fibrillation recurrence was observed (OR 15; 95% CI 1.5-164; P=0.003). CONCLUSION: Left atrial ganglionated plexi detection was unsuccessful in a considerable percentage of patients. Preoperative heart rate significantly influenced positive ganglionated plexi detection and number of ablated ganglia. Higher number of detected ganglionated plexi was related with early recurrence of atrial fibrillation.
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Affiliation(s)
- Grzegorz Suwalski
- Department of Cardiac Surgery, Military Institute of Medicine, Warsaw, Poland
| | - Małgorzata M Marczewska
- Department of Internal Diseases, Arterial Hypertension and Angiology, Medical University of Warsaw, Poland
| | - Kamil Kaczejko
- Department of Cardiac Surgery, Military Institute of Medicine, Warsaw, Poland
| | - Jakub Mróz
- Department of Cardiac Surgery, Military Institute of Medicine, Warsaw, Poland
| | - Leszek Gryszko
- Department of Cardiac Surgery, Military Institute of Medicine, Warsaw, Poland
| | - Andrzej Cwetsch
- Department of Cardiac Surgery, Military Institute of Medicine, Warsaw, Poland
| | - Andrzej Skrobowski
- Department of Cardiac Surgery, Military Institute of Medicine, Warsaw, Poland
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Xu FQ, Yu RH, Guo JJ, Bai R, Liu N, An YI, Guo XY, Tang RB, Long DEY, Sang CH, DU X, Dong JZ, Ma CS. Catheter Ablation of Recurrent Paroxysmal Atrial Fibrillation: Is Gap-Closure Combining Ganglionated Plexi Ablation More Effective? PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 40:672-682. [PMID: 28251658 DOI: 10.1111/pace.13064] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 02/15/2017] [Accepted: 02/16/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND For repeat treatment with paroxysmal atrial fibrillation (PAF) recurrence, gap-closure at pulmonary vein ostia alone is not enough. Many recent studies indicated that ganglionated plexi (GPs) denervation could reduce the recurrence of AF. However, it is unclear whether the clinical outcomes of additional GP ablation plus pulmonary veins (PVs ) reisolation during a repeat procedure were associated with less recurrence in PAF patients. The purpose of this study was to evaluate if a repeat procedure of GP ablation (GPA) combining repeated procedure of pulmonary vein isolation (re-PVI), i.e., gap-closure, can offer additional benefit for patients with PAF recurrence. METHOD A total of 123 consecutive patients with PAF recurrence who underwent success repeat procedures were retrospectively analyzed in our center (2014-2015). Note that 64 patients (group 1, GPA group) were performed with GPA plus re-PVI, while 59 patients (group 2, re-PVI group) had re-PVI (gap-closure) alone. Organized atrial tachycardias (OATs) documented or induced at the end of the procedure were all mapped and ablated. Patients were scheduled for a 12-month follow-up. Clinical presentation and outcome data for the two groups were assessed. RESULT At the 12-month follow-up 58 of 64 patients (90.6%) in group 1 and 46 of 59 patients (78%) in group 2 remained in sinus rhythm (SR) off antiarrhythmia drugs (AADs) (P = 0.045). CONCLUSION GPA conferred incremental benefit when performed in addition to re-PVI in patients with PAF recurrence; the GPA group yielded higher success rates than the re-PVI group.
