1
|
Law M, Sachdeva R, Darrow D, Krassioukov A. Cardiovascular Effects of Spinal Cord Stimulation: The Highs, the Lows, and the Don't Knows. Neuromodulation 2023:S1094-7159(23)00714-6. [PMID: 37665302 DOI: 10.1016/j.neurom.2023.07.010] [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: 05/30/2023] [Revised: 07/31/2023] [Accepted: 07/31/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND AND OBJECTIVES There are many potential etiologies of impaired cardiovascular control, from chronic stress to neurodegenerative conditions or central nervous system lesions. Since 1959, spinal cord stimulation (SCS) has been reported to modulate blood pressure (BP), heart rate (HR), and HR variability (HRV), yet the specific stimulation sites and parameters to induce a targeted cardiovascular (CV) change for mitigating abnormal hemodynamics remain unclear. To investigate the ability and parameters of SCS to modulate the CV, we reviewed clinical studies using SCS with reported HR, BP, or HRV findings. MATERIALS AND METHODS A keyword-based electronic search was conducted through MEDLINE, Embase, and PubMed data bases, last searched on February 3, 2023. Inclusion criteria were studies with human participants receiving SCS with comparison with SCS turned off, with reporting of either HR, HRV, or BP findings. Non-English studies, conference abstracts, and studies not reporting standalone effects of SCS when comparing SCS with non-SCS interventions were excluded. Results were plotted for visual analysis. When available, participant-specific stimulation parameters and effects were extracted and quantitatively analyzed using ordinary least squares regression. RESULTS A total of 59 studies were included in this review; 51 studies delivered SCS invasively through implanted/percutaneous leads. Eight studies used noninvasive, transcutaneous electrodes. We found numerous reports of cervical, high thoracic, and mid-to-low thoracolumbar SCS increasing resting BP, and cervical/mid-to-low thoracolumbar SCS decreasing BP. The effect of SCS location on HR and HRV was equivocal. We were unable to analyze stimulation parameters owing to inadequate parameter reporting in many publications. CONCLUSIONS Our findings suggest CV neuromodulation, particularly BP modulation, with SCS to be a promising frontier. Further research with larger randomized controlled trials and detailed reporting of SCS parameters will be necessary for appropriate evaluation of SCS as a CV therapy.
Collapse
Affiliation(s)
- Marco Law
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Rahul Sachdeva
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
| | - David Darrow
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA; Division of Neurosurgery, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Andrei Krassioukov
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada; G.F. Strong Rehabilitation Centre, Vancouver Coastal Health, Vancouver, BC, Canada
| |
Collapse
|
2
|
Lai Y, Yu L, Jiang H. Autonomic Neuromodulation for Preventing and Treating Ventricular Arrhythmias. Front Physiol 2019; 10:200. [PMID: 30914967 PMCID: PMC6421499 DOI: 10.3389/fphys.2019.00200] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 02/15/2019] [Indexed: 12/18/2022] Open
Abstract
The cardiac autonomic nervous system (CANS) is associated with modulation of cardiac electrophysiology and arrhythmogenesis. In this mini review, we will briefly introduce cardiac autonomic anatomy and autonomic activity in ventricular arrhythmias (VAs) and discuss novel approaches of CANS modulation for treating VAs. Studies over the decades have provided a better understanding of cardiac autonomic innervation and revealed overwhelming evidence of the relationship between autonomic tone and VAs. A high sympathetic tone and low parasympathetic (vagal) tone are considered as the major triggers of VAs in patients with myocardial ischemia, which can cause sudden cardiac death. In recent years, novel methods of autonomic neuromodulation have been investigated to prevent VAs, and they have been verified as being beneficial for malignant VAs in animal models and humans. The clinical outcome of autonomic neuromodulation depends on the level of cardiac neuraxis, stimulation parameters, and patient's pathological status. Since autonomic modulation for VA treatment is still in the early stage of clinical application, more basic and clinical studies should be performed to clarify these mechanisms and optimize autonomic neuromodulation therapies for patients with VAs in the future.
