1
|
Coyle C, Koutsoftidis S, Kim MY, Porter B, Keene D, Luther V, Handa B, Kay J, Lim E, Malcolme-Lawes L, Koa-Wing M, Lim PB, Whinnett ZI, Ng FS, Qureshi N, Peters NS, Linton NWF, Drakakis E, Kanagaratnam P. Feasibility of mapping and ablating ectopy-triggering ganglionated plexus reproducibly in persistent atrial fibrillation. J Interv Card Electrophysiol 2023:10.1007/s10840-023-01517-9. [PMID: 36867371 DOI: 10.1007/s10840-023-01517-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 02/19/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND Ablation of autonomic ectopy-triggering ganglionated plexuses (ET-GP) has been used to treat paroxysmal atrial fibrillation (AF). It is not known if ET-GP localisation is reproducible between different stimulators or whether ET-GP can be mapped and ablated in persistent AF. We tested the reproducibility of the left atrial ET-GP location using different high-frequency high-output stimulators in AF. In addition, we tested the feasibility of identifying ET-GP locations in persistent atrial fibrillation. METHODS Nine patients undergoing clinically-indicated paroxysmal AF ablation received pacing-synchronised high-frequency stimulation (HFS), delivered in SR during the left atrial refractory period, to compare ET-GP localisation between a custom-built current-controlled stimulator (Tau20) and a voltage-controlled stimulator (Grass S88, SIU5). Two patients with persistent AF underwent cardioversion, left atrial ET-GP mapping with the Tau20 and ablation (Precision™, Tacticath™ [n = 1] or Carto™, SmartTouch™ [n = 1]). Pulmonary vein isolation (PVI) was not performed. Efficacy of ablation at ET-GP sites alone without PVI was assessed at 1 year. RESULTS The mean output to identify ET-GP was 34 mA (n = 5). Reproducibility of response to synchronised HFS was 100% (Tau20 vs Grass S88; [n = 16] [kappa = 1, SE = 0.00, 95% CI 1 to 1)][Tau20 v Tau20; [n = 13] [kappa = 1, SE = 0, 95% CI 1 to 1]). Two patients with persistent AF had 10 and 7 ET-GP sites identified requiring 6 and 3 min of radiofrequency ablation respectively to abolish ET-GP response. Both patients were free from AF for > 365 days without anti-arrhythmics. CONCLUSIONS ET-GP sites are identified at the same location by different stimulators. ET-GP ablation alone was able to prevent AF recurrence in persistent AF, and further studies would be warranted.
Collapse
Affiliation(s)
- Clare Coyle
- NHLI, Imperial College London, London, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | | | - Min-Young Kim
- NHLI, Imperial College London, London, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Bradley Porter
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Daniel Keene
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Vishal Luther
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Balvinder Handa
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Jamie Kay
- NHLI, Imperial College London, London, UK
| | - Elaine Lim
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | | | - Michael Koa-Wing
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Phang Boon Lim
- NHLI, Imperial College London, London, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Zachary I Whinnett
- NHLI, Imperial College London, London, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Fu Siong Ng
- NHLI, Imperial College London, London, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Norman Qureshi
- NHLI, Imperial College London, London, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Nicholas S Peters
- NHLI, Imperial College London, London, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Nicholas W F Linton
- NHLI, Imperial College London, London, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
- Department of Bioengineering, Imperial College London, London, UK
| | | | - Prapa Kanagaratnam
- NHLI, Imperial College London, London, UK.
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK.
