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Weng CJ, Li CH, Lin YJ, Chang SL, Hu YF, Chung FP, Liao JN, Tuan TC, Chao TF, Lin CY, Chang TY, Ling-Kuo, Liu CM, Liu SH, Chen WT, Chang WH, Chương NKT, Kuo MR, Kao PH, Li GY, Ahliah I, Chen SA, Lo LW. Skin sympathetic nerve activity in different ablation settings for atrial fibrillation. J Cardiol 2024; 83:306-312. [PMID: 37838339 DOI: 10.1016/j.jjcc.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 10/04/2023] [Accepted: 10/06/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND Modifying the autonomic system after catheter ablation may prevent the recurrence of atrial fibrillation (AF). Evaluation of skin sympathetic nerve activity (SKNA) is a noninvasive method for the assessment of sympathetic activity. However, there are few studies on the effects of different energy settings on SKNA. OBJECTIVE To investigate the changes in SKNA in different energy settings and their relationship to AF ablation outcomes. METHODS Seventy-two patients with paroxysmal and persistent AF were enrolled. Forty-three patients received AF ablation with the conventional (ConV) energy setting (low power for long duration), and 29 patients using a high-power, short-duration (HPSD) strategy. The SKNA was acquired from the right arm 1 day before and after the radiofrequency ablation. We analyzed the SKNA and ablation outcomes in the different energy settings. RESULTS Both groups had a similar baseline average SKNA (aSKNA). We found that the median aSKNA increased significantly from 446.82 μV to 805.93 μV (p = 0.003) in the ConV group but not in the HPSD group. In the ConV group, patients without AF recurrence had higher aSKNA values. However, the 1-year AF recurrence rate remained similar between both groups (35 % vs. 28 %, p = 0.52). CONCLUSION The post-ablation aSKNA levels increased significantly in the ConV group but did not change significantly in the HPSD group, which may reflect different neuromodulatory effects. However, the one-year AF recurrence rates were similar for both groups. These results demonstrate that the HPSD strategy has durable lesion creation but less lesion depth, which may reduce collateral damage.
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Affiliation(s)
- Chi-Jen Weng
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Cheng-Hung Li
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Lin Chang
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yu-Feng Hu
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Fa-Po Chung
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jo-Nan Liao
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ta-Chuan Tuan
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tze-Fan Chao
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chin-Yu Lin
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ting-Yung Chang
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ling-Kuo
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chih-Min Liu
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shin-Huei Liu
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wei-Tso Chen
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Division of Cardiology, Department of Medicine, Hualien Tzu Chi Hospital, Hualien, Taiwan
| | - Wen-Han Chang
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Nguyễn Khắc Thiên Chương
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ming-Ren Kuo
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Pei-Heng Kao
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Guan-Yi Li
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ibrahim Ahliah
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shih-Ann Chen
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan; National Chung Hsing University, Taichung, Taiwan.
| | - Li-Wei Lo
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Saleeb-Mousa J, Nathanael D, Coney AM, Kalla M, Brain KL, Holmes AP. Mechanisms of Atrial Fibrillation in Obstructive Sleep Apnoea. Cells 2023; 12:1661. [PMID: 37371131 DOI: 10.3390/cells12121661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Obstructive sleep apnoea (OSA) is a strong independent risk factor for atrial fibrillation (AF). Emerging clinical data cite adverse effects of OSA on AF induction, maintenance, disease severity, and responsiveness to treatment. Prevention using continuous positive airway pressure (CPAP) is effective in some groups but is limited by its poor compliance. Thus, an improved understanding of the underlying arrhythmogenic mechanisms will facilitate the development of novel therapies and/or better selection of those currently available to complement CPAP in alleviating the burden of AF in OSA. Arrhythmogenesis in OSA is a multifactorial process characterised by a combination of acute atrial stimulation on a background of chronic electrical, structural, and autonomic remodelling. Chronic intermittent hypoxia (CIH), a key feature of OSA, is associated with long-term adaptive changes in myocyte ion channel currents, sensitising the atria to episodic bursts of autonomic reflex activity. CIH is also a potent driver of inflammatory and hypoxic stress, leading to fibrosis, connexin downregulation, and conduction slowing. Atrial stretch is brought about by negative thoracic pressure (NTP) swings during apnoea, promoting further chronic structural remodelling, as well as acutely dysregulating calcium handling and electrical function. Here, we provide an up-to-date review of these topical mechanistic insights and their roles in arrhythmia.
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Affiliation(s)
- James Saleeb-Mousa
- School of Biomedical Sciences, Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
- School of Biomedical Sciences, Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Demitris Nathanael
- School of Biomedical Sciences, Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Andrew M Coney
- School of Biomedical Sciences, Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
- School of Biomedical Sciences, Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Manish Kalla
- School of Biomedical Sciences, Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
- Queen Elizabeth Hospital, Birmingham B15 2GW, UK
| | - Keith L Brain
- School of Biomedical Sciences, Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
- School of Biomedical Sciences, Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Andrew P Holmes
- School of Biomedical Sciences, Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
- School of Biomedical Sciences, Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
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3
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Barron L, Moon MR. Commentary: Atrial fibrillation: Surgeons can do more than operate. J Thorac Cardiovasc Surg 2023; 165:e175-e176. [PMID: 35489834 DOI: 10.1016/j.jtcvs.2022.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 03/29/2022] [Accepted: 03/30/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Lauren Barron
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Mo.
| | - Marc R Moon
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Texas Heart Insititute, Houston, Tex
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Chakraborty P, Farhat K, Po SS, Armoundas AA, Stavrakis S. Autonomic Nervous System and Cardiac Metabolism: Links Between Autonomic and Metabolic Remodeling in Atrial Fibrillation. JACC Clin Electrophysiol 2023:S2405-500X(23)00117-2. [PMID: 37086229 DOI: 10.1016/j.jacep.2023.02.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/27/2023] [Accepted: 02/16/2023] [Indexed: 04/23/2023]
Abstract
Simultaneous activation of the sympathetic and parasympathetic nervous systems is crucial for the initiation of paroxysmal atrial fibrillation (AF). However, unbalanced activation of the sympathetic system is characteristic of autonomic remodeling in long-standing persistent AF. Moreover, the adrenergic activation-induced metabolic derangements provide a milieu for acute AF and promote the transition from the paroxysmal to the persistent phase of AF. On the other hand, cholinergic activation ameliorates the maladaptive metabolic remodeling in the face of metabolic challenges. Selective inhibition of the sympathetic system and restoration of the balance of the cholinergic system by neuromodulation is emerging as a novel nonpharmacologic strategy for managing AF. This review explores the link between cardiac autonomic and metabolic remodeling and the potential roles of different autonomic modulation strategies on atrial metabolic aberrations in AF.
