1
|
Tompkins JD, Hoover DB, Havton LA, Patel JC, Cho Y, Smith EH, Biscola NP, Ajijola OA, Shivkumar K, Ardell JL. Comparative specialization of intrinsic cardiac neurons in humans, mice, and pigs. bioRxiv 2024:2024.04.04.588174. [PMID: 38645175 PMCID: PMC11030249 DOI: 10.1101/2024.04.04.588174] [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] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
Intrinsic cardiac neurons (ICNs) play a crucial role in the proper functioning of the heart; yet a paucity of data pertaining to human ICNs exists. We took a multidisciplinary approach to complete a detailed cellular comparison of the structure and function of ICNs from mice, pigs, and humans. Immunohistochemistry of whole and sectioned ganglia, transmission electron microscopy, intracellular microelectrode recording and dye filling for quantitative morphometry were used to define the neurophysiology, histochemistry, and ultrastructure of these cells across species. The densely packed, smaller ICNs of mouse lacked dendrites, formed axosomatic connections, and had high synaptic efficacy constituting an obligatory synapse. At Pig ICNs, a convergence of subthreshold cholinergic inputs onto extensive dendritic arbors supported greater summation and integration of synaptic input. Human ICNs were tonically firing, with synaptic stimulation evoking large suprathreshold excitatory postsynaptic potentials like mouse, and subthreshold potentials like pig. Ultrastructural examination of synaptic terminals revealed conserved architecture, yet small clear vesicles (SCVs) were larger in pigs and humans. The presence and localization of ganglionic neuropeptides was distinct, with abundant VIP observed in human but not pig or mouse ganglia, and little SP or CGRP in pig ganglia. Action potential waveforms were similar, but human ICNs had larger after-hyperpolarizations. Intrinsic excitability differed; 93% of human cells were tonic, all pig neurons were phasic, and both phasic and tonic phenotypes were observed in mouse. In combination, this publicly accessible, multimodal atlas of ICNs from mice, pigs, and humans identifies similarities and differences in the evolution of ICNs.
Collapse
Affiliation(s)
- John D. Tompkins
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Donald B. Hoover
- Department of Biomedical Sciences, Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Leif A. Havton
- Departments of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Janaki C. Patel
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Youngjin Cho
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Elizabeth H. Smith
- Department of Biomedical Sciences, Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Natalia P. Biscola
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Olujimi A. Ajijola
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jeffrey L. Ardell
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| |
Collapse
|
2
|
Thompson N, Ravagli E, Mastitskaya S, Challita R, Hadaya J, Iacoviello F, Shah Idil A, Shearing PR, Ajijola OA, Ardell JL, Shivkumar K, Holder D, Aristovich K. Anatomical and functional organization of cardiac fibers in the porcine cervical vagus nerve allows spatially selective efferent neuromodulation. bioRxiv 2024:2024.01.09.574861. [PMID: 38260584 PMCID: PMC10802425 DOI: 10.1101/2024.01.09.574861] [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] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Cardiac disease progression reflects the dynamic interaction between adversely remodeled neurohumoral control systems and an abnormal cardiac substrate. Vagal nerve stimulation (VNS) is an attractive neuromodulatory option to dampen this dynamic interaction; however, it is limited by off-target effects. Spatially-selective VNS (sVNS) offers a promising solution to induce cardioprotection while mitigating off-target effects by specifically targeting pre-ganglionic parasympathetic efferent cardiac fibers. This approach also has the potential to enhance therapeutic outcomes by eliminating time-consuming titration required for optimal VNS. Recent studies have demonstrated the independent modulation of breathing rate, heart rate, and laryngeal contraction through sVNS. However, the spatial organization of afferent and efferent cardiac-related fibers within the vagus nerve remains unexplored. By using trial-and-error sVNS in vivo in combination with ex vivo micro-computed tomography fascicle tracing, we show the significant spatial separation of cardiac afferent and efferent fibers (179±55° SD microCT, p<0.05 and 200±137° SD, p<0.05 sVNS - degrees of separation across a cross-section of nerve) at the mid-cervical level. We also show that cardiac afferent fibers are located in proximity to pulmonary fibers consistent with recent findings of cardiopulmonary convergent neurons and circuits. We demonstrate the ability of sVNS to selectively elicit desired scalable heart rate decrease without stimulating afferent-related reflexes. By elucidating the spatial organization of cardiac-related fibers within the vagus nerve, our findings pave the way for more targeted neuromodulation, thereby reducing off-target effects and eliminating the need for titration. This, in turn, will enhance the precision and efficacy of VNS therapy in treating cardiac pathology, allowing for improved therapeutic efficacy.
Collapse
Affiliation(s)
- Nicole Thompson
- EIT and Neurophysiology Research Group, Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Enrico Ravagli
- EIT and Neurophysiology Research Group, Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Svetlana Mastitskaya
- EIT and Neurophysiology Research Group, Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Ronald Challita
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Joseph Hadaya
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Francesco Iacoviello
- Electrochemical Innovation Lab, Department of Chemical Engineering, University College London, London, United Kingdom
| | - Ahmad Shah Idil
- EIT and Neurophysiology Research Group, Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Paul R. Shearing
- Electrochemical Innovation Lab, Department of Chemical Engineering, University College London, London, United Kingdom
| | - Olujimi A. Ajijola
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Jeffrey L. Ardell
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - David Holder
- EIT and Neurophysiology Research Group, Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Kirill Aristovich
- EIT and Neurophysiology Research Group, Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| |
Collapse
|
3
|
Hadaya J, Dajani AH, Cha S, Hanna P, Challita R, Hoover DB, Ajijola OA, Shivkumar K, Ardell JL. Vagal Nerve Stimulation Reduces Ventricular Arrhythmias and Mitigates Adverse Neural Cardiac Remodeling Post-Myocardial Infarction. JACC Basic Transl Sci 2023; 8:1100-1118. [PMID: 37791302 PMCID: PMC10543930 DOI: 10.1016/j.jacbts.2023.03.025] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 03/29/2023] [Accepted: 03/29/2023] [Indexed: 10/05/2023]
Abstract
This study sought to evaluate the impact of chronic vagal nerve stimulation (cVNS) on cardiac and extracardiac neural structure/function after myocardial infarction (MI). Groups were control, MI, and MI + cVNS; cVNS was started 2 days post-MI. Terminal experiments were performed 6 weeks post-MI. MI impaired left ventricular mechanical function, evoked anisotropic electrical conduction, increased susceptibility to ventricular tachycardia and fibrillation, and altered neuronal and glial phenotypes in the stellate and dorsal root ganglia, including glial activation. cVNS improved cardiac mechanical function and reduced ventricular tachycardia/ventricular fibrillation post-MI, partly by stabilizing activation/repolarization in the border zone. MI-associated extracardiac neural remodeling, particularly glial activation, was mitigated with cVNS.