Collapse
Affiliation(s)
- Yanqiu Lai
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China.,Cardiovascular Research Institute, Wuhan University, Wuhan, China.,Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Lilei Yu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China.,Cardiovascular Research Institute, Wuhan University, Wuhan, China.,Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Hong Jiang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China.,Cardiovascular Research Institute, Wuhan University, Wuhan, China.,Hubei Key Laboratory of Cardiology, Wuhan, China
| |
Collapse
|
3
|
Zhang L, Lu Y, Zhou X, Tang B. Spinal cord stimulation: A potential therapeutic approach for post-myocardial infarction patients. Int J Cardiol 2015; 203:1129-30. [PMID: 26608011 DOI: 10.1016/j.ijcard.2015.09.060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 09/21/2015] [Indexed: 11/19/2022]
Affiliation(s)
- Ling Zhang
- Department of Cardiology, First Affiliated Hospital, Xinjiang Medical University, Urumqi 830054, China
| | - Yanmei Lu
- Department of Cardiology, First Affiliated Hospital, Xinjiang Medical University, Urumqi 830054, China
| | - Xianhui Zhou
- Department of Cardiology, First Affiliated Hospital, Xinjiang Medical University, Urumqi 830054, China
| | - Baopeng Tang
- Department of Cardiology, First Affiliated Hospital, Xinjiang Medical University, Urumqi 830054, China.
| |
Collapse
|
4
|
Wang S, Zhou X, Huang B, Wang Z, Liao K, Saren G, Lu Z, Chen M, Yu L, Jiang H. Spinal cord stimulation protects against ventricular arrhythmias by suppressing left stellate ganglion neural activity in an acute myocardial infarction canine model. Heart Rhythm 2015; 12:1628-35. [PMID: 25778432 DOI: 10.1016/j.hrthm.2015.03.023] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Previous studies have shown that spinal cord stimulation (SCS) may reduce ventricular arrhythmias (VAs) induced by acute myocardial infarction (AMI). Furthermore, activation of left stellate ganglion (LSG) appears to facilitate VAs after AMI. OBJECTIVE The purpose of this study was to investigate whether pretreatment with SCS could protect against VAs by reducing LSG neural activity in an AMI canine model. METHODS Thirty dogs were anesthetized and randomly divided into SCS group (with SCS, n = 15) and sham group (sham operation without SCS, n = 15). SCS was performed for 1 hour before AMI. Heart rate variability (HRV), ventricular effective refractory period (ERP), serum norepinephrine level, LSG function measured by blood pressure increases in response to LSG stimulation, and LSG neural activity were measured for 1 minute at baseline and 1 hour after SCS. AMI was induced by left anterior descending coronary artery ligation, and then HRV, LSG neural activity, and VAs were measured. RESULTS Compared to baseline, SCS for 1 hour significantly prolonged ventricular ERP, increased HRV, and attenuated LSG function and LSG activity in the SCS group, whereas no significant change was shown in the sham group. AMI resulted in a significant decrease in HRV and increase in LSG neural activity in the sham group, which were attenuated in the SCS group (frequency: 99 ± 34 impulses/min vs 62 ± 22 impulses/min; amplitude: 0.41 ± 0.12 mV vs 0.18 ± 0.05 mV; both P <.05). The incidence of VAs was significantly lower in the SCS group than in the sham group. CONCLUSION SCS may prevent AMI-induced VAs, possibly by suppressing LSG activity.