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Affiliation(s)
- Praloy Chakraborty
- Cardiovascular Section, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Kassem Farhat
- Cardiovascular Section, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Sunny S Po
- Cardiovascular Section, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Antonis A Armoundas
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA; Broad Institute, Massachusetts Institute of Technology, Boston, Massachusetts, USA
| | - Stavros Stavrakis
- Cardiovascular Section, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA.
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Regions of Highly Recurrent Electrogram Morphology With Low Cycle Length Reflect Substrate for Atrial Fibrillation. JACC. BASIC TO TRANSLATIONAL SCIENCE 2022; 8:68-84. [PMID: 36777167 PMCID: PMC9911322 DOI: 10.1016/j.jacbts.2022.07.011] [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: 12/20/2021] [Revised: 07/20/2022] [Accepted: 07/20/2022] [Indexed: 11/27/2022]
Abstract
Traditional anatomically guided ablation and attempts to perform electrogram-guided atrial fibrillation (AF) ablation (CFAE, DF, and FIRM) have not been shown to be sufficient treatment for persistent AF. Using biatrial high-density electrophysiologic mapping in a canine rapid atrial pacing model of AF, we systematically investigated the relationship of electrogram morphology recurrence (EMR) (Rec% and CLR) with established AF electrogram parameters and tissue characteristics. Rec% correlates with stability of rotational activity and with the spatial distribution of parasympathetic nerve fibers. These results have indicated that EMR may therefore be a viable therapeutic target in persistent AF.
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Key Words
- AF, atrial fibrillation
- AI, anisotropy index
- CFAE, complex fractionated atrial electrogram
- CLR, cycle length of the most recurrent electrogram morphology
- DF, dominant frequency
- EGM, electrogram
- EMR, electrogram morphology recurrence
- FFT, fast Fourier transform
- FI, fractionation interval
- FIRM, focal impulse and rotor mapping
- LAA, left atrial appendage
- LAFW, left atrial free wall
- LAT, local activation time
- OI, organization index
- PLA, posterior left atrium
- PV, pulmonary vein
- RAA, right atrial appendage
- RAFW, right atrial free wall
- RAP, rapid atrial pacing
- Rec%, recurrence percentage
- ShEn, Shannon’s entropy
- arrhythmias
- atrial fibrillation
- fibrosis
- mapping
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6
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Mehra R, Tjurmina OA, Ajijola OA, Arora R, Bolser DC, Chapleau MW, Chen PS, Clancy CE, Delisle BP, Gold MR, Goldberger JJ, Goldstein DS, Habecker BA, Handoko ML, Harvey R, Hummel JP, Hund T, Meyer C, Redline S, Ripplinger CM, Simon MA, Somers VK, Stavrakis S, Taylor-Clark T, Undem BJ, Verrier RL, Zucker IH, Sopko G, Shivkumar K. Research Opportunities in Autonomic Neural Mechanisms of Cardiopulmonary Regulation: A Report From the National Heart, Lung, and Blood Institute and the National Institutes of Health Office of the Director Workshop. JACC Basic Transl Sci 2022; 7:265-293. [PMID: 35411324 PMCID: PMC8993767 DOI: 10.1016/j.jacbts.2021.11.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 11/09/2021] [Accepted: 11/10/2021] [Indexed: 12/22/2022]
Abstract
This virtual workshop was convened by the National Heart, Lung, and Blood Institute, in partnership with the Office of Strategic Coordination of the Office of the National Institutes of Health Director, and held September 2 to 3, 2020. The intent was to assemble a multidisciplinary group of experts in basic, translational, and clinical research in neuroscience and cardiopulmonary disorders to identify knowledge gaps, guide future research efforts, and foster multidisciplinary collaborations pertaining to autonomic neural mechanisms of cardiopulmonary regulation. The group critically evaluated the current state of knowledge of the roles that the autonomic nervous system plays in regulation of cardiopulmonary function in health and in pathophysiology of arrhythmias, heart failure, sleep and circadian dysfunction, and breathing disorders. Opportunities to leverage the Common Fund's SPARC (Stimulating Peripheral Activity to Relieve Conditions) program were characterized as related to nonpharmacologic neuromodulation and device-based therapies. Common themes discussed include knowledge gaps, research priorities, and approaches to develop novel predictive markers of autonomic dysfunction. Approaches to precisely target neural pathophysiological mechanisms to herald new therapies for arrhythmias, heart failure, sleep and circadian rhythm physiology, and breathing disorders were also detailed.
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Key Words
- ACE, angiotensin-converting enzyme
- AD, autonomic dysregulation
- AF, atrial fibrillation
- ANS, autonomic nervous system
- Ach, acetylcholine
- CNS, central nervous system
- COPD, chronic obstructive pulmonary disease
- CSA, central sleep apnea
- CVD, cardiovascular disease
- ECG, electrocardiogram
- EV, extracellular vesicle
- GP, ganglionated plexi
- HF, heart failure
- HFpEF, heart failure with preserved ejection fraction
- HFrEF, heart failure with reduced ejection fraction
- HRV, heart rate variability
- LQT, long QT
- MI, myocardial infarction
- NE, norepinephrine
- NHLBI, National Heart, Lung, and Blood Institute
- NPY, neuropeptide Y
- NREM, non-rapid eye movement
- OSA, obstructive sleep apnea
- PAH, pulmonary arterial hypertension
- PV, pulmonary vein
- REM, rapid eye movement
- RV, right ventricular
- SCD, sudden cardiac death
- SDB, sleep disordered breathing
- SNA, sympathetic nerve activity
- SNSA, sympathetic nervous system activity
- TLD, targeted lung denervation
- asthma
- atrial fibrillation
- autonomic nervous system
- cardiopulmonary
- chronic obstructive pulmonary disease
- circadian
- heart failure
- pulmonary arterial hypertension
- sleep apnea
- ventricular arrhythmia
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Affiliation(s)
- Reena Mehra
- Cleveland Clinic, Cleveland, Ohio, USA
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Olga A. Tjurmina
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | | | - Rishi Arora
- Feinberg School of Medicine at Northwestern University, Chicago, Illinois, USA
| | | | - Mark W. Chapleau
- University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | | | | | | | - Michael R. Gold
- Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - David S. Goldstein
- National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, USA
| | - Beth A. Habecker
- Oregon Health and Science University School of Medicine, Portland, Oregon, USA
| | - M. Louis Handoko
- Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | | | - James P. Hummel
- Yale University School of Medicine, New Haven, Connecticut, USA
| | | | | | | | | | - Marc A. Simon
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- University of California-San Francisco, San Francisco, California, USA
| | | | - Stavros Stavrakis
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | | | | | - Richard L. Verrier
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - George Sopko
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
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7
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Depes D, Mennander A, Paavonen T, Kholová I. Autonomic Nerves in Myocardial Sleeves around Caval Veins: Potential Role in Cardiovascular Mortality? Cardiovasc Pathol 2022; 59:107426. [DOI: 10.1016/j.carpath.2022.107426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/24/2022] [Accepted: 03/26/2022] [Indexed: 11/15/2022] Open
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Nguyen DD, Akoum N, Hourmozdi J, Prutkin JM, Robinson M, Tregoning DM, Saour BM, Chatterjee NA, Sridhar AR. Catheter ablation of atrial fibrillation results in significant QTc prolongation in the postoperative period. Heart Rhythm O2 2021; 2:500-510. [PMID: 34667966 PMCID: PMC8505209 DOI: 10.1016/j.hroo.2021.08.004] [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] [Indexed: 11/25/2022] Open
Abstract