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK.
| |
Collapse
|
2
|
Kim MY, Nesbitt J, Koutsoftidis S, Brook J, Pitcher DS, Cantwell CD, Handa B, Jenkins C, Houston C, Rothery S, Jothidasan A, Perkins J, Bristow P, Linton NWF, Drakakis E, Peters NS, Chowdhury RA, Kanagaratnam P, Ng FS. Immunohistochemical characteristics of local sites that trigger atrial arrhythmias in response to high-frequency stimulation. Europace 2023; 25:726-738. [PMID: 36260428 PMCID: PMC9935019 DOI: 10.1093/europace/euac176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 08/19/2022] [Indexed: 01/26/2023] Open
Abstract
AIMS The response to high frequency stimulation (HFS) is used to locate putative sites of ganglionated plexuses (GPs), which are implicated in triggering atrial fibrillation (AF). To identify topological and immunohistochemical characteristics of presumed GP sites functionally identified by HFS. METHODS AND RESULTS Sixty-three atrial sites were tested with HFS in four Langendorff-perfused porcine hearts. A 3.5 mm tip quadripolar ablation catheter was used to stimulate and deliver HFS to the left and right atrial epicardium, within the local atrial refractory period. Tissue samples from sites triggering atrial ectopy/AF (ET) sites and non-ET sites were stained with choline acetyltransferase (ChAT) and tyrosine hydroxylase (TH), for quantification of parasympathetic and sympathetic nerves, respectively. The average cross-sectional area (CSA) of nerves was also calculated. Histomorphometry of six ET sites (9.5%) identified by HFS evoking at least a single atrial ectopic was compared with non-ET sites. All ET sites contained ChAT-immunoreactive (ChAT-IR) and/or TH-immunoreactive nerves (TH-IR). Nerve density was greater in ET sites compared to non-ET sites (nerves/cm2: 162.3 ± 110.9 vs. 69.65 ± 72.48; P = 0.047). Overall, TH-IR nerves had a larger CSA than ChAT-IR nerves (µm2: 11 196 ± 35 141 vs. 2070 ± 5841; P < 0.0001), but in ET sites, TH-IR nerves were smaller than in non-ET sites (µm2: 6021 ± 14 586 vs. 25 254 ± 61 499; P < 0.001). CONCLUSIONS ET sites identified by HFS contained a higher density of smaller nerves than non-ET sites. The majority of these nerves were within the atrial myocardium. This has important clinical implications for devising an effective therapeutic strategy for targeting autonomic triggers of AF.
Collapse
Affiliation(s)
- Min-Young Kim
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK.,Department of Cardiology, Hammersmith Hospital, 72 Du Cane Rd, London, W12 0HS, UK.,Imperial Centre for Cardiac Engineering, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
| | - James Nesbitt
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK.,Department of Cardiology, Hammersmith Hospital, 72 Du Cane Rd, London, W12 0HS, UK
| | - Simos Koutsoftidis
- Imperial Centre for Cardiac Engineering, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
| | - Joseph Brook
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK.,Imperial Centre for Cardiac Engineering, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
| | - David S Pitcher
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK.,Imperial Centre for Cardiac Engineering, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
| | - Chris D Cantwell
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK.,Imperial Centre for Cardiac Engineering, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
| | - Balvinder Handa
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK.,Department of Cardiology, Hammersmith Hospital, 72 Du Cane Rd, London, W12 0HS, UK.,Imperial Centre for Cardiac Engineering, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
| | - Catherine Jenkins
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK.,Imperial Centre for Cardiac Engineering, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
| | - Charles Houston
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK.,Imperial Centre for Cardiac Engineering, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
| | - Stephen Rothery
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK.,Imperial Centre for Cardiac Engineering, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK.,The Facility for Imaging by Light Microscopy, Sir Alexander Fleming Building, South Kensington Campus, Imperial College London, Exhibition Road, London SW7 2AZ, UK