Collapse
Affiliation(s)
- Joseph Hadaya
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Molecular, Cellular, and Integrative Physiology Program, University of California, Los Angeles, Los Angeles, California, USA
| | - Al-Hassan Dajani
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Steven Cha
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Peter Hanna
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Molecular, Cellular, and Integrative Physiology Program, University of California, Los Angeles, Los Angeles, California, USA
| | - Ronald Challita
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Donald B. Hoover
- Department of Biomedical Sciences, Quillen College of Medicine, East Tennessee State University, Johnson City, Tennessee, USA
- Center of Excellence in Inflammation, Infectious Disease and Immunity, East Tennessee State University, Johnson City, Tennessee, USA
| | - Olujimi A. Ajijola
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Molecular, Cellular, and Integrative Physiology Program, University of California, Los Angeles, Los Angeles, California, USA
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Molecular, Cellular, and Integrative Physiology Program, University of California, Los Angeles, Los Angeles, California, USA
| | - Jeffrey L. Ardell
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Molecular, Cellular, and Integrative Physiology Program, University of California, Los Angeles, Los Angeles, California, USA
| |
Collapse
|
4
|
Salavatian S, Kuwabara Y, Wong B, Fritz JR, Howard-Quijano K, Foreman RD, Armour JA, Ardell JL, Mahajan A. Spinal neuromodulation mitigates myocardial ischemia-induced sympathoexcitation by suppressing the intermediolateral nucleus hyperactivity and spinal neural synchrony. Front Neurosci 2023; 17:1180294. [PMID: 37332861 PMCID: PMC10272539 DOI: 10.3389/fnins.2023.1180294] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/16/2023] [Indexed: 06/20/2023] Open
Abstract
Introduction Myocardial ischemia disrupts the cardio-spinal neural network that controls the cardiac sympathetic preganglionic neurons, leading to sympathoexcitation and ventricular tachyarrhythmias (VTs). Spinal cord stimulation (SCS) is capable of suppressing the sympathoexcitation caused by myocardial ischemia. However, how SCS modulates the spinal neural network is not fully known. Methods In this pre-clinical study, we investigated the impact of SCS on the spinal neural network in mitigating myocardial ischemia-induced sympathoexcitation and arrhythmogenicity. Ten Yorkshire pigs with left circumflex coronary artery (LCX) occlusion-induced chronic myocardial infarction (MI) were anesthetized and underwent laminectomy and a sternotomy at 4-5 weeks post-MI. The activation recovery interval (ARI) and dispersion of repolarization (DOR) were analyzed to evaluate the extent of sympathoexcitation and arrhythmogenicity during the left anterior descending coronary artery (LAD) ischemia. Extracellular in vivo and in situ spinal dorsal horn (DH) and intermediolateral column (IML) neural recordings were performed using a multichannel microelectrode array inserted at the T2-T3 segment of the spinal cord. SCS was performed for 30 min at 1 kHz, 0.03 ms, 90% motor threshold. LAD ischemia was induced pre- and 1 min post-SCS to investigate how SCS modulates spinal neural network processing of myocardial ischemia. DH and IML neural interactions, including neuronal synchrony as well as cardiac sympathoexcitation and arrhythmogenicity markers were evaluated during myocardial ischemia pre- vs. post-SCS. Results ARI shortening in the ischemic region and global DOR augmentation due to LAD ischemia was mitigated by SCS. Neural firing response of ischemia-sensitive neurons during LAD ischemia and reperfusion was blunted by SCS. Further, SCS showed a similar effect in suppressing the firing response of IML and DH neurons during LAD ischemia. SCS exhibited a similar suppressive impact on the mechanical, nociceptive and multimodal ischemia sensitive neurons. The LAD ischemia and reperfusion-induced augmentation in neuronal synchrony between DH-DH and DH-IML pairs of neurons were mitigated by the SCS. Discussion These results suggest that SCS is decreasing the sympathoexcitation and arrhythmogenicity by suppressing the interactions between the spinal DH and IML neurons and activity of IML preganglionic sympathetic neurons.