Background The corrected QT interval (QTc) is a measure of ventricular repolarization time, and a prolonged QTc increases risk for malignant ventricular arrhythmias. Pulmonary vein isolation (PVI) may increase QTc but its effects have not been well studied. Objective Determine the incidence, risk factors, and outcomes of patients presenting for PVI in sinus and atrial fibrillation with postoperative QTc prolongation in a large cohort. Methods We performed a single-center retrospective study of consecutive atrial fibrillation ablations. QTc durations using Bazett correction were obtained from electrocardiograms at different postoperative intervals and compared to preoperative QTc. We studied clinical outcomes including clinically significant ventricular arrhythmia and death. A multivariable model was used to identify factors associated with clinically significant QTc prolongation, defined as ΔQTc ≥60 ms or new QTc duration ≥500 ms. Results A total of 352 PVIs were included in this study. We observed a statistically significant increase in mean QTc compared to baseline (446.3 ± 37.8 ms) on postoperative day (POD)0 (471.7 ± 38.2 ms, P < .001) and at POD1 (456.5 ± 35.0 ms, P < .001). There was no significant difference at 1 month (452.4 ± 33.5 ms, P = .39) and 3 months (447.3 ± 40.0 ms, P = .78). Sixty-six patients (19.2%) developed ΔQTc ≥60 ms or QTc ≥500 ms on POD0, with 4.1% persisting past 90 days. Female sex (odds ratio [OR] = 1.82, 95% confidence interval [CI] =1.01–3.29, P = .047) and history of coronary artery disease (OR = 2.16, 95% CI = 1.03–4.55, P = .042) were independently predictive of QTc prolongation ≥500 ms or ΔQTc ≥60 ms. There were no episodes of clinically significant ventricular arrhythmia or death attributable to arrhythmia. Conclusion QTc duration increased significantly immediately post-PVI and returned to baseline by 1 month. PVI did not provoke significant ventricular arrhythmias in our cohort.
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Affiliation(s)
- Dan D Nguyen
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington
| | - Nazem Akoum
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington
| | - Jonathan Hourmozdi
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington
| | - Jordan M Prutkin
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington
| | - Melissa Robinson
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington
| | - Deanna M Tregoning
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington
| | - Basil M Saour
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington
| | - Neal A Chatterjee
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington
| | - Arun R Sridhar
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington
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Hanna P, Buch E, Stavrakis S, Meyer C, Tompkins JD, Ardell JL, Shivkumar K. Neuroscientific therapies for atrial fibrillation. Cardiovasc Res 2021; 117:1732-1745. [PMID: 33989382 PMCID: PMC8208752 DOI: 10.1093/cvr/cvab172] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 05/13/2021] [Indexed: 02/06/2023] Open
Abstract
The cardiac autonomic nervous system (ANS) plays an integral role in normal cardiac physiology as well as in disease states that cause cardiac arrhythmias. The cardiac ANS, comprised of a complex neural hierarchy in a nested series of interacting feedback loops, regulates atrial electrophysiology and is itself susceptible to remodelling by atrial rhythm. In light of the challenges of treating atrial fibrillation (AF) with conventional pharmacologic and myoablative techniques, increasingly interest has begun to focus on targeting the cardiac neuraxis for AF. Strong evidence from animal models and clinical patients demonstrates that parasympathetic and sympathetic activity within this neuraxis may trigger AF, and the ANS may either induce atrial remodelling or undergo remodelling itself to serve as a substrate for AF. Multiple nexus points within the cardiac neuraxis are therapeutic targets, and neuroablative and neuromodulatory therapies for AF include ganglionated plexus ablation, epicardial botulinum toxin injection, vagal nerve (tragus) stimulation, renal denervation, stellate ganglion block/resection, baroreceptor activation therapy, and spinal cord stimulation. Pre-clinical and clinical studies on these modalities have had promising results and are reviewed here.
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Affiliation(s)
- Peter Hanna
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
- Neurocardiology Research Program of Excellence, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
- Molecular, Cellular & Integrative Physiology Program, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
| | - Eric Buch
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
| | - Stavros Stavrakis
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, 1100 N Lindsay Ave, Oklahoma City, OK 73104, USA
| | - Christian Meyer
- Division of Cardiology, cardiac Neuro- and Electrophysiology Research Consortium (cNEP), EVK Düsseldorf, Teaching Hospital University of Düsseldorf, Kirchfeldstraße 40, 40217 Düsseldorf, Germany
- Institute of Neural and Sensory Physiology, cardiac Neuro- and Electrophysiology Research Consortium (cNEP), University of Düsseldorf, Universitätsstraße 1, 40225 Düsseldorf, Germany
| | - John D Tompkins
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
- Neurocardiology Research Program of Excellence, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
| | - Jeffrey L Ardell
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
- Neurocardiology Research Program of Excellence, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
- Molecular, Cellular & Integrative Physiology Program, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
| | - Kalyanam Shivkumar
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
- Neurocardiology Research Program of Excellence, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
- Molecular, Cellular & Integrative Physiology Program, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
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10
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Nakamura T, Takami M, Fukuzawa K, Kiuchi K, Kono H, Kobori A, Sakamoto Y, Watanabe R, Okumura Y, Yamashita S, Yamashiro K, Miyamoto K, Kusano K, Kanda T, Masuda M, Yoshitani K, Yoshida A, Hirayama Y, Adachi K, Mine T, Shimane A, Takeda M, Takei A, Okajima K, Fujiwara R, Hirata KI. Incidence and Characteristics of Coronary Artery Spasms Related to Atrial Fibrillation Ablation Procedures - Large-Scale Multicenter Analysis. Circ J 2021; 85:264-271. [PMID: 33431721 DOI: 10.1253/circj.cj-20-1096] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Coronary artery spasms (CASs), which can cause angina attacks and sudden death, have been recently reported during catheter ablation. The aim of the present study was to report the incidence, characteristics, and prognosis of CASs related to atrial fibrillation (AF) ablation procedures.Methods and Results:The AF ablation records of 22,232 patients treated in 15 Japanese hospitals were reviewed. CASs associated with AF ablation occurred in 42 of 22,232 patients (0.19%). CASs occurred during ablation energy applications in 21 patients (50%). CASs also occurred before ablation in 9 patients (21%) and after ablation in 12 patients (29%). The initial change in the electrocardiogram was ST-segment elevation in the inferior leads in 33 patients (79%). Emergency coronary angiography revealed coronary artery stenosis and occlusions, which were relieved by nitrate administration. No air bubbles were observed. A comparison of the incidence of CASs during pulmonary vein isolation between the different ablation energy sources revealed a significantly higher incidence with cryoballoon ablation (11/3,288; 0.34%) than with radiofrequency catheter, hot balloon, or laser balloon ablation (8/18,596 [0.04%], 0/237 [0%], and 0/111 [0%], respectively; P<0.001). CASs most often occurred during ablation of the left superior pulmonary vein. All patients recovered without sequelae. CONCLUSIONS CASs related to AF ablation are rare, but should be considered as a dangerous complication that can occur anytime during the periprocedural period.