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Affiliation(s)
- Feng-Qiang Xu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China.,Department of Cardiology, The Affiliated Cardiovascular Hospital of Qingdao University, Qingdao, China
| | - Rong-Hui Yu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Jun-Jie Guo
- Department of Cardiology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Rong Bai
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Nian Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Y I An
- Department of Cardiology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xue-Yuan Guo
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Ri-Bo Tang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - DE-Yong Long
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Cai-Hua Sang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Xin DU
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Jian-Zeng Dong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Chang-Sheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China
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26
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Wake E, Brack K. Characterization of the intrinsic cardiac nervous system. Auton Neurosci 2016; 199:3-16. [DOI: 10.1016/j.autneu.2016.08.006] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 06/29/2016] [Accepted: 08/03/2016] [Indexed: 11/29/2022]
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27
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Sun W, Zheng L, Qiao Y, Shi R, Hou B, Wu L, Guo J, Zhang S, Yao Y. Catheter Ablation as a Treatment for Vasovagal Syncope: Long-Term Outcome of Endocardial Autonomic Modification of the Left Atrium. J Am Heart Assoc 2016; 5:JAHA.116.003471. [PMID: 27402231 PMCID: PMC5015383 DOI: 10.1161/jaha.116.003471] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Autonomic modification through catheter ablation of ganglionated plexi (GPs) in the left atrium has been reported previously as a treatment for vasovagal syncope. This study aimed to observe the long‐term outcome in a larger cohort. Methods and Results A total of 57 consecutive patients (aged 43.2±13.4 years; 35 women) with refractory vasovagal syncope were enrolled, and high‐frequency stimulation and anatomically guided GP ablation were performed in 10 and 47 cases, respectively. A total of 127 GP sites with positive vagal response were successfully elicited and ablated, including 52 left superior, 19 left lateral, 18 left inferior, 27 right anterior, and 11 right inferior GPs. During follow‐up of 36.4±22.2 months (range 12–102 months), 52 patients (91.2%) remained free from syncope. Prodromes recurred in 16 patients. No statistical differences were found between the high‐frequency stimulation and anatomically guided ablation groups in either freedom from syncope (100% versus 89.4%, P=0.348) or recurrent prodromes (50% versus 76.6%, P=0.167). The deceleration capacity, heart rate, and heart rate variability measurements demonstrated a reduced vagal tone lasting for at least 12 months after the procedure, with improved tolerance of repeated head‐up tilt testing. No complications were observed except for transient sinus tachycardia that occurred in 1 patient. Conclusions Left atrial GP ablation showed excellent long‐term clinical outcomes and might be considered as a therapeutic option for patients with symptomatic vasovagal syncope.
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Affiliation(s)
- Wei Sun
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lihui Zheng
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Qiao
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rui Shi
- Department of Cardiovascular Medicine, The First Affiliated Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, Shaanxi, China
| | - Bingbo Hou
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lingmin Wu
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinrui Guo
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu Zhang
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Yao
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Cheng WL, Kao YH, Chen SA, Chen YJ. Pathophysiology of cancer therapy-provoked atrial fibrillation. Int J Cardiol 2016; 219:186-94. [PMID: 27327505 DOI: 10.1016/j.ijcard.2016.06.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 06/11/2016] [Indexed: 02/07/2023]
Abstract
Atrial fibrillation (AF) occurs with increased frequency in cancer patients, especially in patients who undergo surgery or chemotherapy. AF disturbs the prognosis of cancer patients and challenges therapeutic outcomes of cancer treatment. Elucidating the mechanisms of cancer-induced AF would help identify specific strategies for preventing AF occurrence. In addition to concurrent risk factors of cancer and AF, cancer surgery, side effects of anticancer agents, and cancer-associated immune responses play critical roles in the genesis of AF. In this review, we provide succinct potential mechanisms of AF genesis in cancer patients.
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Affiliation(s)
- Wan-Li Cheng
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yu-Hsun Kao
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Medical Education and Research, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Shih-Ann Chen
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Cardiology and Cardiovascular Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Jen Chen
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
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29
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Kapa S, DeSimone CV, Asirvatham SJ. Innervation of the heart: An invisible grid within a black box. Trends Cardiovasc Med 2016; 26:245-57. [PMID: 26254961 PMCID: PMC4706824 DOI: 10.1016/j.tcm.2015.07.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 06/30/2015] [Accepted: 07/02/2015] [Indexed: 02/07/2023]
Abstract
Autonomic control of cardiovascular function is mediated by a complex interplay between central, peripheral, and innate cardiac components. This interplay is what mediates the normal cardiovascular response to physiologic and pathologic stressors, including blood pressure, cardiac contractile function, and arrhythmias. However, in order to understand how modern therapies directly affecting autonomic function may be harnessed to treat various cardiovascular disease states requires an intimate understanding of anatomic and physiologic features of the innervation of the heart. Thus, in this review, we focus on defining features of the central, peripheral, and cardiac components of cardiac innervation, how each component may contribute to dysregulation of normal cardiac function in various disease states, and how modulation of these components may offer therapeutic options for these diseases.
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Affiliation(s)
- Suraj Kapa
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Christopher V DeSimone
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Samuel J Asirvatham
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN; Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, MN.