Collapse
Affiliation(s)
- Siamak Salavatian
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Yuki Kuwabara
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Benjamin Wong
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jonathan R. Fritz
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Kimberly Howard-Quijano
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Robert D. Foreman
- Department of Physiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - J. Andrew Armour
- Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Jeffrey L. Ardell
- Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Aman Mahajan
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| |
Collapse
|
5
|
Tompkins JD, Buckley U, Salavatian S, Shivkumar K, Ardell JL. Vagally-mediated heart block after myocardial infarction associated with plasticity of epicardial neurons controlling the atrioventricular node. Front Synaptic Neurosci 2022; 14:960458. [PMID: 36147731 PMCID: PMC9488518 DOI: 10.3389/fnsyn.2022.960458] [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: 06/03/2022] [Accepted: 07/26/2022] [Indexed: 11/25/2022] Open
Abstract
Imbalances in the opposing actions of sympathetic and parasympathetic nerves controlling the heart enhance risk for arrhythmia and sudden cardiac death after myocardial infarction (MI). Plasticity in peripheral neuron function may underlie the observed changes in cardiomotor nerve activity. We studied vagal control of the heart in pigs after chronic infarction of the left ventricle. Stimulation of the cervical vagus nerve produced greater bradycardic responses 8-weeks after MI. Recordings of epicardial electrocardiograms demonstrate increased severity and duration of atrioventricular (AV) block in MI-pigs during 20 Hz vagal stimulation. Intracellular voltage recordings from isolated neurons of the inferior vena cava-inferior left atrium (IVC-ILA) ganglionated plexus, a cluster of epicardial neurons receiving innervation from the vagus known to regulate the AV node, were used to assess plasticity of membrane and synaptic physiology of intrinsic cardiac neurons (ICNs) after MI. Changes to both passive and active membrane properties were observed, including more negative resting membrane potentials and greater input resistances in MI-pig ICNs, concomitant with a depression of neuronal excitability. Immunoreactivity to pituitary adenylate cyclase-activating polypeptide (PACAP), a cardiotropic peptide known to modulate cardiac neuron excitability, was localized to perineuronal varicosities surrounding pig IVC-ILA neurons. Exogenous application of PACAP increased excitability of control but not MI-ICNs. Stimulation (20 Hz) of interganglionic nerves in the ex vivo whole-mount preparations elicited slow excitatory postsynaptic potentials (sEPSPs) which persisted in hexamethonium (500 μM), but were blocked by atropine (1 μM), indicating muscarinic receptor-mediated inhibition of M-current. Extracellular application of 1 mM BaCl2 to inhibit M-current increased neuronal excitability. The muscarine-sensitive sEPSPs were observed more frequently and were of larger amplitude in IVC-ILA neurons from MI animals. In conclusion, we suggest the increased probability of muscarinic sEPSPs play a role in the potentiation of the vagus nerve mediated-slowing of AV nodal conduction following chronic MI. We identify both a novel role of a muscarinic sensitive current in the regulation of synaptic strength at ICNs projecting to the AV node, and demonstrate changes to both intrinsic plasticity and synaptic plasticity of IVC-ILA neurons which may contribute to greater risk for heart block and sudden cardiac death after MI.
Collapse
|
6
|
Hadaya J, Ardell JL. Renal Dysfunction in Heart Failure: The Role of Cardiac Afferent Fibers. JACC Basic Transl Sci 2022; 7:597-599. [PMID: 35818506 PMCID: PMC9270584 DOI: 10.1016/j.jacbts.2022.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Joseph Hadaya
- University of California, Los Angeles (UCLA) Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,UCLA Molecular, Cellular, and Integrative Physiology Program, Los Angeles, California, USA
| | - Jeffrey L Ardell
- University of California, Los Angeles (UCLA) Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,UCLA Molecular, Cellular, and Integrative Physiology Program, Los Angeles, California, USA
| |
Collapse
|
7
|
Kluge N, Chan SA, Ardell JL, Smith C. Time-Resolved <em>In Vivo</em> Measurement of Neuropeptide Dynamics by Capacitive Immunoprobe in Porcine Heart. J Vis Exp 2022. [DOI: 10.3791/63926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
|
8
|
Habibagahi I, Omidbeigi M, Hadaya J, Lyu H, Jang J, Ardell JL, Bari AA, Babakhani A. Vagus nerve stimulation using a miniaturized wirelessly powered stimulator in pigs. Sci Rep 2022; 12:8184. [PMID: 35581302 PMCID: PMC9114380 DOI: 10.1038/s41598-022-11850-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 01/04/2022] [Accepted: 04/26/2022] [Indexed: 11/09/2022] Open
Abstract
Neuromodulation of peripheral nerves has been clinically used for a wide range of indications. Wireless and batteryless stimulators offer important capabilities such as no need for reoperation, and extended life compared to their wired counterparts. However, there are challenging trade-offs between the device size and its operating range, which can limit their use. This study aimed to examine the functionality of newly designed wirelessly powered and controlled implants in vagus nerve stimulation for pigs. The implant used near field inductive coupling at 13.56 MHz industrial, scientific, and medical band to harvest power from an external coil. The circular implant had a diameter of 13 mm and weighed 483 mg with cuff electrodes. The efficiency of the inductive link and robustness to distance and misalignment were optimized. As a result, the specific absorption rate was orders of magnitude lower than the safety limit, and the stimulation can be performed using only 0.1 W of external power. For the first time, wireless and batteryless VNS with more than 5 cm operation range was demonstrated in pigs. A total of 84 vagus nerve stimulations (10 s each) have been performed in three adult pigs. In a quantitative comparison of the effectiveness of VNS devices, the efficiency of systems on reducing heart rate was similar in both conventional (75%) and wireless (78.5%) systems. The pulse width and frequency of the stimulation were swept on both systems, and the response for physiological markers was drawn. The results were easily reproducible, and methods used in this study can serve as a basis for future wirelessly powered implants.
Collapse
Affiliation(s)
- Iman Habibagahi
- Electrical and Computer Engineering Department, University of California Los Angeles, Los Angeles, CA, USA.
| | - Mahmoud Omidbeigi
- Department of Neurosurgery, University of California at Los Angeles, Los Angeles, CA, USA.
| | - Joseph Hadaya
- UCLA Cardiac Arrhythmia Center, University of California Los Angeles, Los Angeles, CA, USA.,UCLA Neurocardiology Research Program of Excellence, University of California Los Angeles, Los Angeles, CA, USA.,Molecular, Cellular and Integrative Physiology Program, University of California Los Angeles, Los Angeles, CA, USA
| | - Hongming Lyu
- Electrical and Computer Engineering Department, University of California Los Angeles, Los Angeles, CA, USA
| | - Jaeeun Jang
- Electrical and Computer Engineering Department, University of California Los Angeles, Los Angeles, CA, USA
| | - Jeffrey L Ardell
- UCLA Cardiac Arrhythmia Center, University of California Los Angeles, Los Angeles, CA, USA.,UCLA Neurocardiology Research Program of Excellence, University of California Los Angeles, Los Angeles, CA, USA
| | - Ausaf A Bari
- Department of Neurosurgery, University of California at Los Angeles, Los Angeles, CA, USA
| | - Aydin Babakhani
- Electrical and Computer Engineering Department, University of California Los Angeles, Los Angeles, CA, USA.