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Affiliation(s)
- Toshihiro Nakamura
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Mitsuru Takami
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Koji Fukuzawa
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Kunihiko Kiuchi
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Hiroyuki Kono
- Department of Cardiology, Kobe City Medical Center General Hospital
| | - Atsushi Kobori
- Department of Cardiology, Kobe City Medical Center General Hospital
| | | | - Ryuta Watanabe
- Division of Cardiology, Department of Medicine, Nihon University of Medicine
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University of Medicine
| | | | | | - Koji Miyamoto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | | | - Kazuyasu Yoshitani
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | | | | | | | - Takanao Mine
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine
| | - Akira Shimane
- Department of Cardiology, Himeji Cardiovascular Center
| | | | - Asumi Takei
- Department of Cardiology, Kobe Rosai Hospital
| | | | - Ryudo Fujiwara
- Cardiovascular Division, Osaka Saiseikai Nakatsu Hospital
| | - Ken-Ichi Hirata
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
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11
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Pfenniger A, Geist GE, Arora R. Autonomic Dysfunction and Neurohormonal Disorders in Atrial Fibrillation. Card Electrophysiol Clin 2021; 13:183-190. [PMID: 33516396 DOI: 10.1016/j.ccep.2020.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Atrial fibrillation (AF) is the most commonly diagnosed arrhythmia and eludes an efficacious cure despite an increasing prevalence and a significant association with morbidity and mortality. In addition to an array of clinical sequelae, the origins and propagation of AF are multifactorial. In recent years, the contribution from the autonomic nervous system has been an area of particular interest. This review highlights the relevant physiology of autonomic and neurohormonal contributions to AF origin and maintenance, the current state of the literature on targeted therapies, and the path forward for clinical interventions.
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Affiliation(s)
- Anna Pfenniger
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, 251 East Huron, Feinberg 8-503, Chicago, IL 60611, USA
| | - Gail Elizabeth Geist
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, 251 East Huron, Feinberg 8-503, Chicago, IL 60611, USA
| | - Rishi Arora
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, 251 East Huron, Feinberg 8-503, Chicago, IL 60611, USA.
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12
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Goldberger JJ, Arora R, Buckley U, Shivkumar K. Autonomic Nervous System Dysfunction: JACC Focus Seminar. J Am Coll Cardiol 2020; 73:1189-1206. [PMID: 30871703 DOI: 10.1016/j.jacc.2018.12.064] [Citation(s) in RCA: 124] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 12/21/2018] [Accepted: 12/30/2018] [Indexed: 12/20/2022]
Abstract
Autonomic nervous system control of the heart is a dynamic process in both health and disease. A multilevel neural network is responsible for control of chronotropy, lusitropy, dromotropy, and inotropy. Intrinsic autonomic dysfunction arises from diseases that directly affect the autonomic nerves, such as diabetes mellitus and the syndromes of primary autonomic failure. Extrinsic autonomic dysfunction reflects the changes in autonomic function that are secondarily induced by cardiac or other disease. An array of tests interrogate various aspects of cardiac autonomic control in either resting conditions or with physiological perturbations from resting conditions. The prognostic significance of these assessments have been well established. Clinical usefulness has not been established, and the precise mechanistic link to mortality is less well established. Further efforts are required to develop optimal approaches to delineate cardiac autonomic dysfunction and its adverse effects to develop tools that can be used to guide clinical decision-making.
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Affiliation(s)
- Jeffrey J Goldberger
- Cardiovascular Division, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida.
| | - Rishi Arora
- Feinberg Cardiovascular Research Institute, Division of Cardiology, Department of Medicine, Northwestern University-Feinberg School of Medicine, Chicago, Illinois
| | - Una Buckley
- Cardiac Arrhythmia Center and Neurocardiology Research Center of Excellence, University of California-Los Angeles Los Angeles, California
| | - Kalyanam Shivkumar
- Cardiac Arrhythmia Center and Neurocardiology Research Center of Excellence, University of California-Los Angeles Los Angeles, California
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13
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Cho KH, Kim JH, Murakami G, Abe H, Rodríguez-Vázquez JF, Chai OH. Nerve distribution in myocardium including the atrial and ventricular septa in late stage human fetuses. Anat Cell Biol 2019; 52:48-56. [PMID: 30984452 PMCID: PMC6449578 DOI: 10.5115/acb.2019.52.1.48] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 08/23/2018] [Accepted: 10/12/2018] [Indexed: 12/14/2022] Open
Abstract
Few information had been reported on deep intracardiac nerves in the myocardium of late human fetuses such as nerves at the atrial-pulmonary vein junction and in the atrial and ventricular septa. We examined histological sections of the heart obtained from 12 human fetuses at 25–33 weeks. A high density of intracardiac nerves was evident around the mitral valve annulus in contrast to few nerves around the tricuspid annulus. To the crux at the atrioventricular sulcus, the degenerating left common cardinal vein brought abundant nerve bundles coming from cardiac nerves descending along the anterior aspect of the pulmonary trunk. Likewise, nerve bundles in the left atrial nerve fold came from cardiac nerves between the ascending aorta and pulmonary artery. Conversely, another nerves from the venous pole to the atrium seemed to be much limited in number. Moreover, the primary atrial septum contained much fewer nerves than the secondary septum. Therefore, nerve density in the atrial wall varied considerably between sites. As ventricular muscles were degenerated from the luminal side for sculpturing of papillary muscles and trabeculae, deep nerves became exposed to the ventricular endothelium. Likewise, as pectineal muscles were sculptured, nerves were exposed in the atrial endothelium. Consequently, a myocardial assembly or sculpture seemed to be associated with degeneration and reconstruction of early-developed nerves. A failure in reconstruction during further expansion of the left atrium might be connected with an individual variation in anatomical substrates of atrial fibrillation.