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30
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Kyriacou A, Hayat S, Qureshi N, Peters NS, Kanagaratnam P, Lim PB. Dissociated pulmonary vein potentials: Expression of the cardiac autonomic nervous system following pulmonary vein isolation? HeartRhythm Case Rep 2016; 1:401-405. [PMID: 26949598 PMCID: PMC4750876 DOI: 10.1016/j.hrcr.2015.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- Andreas Kyriacou
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Sajad Hayat
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Norman Qureshi
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Nicholas S Peters
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Prapa Kanagaratnam
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Phang Boon Lim
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Imperial College Healthcare NHS Trust, London, United Kingdom
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31
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Ripplinger CM, Noujaim SF, Linz D. The nervous heart. PROGRESS IN BIOPHYSICS AND MOLECULAR BIOLOGY 2016; 120:199-209. [PMID: 26780507 DOI: 10.1016/j.pbiomolbio.2015.12.015] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 12/29/2015] [Accepted: 12/31/2015] [Indexed: 12/23/2022]
Abstract
Many cardiac electrophysiological abnormalities are accompanied by autonomic nervous system dysfunction. Here, we review mechanisms by which the cardiac nervous system controls normal and abnormal excitability and may contribute to atrial and ventricular tachyarrhythmias. Moreover, we explore the potential antiarrhythmic and/or arrhythmogenic effects of modulating the autonomic nervous system by several strategies, including ganglionated plexi ablation, vagal and spinal cord stimulations, and renal sympathetic denervation as therapies for atrial and ventricular arrhythmias.
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Affiliation(s)
- Crystal M Ripplinger
- Department of Pharmacology, University of California Davis, 451 Health Sciences Drive, Davis, CA 95616, USA.
| | - Sami F Noujaim
- Molecular Pharmacology and Physiology, University of South Florida, 12901 Bruce B Downs Blvd, Tampa, FL 33612, USA.
| | - Dominik Linz
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, 66421 Homburg, Saar, Germany.
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32
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Syed FF, Oral H. Electrophysiological Perspectives on Hybrid Ablation of Atrial Fibrillation. J Atr Fibrillation 2015; 8:1290. [PMID: 27957227 DOI: 10.4022/jafib.1290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 10/05/2015] [Accepted: 12/14/2015] [Indexed: 12/14/2022]
Abstract
To overcome limitations of minimally invasive surgical ablation as a standalone procedure in eliminating atrial fibrillation (AF), hybrid approaches incorporating adjunctive endovascular catheter ablation have been proposed in recent years. The endovascular component targets residual conduction gaps and identifies additional electrophysiological targets with the goal of minimizing recurrent atrial arrhythmia. We performed a systematic review of published studies of hybrid AF ablation, analyzing 432 pooled patients (19% paroxysmal, 29% persistent, 52% long-standing persistent) treated using three different approaches: A. bilateral thoracoscopy with bipolar radiofrequency (RF) clamp-based approach; B. right thoracoscopic suction monopolar RF catheter-based approach; and C. subxiphoid posterior pericardioscopic ("convergent") approach. Freedom from recurrence off antiarrhythmic medications at 12 months was seen in 88.1% [133/151] for A, 73.4% [47/64] for B, and 59.3% [80/135] for C, with no significant difference between paroxysmal (76.9%) and persistent/long-standing persistent AF (73.4%). Death and major surgical complications were reported in 8.5% with A, 0% with B and 8.6% with C. A critical appraisal of hybrid ablation is presented, drawing from experiences and insights published over the years on catheter ablation of AF, with a discussion of the rationale underlying hybrid ablation, its strengths and limitations, where it may have a unique role in clinical management of patients with AF, which questions remain unanswered and areas for further investigation.
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Affiliation(s)
- Faisal F Syed
- Cardiac Arrhythmia Service, University of Michigan, Ann Arbor, MI
| | - Hakan Oral
- Cardiac Arrhythmia Service, University of Michigan, Ann Arbor, MI
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33
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Lee G, Hunter RJ, Lovell MJ, Finlay M, Ullah W, Baker V, Dhinoja MB, Sporton S, Earley MJ, Schilling RJ. Use of a contact force-sensing ablation catheter with advanced catheter location significantly reduces fluoroscopy time and radiation dose in catheter ablation of atrial fibrillation. Europace 2015; 18:211-8. [DOI: 10.1093/europace/euv186] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 04/27/2015] [Indexed: 11/13/2022] Open
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Abstract
Optimal cardiac function depends on proper timing of excitation and contraction in various regions of the heart, as well as on appropriate heart rate. This is accomplished via specialized electrical properties of various components of the system, including the sinoatrial node, atria, atrioventricular node, His-Purkinje system, and ventricles. Here we review the major regionally determined electrical properties of these cardiac regions and present the available data regarding the molecular and ionic bases of regional cardiac function and dysfunction. Understanding these differences is of fundamental importance for the investigation of arrhythmia mechanisms and pharmacotherapy.