| |
Collapse
|
9
|
Salavatian S, Wong B, Fritz JR, Kuwabara Y, Varghese CG, Howard‐Quijano K, Armour A, Foreman RD, Ardell JL, Mahajan A. Spinal cord stimulation mitigates the myocardial ischemia induced sympathoexcitation by suppressing the spinal neural synchrony and intermediolateral nucleus hyperactivity. FASEB J 2022. [DOI: 10.1096/fasebj.2022.36.s1.r2671] [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] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
10
|
Hadaya J, Chan CA, Mori S, Hoover DB, Shivkumar K, Ardell JL. Chronic Vagal Nerve Stimulation Rescues Sympathetic Control of the Heart following Myocardial Infarction. FASEB J 2022. [DOI: 10.1096/fasebj.2022.36.s1.r2397] [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] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Joseph Hadaya
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of ExcellenceUniversity of CaliforniaLos AngelesCA
| | - Christopher A. Chan
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of ExcellenceUniversity of CaliforniaLos AngelesCA
| | - Shumpei Mori
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of ExcellenceUniversity of CaliforniaLos AngelesCA
| | - Donald B. Hoover
- Department of Biomedical SciencesQuillen College of Medicine, East Tennessee State UniversityJohnson CityTN
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of ExcellenceUniversity of CaliforniaLos AngelesCA
| | - Jeffrey L. Ardell
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of ExcellenceUniversity of CaliforniaLos AngelesCA
| |
Collapse
|
11
|
Konstam MA, Mann DL, Udelson JJE, Ardell JL, De Ferrari GM, Cowie MR, Klein HU, Gregory DD, Massaro JM, Libbus I, DiCarlo LA, Butler J, Parker JD, Teerlink JR. Advances in Our Clinical Understanding of Autonomic Regulation Therapy Using Vagal Nerve Stimulation in Patients Living With Heart Failure. Front Physiol 2022; 13:857538. [PMID: 35530511 PMCID: PMC9068946 DOI: 10.3389/fphys.2022.857538] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/21/2022] [Indexed: 11/17/2022] Open
Abstract
The ANTHEM-HF, INOVATE-HF, and NECTAR-HF clinical studies of autonomic regulation therapy (ART) using vagus nerve stimulation (VNS) systems have collectively provided dose-ranging information enabling the development of several working hypotheses on how stimulation frequency can be utilized during VNS for tolerability and improving cardiovascular outcomes in patients living with heart failure (HF) and reduced ejection fraction (HFrEF). Changes in heart rate dynamics, comprising reduced heart rate (HR) and increased HR variability, are a biomarker of autonomic nerve system engagement and cardiac control, and appear to be sensitive to VNS that is delivered using a stimulation frequency that is similar to the natural operating frequency of the vagus nerve. Among prior studies, the ANTHEM-HF Pilot Study has provided the clearest evidence of autonomic engagement with VNS that was delivered using a stimulation frequency that was within the operating range of the vagus nerve. Achieving autonomic engagement was accompanied by improvement from baseline in six-minute walk duration (6MWD), health-related quality of life, and left ventricular EF (LVEF), over and above those achieved by concomitant guideline-directed medical therapy (GDMT) administered to counteract harmful neurohormonal activation, with relative freedom from deleterious effects. Autonomic engagement and positive directional changes have persisted over time, and an exploratory analysis suggests that improvement in autonomic tone, symptoms, and physical capacity may be independent of baseline NT-proBNP values. Based upon these encouraging observations, prospective, randomized controlled trials examining the effects on symptoms and cardiac function as well as natural history have been warranted. A multi-national, large-scale, randomized, controlled trial is well underway to determine the outcomes associated with ART using autonomic nervous system engagement as a guide for VNS delivery.
Collapse
Affiliation(s)
- Marvin A Konstam
- The CardioVascular Center at Tufts Medical Center, Boston, MA, United States
| | - Douglas L Mann
- Center for Cardiovascular Research, Washington University School of Medicine, Saint Louis, MO, United States
| | | | - Jeffrey L Ardell
- UCLA Neurocardiology Program of Excellence, University of California, Los Angeles, Los Angeles, CA, United States
| | | | - Martin R Cowie
- School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Helmut U Klein
- Division of Cardiology, University of Rochester Medical Center, Rochester, NY, United States
| | - Douglas D Gregory
- Clinical Cardiovascular Science Foundation, Boston, MA, United States
| | - Joseph M Massaro
- Department of Biostatistics, School of Public Health, Boston University, Boston, MA, United States
| | - Imad Libbus
- LivaNova USA Incorporated, Houston, TX, United States
| | | | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, United States
| | - John D Parker
- University of Toronto, University Health Network, Toronto, ON, Canada
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California, San Francisco, San Francisco, CA, United States
| |
Collapse
|
12
|
Hadaya J, Chan C, Dajani AH, Challita R, Cha S, Hanna P, Shivkumar K, Ardell JL. PO-645-03 CHRONIC VAGAL NERVE STIMULATION REDUCES VENTRICULAR ARRHYTHMIAS FOLLOWING MYOCARDIAL INFARCTION. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
13
|
Salavatian S, Hoang JD, Yamaguchi N, Lokhandwala ZA, Swid MA, Armour JA, Ardell JL, Vaseghi M. Myocardial infarction reduces cardiac nociceptive neurotransmission through the vagal ganglia. JCI Insight 2022; 7:155747. [PMID: 35015733 PMCID: PMC8876456 DOI: 10.1172/jci.insight.155747] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 01/05/2022] [Indexed: 12/05/2022] Open
Abstract
Myocardial infarction causes pathological changes in the autonomic nervous system, which exacerbate heart failure and predispose to fatal ventricular arrhythmias and sudden death. These changes are characterized by sympathetic activation and parasympathetic dysfunction (reduced vagal tone). Reasons for the central vagal withdrawal and, specifically, whether myocardial infarction causes changes in cardiac vagal afferent neurotransmission that then affect efferent tone, remain unknown. The objective of this study was to evaluate whether myocardial infarction causes changes in vagal neuronal afferent signaling. Using in vivo neural recordings from the inferior vagal (nodose) ganglia and immunohistochemical analyses, structural and functional alterations in vagal sensory neurons were characterized in a chronic porcine infarct model and compared with normal animals. Myocardial infarction caused an increase in the number of nociceptive neurons but a paradoxical decrease in functional nociceptive signaling. No changes in mechanosensitive neurons were observed. Notably, nociceptive neurons demonstrated an increase in GABAergic expression. Given that nociceptive signaling through the vagal ganglia increases efferent vagal tone, the results of this study suggest that a decrease in functional nociception, possibly due to an increase in expression of inhibitory neurotransmitters, may contribute to vagal withdrawal after myocardial infarction.