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Affiliation(s)
- Kwang Ho Cho
- Department of Neurology, Wonkwang University School of Medicine and Hospital, Institute of Wonkwang Medical Science, Iksan, Korea
| | - Ji Hyun Kim
- Department of Anatomy and Institute of Medical Sciences, Chonbuk National University Medical School, Jeonju, Korea
| | - Gen Murakami
- Division of Internal Medicine, Asuka Hospital, Sapporo, Japan
| | - Hiroshi Abe
- Department of Anatomy, Akita University School of Medicine, Akita, Japan
| | | | - Ok Hee Chai
- Department of Anatomy and Institute of Medical Sciences, Chonbuk National University Medical School, Jeonju, Korea
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14
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A Review of the Use of Cryoballoon Ablation for the Treatment of Persistent Atrial Fibrillation. CURRENT CARDIOVASCULAR RISK REPORTS 2019. [DOI: 10.1007/s12170-019-0605-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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15
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Carnagarin R, Kiuchi MG, Ho JK, Matthews VB, Schlaich MP. Sympathetic Nervous System Activation and Its Modulation: Role in Atrial Fibrillation. Front Neurosci 2019; 12:1058. [PMID: 30728760 PMCID: PMC6351490 DOI: 10.3389/fnins.2018.01058] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 12/31/2018] [Indexed: 12/17/2022] Open
Abstract
The autonomic nervous system (ANS) has a significant influence on the structural integrity and electrical conductivity of the atria. Aberrant activation of the sympathetic nervous system can induce heterogeneous changes with arrhythmogenic potential which can result in atrial tachycardia, atrial tachyarrhythmias and atrial fibrillation (AF). Methods to modulate autonomic activity primarily through reduction of sympathetic outflow reduce the incidence of spontaneous or induced atrial arrhythmias in animal models and humans, suggestive of the potential application of such strategies in the management of AF. In this review we focus on the relationship between the ANS, sympathetic overdrive and the pathophysiology of AF, and the potential of sympathetic neuromodulation in the management of AF. We conclude that sympathetic activity plays an important role in the initiation and maintenance of AF, and modulating ANS function is an important therapeutic approach to improve the management of AF in selected categories of patients. Potential therapeutic applications include pharmacological inhibition with central and peripheral sympatholytic agents and various device based approaches. While the role of the sympathetic nervous system has long been recognized, new developments in science and technology in this field promise exciting prospects for the future.
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Affiliation(s)
- Revathy Carnagarin
- Dobney Hypertension Centre, School of Medicine, Royal Perth Hospital Unit, Medical Research Foundation, The University of Western Australia, Perth, WA, Australia
| | - Marcio G Kiuchi
- Dobney Hypertension Centre, School of Medicine, Royal Perth Hospital Unit, Medical Research Foundation, The University of Western Australia, Perth, WA, Australia
| | - Jan K Ho
- Dobney Hypertension Centre, School of Medicine, Royal Perth Hospital Unit, Medical Research Foundation, The University of Western Australia, Perth, WA, Australia
| | - Vance B Matthews
- Dobney Hypertension Centre, School of Medicine, Royal Perth Hospital Unit, Medical Research Foundation, The University of Western Australia, Perth, WA, Australia
| | - Markus P Schlaich
- Dobney Hypertension Centre, School of Medicine, Royal Perth Hospital Unit, Medical Research Foundation, The University of Western Australia, Perth, WA, Australia.,Departments of Cardiology and Nephrology, Royal Perth Hospital, Perth, WA, Australia.,Neurovascular Hypertension and Kidney Disease Laboratory, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
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16
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Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia and is associated with pronounced morbidity and mortality. Its prevalence, expected to further increase for the forthcoming years, and associated frequent hospitalizations turn AF into a major health problem. Structural and electrical atrial remodelling underlie the substrate for AF, but the exact mechanisms driving this remodelling remain incompletely understood. Recent studies have shown that microRNAs (miRNA), short non-coding RNAs that regulate gene expression, may be involved in the pathophysiology of AF. MiRNAs have been implicated in AF-induced ion channel remodelling and fibrosis. MiRNAs could therefore provide insight into AF pathophysiology or become novel targets for therapy with miRNA mimics or anti-miRNAs. Moreover, circulating miRNAs have been suggested as a new class of diagnostic and prognostic biomarkers of AF. However, the origin and function of miRNAs in tissue and plasma frequently remain unknown and studies investigating the role of miRNAs in AF vary in design and focus and even present contradicting results. Here, we provide a systematic review of the available clinical and functional studies investigating the tissue and plasma miRNAs in AF and will thereafter discuss the potential of miRNAs as biomarkers or novel therapeutic targets in AF.
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17
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Driessen AHG, Berger WR, Krul SPJ, van den Berg NWE, Neefs J, Piersma FR, Chan Pin Yin DRPP, de Jong JSSG, van Boven WP, de Groot JR. Ganglion Plexus Ablation in Advanced Atrial Fibrillation: The AFACT Study. J Am Coll Cardiol 2017; 68:1155-1165. [PMID: 27609676 DOI: 10.1016/j.jacc.2016.06.036] [Citation(s) in RCA: 147] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 06/07/2016] [Accepted: 06/08/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Patients with long duration of atrial fibrillation (AF), enlarged atria, or failed catheter ablation have advanced AF and may require more extensive treatment than pulmonary vein isolation. OBJECTIVES The aim of this study was to investigate the efficacy and safety of additional ganglion plexus (GP) ablation in patients undergoing thoracoscopic AF surgery. METHODS Patients with paroxysmal AF underwent pulmonary vein isolation. Patients with persistent AF also received additional lines (Dallas lesion set). Patients were randomized 1:1 to additional epicardial ablation of the 4 major GPs and Marshall's ligament (GP group) or no extra ablation (control) and followed every 3 months for 1 year. After a 3-month blanking period, all antiarrhythmic drugs were discontinued. RESULTS Two hundred forty patients with a mean AF duration of 5.7 ± 5.1 years (59% persistent) were included. Mean procedure times were 185 ± 54 min and 168 ± 54 min (p = 0.015) in the GP (n = 117) and control groups (n = 123), respectively. GP ablation abated 100% of evoked vagal responses; these responses remained in 87% of control subjects. Major bleeding occurred in 9 patients (all in the GP group; p < 0.001); 8 patients were managed thoracoscopically, and 1 underwent sternotomy. Sinus node dysfunction occurred in 12 patients in the GP group and 4 control subjects (p = 0.038), and 6 pacemakers were implanted (all in the GP group; p = 0.013). After 1 year, 4 patients had died (all in the GP group, not procedure related; p = 0.055), and 9 were lost to follow-up. Freedom from AF recurrence in the GP and control groups was not statistically different whether patients had paroxysmal or persistent AF. At 1 year, 82% of patients were not taking antiarrhythmic drugs. CONCLUSIONS GP ablation during thoracoscopic surgery for advanced AF has no detectable effect on AF recurrence but causes more major adverse events, major bleeding, sinus node dysfunction, and pacemaker implantation. (Atrial Fibrillation Ablation and Autonomic Modulation via Thoracoscopic Surgery [AFACT]; NCT01091389).