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Affiliation(s)
- Daniel C Bartos
- Department of Pharmacology, University of California Davis, Davis, California, USA
| | - Eleonora Grandi
- Department of Pharmacology, University of California Davis, Davis, California, USA
| | - Crystal M Ripplinger
- Department of Pharmacology, University of California Davis, Davis, California, USA
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35
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Kanmanthareddy A, Vallakati A, Reddy Yeruva M, Dixit S, DI Biase L, Mansour M, Boolani H, Gunda S, Bunch TJ, Day JD, Ruskin JN, Buddam A, Koripalli S, Bommana S, Natale A, Lakkireddy D. Pulmonary vein isolation for atrial fibrillation in the postpneumonectomy population: a feasibility, safety, and outcomes study. J Cardiovasc Electrophysiol 2015; 26:385-389. [PMID: 25588757 DOI: 10.1111/jce.12619] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 12/01/2014] [Accepted: 12/08/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pulmonary vein isolation (PVI) of the remnant pulmonary vein (PV) stumps in pneumonectomy patients has not been well characterized. METHODS This is a multicenter observational study of patients with a remnant PV stump after pneumonectomy. Consecutive patients with a history of pneumonectomy and who had undergone RF ablation for drug refractory AF were identified from the AF database at the participating institutions. RESULTS There were 15 patients in whom pneumonectomy was performed, for resection of tumors in 10, infection in 4, and bullae in 1 patient and who underwent RF ablation for AF. The mean age was 63 ± 7 years. The stumps were from the right lower PV in 5, left upper PV in 5, left lower PV in 3, and right upper PV in 2 patients. All the PV stumps were electrically active with PV potentials and 9 (60%) of them had triggered activity. PVI was performed in 14 and focal isolation in 1 patient. At 1-year follow-up, 80% were free of AF, off of antiarrhythmic medications. CONCLUSION PV stumps in AF patients with previous pneumonectomy are electrically active and are frequently the sites of active firing. Isolation of these PV stumps can be accomplished safely and effectively using catheter ablation with no practical concern for PV stenosis or compromising PV stump integrity.
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Affiliation(s)
| | - Ajay Vallakati
- Division of Cardiology, Case Western Reserve University, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Madhu Reddy Yeruva
- KU Cardiovascular Research Institute, The University of Kansas Hospital and Medical Center, Kansas City, Kansas, USA
| | - Sanjay Dixit
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Luigi DI Biase
- Division of Cardiology, Albert Einstein Montefiore Medical Center, Bronx, New York, USA
| | - Moussa Mansour
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hemant Boolani
- Division of Cardiology, Howard University Hospital, Washington, District of Columbia, USA
| | - Sampath Gunda
- KU Cardiovascular Research Institute, The University of Kansas Hospital and Medical Center, Kansas City, Kansas, USA
| | - T Jared Bunch
- KU Cardiovascular Research Institute, The University of Kansas Hospital and Medical Center, Kansas City, Kansas, USA
| | - John D Day
- Division of Cardiology, Intermountain Heart Institute, Salt Lake City, Utah, USA
| | - Jeremy N Ruskin
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Avanija Buddam
- KU Cardiovascular Research Institute, The University of Kansas Hospital and Medical Center, Kansas City, Kansas, USA
| | - Sandeep Koripalli
- KU Cardiovascular Research Institute, The University of Kansas Hospital and Medical Center, Kansas City, Kansas, USA
| | - Sudharani Bommana
- KU Cardiovascular Research Institute, The University of Kansas Hospital and Medical Center, Kansas City, Kansas, USA
| | - Andrea Natale
- Division of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Dhanunjaya Lakkireddy
- KU Cardiovascular Research Institute, The University of Kansas Hospital and Medical Center, Kansas City, Kansas, USA
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Krul SP, Meijborg VM, Berger WR, Linnenbank AC, Driessen AH, van Boven WJ, Wilde AA, de Bakker JM, Coronel R, de Groot JR. Disparate response of high-frequency ganglionic plexus stimulation on sinus node function and atrial propagation in patients with atrial fibrillation. Heart Rhythm 2014; 11:1743-51. [DOI: 10.1016/j.hrthm.2014.04.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Indexed: 11/29/2022]
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37
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Takami M, Yamashiro K, Sakamoto Y, Satoh K, Suzuki T. Impact of ganglionated plexi ablation on high-frequency stimulation-induced changes in atrial fibrillation cycle length in the pulmonary vein. J Arrhythm 2014. [DOI: 10.1016/j.joa.2013.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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38
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Waks JW, Josephson ME. Mechanisms of Atrial Fibrillation - Reentry, Rotors and Reality. Arrhythm Electrophysiol Rev 2014; 3:90-100. [PMID: 26835073 DOI: 10.15420/aer.2014.3.2.90] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 08/08/2014] [Indexed: 01/02/2023] Open
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice, yet our understanding of the mechanisms that initiate and sustain this arrhythmia remains quite poor. Over the last 50 years, various mechanisms of AF have been proposed, yet none has been consistently observed in both experimental studies and in humans. Recently, there has been increasing interest in understanding how spiral waves or rotors - which are specific, organised forms of functional reentry - sustain human AF and how they might be therapeutic targets for catheter-based ablation. The following review describes the historical understanding of reentry and AF mechanisms from earlier in the 20th century, advances in our understanding of mechanisms that are able to sustain AF with a focus on rotors and complex fractionated atrial electrograms (CFAEs), and how the study of AF mechanisms has resulted in new strategies for treating AF with novel forms of catheter ablation.