| | - Anand Jothidasan
- Department of Cardiothoracic Surgery, Royal Brompton and Harefield NHS Foundation Trust, 1 Manresa Rd, London SW3 6LR, UK
| | - Justin Perkins
- Royal Veterinary College, 4 Royal College St, London NW1 0TU, UK
| | - Poppy Bristow
- Royal Veterinary College, 4 Royal College St, London NW1 0TU, UK
| | - Nick W F Linton
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK.,Department of Cardiology, Hammersmith Hospital, 72 Du Cane Rd, London, W12 0HS, UK.,Imperial Centre for Cardiac Engineering, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
| | - Emm Drakakis
- Imperial Centre for Cardiac Engineering, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
| | - Nicholas S Peters
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK.,Department of Cardiology, Hammersmith Hospital, 72 Du Cane Rd, London, W12 0HS, UK.,Imperial Centre for Cardiac Engineering, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
| | - Rasheda A Chowdhury
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK.,Imperial Centre for Cardiac Engineering, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
| | - Prapa Kanagaratnam
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK.,Department of Cardiology, Hammersmith Hospital, 72 Du Cane Rd, London, W12 0HS, UK.,Imperial Centre for Cardiac Engineering, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
| | - Fu Siong Ng
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK.,Department of Cardiology, Hammersmith Hospital, 72 Du Cane Rd, London, W12 0HS, UK.,Imperial Centre for Cardiac Engineering, Imperial College London, Level 2, Faculty Building, South Kensington Campus, London SW7 2AZ, UK
| |
Collapse
|
3
|
Ling X, Wang J, Qin X, Lin C, Jie W, Chen Y, Fu D, Yang Y, Meng Q, Lin J, Liu H, Li T, Guo J. Predictive value of TRPV2 expression from peripheral blood mononuclear cells on the early recurrence of atrial fibrillation after radiofrequency catheter ablation. BMC Cardiovasc Disord 2022; 22:546. [PMID: 36513971 PMCID: PMC9746099 DOI: 10.1186/s12872-022-02992-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Recent study has shown that the transient receptor potential vanilloid 2 (TRPV2) channel was exclusively upregulated in patients with atrial fibrillation (AF), and that this overexpression might be detrimental for occurrence and maintenance of AF. We aimed to characterize the expression levels of TRPV2 mRNA in peripheral blood mononuclear cells (PBMCs) with/without early recurrence of atrial fibrillation (ERAF) after radiofrequency catheter ablation (RFCA), and to find a reliable predictor for ERAF. METHODS 65 patients of AF, who underwent RFCA successfully, then divided into two groups according to ERAF during following 3 months. PBMCs were isolated from whole blood by Ficoll gradient centrifugation before and after RFCA. Gene set enrichment analysis was performed to evaluate TRPV channels expression levels and Kyoto Encyclopedia of Genes and Genomes (KEGG) mapping was used for pathway enrichment analysis. RESULTS There was no significant difference in the TRPV2 mRNA expression level between the two groups before RFCA, while without ERAF group of TRPV2 expression was markedly reduced compared to ERAF group after RFCA. Moreover, the number of TRPV2 expression was confirmed as an independent predictor for the first time through receiver operating characteristic and Kaplan-Meier survival curve analysis. It should be pointed out that the above results were only used to predict ERAF, and have no predictive significance for late recurrence of atrial fibrillation according to the current data. Additionally, ERAF was inversely correlated with P wave dispersion. KEGG mapping further clustered 41 pathways, revealing that ''cyclic guanosine monophosphate-protein kinase G signaling pathway'' was significantly enriched. CONCLUSIONS We firstly assume that downregulated expression of peripheral TRPV2 appear in patients without ERAF after RFCA. TRPV2 may thus represent a novel predictor of early phase after successful radiofrequency ablation.