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Affiliation(s)
- Antoine H G Driessen
- Department of Cardiothoracic Surgery, Heart Center, Academic Medical Center/University of Amsterdam, Amsterdam, the Netherlands
| | - Wouter R Berger
- Department of Cardiothoracic Surgery, Heart Center, Academic Medical Center/University of Amsterdam, Amsterdam, the Netherlands
| | - Sébastien P J Krul
- Department of Cardiology, Heart Center, Academic Medical Center/University of Amsterdam, Amsterdam, the Netherlands
| | - Nicoline W E van den Berg
- Department of Cardiology, Heart Center, Academic Medical Center/University of Amsterdam, Amsterdam, the Netherlands
| | - Jolien Neefs
- Department of Cardiology, Heart Center, Academic Medical Center/University of Amsterdam, Amsterdam, the Netherlands
| | - Femke R Piersma
- Department of Cardiology, Heart Center, Academic Medical Center/University of Amsterdam, Amsterdam, the Netherlands
| | - Dean R P P Chan Pin Yin
- Department of Cardiology, Heart Center, Academic Medical Center/University of Amsterdam, Amsterdam, the Netherlands
| | - Jonas S S G de Jong
- Department of Cardiology, Onze Lieve Vrouwe Hospital, Amsterdam, the Netherlands
| | - WimJan P van Boven
- Department of Cardiothoracic Surgery, Heart Center, Academic Medical Center/University of Amsterdam, Amsterdam, the Netherlands
| | - Joris R de Groot
- Department of Cardiology, Heart Center, Academic Medical Center/University of Amsterdam, Amsterdam, the Netherlands.
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18
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Czick ME, Shapter CL, Silverman DI. Atrial Fibrillation: The Science behind Its Defiance. Aging Dis 2016; 7:635-656. [PMID: 27699086 PMCID: PMC5036958 DOI: 10.14336/ad.2016.0211] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 02/11/2016] [Indexed: 12/19/2022] Open
Abstract
Atrial fibrillation (AF) is the most prevalent arrhythmia in the world, due both to its tenacious treatment resistance, and to the tremendous number of risk factors that set the stage for the atria to fibrillate. Cardiopulmonary, behavioral, and psychological risk factors generate electrical and structural alterations of the atria that promote reentry and wavebreak. These culminate in fibrillation once atrial ectopic beats set the arrhythmia process in motion. There is growing evidence that chronic stress can physically alter the emotion centers of the limbic system, changing their input to the hypothalamic-limbic-autonomic network that regulates autonomic outflow. This leads to imbalance of the parasympathetic and sympathetic nervous systems, most often in favor of sympathetic overactivation. Autonomic imbalance acts as a driving force behind the atrial ectopy and reentry that promote AF. Careful study of AF pathophysiology can illuminate the means that enable AF to elude both pharmacological control and surgical cure, by revealing ways in which antiarrhythmic drugs and surgical and ablation procedures may paradoxically promote fibrillation. Understanding AF pathophysiology can also help clarify the mechanisms by which emerging modalities aiming to correct autonomic imbalance, such as renal sympathetic denervation, may offer potential to better control this arrhythmia. Finally, growing evidence supports lifestyle modification approaches as adjuncts to improve AF control.
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Affiliation(s)
| | | | - David I. Silverman
- Echocardiography Laboratory, Hartford Hospital, Hartford, CT 06106, USA.
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19
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Tomson TT, Arora R. Modulation of Cardiac Potassium Current by Neural Tone and Ischemia. Card Electrophysiol Clin 2016; 8:349-60. [PMID: 27261826 DOI: 10.1016/j.ccep.2016.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The cardiac action potential is generated by intricate flows of ions across myocyte cell membranes in a coordinated fashion to control myocardial contraction and the heart rhythm. Modulation of the flow of these ions in response to a variety of stimuli results in changes to the action potential. Abnormal or altered ion currents can result in cardiac arrhythmias. Abnormalities of autonomic regulation of potassium current play a role in the genesis of cardiac arrhythmias, and alterations in acetylcholine-activated potassium channels may play a key role in atrial fibrillation. Ischemia is another important modulator of cardiac cellular electrophysiology.
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Affiliation(s)
- Todd T Tomson
- Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Rishi Arora
- Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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20
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Krul SPJ, Berger WR, Veldkamp MW, Driessen AHG, Wilde AAM, Deneke T, de Bakker JMT, Coronel R, de Groot JR. Treatment of Atrial and Ventricular Arrhythmias Through Autonomic Modulation. JACC Clin Electrophysiol 2015; 1:496-508. [PMID: 29759403 DOI: 10.1016/j.jacep.2015.09.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 08/19/2015] [Accepted: 09/24/2015] [Indexed: 11/26/2022]
Abstract
This paper reviews the contribution of autonomic nervous system (ANS) modulation in the treatment of arrhythmias. Both the atria and ventricles are innervated by an extensive network of nerve fibers of parasympathetic and sympathetic origin. Both the parasympathetic and sympathetic nervous system exert arrhythmogenic electrophysiological effects on atrial and pulmonary vein myocardium, while in the ventricle the sympathetic nervous system plays a more dominant role in arrhythmogenesis. Identification of ANS activity is possible with nuclear imaging. This technique may provide further insight in mechanisms and treatment targets. Additionally, the myocardial effects of the intrinsic ANS can be identified through stimulation of the ganglionic plexuses. These can be ablated for the treatment of atrial fibrillation. New (non-) invasive treatment options targeting the extrinsic cardiac ANS, such as low-level tragus stimulation and renal denervation, provide interesting future treatment possibilities both for atrial fibrillation and ventricular arrhythmias. However, the first randomized trials have yet to be performed. Future clinical studies on modifying the ANS may not only improve the outcome of ablation therapy but may also advance our understanding of the manner in which the ANS interacts with the myocardium to modify arrhythmogenic triggers and substrate.