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Affiliation(s)
- Jonathan W Waks
- Clinical Fellow in Cardiac Electrophysiology, Harvard Medical School, Harvard-Thorndike Electrophysiology Institute and Arrhythmia Service, Beth Israel Deaconess Medical Center, Boston, US
| | - Mark E Josephson
- Herman C. Dana Professor of Medicine, Harvard Medical School, Chief of the Cardiovascular Division, Beth Israel Deaconess Medical Center and Director, Harvard-Thorndike Electrophysiology Institute and Arrhythmia Service, Beth Israel Deaconess Medical Center, Boston, US
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Báez-Escudero JL, Keida T, Dave AS, Okishige K, Valderrábano M. Ethanol infusion in the vein of Marshall leads to parasympathetic denervation of the human left atrium: implications for atrial fibrillation. J Am Coll Cardiol 2014; 63:1892-901. [PMID: 24561151 DOI: 10.1016/j.jacc.2014.01.032] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Revised: 12/18/2013] [Accepted: 01/07/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This study sought to determine whether ethanol infusion in the vein of Marshall (VOM) can ablate intrinsic cardiac nerves (ICN). BACKGROUND ICN cluster around the left atrial epicardium and are implicated in the genesis of atrial fibrillation (AF). METHODS Patients undergoing catheter AF ablation underwent adjunctive ethanol injection in the VOM. A multipolar catheter was introduced in the VOM and used for high-frequency stimulation (HFS), either as HFS with P-wave synchronized (SynchHFS), 30 pulses, 100 Hz (n = 8) or as HFS with 3 to 10 s bursts (BurstHFS), 33 Hz (n = 72) at 25 mA for 1-ms duration. Atrioventricular (AV) nodal conduction slowing (asystole >2 s or R-R interval prolongation >50%) and AF inducibility were assessed before and after VOM ethanol infusion. Up to 4 1-ml infusions of 98% ethanol were delivered via an angioplasty balloon in the VOM. RESULTS SynchHFS induced AF in 8 of 8 patients. In 4 of 8 AF initiated spontaneously without VOM capture. No parasympathetic responses were elicited by SynchHFS. BurstHFS was performed in 32 patients undergoing de novo AF ablation (Group 1) and 40 patients undergoing repeat ablation (Group 2). Parasympathetic responses were found in all 32 Group 1 patients and in 75% of Group 2 patients. After VOM ethanol infusion, parasympathetic responses were abolished in all patients (both groups). There were no acute complications related to VOM ethanol infusion. CONCLUSIONS The VOM contains ICN that connect with the AV node and can trigger AF. Retrograde ethanol infusion in the VOM reliably eliminates local ICN responses. The VOM is a vascular route for ICN-targeting therapies.
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Affiliation(s)
- José L Báez-Escudero
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research Institute, The Methodist Hospital, Houston, Texas
| | - Takehiko Keida
- Department of Cardiology, Edogawa Hospital, Tokyo, Japan
| | - Amish S Dave
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research Institute, The Methodist Hospital, Houston, Texas
| | | | - Miguel Valderrábano
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research Institute, The Methodist Hospital, Houston, Texas.
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Abstract
Atrial fibrillation is the most common arrhythmia affecting patients today. Disease prevalence is increasing at an alarming rate worldwide, and is associated with often catastrophic and costly consequences, including heart failure, syncope, dementia, and stroke. Therapies including anticoagulants, anti-arrhythmic medications, devices, and non-pharmacologic procedures in the last 30 years have improved patients' functionality with the disease. Nonetheless, it remains imperative that further research into AF epidemiology, genetics, detection, and treatments continues to push forward rapidly as the worldwide population ages dramatically over the next 20 years.