Collapse
Affiliation(s)
- Songyun Wang
- Department of Cardiology, Renmin Hospital of Wuhan University, Cardiovascular Research Institute of Wuhan University, Wuhan, China
| | - Xiaoya Zhou
- Department of Cardiology, Renmin Hospital of Wuhan University, Cardiovascular Research Institute of Wuhan University, Wuhan, China
| | - Bing Huang
- Department of Cardiology, Renmin Hospital of Wuhan University, Cardiovascular Research Institute of Wuhan University, Wuhan, China
| | - Zhuo Wang
- Department of Cardiology, Renmin Hospital of Wuhan University, Cardiovascular Research Institute of Wuhan University, Wuhan, China
| | - Kai Liao
- Department of Cardiology, Renmin Hospital of Wuhan University, Cardiovascular Research Institute of Wuhan University, Wuhan, China
| | - Gaowa Saren
- Department of Cardiology, Renmin Hospital of Wuhan University, Cardiovascular Research Institute of Wuhan University, Wuhan, China
| | - Zhibing Lu
- Department of Cardiology, Renmin Hospital of Wuhan University, Cardiovascular Research Institute of Wuhan University, Wuhan, China
| | - Mingxian Chen
- Department of Cardiology, Second Xiangya Hospital of Central South University, Hunan, China
| | - Lilei Yu
- Department of Cardiology, Renmin Hospital of Wuhan University, Cardiovascular Research Institute of Wuhan University, Wuhan, China
| | - Hong Jiang
- Department of Cardiology, Renmin Hospital of Wuhan University, Cardiovascular Research Institute of Wuhan University, Wuhan, China,.
| |
Collapse
|
5
|
Hucker WJ, Singh JP, Parks K, Armoundas AA. Device-Based Approaches to Modulate the Autonomic Nervous System and Cardiac Electrophysiology. Arrhythm Electrophysiol Rev 2014; 3:30-5. [PMID: 26835062 PMCID: PMC4711497 DOI: 10.15420/aer.2011.3.1.30] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 04/04/2014] [Indexed: 01/29/2023] Open
Abstract
Alterations in resting autonomic tone can be pathogenic in many cardiovascular disease states, such as heart failure and hypertension. Indeed, autonomic modulation by way of beta-blockade is a standard treatment of these conditions. There is a significant interest in developing non-pharmacological methods of autonomic modulation as well. For instance, clinical trials of vagal stimulation and spinal cord stimulation in the treatment of heart failure are currently underway, and renal denervation has been studied recently in the treatment of resistant hypertension. Notably, autonomic stimulation is also a potent modulator of cardiac electrophysiology. Manipulating the autonomic nervous system in studies designed to treat heart failure and hypertension have revealed that autonomic modulation may have a role in the treatment of common atrial and ventricular arrhythmias as well. Experimental data on vagal nerve and spinal cord stimulation suggest that each technique may reduce ventricular arrhythmias. Similarly, renal denervation may play a role in the treatment of atrial fibrillation, as well as in controlling refractory ventricular arrhythmias. In this review, we present the current experimental and clinical data on the effect of these therapeutic modalities on cardiac electrophysiology and their potential role in arrhythmia management.
Collapse
Affiliation(s)
- William J Hucker
- Fellow in Cardiovascular Medicine, Division of Cardiology, Massachusetts General Hospital, US;
| | - Jagmeet P Singh
- Associate Professor of Medicine, Harvard Medical School, Director, Resynchronization and Advanced Cardiac Therapeutics Program, Massachusetts General Hospital, US
| | - Kimberly Parks
- Instructor in Medicine, Harvard Medical School, Advanced Heart Failure and Transplantation, Massachusetts General Hospital, US
| | - Antonis A Armoundas
- Assistant Professor of Medicine, Harvard Medical School Cardiovascular Research Center, Massachusetts General Hospital, US
| |
Collapse
|
6
|
Spinal cord stimulation for heart failure: preclinical studies to determine optimal stimulation parameters for clinical efficacy. J Cardiovasc Transl Res 2014; 7:321-9. [PMID: 24569871 DOI: 10.1007/s12265-014-9547-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 02/03/2014] [Indexed: 10/25/2022]
Abstract
Spinal cord stimulation with implantable devices has been used worldwide for decades to treat regional pain conditions and cardiac angina refractory to conventional therapies. Preclinical studies with spinal cord stimulation in experimental animal models of heart disease have described interesting effects on cardiac and autonomic nervous system physiology. In canine and porcine animals with failing hearts, spinal cord stimulation reverses left ventricular dilation and improves cardiac function, while suppressing the prevalence of cardiac arrhythmias. In this paper, we present further canine studies that determined the optimal site and intensity of spinal cord stimulation that produced the most robust and beneficial clinical response in heart failure animals. We then explore and discuss the clinically relevant aspects and potential impediments that may be encountered in translating spinal cord stimulation to human patients with advanced cardiac disease.