Collapse
Affiliation(s)
- Siamak Salavatian
- UCLA Cardiac Arrhythmia Center, UCLA, Los Angeles, United States of America
| | - Jonathan D Hoang
- UCLA Cardiac Arrhythmia Center, UCLA, Los Angeles, United States of America
| | - Naoko Yamaguchi
- UCLA Cardiac Arrhythmia Center, UCLA, Los Angeles, United States of America
| | | | - Mohammed Amer Swid
- UCLA Cardiac Arrhythmia Center, UCLA, Los Angeles, United States of America
| | - J Andrew Armour
- UCLA Cardiac Arrhythmia Center, UCLA, Los Angeles, United States of America
| | - Jeffrey L Ardell
- UCLA Cardiac Arrhythmia Center, UCLA, Los Angeles, United States of America
| | - Marmar Vaseghi
- UCLA Cardiac Arrhythmia Center, UCLA, Los Angeles, United States of America
| |
Collapse
|
14
|
Hadaya J, Buckley U, Gurel NZ, Chan CA, Swid MA, Bhadra N, Vrabec TL, Hoang JD, Smith C, Shivkumar K, Ardell JL. Scalable and reversible axonal neuromodulation of the sympathetic chain for cardiac control. Am J Physiol Heart Circ Physiol 2022; 322:H105-H115. [PMID: 34860595 PMCID: PMC8714250 DOI: 10.1152/ajpheart.00568.2021] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Maladaptation of the sympathetic nervous system contributes to the progression of cardiovascular disease and risk for sudden cardiac death, the leading cause of mortality worldwide. Axonal modulation therapy (AMT) directed at the paravertebral chain blocks sympathetic efferent outflow to the heart and maybe a promising strategy to mitigate excess disease-associated sympathoexcitation. The present work evaluates AMT, directed at the sympathetic chain, in blocking sympathoexcitation using a porcine model. In anesthetized porcine (n = 14), we applied AMT to the right T1-T2 paravertebral chain and performed electrical stimulation of the distal portion of the right sympathetic chain (RSS). RSS-evoked changes in heart rate, contractility, ventricular activation recovery interval (ARI), and norepinephrine release were examined with and without kilohertz frequency alternating current block (KHFAC). To evaluate efficacy of AMT in the setting of sympathectomy, evaluations were performed in the intact state and repeated after left and bilateral sympathectomy. We found strong correlations between AMT intensity and block of sympathetic stimulation-evoked changes in cardiac electrical and mechanical indices (r = 0.83-0.96, effect size d = 1.9-5.7), as well as evidence of sustainability and memory. AMT significantly reduced RSS-evoked left ventricular interstitial norepinephrine release, as well as coronary sinus norepinephrine levels. Moreover, AMT remained efficacious following removal of the left sympathetic chain, with similar mitigation of evoked cardiac changes and reduction of catecholamine release. With growth of neuromodulation, an on-demand or reactionary system for reversible AMT may have therapeutic potential for cardiovascular disease-associated sympathoexcitation.NEW & NOTEWORTHY Autonomic imbalance and excess sympathetic activity have been implicated in the pathogenesis of cardiovascular disease and are targets for existing medical therapy. Neuromodulation may allow for control of sympathetic projections to the heart in an on-demand and reversible manner. This study provides proof-of-concept evidence that axonal modulation therapy (AMT) blocks sympathoexcitation by defining scalability, sustainability, and memory properties of AMT. Moreover, AMT directly reduces release of myocardial norepinephrine, a mediator of arrhythmias and heart failure.