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Affiliation(s)
- Thomas M. Munger
- Heart Rhythm Services, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA;
| | - Li-Qun Wu
- Department of Cardiology, Rui Jin Hospital, Shanghai Jiao Tong University of Medicine, Shanghai 200025, China;
| | - Win K. Shen
- Division of Cardiovascular Diseases, Mayo Clinic, Phoenix, AZ 85054, USA.
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Townsley MI. Structure and composition of pulmonary arteries, capillaries, and veins. Compr Physiol 2013; 2:675-709. [PMID: 23606929 DOI: 10.1002/cphy.c100081] [Citation(s) in RCA: 156] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The pulmonary vasculature comprises three anatomic compartments connected in series: the arterial tree, an extensive capillary bed, and the venular tree. Although, in general, this vasculature is thin-walled, structure is nonetheless complex. Contributions to structure (and thus potentially to function) from cells other than endothelial and smooth muscle cells as well as those from the extracellular matrix should be considered. This review is multifaceted, bringing together information regarding (i) classification of pulmonary vessels, (ii) branching geometry in the pulmonary vascular tree, (iii) a quantitative view of structure based on morphometry of the vascular wall, (iv) the relationship of nerves, a variety of interstitial cells, matrix proteins, and striated myocytes to smooth muscle and endothelium in the vascular wall, (v) heterogeneity within cell populations and between vascular compartments, (vi) homo- and heterotypic cell-cell junctional complexes, and (vii) the relation of the pulmonary vasculature to that of airways. These issues for pulmonary vascular structure are compared, when data is available, across species from human to mouse and shrew. Data from studies utilizing vascular casting, light and electron microscopy, as well as models developed from those data, are discussed. Finally, the need for rigorous quantitative approaches to study of vascular structure in lung is highlighted.
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Affiliation(s)
- Mary I Townsley
- University of South Alabama, Department of Physiology, and Center for Lung Biology, Mobile, Alabama, USA.
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Corradi D, Callegari S, Gelsomino S, Lorusso R, Macchi E. Morphology and pathophysiology of target anatomical sites for ablation procedures in patients with atrial fibrillation. Int J Cardiol 2013; 168:1769-78. [DOI: 10.1016/j.ijcard.2013.06.141] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 06/30/2013] [Indexed: 10/26/2022]
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Denervation as a common mechanism underlying different pulmonary vein isolation strategies for paroxysmal atrial fibrillation: evidenced by heart rate variability after ablation. ScientificWorldJournal 2013; 2013:569564. [PMID: 24058286 PMCID: PMC3766572 DOI: 10.1155/2013/569564] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2013] [Accepted: 07/19/2013] [Indexed: 11/17/2022] Open
Abstract
BACKGROUNDS Segmental and circumferential pulmonary vein isolations (SPVI and CPVI) have been demonstrated to be effective therapies for paroxysmal atrial fibrillation (PAF). PVI is well established as the endpoint of different ablation techniques, whereas it may not completely account for the long-term success. METHODS 181 drug-refractory symptomatic PAF patients were referred for segmental or circumferential PVI (SPVI = 67; CPVI = 114). Heart rate variability (HRV) was assessed before and after the final ablation. RESULTS After following up for 62.23 ± 12.75 months, patients underwent 1.41 ± 0.68 procedures in average, and the success rates in SPVI and CPVI groups were comparable. 119 patients were free from AF recurrence (SPVI-S, n = 43; CPVI-S, n = 76). 56 patients had recurrent episodes (SPVI-R, n = 21; CPVI-R, n = 35). Either ablation technique decreased HRV significantly. Postablation SDNN and rMSSD were significantly lower in SPVI-S and CPVI-S subgroups than in SPVI-R and CPVI-R subgroups (SPVI-S versus SPVI-R: SDNN 91.8 ± 32.6 versus 111.5 ± 36.2 ms, rMSSD 47.4 ± 32.3 versus 55.2 ± 35.2 ms; CPVI-S versus CPVI-R: SDNN 83.0 ± 35.6 versus 101.0 ± 40.7 ms, rMSSD 41.1 ± 22.9 versus 59.2 ± 44.8 ms; all P < 0.05). Attenuation of SDNN and rMSSD remained for 12 months in SPVI-S and CPVI-S subgroups, whereas it recovered earlier in SPVI-R and CPVI-R subgroups. Multivariate logistic regression analysis identified SDNN as the only predictor of long-term success. CONCLUSIONS Beyond PVI, denervation may be a common mechanism underlying different ablation strategies for PAF.