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Affiliation(s)
- Sébastien P J Krul
- Heart Center, Department of Clinical and Experimental Cardiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Wouter R Berger
- Heart Center, Department of Clinical and Experimental Cardiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Marieke W Veldkamp
- Heart Center, Department of Clinical and Experimental Cardiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Antoine H G Driessen
- Heart Center, Department of Clinical and Experimental Cardiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Arthur A M Wilde
- Heart Center, Department of Clinical and Experimental Cardiology, Academic Medical Center, Amsterdam, the Netherlands; Princess Al-Jawhara Al-Brahim Centre of Excellence in Research of Hereditary Disorders, Jeddah, Kingdom of Saudi Arabia
| | - Thomas Deneke
- Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Jacques M T de Bakker
- Heart Center, Department of Clinical and Experimental Cardiology, Academic Medical Center, Amsterdam, the Netherlands; Interuniversity Cardiology Institute of the Netherlands, Utrecht, the Netherlands
| | - Ruben Coronel
- Heart Center, Department of Clinical and Experimental Cardiology, Academic Medical Center, Amsterdam, the Netherlands; L'Institut de RYthmologie et de modélisation Cardiaque (LIRYC), Université Bordeaux Segalen, Bordeaux, France
| | - Joris R de Groot
- Heart Center, Department of Clinical and Experimental Cardiology, Academic Medical Center, Amsterdam, the Netherlands.
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21
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Liu Q, Chen D, Wang Y, Zhao X, Zheng Y. Cardiac autonomic nerve distribution and arrhythmia. Neural Regen Res 2014; 7:2834-41. [PMID: 25317134 PMCID: PMC4190866 DOI: 10.3969/j.issn.1673-5374.2012.35.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Accepted: 11/09/2012] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE: To analyze the distribution characteristics of cardiac autonomic nerves and to explore the correlation between cardiac autonomic nerve distribution and arrhythmia. DATA RETRIEVAL: A computer-based retrieval was performed for papers examining the distribution of cardiac autonomic nerves, using heart, autonomic nerve, sympathetic nerve, vagus nerve, nerve distribution, rhythm and atrial fibrillation as the key words. SELECTION CRITERIA: A total of 165 studies examining the distribution of cardiac autonomic nerve were screened, and 46 of them were eventually included. MAIN OUTCOME MEASURES: The distribution and characteristics of cardiac autonomic nerves were observed, and immunohistochemical staining was applied to determine the levels of tyrosine hydroxylase and acetylcholine transferase (main markers of cardiac autonomic nerve distribution). In addition, the correlation between cardiac autonomic nerve distribution and cardiac arrhythmia was investigated. RESULTS: Cardiac autonomic nerves were reported to exhibit a disordered distribution in different sites, mainly at the surface of the cardiac atrium and pulmonary vein, forming a ganglia plexus. The distribution of the pulmonary vein autonomic nerve was prominent at the proximal end rather than the distal end, at the upper left rather than the lower right, at the epicardial membrane rather than the endocardial membrane, at the left atrium rather than the right atrium, and at the posterior wall rather than the anterior wall. The main markers used for cardiac autonomic nerves were tyrosine hydroxylase and acetylcholine transferase. Protein gene product 9.5 was used to label the immunoreactive nerve distribution, and the distribution density of autonomic nerves was determined using a computer-aided morphometric analysis system. CONCLUSION: The uneven distribution of the cardiac autonomic nerves is the leading cause of the occurrence of arrhythmia, and the cardiac autonomic nerves play an important role in the occurrence, maintenance, and symptoms of arrhythmia.
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Affiliation(s)
- Quan Liu
- Department of Cardiovascular Disease, the First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Dongmei Chen
- Department of Cardiovascular Disease, the First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Yonggang Wang
- Department of Cardiovascular Disease, the First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Xin Zhao
- Department of Cardiovascular Disease, the First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Yang Zheng
- Department of Cardiovascular Disease, the First Hospital of Jilin University, Changchun 130021, Jilin Province, China
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22
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Yu Y, Wei C, Liu L, Lian AL, Qu XF, Yu G. Atrial fibrillation increases sympathetic and parasympathetic neurons in the intrinsic cardiac nervous system. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2014; 37:1462-9. [PMID: 25053212 DOI: 10.1111/pace.12450] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 03/22/2014] [Accepted: 05/25/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Chronic atrial fibrillation (AF) leads to heterogeneous autonomic nerve innervation termed neural remodeling. The quantitative changes in neural density as a function of autonomic remodeling and its association with sustained AF has not been previously determined. METHOD AND RESULTS Seven dogs (paced group) were chronically paced with electrodes sutured to the epicardium of left atrial appendages. Seven dogs (control animals) were not paced. All paced dogs developed sustained AF by 5 weeks of pacing. The fat pads on the atrial epicardium containing ganglionated plexuses (GP) were separated along with underlying myocardial tissue. Immunocytochemical techniques were used to identify the neurons immunoreactive to anti-tyrosine hydroxylase (TH) and anti-acetylcholine antibodies. After chronic AF, sympathetic and parasympathetic neurons in the atrial intrinsic cardiac ganglia increased significantly. In paced dogs, the density of sympathetic neurons was 3,022 ± 507 μm(2) /mm(2) in the right atrial GP (vs control P < 0.01), 8,571 ± 476 μm(2) /mm(2) in the ventral left atrial GP (vs control P < 0.0001), 6,422 ± 464 μm(2) /mm(2) in the dorsal atrial GP (vs control P < 0.0001) and 5,392 ± 595 μm(2) /mm(2) in the inferior vena cava-inferior atrial GP (vs control P <0.0001), respectively. The density of parasympathetic neurons was 4,396 ± 877 μm(2) /mm(2) in the right atrial GP, 7,769 ± 465 μm(2) /mm(2) in the ventral left atrial GP, 7,016.47 ± 687 μm(2) /mm(2) in the dorsal atrial GP and 5,485 ± 554 μm(2) /mm(2) in the inferior vena cava-inferior atrial GP, respectively, which was higher than control cohorts in corresponding GP (P < 0.05). CONCLUSIONS This study provides evidence for the remodeling in atrial intrinsic cardiac ganglia in the dogs with pacing induced AF. A significant increase of sympathetic and parasympathetic neurons was present in atrial intrinsic cardiac ganglia.