Collapse
Affiliation(s)
- Joseph Hadaya
- 1Cardiac Arrhythmia Center and Neurocardiology Research Program of
Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California,2UCLA Molecular, Cellular and Integrative Physiology
Program, Los Angeles, California
| | - Una Buckley
- 1Cardiac Arrhythmia Center and Neurocardiology Research Program of
Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Nil Z. Gurel
- 1Cardiac Arrhythmia Center and Neurocardiology Research Program of
Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Christopher A. Chan
- 1Cardiac Arrhythmia Center and Neurocardiology Research Program of
Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Mohammed A. Swid
- 1Cardiac Arrhythmia Center and Neurocardiology Research Program of
Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Niloy Bhadra
- 3Department of Physical Medicine and Rehabilitation, MetroHealth Medical Center, Cleveland, Ohio,4Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio
| | - Tina L. Vrabec
- 3Department of Physical Medicine and Rehabilitation, MetroHealth Medical Center, Cleveland, Ohio,4Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio
| | - Jonathan D. Hoang
- 1Cardiac Arrhythmia Center and Neurocardiology Research Program of
Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California,2UCLA Molecular, Cellular and Integrative Physiology
Program, Los Angeles, California
| | - Corey Smith
- 5Department of Physiology and Biophysics, Case Western Reserve University, Cleveland, Ohio
| | - Kalyanam Shivkumar
- 1Cardiac Arrhythmia Center and Neurocardiology Research Program of
Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California,2UCLA Molecular, Cellular and Integrative Physiology
Program, Los Angeles, California
| | - Jeffrey L. Ardell
- 1Cardiac Arrhythmia Center and Neurocardiology Research Program of
Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California,2UCLA Molecular, Cellular and Integrative Physiology
Program, Los Angeles, California
| |
Collapse
|
15
|
Dede E, Gregory DD, Ardell JL, Libbus I, DiCarlo LA, Premchand RK, Sharma K, Mittal S, Monteiro R, Anand IS, Düngen HD. Therapeutic responsiveness to vagus nerve stimulation in patients receiving beta-blockade for heart failure with reduced ejection fraction. Int J Cardiol Heart Vasc 2021; 37:100888. [PMID: 34754899 PMCID: PMC8556756 DOI: 10.1016/j.ijcha.2021.100888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/19/2021] [Accepted: 10/06/2021] [Indexed: 12/23/2022]
Abstract
Background The effect of beta-blockade (BB) on response to vagus nerve stimulation (VNS) has not been reported in patients with heart failure and reduced ejection fraction (HFrEF). In the ANTHEM-HF Study, 60 patients received chronic cervical VNS. Background pharmacological therapy remained unchanged during the study, and VNS intensity was stable once up-titrated. Significant improvement from baseline occurred in resting 24-hour heart rate (HR), 24-hour HR variability (SDNN), left ventricular EF (LVEF), 6-minute walk distance (6MWD), and quality of life (MLWHFS) at 6 months post-titration. We evaluated whether response to VNS was related to percentage of target BB dose (PTBBD) at baseline. Methods Patients were categorized by baseline PTBBD, then analyzed for changes from baseline in symptoms and function at 6 months after VNS titration. Results All patients received BB, either PTBBD ≥ 50 % (16 patients, 27 %; group 1) or PTBBD < 50 % (44 patients, 73 %; group 2). Heart rate, systolic blood pressure, LVEF, use of ACE/ARB, and use of MRA were similar between the two groups at baseline. Six months after up-titration, VNS reduced HR and significantly improved SDNN, LVEF, 6MWD, and MLWHFS equally in both groups. Conclusions In the ANTHEM-HF study, VNS responsiveness appeared to be independent of the baseline BB dose administered.
Collapse
Affiliation(s)
- Enea Dede
- Charité Universitätsmedizin Berlin, Germany
| | | | | | | | | | | | - Kamal Sharma
- Sanjivani Super Specialty Hospitals, Ahmedabad, India
| | | | | | | | | |
Collapse
|
16
|
Moss A, Robbins S, Achanta S, Kuttippurathu L, Turick S, Nieves S, Hanna P, Smith EH, Hoover DB, Chen J, Cheng Z(J, Ardell JL, Shivkumar K, Schwaber JS, Vadigepalli R. A single cell transcriptomics map of paracrine networks in the intrinsic cardiac nervous system. iScience 2021; 24:102713. [PMID: 34337356 PMCID: PMC8324809 DOI: 10.1016/j.isci.2021.102713] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/12/2021] [Accepted: 06/08/2021] [Indexed: 12/23/2022] Open
Abstract
We developed a spatially-tracked single neuron transcriptomics map of an intrinsic cardiac ganglion, the right atrial ganglionic plexus (RAGP) that is a critical mediator of sinoatrial node (SAN) activity. This 3D representation of RAGP used neuronal tracing to extensively map the spatial distribution of the subset of neurons that project to the SAN. RNA-seq of laser capture microdissected neurons revealed a distinct composition of RAGP neurons compared to the central nervous system and a surprising finding that cholinergic and catecholaminergic markers are coexpressed, suggesting multipotential phenotypes that can drive neuroplasticity within RAGP. High-throughput qPCR of hundreds of laser capture microdissected single neurons confirmed these findings and revealed a high dimensionality of neuromodulatory factors that contribute to dynamic control of the heart. Neuropeptide-receptor coexpression analysis revealed a combinatorial paracrine neuromodulatory network within RAGP informing follow-on studies on the vagal control of RAGP to regulate cardiac function in health and disease.
Collapse
Affiliation(s)
- Alison Moss
- Daniel Baugh Institute of Functional Genomics/Computational Biology, Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Shaina Robbins
- Daniel Baugh Institute of Functional Genomics/Computational Biology, Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Sirisha Achanta
- Daniel Baugh Institute of Functional Genomics/Computational Biology, Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Lakshmi Kuttippurathu
- Daniel Baugh Institute of Functional Genomics/Computational Biology, Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Scott Turick
- Daniel Baugh Institute of Functional Genomics/Computational Biology, Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Sean Nieves
- Daniel Baugh Institute of Functional Genomics/Computational Biology, Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Peter Hanna
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, Department of Medicine, UCLA, Los Angeles, CA, USA
| | - Elizabeth H. Smith
- Department of Biomedical Sciences, James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Donald B. Hoover
- Department of Biomedical Sciences, James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Jin Chen
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, FL, USA
| | - Zixi (Jack) Cheng
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, FL, USA
| | - Jeffrey L. Ardell
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, Department of Medicine, UCLA, Los Angeles, CA, USA
| | - Kalyanam Shivkumar
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, Department of Medicine, UCLA, Los Angeles, CA, USA
| | - James S. Schwaber
- Daniel Baugh Institute of Functional Genomics/Computational Biology, Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Rajanikanth Vadigepalli
- Daniel Baugh Institute of Functional Genomics/Computational Biology, Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University, Philadelphia, PA, USA
| |
Collapse
|
17
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
18
|
Hanna P, Dacey MJ, Brennan J, Moss A, Robbins S, Achanta S, Biscola NP, Swid MA, Rajendran PS, Mori S, Hadaya JE, Smith EH, Peirce SG, Chen J, Havton LA, Cheng Z(J, Vadigepalli R, Schwaber J, Lux RL, Efimov I, Tompkins JD, Hoover DB, Ardell JL, Shivkumar K. Innervation and Neuronal Control of the Mammalian Sinoatrial Node a Comprehensive Atlas. Circ Res 2021; 128:1279-1296. [PMID: 33629877 PMCID: PMC8284939 DOI: 10.1161/circresaha.120.318458] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
[Figure: see text].