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Sánchez-Quintana D, López-Mínguez JR, Pizarro G, Murillo M, Cabrera JA. Triggers and anatomical substrates in the genesis and perpetuation of atrial fibrillation. Curr Cardiol Rev 2013; 8:310-26. [PMID: 22920484 PMCID: PMC3492815 DOI: 10.2174/157340312803760721] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2012] [Revised: 05/14/2012] [Accepted: 05/31/2012] [Indexed: 12/21/2022] Open
Abstract
The definition of atrial fibrillation (AF) as a functional electrical disorder does not reflect the significant underlying structural abnormalities. Atrial and Pulmonary Vein (PV) muscle sleeve microstructural remodeling is present, and establishes a vulnerable substrate for AF maintenance. In spite of an incomplete understanding of the anatomo-functional basis for AF, current evidence demonstrates that this arrhythmia usually requires a trigger for initiation and a vulnerable electrophysiological and/or anatomical substrate for maintenance. It is still unclear whether the trigger mechanisms include focal enhanced automaticity, triggered activity and/or micro re-entry from myocardial tissue. Initiation of AF can be favored by both parasympathetic and sympathetic stimulation, which also seem to play a role in maintaining AF. Finally, evolving clinical evidence demonstrates that inflammation is associated with new-onset and recurrent AF through a mechanism that possibly involves cellular degeneration, apoptosis, and subsequent atrial fibrosis.
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Affiliation(s)
- Damián Sánchez-Quintana
- Departamento de Anatomía y Biología Celular, Facultad de Medicina, Universidad de Extremadura, Badajoz, Spain.
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Zarzoso M, Rysevaite K, Milstein ML, Calvo CJ, Kean AC, Atienza F, Pauza DH, Jalife J, Noujaim SF. Nerves projecting from the intrinsic cardiac ganglia of the pulmonary veins modulate sinoatrial node pacemaker function. Cardiovasc Res 2013; 99:566-75. [PMID: 23559611 DOI: 10.1093/cvr/cvt081] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS Pulmonary vein ganglia (PVG) are targets for atrial fibrillation ablation. However, the functional relevance of PVG to the normal heart rhythm remains unclear. Our aim was to investigate whether PVG can modulate sinoatrial node (SAN) function. METHODS AND RESULTS Forty-nine C57BL and seven Connexin40+/EGFP mice were studied. We used tyrosine-hydroxylase (TH) and choline-acetyltransferase immunofluorescence labelling to characterize adrenergic and cholinergic neural elements. PVG projected postganglionic nerves to the SAN, which entered the SAN as an extensive, mesh-like neural network. PVG neurones were adrenergic, cholinergic, and biphenotypic. Histochemical characterization of two human embryonic hearts showed similarities between mouse and human neuroanatomy: direct neural communications between PVG and SAN. In Langendorff perfused mouse hearts, PVG were stimulated using 200-2000 ms trains of pulses (300 μs, 400 µA, 200 Hz). PVG stimulation caused an initial heart rate (HR) slowing (36 ± 9%) followed by acceleration. PVG stimulation in the presence of propranolol caused HR slowing (43 ± 13%) that was sustained over 20 beats. PVG stimulation with atropine progressively increased HR. Time-course effects were enhanced with 1000 and 2000 ms trains (P < 0.05 vs. 200 ms). In optical mapping, PVG stimulation shifted the origin of SAN discharges. In five paroxysmal AF patients undergoing pulmonary vein ablation, application of radiofrequency energy to the PVG area during sinus rhythm produced a decrease in HR similar to that observed in isolated mouse hearts. CONCLUSION PVG have functional and anatomical biphenotypic characteristics. They can have significant effects on the electrophysiological control of the SAN.