Collapse
|
7
|
Kuck KH, Bordachar P, Borggrefe M, Boriani G, Burri H, Leyva F, Schauerte P, Theuns D, Thibault B, Kirchhof P, Hasenfuss G, Dickstein K, Leclercq C, Linde C, Tavazzi L, Ruschitzka F. New devices in heart failure: an European Heart Rhythm Association report: Developed by the European Heart Rhythm Association; Endorsed by the Heart Failure Association. Europace 2013; 16:109-28. [DOI: 10.1093/europace/eut311] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
8
|
Grimaldi R, de Luca A, Kornet L, Castagno D, Gaita F. Can spinal cord stimulation reduce ventricular arrhythmias? Heart Rhythm 2012; 9:1884-7. [DOI: 10.1016/j.hrthm.2012.08.007] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Indexed: 01/06/2023]
|
9
|
|
10
|
Verrier RL, Klingenheben T, Malik M, El-Sherif N, Exner DV, Hohnloser SH, Ikeda T, Martínez JP, Narayan SM, Nieminen T, Rosenbaum DS. Microvolt T-wave alternans physiological basis, methods of measurement, and clinical utility--consensus guideline by International Society for Holter and Noninvasive Electrocardiology. J Am Coll Cardiol 2011; 58:1309-24. [PMID: 21920259 DOI: 10.1016/j.jacc.2011.06.029] [Citation(s) in RCA: 286] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2011] [Revised: 06/10/2011] [Accepted: 06/13/2011] [Indexed: 10/17/2022]
Abstract
This consensus guideline was prepared on behalf of the International Society for Holter and Noninvasive Electrocardiology and is cosponsored by the Japanese Circulation Society, the Computers in Cardiology Working Group on e-Cardiology of the European Society of Cardiology, and the European Cardiac Arrhythmia Society. It discusses the electrocardiographic phenomenon of T-wave alternans (TWA) (i.e., a beat-to-beat alternation in the morphology and amplitude of the ST-segment or T-wave). This statement focuses on its physiological basis and measurement technologies and its clinical utility in stratifying risk for life-threatening ventricular arrhythmias. Signal processing techniques including the frequency-domain Spectral Method and the time-domain Modified Moving Average method have demonstrated the utility of TWA in arrhythmia risk stratification in prospective studies in >12,000 patients. The majority of exercise-based studies using both methods have reported high relative risks for cardiovascular mortality and for sudden cardiac death in patients with preserved as well as depressed left ventricular ejection fraction. Studies with ambulatory electrocardiogram-based TWA analysis with Modified Moving Average method have yielded significant predictive capacity. However, negative studies with the Spectral Method have also appeared, including 2 interventional studies in patients with implantable defibrillators. Meta-analyses have been performed to gain insights into this issue. Frontiers of TWA research include use in arrhythmia risk stratification of individuals with preserved ejection fraction, improvements in predictivity with quantitative analysis, and utility in guiding medical as well as device-based therapy. Overall, although TWA appears to be a useful marker of risk for arrhythmic and cardiovascular death, there is as yet no definitive evidence that it can guide therapy.