Collapse
Affiliation(s)
- Peter Hanna
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, Department of Medicine
- UCLA Molecular, Cellular & Integrative Physiology Program, UCLA
| | - Michael J. Dacey
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, Department of Medicine
- UCLA Molecular, Cellular & Integrative Physiology Program, UCLA
| | - Jaclyn Brennan
- Bioengineering, George Washington University, Washington, DC
| | - Alison Moss
- Daniel Baugh Institute for Functional Genomics/Computational Biology, Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University, Philadelphia, PA
| | - Shaina Robbins
- Daniel Baugh Institute for Functional Genomics/Computational Biology, Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University, Philadelphia, PA
| | - Sirisha Achanta
- Daniel Baugh Institute for Functional Genomics/Computational Biology, Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University, Philadelphia, PA
| | | | - Mohammed A. Swid
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, Department of Medicine
| | - Pradeep S. Rajendran
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, Department of Medicine
| | - Shumpei Mori
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, Department of Medicine
| | - Joseph E. Hadaya
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, Department of Medicine
| | | | | | - Jin Chen
- University of Central Florida, Burnett School of Biomedical Sciences, College of Medicine, Orlando, FL
| | - Leif A. Havton
- Neurology, Icahn School of Medicine at Mount Sinai, New York City, NY
- Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY
- VA RR&D National Center of Excellence for the Medical Consequences of Spinal and; Cord Injury and Neurology Service, James J. Peters Veterans Administration Medical Center, Bronx, NY
| | - Zixi (Jack) Cheng
- University of Central Florida, Burnett School of Biomedical Sciences, College of Medicine, Orlando, FL
| | - Rajanikanth Vadigepalli
- Daniel Baugh Institute for Functional Genomics/Computational Biology, Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University, Philadelphia, PA
| | - James Schwaber
- Daniel Baugh Institute for Functional Genomics/Computational Biology, Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University, Philadelphia, PA
| | - Robert L. Lux
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, Department of Medicine
| | - Igor Efimov
- Bioengineering, George Washington University, Washington, DC
| | - John D. Tompkins
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, Department of Medicine
| | - Donald B. Hoover
- Biomedical Sciences
- Center of Excellence in Inflammation, Infectious Disease and Immunity, James H. Quillen College of Medicine, East Tennessee State University
| | - Jeffrey L. Ardell
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, Department of Medicine
- UCLA Molecular, Cellular & Integrative Physiology Program, UCLA
| | - Kalyanam Shivkumar
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, Department of Medicine
- UCLA Molecular, Cellular & Integrative Physiology Program, UCLA
| |
Collapse
|
19
|
Fontaine AK, Futia GL, Rajendran PS, Littich SF, Mizoguchi N, Shivkumar K, Ardell JL, Restrepo D, Caldwell JH, Gibson EA, Weir RFF. Optical vagus nerve modulation of heart and respiration via heart-injected retrograde AAV. Sci Rep 2021; 11:3664. [PMID: 33574459 PMCID: PMC7878800 DOI: 10.1038/s41598-021-83280-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 09/28/2020] [Accepted: 01/18/2021] [Indexed: 12/16/2022] Open
Abstract
Vagus nerve stimulation has shown many benefits for disease therapies but current approaches involve imprecise electrical stimulation that gives rise to off-target effects, while the functionally relevant pathways remain poorly understood. One method to overcome these limitations is the use of optogenetic techniques, which facilitate targeted neural communication with light-sensitive actuators (opsins) and can be targeted to organs of interest based on the location of viral delivery. Here, we tested whether retrograde adeno-associated virus (rAAV2-retro) injected in the heart can be used to selectively express opsins in vagus nerve fibers controlling cardiac function. Furthermore, we investigated whether perturbations in cardiac function could be achieved with photostimulation at the cervical vagus nerve. Viral injection in the heart resulted in robust, primarily afferent, opsin reporter expression in the vagus nerve, nodose ganglion, and brainstem. Photostimulation using both one-photon stimulation and two-photon holography with a GRIN-lens incorporated nerve cuff, was tested on the pilot-cohort of injected mice. Changes in heart rate, surface electrocardiogram, and respiratory responses were observed in response to both one- and two-photon photostimulation. The results demonstrate feasibility of retrograde labeling for organ targeted optical neuromodulation.
Collapse
Affiliation(s)
- Arjun K Fontaine
- Departments of Bioengineering, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA.
- Biomechatronics Development Laboratory, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA.
| | - Gregory L Futia
- Departments of Bioengineering, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
| | - Pradeep S Rajendran
- UCLA Cardiac Arrhythmia Center, University of California Los Angeles, Los Angeles, CA, USA
- UCLA Neurocardiology Research Program of Excellence, University of California Los Angeles, Los Angeles, CA, USA
| | - Samuel F Littich
- Departments of Bioengineering, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
- Biomechatronics Development Laboratory, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
| | - Naoko Mizoguchi
- Departments of Cell and Developmental Biology, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
- Division of Pharmacology, Department of Diagnostic and Therapeutic Sciences, Meikai University School of Dentistry, Saitama, Japan
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, University of California Los Angeles, Los Angeles, CA, USA
- UCLA Neurocardiology Research Program of Excellence, University of California Los Angeles, Los Angeles, CA, USA
| | - Jeffrey L Ardell
- UCLA Cardiac Arrhythmia Center, University of California Los Angeles, Los Angeles, CA, USA
- UCLA Neurocardiology Research Program of Excellence, University of California Los Angeles, Los Angeles, CA, USA
| | - Diego Restrepo
- Departments of Cell and Developmental Biology, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
| | - John H Caldwell
- Departments of Cell and Developmental Biology, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
| | - Emily A Gibson
- Departments of Bioengineering, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
| | - Richard F Ff Weir
- Departments of Bioengineering, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
- Biomechatronics Development Laboratory, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
- Rocky Mountain Veterans Affairs Medical Center (VAMC), Aurora, CO, USA
| |
Collapse
|
20
|