Collapse
Affiliation(s)
- Xuebin Ling
- grid.443397.e0000 0004 0368 7493Key Laboratory of Tropical Cardiovascular Diseases Research of Hainan Province, Cardiovascular Diseases Institute of the First Affiliated Hospital, Department of Cardiovascular Surgery, the Second Affiliated Hospital of Hainan Medical University, Key Laboratory of Emergency and Trauma of Ministry of Education, Hainan Medical University, Haikou, 571199 China
| | - Jun Wang
- grid.443397.e0000 0004 0368 7493Key Laboratory of Tropical Cardiovascular Diseases Research of Hainan Province, Cardiovascular Diseases Institute of the First Affiliated Hospital, Department of Cardiovascular Surgery, the Second Affiliated Hospital of Hainan Medical University, Key Laboratory of Emergency and Trauma of Ministry of Education, Hainan Medical University, Haikou, 571199 China
| | - Xue Qin
- grid.443397.e0000 0004 0368 7493Key Laboratory of Tropical Cardiovascular Diseases Research of Hainan Province, Cardiovascular Diseases Institute of the First Affiliated Hospital, Department of Cardiovascular Surgery, the Second Affiliated Hospital of Hainan Medical University, Key Laboratory of Emergency and Trauma of Ministry of Education, Hainan Medical University, Haikou, 571199 China
| | - Chufen Lin
- grid.216417.70000 0001 0379 7164Department of Health Medicine, Affiliated Haikou Hospital of Xiangya Medical College, Central South University, Haikou, 570208 Hainan China
| | - Wei Jie
- grid.443397.e0000 0004 0368 7493Key Laboratory of Tropical Cardiovascular Diseases Research of Hainan Province, Cardiovascular Diseases Institute of the First Affiliated Hospital, Department of Cardiovascular Surgery, the Second Affiliated Hospital of Hainan Medical University, Key Laboratory of Emergency and Trauma of Ministry of Education, Hainan Medical University, Haikou, 571199 China
| | - Yane Chen
- grid.443397.e0000 0004 0368 7493Key Laboratory of Tropical Cardiovascular Diseases Research of Hainan Province, Cardiovascular Diseases Institute of the First Affiliated Hospital, Department of Cardiovascular Surgery, the Second Affiliated Hospital of Hainan Medical University, Key Laboratory of Emergency and Trauma of Ministry of Education, Hainan Medical University, Haikou, 571199 China
| | - Dajia Fu
- grid.443397.e0000 0004 0368 7493Key Laboratory of Tropical Cardiovascular Diseases Research of Hainan Province, Cardiovascular Diseases Institute of the First Affiliated Hospital, Department of Cardiovascular Surgery, the Second Affiliated Hospital of Hainan Medical University, Key Laboratory of Emergency and Trauma of Ministry of Education, Hainan Medical University, Haikou, 571199 China
| | - Yang Yang
- grid.443397.e0000 0004 0368 7493Key Laboratory of Tropical Cardiovascular Diseases Research of Hainan Province, Cardiovascular Diseases Institute of the First Affiliated Hospital, Department of Cardiovascular Surgery, the Second Affiliated Hospital of Hainan Medical University, Key Laboratory of Emergency and Trauma of Ministry of Education, Hainan Medical University, Haikou, 571199 China
| | - Qingwen Meng
- grid.443397.e0000 0004 0368 7493Key Laboratory of Tropical Cardiovascular Diseases Research of Hainan Province, Cardiovascular Diseases Institute of the First Affiliated Hospital, Department of Cardiovascular Surgery, the Second Affiliated Hospital of Hainan Medical University, Key Laboratory of Emergency and Trauma of Ministry of Education, Hainan Medical University, Haikou, 571199 China
| | - Jing Lin
- grid.443397.e0000 0004 0368 7493Key Laboratory of Tropical Cardiovascular Diseases Research of Hainan Province, Cardiovascular Diseases Institute of the First Affiliated Hospital, Department of Cardiovascular Surgery, the Second Affiliated Hospital of Hainan Medical University, Key Laboratory of Emergency and Trauma of Ministry of Education, Hainan Medical University, Haikou, 571199 China
| | - Hui Liu
- grid.443397.e0000 0004 0368 7493Department of Anatomy, School of Basic Medicine and Life Science, Hainan Medical University, Haikou, 571199 Hainan China
| | - Tianfa Li
- grid.443397.e0000 0004 0368 7493Key Laboratory of Tropical Cardiovascular Diseases Research of Hainan Province, Cardiovascular Diseases Institute of the First Affiliated Hospital, Department of Cardiovascular Surgery, the Second Affiliated Hospital of Hainan Medical University, Key Laboratory of Emergency and Trauma of Ministry of Education, Hainan Medical University, Haikou, 571199 China
| | - Junli Guo
- grid.443397.e0000 0004 0368 7493Key Laboratory of Tropical Cardiovascular Diseases Research of Hainan Province, Cardiovascular Diseases Institute of the First Affiliated Hospital, Department of Cardiovascular Surgery, the Second Affiliated Hospital of Hainan Medical University, Key Laboratory of Emergency and Trauma of Ministry of Education, Hainan Medical University, Haikou, 571199 China
| |
Collapse
|
4
|
Kim MY, Stavrakis S. For Better or Worse, Pulse Field Ablation Is Kinder to Some Nerves. JACC Clin Electrophysiol 2022; 8:905-907. [PMID: 35863817 DOI: 10.1016/j.jacep.2022.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 05/12/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Min-Young Kim
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Stavros Stavrakis
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA.