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Affiliation(s)
- Manuel Zarzoso
- Center for Arrhythmia Research, University of Michigan, Ann Arbor, MI, USA
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Sánchez-Quintana D, Pizarro G, López-Mínguez JR, Ho SY, Cabrera JA. Standardized review of atrial anatomy for cardiac electrophysiologists. J Cardiovasc Transl Res 2013; 6:124-44. [PMID: 23389853 DOI: 10.1007/s12265-013-9447-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 01/22/2013] [Indexed: 10/27/2022]
Abstract
Catheter ablation of cardiac arrhythmias has rapidly evolved from a highly experimental procedure to a standard form of therapy for various tachyarrhythmias. The advances in this field have included, first, the development of techniques of catheter ablation that often requires the precise destruction of minute amounts of arrhythmogenic tissues and, second, techniques of resynchronization therapy that require pacing different parts of the ventricles. A detailed prepocedural knowledge of cardiac anatomy can improve the safety of the procedure and its rate success. It helps the electrophysiologist to choose the appropiate region for ablation, shortening the procedural time. The atrial anatomy structures are usually localized before ablation by different imaging techniques such as fluoroscopy, electroanatomic mapping, intracardiac echocardiography or multidetector computed tomography. In this review, we describe the normal anatomy of the atria, highlighting the landmarks of interest to intervencional cardiologist, stressing their relationship to other structures. This article is part of a JCTR special issue on Cardiac Anatomy.
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Affiliation(s)
- Damián Sánchez-Quintana
- Departamento de Anatomía y Biología Celular, Facultad de Medicina, Universidad de Extremadura, Avenida de Elvas s/n, 06071 Badajoz, Spain.
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Wong MCG, Kalman JM, Ling LH, Medi C, Teh A, Lee G, Kumar S, Morton JB, Kistler PM. Left septal atrial tachycardias: electrocardiographic and electrophysiologic characterization of a paraseptal focus. J Cardiovasc Electrophysiol 2012; 24:413-8. [PMID: 23252694 DOI: 10.1111/jce.12049] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The objective was to characterize the electrocardiographic and electrophysiological features of focal atrial tachycardia (FAT) originating from the left septum (LS). BACKGROUND FAT is recognized to occur at predefined anatomic locations rather than randomly throughout the atria. We describe the ECG and EP features of ATs originating from the LS as an important site for apparent perinodal tachycardias. METHODS Nine patients presenting with LS FAT from a consecutive series of 384 underwent EP/RFA for symptomatic FAT. RESULTS The mean age was 56 ± 12 years; 7 female with symptoms for 36 ± 28 months. P wave morphology (PWM) was negative/positive in lead V1 and across the precordial leads and negative or negative/positive in inferior leads in all patients. Tachycardia was incessant in 6 out of 9 patients with a mean tachycardia cycle length 421 ± 56 milliseconds. His A was ahead of P wave in all patients (mean -15 ± 5 milliseconds) and earlier than CS proximal (mean 4 ± 9 milliseconds). Successful acute focal ablation achieved at a mean of 31 ± 12 milliseconds ahead of P wave with no recurrences at a mean follow-up of 30 ± 28 months. CONCLUSION Although the left septum is an uncommon site for focal AT an awareness of this location for harboring foci is particularly important when mapping apparently right-sided septal tachycardias.
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Affiliation(s)
- Michael C G Wong
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
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Abstract
Catheter ablation is at the forefront of the management of a range of atrial arrhythmias. In this Series paper, we discuss the underlying mechanisms and the current role of catheter ablation for the three most common atrial arrhythmias encountered in clinical practice: focal atrial tachycardia, atrial flutter, and atrial fibrillation. The mechanisms of focal atrial tachycardia and atrial flutter are well understood, and these arrhythmias are amenable to curative catheter ablation with high success rates. In most cases, paroxysmal atrial fibrillation is initiated by triggers located within pulmonary vein musculature. Circumferential ablation to isolate this musculature is associated with high success rates for elimination of paroxysmal atrial fibrillation in selected populations. Because of the problem of recurrent pulmonary vein connection, more than one procedure will be needed in about 30% of patients, and new technologies are being developed to reduce this occurrence. The mechanisms that sustain persistent atrial fibrillation are not well understood and are the subject of continuing investigation. As such, ablation approaches and technologies for this arrhythmia are still evolving.
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Affiliation(s)
- Geoffrey Lee
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, VIC, Australia
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2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. J Interv Card Electrophysiol 2012; 33:171-257. [PMID: 22382715 DOI: 10.1007/s10840-012-9672-7] [Citation(s) in RCA: 256] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
This is a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation, developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology and the European Cardiac Arrhythmia Society (ECAS), and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). This is endorsed by the governing bodies of the ACC Foundation, the AHA, the ECAS, the EHRA, the STS, the APHRS, and the HRS.
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HIGUCHI KOJI, MARROUCHE NASSIRF. Still Looking for the Right Mechanism as a Target During Ablation of Atrial Fibrillation. J Cardiovasc Electrophysiol 2012; 23:601-3. [DOI: 10.1111/j.1540-8167.2012.02303.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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