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Affiliation(s)
- Yang Yu
- Department of Cardiovascular Diseases, First Hospital of Harbin Medical University, Harbin, Heilongjiang, China
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23
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Hasan W, Smith PG. Decreased adrenoceptor stimulation in heart failure rats reduces NGF expression by cardiac parasympathetic neurons. Auton Neurosci 2013; 181:13-20. [PMID: 24332566 DOI: 10.1016/j.autneu.2013.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Revised: 11/11/2013] [Accepted: 11/26/2013] [Indexed: 10/25/2022]
Abstract
Postganglionic cardiac parasympathetic and sympathetic nerves are physically proximate in atrial cardiac tissue allowing reciprocal inhibition of neurotransmitter release, depending on demands from central cardiovascular centers or reflex pathways. Parasympathetic cardiac ganglion (CG) neurons synthesize and release the sympathetic neurotrophin nerve growth factor (NGF), which may serve to maintain these close connections. In this study we investigated whether NGF synthesis by CG neurons is altered in heart failure, and whether norepinephrine from sympathetic neurons promotes NGF synthesis. NGF and proNGF immunoreactivity in CG neurons in heart failure rats following chronic coronary artery ligation was investigated. NGF immunoreactivity was decreased significantly in heart failure rats compared to sham-operated animals, whereas proNGF expression was unchanged. Changes in neurochemistry of CG neurons included attenuated expression of the cholinergic marker vesicular acetylcholine transporter, and increased expression of the neuropeptide vasoactive intestinal polypeptide. To further investigate norepinephrine's role in promoting NGF synthesis, we cultured CG neurons treated with adrenergic receptor (AR) agonists. An 82% increase in NGF mRNA levels was detected after 1h of isoproterenol (β-AR agonist) treatment, which increased an additional 22% at 24h. Antagonist treatment blocked isoproterenol-induced increases in NGF transcripts. In contrast, the α-AR agonist phenylephrine did not alter NGF mRNA expression. These results are consistent with β-AR mediated maintenance of NGF synthesis in CG neurons. In heart failure, a decrease in NGF synthesis by CG neurons may potentially contribute to reduced connections with adjacent sympathetic nerves.
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Affiliation(s)
- Wohaib Hasan
- Department of Molecular and Integrative Physiology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, United States.
| | - Peter G Smith
- Department of Molecular and Integrative Physiology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, United States
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MÜLLER PATRICK, HARS CHRISTINE, SCHIEDAT FABIAN, BÖSCHE LEIFI, GOTZMANN MICHAEL, STRAUCH JUSTUS, DIETRICH J, VOGT MARKUS, TANNAPFEL ANDREA, DENEKE THOMAS, MÜGGE ANDREAS, EWERS AYDAN. Correlation Between Total Atrial Conduction Time Estimated via Tissue Doppler Imaging (PA-TDI Interval), Structural Atrial Remodeling and New-Onset of Atrial Fibrillation After Cardiac Surgery. J Cardiovasc Electrophysiol 2013; 24:626-31. [DOI: 10.1111/jce.12084] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Revised: 12/10/2012] [Accepted: 12/21/2012] [Indexed: 11/27/2022]
Affiliation(s)
- PATRICK MÜLLER
- the Divisions of Cardiology & Angiology; Ruhr-University Bochum; Germany
| | - CHRISTINE HARS
- the Divisions of Cardiology & Angiology; Ruhr-University Bochum; Germany
| | - FABIAN SCHIEDAT
- the Divisions of Cardiology & Angiology; Ruhr-University Bochum; Germany
| | - LEIF I. BÖSCHE
- the Divisions of Cardiology & Angiology; Ruhr-University Bochum; Germany
| | - MICHAEL GOTZMANN
- the Divisions of Cardiology & Angiology; Ruhr-University Bochum; Germany
| | - JUSTUS STRAUCH
- the Divisions of Cardiac Surgery; Ruhr-University Bochum; Germany
| | - J.W. DIETRICH
- the Divisions of Endocrinology and Diabetes; Ruhr-University Bochum; Germany
| | - MARKUS VOGT
- the Divisions of Institute of Pathology; Ruhr-University Bochum; Germany
| | - ANDREA TANNAPFEL
- the Divisions of Institute of Pathology; Ruhr-University Bochum; Germany
| | - THOMAS DENEKE
- Heart Center Bad Neustadt; Clinic for Electrophysiology; Bad Neustadt Germany
| | - ANDREAS MÜGGE
- the Divisions of Cardiology & Angiology; Ruhr-University Bochum; Germany
| | - AYDAN EWERS
- the Divisions of Cardiology & Angiology; Ruhr-University Bochum; Germany
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Pérez GJ, Desai M, Anderson S, Scornik FS. Large-conductance calcium-activated potassium current modulates excitability in isolated canine intracardiac neurons. Am J Physiol Cell Physiol 2012. [PMID: 23195072 DOI: 10.1152/ajpcell.00148.2012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We studied principal neurons from canine intracardiac (IC) ganglia to determine whether large-conductance calcium-activated potassium (BK) channels play a role in their excitability. We performed whole cell recordings in voltage- and current-clamp modes to measure ion currents and changes in membrane potential from isolated canine IC neurons. Whole cell currents from these neurons showed fast- and slow-activated outward components. Both current components decreased in the absence of calcium and following 1-2 mM tetraethylammonium (TEA) or paxilline. These results suggest that BK channels underlie these current components. Single-channel analysis showed that BK channels from IC neurons do not inactivate in a time-dependent manner, suggesting that the dynamic of the decay of the fast current component is akin to that of intracellular calcium. Immunohistochemical studies showed that BK channels and type 2 ryanodine receptors are coexpressed in IC principal neurons. We tested whether BK current activation in these neurons occurred via a calcium-induced calcium release mechanism. We found that the outward currents of these neurons were not affected by the calcium depletion of intracellular stores with 10 mM caffeine and 10 μM cyclopiazonic acid. Thus, in canine intracardiac neurons, BK currents are directly activated by calcium influx. Membrane potential changes elicited by long (400 ms) current injections showed a tonic firing response that was decreased by TEA or paxilline. These data strongly suggest that the BK current present in canine intracardiac neurons regulates action potential activity and could increase these neurons excitability.
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26
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Arora R. Recent insights into the role of the autonomic nervous system in the creation of substrate for atrial fibrillation: implications for therapies targeting the atrial autonomic nervous system. Circ Arrhythm Electrophysiol 2012; 5:850-9. [PMID: 22895601 DOI: 10.1161/circep.112.972273] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Rishi Arora
- Northwestern Memorial Hospital, Chicago, IL 60611, USA.
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