| |
Collapse
|
5
|
Kim MY, Aksu T. Ganglionated plexus ablation and pulmonary vein isolation: the future of AF ablation. J Interv Card Electrophysiol 2022:10.1007/s10840-022-01253-6. [PMID: 35593930 DOI: 10.1007/s10840-022-01253-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Min-Young Kim
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, Istanbul, 34742, Turkey.
| |
Collapse
|
6
|
Kim MY, Coyle C, Tomlinson DR, Sikkel MB, Sohaib A, Luther V, Leong KM, Malcolme-Lawes L, Low B, Sandler B, Lim E, Todd M, Fudge M, Wright IJ, Koa-Wing M, Ng FS, Qureshi NA, Whinnett ZI, Peters NS, Newcomb D, Wood C, Dhillon G, Hunter RJ, Lim PB, Linton NWF, Kanagaratnam P. Ectopy-triggering ganglionated plexuses ablation to prevent atrial fibrillation: GANGLIA-AF study. Heart Rhythm 2022; 19:516-524. [PMID: 34915187 PMCID: PMC8976158 DOI: 10.1016/j.hrthm.2021.12.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND The ganglionated plexuses (GPs) of the intrinsic cardiac autonomic system may play a role in atrial fibrillation (AF). OBJECTIVE We hypothesized that ablating the ectopy-triggering GPs (ET-GPs) prevents AF. METHODS GANGLIA-AF (ClinicalTrials.gov identifier NCT02487654) was a prospective, randomized, controlled, 3-center trial. ET-GPs were mapped using high frequency stimulation, delivered within the atrial refractory period and ablated until nonfunctional. If triggered AF became incessant, atrioventricular dissociating GPs were ablated. We compared GP ablation (GPA) without pulmonary vein isolation (PVI) against PVI in patients with paroxysmal AF. Follow-up was for 12 months including 3-monthly 48-hour Holter monitors. The primary end point was documented ≥30 seconds of atrial arrhythmia after a 3-month blanking period. RESULTS A total of 102 randomized patients were analyzed on a per-protocol basis after GPA (n = 52; 51%) or PVI (n = 50; 49%). Patients who underwent GPA had 89 ± 26 high frequency stimulation sites tested, identifying a median of 18.5% (interquartile range 16%-21%) of GPs. The radiofrequency ablation time was 22.9 ± 9.8 minutes in GPA and 38 ± 14.4 minutes in PVI (P < .0001). The freedom from ≥30 seconds of atrial arrhythmia at 12-month follow-up was 50% (26 of 52) with GPA vs 64% (32 of 50) with PVI (log-rank, P = .09). ET-GPA without atrioventricular dissociating GPA achieved 58% (22 of 38) freedom from the primary end point. There was a significantly higher reduction in antiarrhythmic drug usage postablation after GPA than after PVI (55.5% vs 36%; P = .05). Patients were referred for redo ablation procedures in 31% (16 of 52) after GPA and 24% (12 of 50) after PVI (P = .53). CONCLUSION GPA did not prevent atrial arrhythmias more than PVI. However, less radiofrequency ablation was delivered to achieve a higher reduction in antiarrhythmic drug usage with GPA than with PVI.