Collapse
Affiliation(s)
- Richard L Verrier
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Odenstedt J, Linderoth B, Bergfeldt L, Ekre O, Grip L, Mannheimer C, Andréll P. Spinal cord stimulation effects on myocardial ischemia, infarct size, ventricular arrhythmia, and noninvasive electrophysiology in a porcine ischemia–reperfusion model. Heart Rhythm 2011; 8:892-8. [DOI: 10.1016/j.hrthm.2011.01.029] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Accepted: 01/12/2011] [Indexed: 12/26/2022]
|
12
|
Nanthakumar K. Spinal cord stimulators for treatment of ventricular arrhythmias: antiarrhythmic in a can. Heart Rhythm 2011; 8:899-900. [PMID: 21316486 DOI: 10.1016/j.hrthm.2011.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2011] [Indexed: 11/29/2022]
|
13
|
The year in arrhythmias—2009 Part II. Heart Rhythm 2010; 7:538-48. [DOI: 10.1016/j.hrthm.2010.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2009] [Indexed: 11/21/2022]
|
14
|
Verrier RL, Kumar K, Nearing BD. Basis for sudden cardiac death prediction by T-wave alternans from an integrative physiology perspective. Heart Rhythm 2009; 6:416-22. [PMID: 19251221 PMCID: PMC2672309 DOI: 10.1016/j.hrthm.2008.11.019] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2008] [Accepted: 11/18/2008] [Indexed: 10/21/2022]
Abstract
Detection of microvolt levels of T-wave alternans (TWA) has been shown to be useful in identifying individuals at heightened risk for sudden cardiac death. The mechanistic bases for TWA are complex, at the cellular level involving multiple mechanisms, particularly instabilities in membrane voltage (i.e., steep action potential duration restitution slope) and disruptions in intracellular calcium cycling dynamics. The integrative factors influencing TWA at the systemic level are also multifold. We focus on three main variables: heart rate, autonomic nervous system activity, and myocardial ischemia. Clinically, there is growing interest in extending TWA testing to include ambulatory ECG monitoring as well as exercise. The former modality permits assessment of the influence of diverse provocative stimuli of daily life, including physical activity, circadian factors, mental stress, and sleep-state related disturbances in respiratory and cardiovascular function. Two major emerging concepts in clinical TWA testing are discussed: quantitative analysis of TWA level to complement the current binary classification scheme, and risk stratification of patients with preserved left ventricular function, the population with the largest absolute number of sudden cardiac deaths.
Collapse
Affiliation(s)
- Richard L Verrier
- Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Cardiovascular Institute, Boston, Massachusetts 02115, USA.
| | | | | |
Collapse
|
15
|
Garcia EDV. T-wave alternans: reviewing the clinical performance, understanding limitations, characterizing methodologies. Ann Noninvasive Electrocardiol 2009; 13:401-20. [PMID: 18973498 DOI: 10.1111/j.1542-474x.2008.00254.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Accurate recognition of individuals at higher immediate risk of sudden cardiac death (SCD) is still an open question. The fortuitous nature of acute cardiovascular events just does not seem to fit the well-known model of ventricular tachycardia/fibrillation induction in a static arrhythmogenic substrate by a synchronous trigger. On the mechanism of SCD, a dynamical electrical instability would better explain the rarity of the simultaneous association of a correct trigger and an appropriate cardiac substrate. Several studies have been conducted trying to measure this cardiac electrical instability (or any valid surrogate) in an ECG beat stream. Among the current possible candidates we can number QT prolongation, QT dispersion, late potentials, T-wave alternans (TWA), and heart rate turbulence. This article reviews the particular role of TWA in the current cardiac risk stratification scenario. TWA findings are still heterogeneous, ranging from very good to nearly null prognostic performance depending on the clinical population observed and clinical protocol in use. To fill the current gaps in the TWA base of knowledge, practitioners, and researchers should better explore the technical features of the several technologies available for TWA evaluation and pay greater attention to the fact that TWA values are responsive to several factors other than medications. Information about the cellular and subcellular mechanisms of TWA is outside the scope of this article, but the reader is referred to some of the good papers available on this topic whenever this extra information could help the understanding of the concepts and facts covered herein.
Collapse
Affiliation(s)
- Euler de Vilhena Garcia
- The Heart Institute (InCor), University of São Paulo Medical School - Electrocardiology Service, São Paulo, Brazil.
| |
Collapse
|
16
|
Madias JE. Spinal cord stimulation and T-wave alternans. Europace 2008; 10:893; author reply 893-4. [DOI: 10.1093/europace/eun141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|