Collapse
Affiliation(s)
- Min-Young Kim
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom; Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Imperial Centre for Cardiac Engineering, Imperial College London, London, United Kingdom
| | - Clare Coyle
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom; Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Imperial Centre for Cardiac Engineering, Imperial College London, London, United Kingdom
| | - David R Tomlinson
- Cardiology Department, Derriford Hospital, University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | - Markus B Sikkel
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Afzal Sohaib
- Cardiology Department, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Vishal Luther
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Kevin M Leong
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Louisa Malcolme-Lawes
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Benjamin Low
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Belinda Sandler
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Elaine Lim
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Michelle Todd
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Michael Fudge
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Ian J Wright
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Michael Koa-Wing
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Fu Siong Ng
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Norman A Qureshi
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Zachary I Whinnett
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Nicholas S Peters
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom; Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Imperial Centre for Cardiac Engineering, Imperial College London, London, United Kingdom
| | - Daniel Newcomb
- Cardiology Department, Derriford Hospital, University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | - Cherith Wood
- Cardiology Department, Derriford Hospital, University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | - Gurpreet Dhillon
- Cardiology Department, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Ross J Hunter
- Cardiology Department, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Phang Boon Lim
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Nicholas W F Linton
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Imperial Centre for Cardiac Engineering, Imperial College London, London, United Kingdom; Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Prapa Kanagaratnam
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom; Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Imperial Centre for Cardiac Engineering, Imperial College London, London, United Kingdom.
| |
Collapse
|
7
|
Yamashita S, Tokuda M, Mahida S, Sato H, Ikewaki H, Oseto H, Yokoyama M, Isogai R, Tokutake K, Yokoyama K, Narui R, Kato M, Tanigawa SI, Sugimoto KI, Yoshimura M, Yamane T. Very long term outcome after linear versus electrogram guided ablation for persistent atrial fibrillation. Sci Rep 2021; 11:23591. [PMID: 34880293 PMCID: PMC8654861 DOI: 10.1038/s41598-021-02935-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 11/22/2021] [Indexed: 11/10/2022] Open
Abstract
The optimal ablation strategy for persistent atrial fibrillation (PsAF) remains to be defined. We sought to compare very long-term outcomes between linear ablation and electrogram (EGM)-guided ablation for PsAF. In a retrospective analysis, long-term arrhythmia-free survival compared between two propensity-score matched cohorts, one with pulmonary vein isolation (PVI) and linear ablation including roof/mitral isthmus line (LINE-group, n = 52) and one with PVI and EGM-guided ablation (EGM-group; n = 52). Overall, 99% of patients underwent successful PVI. Complete block following linear ablation was achieved for 94% of roof lines and 81% of mitral lines (both lines blocked in 75%). AF termination by EGM-guided ablation was accomplished in 40% of patients. Non-PV foci were targeted in 7 (13%) in the LINE-group and 5 (10%) patients in the EGM-group (p = 0.76). During 100 ± 28 months of follow-up, linear ablation was associated with superior arrhythmia-free survival after the initial and last procedure (1.8 ± 0.9 procedures) compared with EGM-group (Logrank test: p = 0.0001 and p = 0.045, respectively). In multivariable analysis, longer AF duration and EGM-guided ablation remained as independent predictors of atrial arrhythmia recurrence. Linear ablation might be a more effective complementary technique to PVI than EGM-guided ablation for PsAF ablation.
Collapse
Affiliation(s)
- Seigo Yamashita
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, 3-19-18 Nishishinbashi, Minato-ku, Tokyo, Japan.
| | - Michifumi Tokuda
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, 3-19-18 Nishishinbashi, Minato-ku, Tokyo, Japan
| | - Saagar Mahida
- Department of Cardiac Electrophysiology, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Hidenori Sato
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, 3-19-18 Nishishinbashi, Minato-ku, Tokyo, Japan
| | - Hirotsugu Ikewaki
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, 3-19-18 Nishishinbashi, Minato-ku, Tokyo, Japan
| | - Hirotsuna Oseto
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, 3-19-18 Nishishinbashi, Minato-ku, Tokyo, Japan
| | - Masaaki Yokoyama
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, 3-19-18 Nishishinbashi, Minato-ku, Tokyo, Japan
| | - Ryota Isogai
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, 3-19-18 Nishishinbashi, Minato-ku, Tokyo, Japan
| | - Kenichi Tokutake
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, 3-19-18 Nishishinbashi, Minato-ku, Tokyo, Japan
| | - Kenichi Yokoyama
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, 3-19-18 Nishishinbashi, Minato-ku, Tokyo, Japan
| | - Ryohsuke Narui
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, 3-19-18 Nishishinbashi, Minato-ku, Tokyo, Japan
| | - Mika Kato
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, 3-19-18 Nishishinbashi, Minato-ku, Tokyo, Japan
| | - Shin-Ichi Tanigawa
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, 3-19-18 Nishishinbashi, Minato-ku, Tokyo, Japan
| | - Ken-Ichi Sugimoto
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, 3-19-18 Nishishinbashi, Minato-ku, Tokyo, Japan
| | - Michihiro Yoshimura
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, 3-19-18 Nishishinbashi, Minato-ku, Tokyo, Japan
| | - Teiichi Yamane
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, 3-19-18 Nishishinbashi, Minato-ku, Tokyo, Japan
| |
Collapse
|
8
|
Hartley A, Shalhoub J, Ng FS, Krahn AD, Laksman Z, Andrade JG, Deyell MW, Kanagaratnam P, Sikkel MB. Size matters in atrial fibrillation: the underestimated importance of reduction of contiguous electrical mass underlying the effectiveness of catheter ablation. Europace 2021; 23:1698-1707. [PMID: 33948648 PMCID: PMC8576280 DOI: 10.1093/europace/euab078] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 03/22/2021] [Indexed: 11/13/2022] Open
Abstract
Evidence has accumulated over the last century of the importance of a critical electrical mass in sustaining atrial fibrillation (AF). AF ablation certainly reduces electrically contiguous atrial mass, but this is not widely accepted to be an important part of its mechanism of action. In this article, we review data showing that atrial size is correlated in many settings with AF propensity. Larger mammals are more likely to exhibit AF. This is seen both in the natural world and in animal models, where it is much easier to create a goat model than a mouse model of AF, for example. This also extends to humans-athletes, taller people, and obese individuals all have large atria and are more likely to exhibit AF. Within an individual, risk factors such as hypertension, valvular disease and ischaemia can enlarge the atrium and increase the risk of AF. With respect to AF ablation, we explore how variations in ablation strategy and the relative effectiveness of these strategies may suggest that a reduction in electrical atrial mass is an important mechanism of action. We counter this with examples in which there is no doubt that mass reduction is less important than competing theories such as ganglionated plexus ablation. We conclude that, when considering future strategies for the ablative therapy of AF, it is important not to discount the possibility that contiguous electrical mass reduction is the most important mechanism despite the disappointing consequence being that enhancing success rates in AF ablation may involve greater tissue destruction.
Collapse
Affiliation(s)
- Adam Hartley
- National Heart and Lung Institute,Imperial College London, London, UK
| | - Joseph Shalhoub
- National Heart and Lung Institute,Imperial College London, London, UK
| | - Fu Siong Ng
- National Heart and Lung Institute,Imperial College London, London, UK
| | - Andrew D Krahn
- Division of Cardiology, University of British Columbia, 740 Hillside Ave, Vancouver, BC V8T 1Z4, Canada
| | - Zachary Laksman
- Division of Cardiology, University of British Columbia, 740 Hillside Ave, Vancouver, BC V8T 1Z4, Canada
| | - Jason G Andrade
- Division of Cardiology, University of British Columbia, 740 Hillside Ave, Vancouver, BC V8T 1Z4, Canada
| | - Marc W Deyell
- Division of Cardiology, University of British Columbia, 740 Hillside Ave, Vancouver, BC V8T 1Z4, Canada
| | | | - Markus B Sikkel
- Division of Cardiology, University of British Columbia, 740 Hillside Ave, Vancouver, BC V8T 1Z4, Canada
- Division of Medical Sciences, University of Victoria, Victoria, Canada
| |
Collapse
|
9
|
Sandler B, Kim MY, Sikkel MB, Malcolme-Lawes L, Koa-Wing M, Whinnett ZI, Coyle C, Linton NWF, Lim PB, Kanagaratnam P. Targeting the ectopy-triggering ganglionated plexuses without pulmonary vein isolation prevents atrial fibrillation. J Cardiovasc Electrophysiol 2021; 32:235-244. [PMID: 33421265 PMCID: PMC8611799 DOI: 10.1111/jce.14870] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/24/2020] [Accepted: 12/05/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Ganglionated plexuses (GPs) are implicated in atrial fibrillation (AF). Endocardial high-frequency stimulation (HFS) delivered within the local atrial refractory period can trigger ectopy and AF from specific GP sites (ET-GP). The aim of this study was to understand the role of ET-GP ablation in the treatment of AF. METHODS Patients with paroxysmal AF indicated for ablation were recruited. HFS mapping was performed globally around the left atrium to identify ET-GP. ET-GP was defined as atrial ectopy or atrial arrhythmia triggered by HFS. All ET-GP were ablated, and PVs were left electrically connected. Outcomes were compared with a control group receiving pulmonary vein isolation (PVI). Patients were followed-up for 12 months with multiple 48-h Holter ECGs. Primary endpoint was ≥30 s AF/atrial tachycardia in ECGs. RESULTS In total, 67 patients were recruited and randomized to ET-GP ablation (n = 39) or PVI (n = 28). In the ET-GP ablation group, 103 ± 28 HFS sites were tested per patient, identifying 21 ± 10 (20%) GPs. ET-GP ablation used 23.3 ± 4.1 kWs total radiofrequency (RF) energy per patient, compared with 55.7 ± 22.7 kWs in PVI (p = <.0001). Duration of procedure was 3.7 ± 1.0 and 3.3 ± 0.7 h in ET-GP ablation group and PVI, respectively (p = .07). Follow-up at 12 months showed that 61% and 49% were free from ≥30 s of AF/AT with PVI and ET-GP ablation respectively (log-rank p = .27). CONCLUSIONS It is feasible to perform detailed global functional mapping with HFS and ablate ET-GP to prevent AF. This provides direct evidence that ET-GPs are part of the AF mechanism. The lower RF requirement implies that ET-GP targets the AF pathway more specifically.
Collapse
Affiliation(s)
- Belinda Sandler
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, London, UK.,Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Min-Young Kim
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, London, UK.,Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Markus B Sikkel
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, London, UK.,Imperial Centre for Cardiac Engineering, Imperial College London, London, UK.,Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Louisa Malcolme-Lawes
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK.,Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Michael Koa-Wing
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK.,Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Zachary I Whinnett
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK.,Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Clare Coyle
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, London, UK.,Imperial Centre for Cardiac Engineering, Imperial College London, London, UK.,Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Nick W F Linton
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, London, UK.,Imperial Centre for Cardiac Engineering, Imperial College London, London, UK.,Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Phang B Lim
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, London, UK.,Imperial Centre for Cardiac Engineering, Imperial College London, London, UK.,Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Prapa Kanagaratnam
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, London, UK.,Imperial Centre for Cardiac Engineering, Imperial College London, London, UK.,Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | | |
Collapse
|