Kluge N, Dacey M, Hadaya J, Shivkumar K, Chan SA, Ardell JL, Smith C. Rapid measurement of cardiac neuropeptide dynamics by capacitive immunoprobe in the porcine heart. Am J Physiol Heart Circ Physiol 2021; 320:H66-H76. [PMID: 33095651 PMCID: PMC7847069 DOI: 10.1152/ajpheart.00674.2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 10/22/2020] [Accepted: 10/22/2020] [Indexed: 01/09/2023]
Abstract
Sympathetic control of regional cardiac function occurs through postganglionic innervation from stellate ganglia and thoracic sympathetic chain. Whereas norepinephrine (NE) is their primary neurotransmitter, neuropeptide Y (NPY) is an abundant cardiac cotransmitter. NPY plays a vital role in homeostatic processes including angiogenesis, vasoconstriction, and cardiac remodeling. Elevated sympathetic stress, resulting in increased NE and NPY release, has been implicated in the pathogenesis of several cardiovascular disorders including hypertension, myocardial infarction, heart failure, and arrhythmias, which may result in sudden cardiac death. Current methods for the detection of NPY in myocardium are limited in their spatial and temporal resolution and take days to weeks to provide results [e.g., interstitial microdialysis with subsequent analysis by enzyme-linked immunosorbent assay (ELISA), high performance liquid chromatography (HPLC), or mass spectrometry]. In this study, we report a novel approach for measurement of interstitial and intravascular NPY using a minimally invasive capacitive immunoprobe (C.I. probe). The first high-spatial and temporal resolution, multichannel measurements of NPY release in vivo are provided in both myocardium and transcardiac vascular space in a beating porcine heart. We provide NPY responses evoked by sympathetic stimulation and ectopic ventricular pacing and compare these to NE release and hemodynamic responses. We extend this approach to measure both NPY and vasoactive intestinal peptide (VIP) and show differential release profiles under sympathetic stimulation. Our data demonstrate rapid and local changes in neurotransmitter profiles in response to sympathetic cardiac stressors. Future implementations include real-time intraoperative determination of cardiac neuropeptides and deployment as a minimally invasive catheter.NEW & NOTEWORTHY The sympathetic nervous system regulates cardiac function through release of neurotransmitters and neuropeptides within the myocardium. Neuropeptide Y (NPY) acts as an acute cardiac vasoconstrictor and chronically to regulate angiogenesis and cardiac remodeling. Current methodologies for the measure of NPY are not capable of providing rapid readouts on a single-sample basis. Here we provide the first in vivo methodology to report dynamic, localized NPY levels within both myocardium and vascular compartments in a beating heart.
Collapse
Affiliation(s)
- Nicholas Kluge
- Department of Physiology and Biophysics, Case Western Reserve University, Cleveland, Ohio
| | - Michael Dacey
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine, University of California, Los Angeles, California
- UCLA Neurocardiology Research Program of Excellence, University of California, Los Angeles, California
- Molecular, Cellular, and Integrative Physiology Program, University of California, Los Angeles, California
| | - Joseph Hadaya
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine, University of California, Los Angeles, California
- UCLA Neurocardiology Research Program of Excellence, University of California, Los Angeles, California
- Molecular, Cellular, and Integrative Physiology Program, University of California, Los Angeles, California
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine, University of California, Los Angeles, California
- UCLA Neurocardiology Research Program of Excellence, University of California, Los Angeles, California
| | - Shyue-An Chan
- Department of Physiology and Biophysics, Case Western Reserve University, Cleveland, Ohio
| | - Jeffrey L Ardell
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine, University of California, Los Angeles, California
- UCLA Neurocardiology Research Program of Excellence, University of California, Los Angeles, California
| | - Corey Smith
- Department of Physiology and Biophysics, Case Western Reserve University, Cleveland, Ohio
| |
Collapse
|
21
|
Abstract
Dysfunction of the autonomic nervous system has been implicated in the pathogenesis of cardiovascular disease, including congestive heart failure and cardiac arrhythmias. Despite advances in the medical and surgical management of these entities, progression of disease persists as does the risk for sudden cardiac death. With improved knowledge of the dynamic relationships between the nervous system and heart, neuromodulatory techniques such as cardiac sympathetic denervation and vagal nerve stimulation (VNS) have emerged as possible therapeutic approaches for the management of these disorders. In this review, we present the structure and function of the cardiac nervous system and the remodeling that occurs in disease states, emphasizing the concept of increased sympathoexcitation and reduced parasympathetic tone. We review preclinical evidence for vagal nerve stimulation, and early results of clinical trials in the setting of congestive heart failure. Vagal nerve stimulation, and other neuromodulatory techniques, may improve the management of cardiovascular disorders, and warrant further study.
Collapse
Affiliation(s)
- Joseph Hadaya
- University of California, Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, Los Angeles, CA, United States.,UCLA Neurocardiology Research Program of Excellence, UCLA, Los Angeles, CA, United States.,Molecular, Cellular, and Integrative Physiology Program, UCLA, Los Angeles, CA, United States
| | - Jeffrey L Ardell
- University of California, Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, Los Angeles, CA, United States.,UCLA Neurocardiology Research Program of Excellence, UCLA, Los Angeles, CA, United States
| |
Collapse
|
22
|
Hanna P, L Ardell J, ShivkumarKalyanam K. Cardiac Neuroanatomy for the Cardiac Electrophysiologist. J Atr Fibrillation 2020; 13:2407. [PMID: 33024507 DOI: 10.4022/jafib.2407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/11/2019] [Accepted: 10/12/2019] [Indexed: 12/22/2022]
Abstract
The cardiac neuraxis is integral to cardiac physiology, and its dysregulation is implicated in cardiovascular disease. Neuromodulatory therapies are being developed that target the cardiac autonomic nervous system (ANS) to treat cardiac pathophysiology. An appreciation of the cardiac neuroanatomy is a prerequisite for development of such targeted therapies. Here, we provide a review of the current understanding of the cardiac ANS. The parasympathetic and sympathetic nervous system are composed of higher order cortical centers, brainstem, spinal cord, intrathoracic extracardiac ganglia and intrinsic cardiac ganglia. A series of interacting feedback loops mediates reflex pathways to exert control over the cardiac conduction system and contractile tissue. Further exploration of this complex regulatory system promises to yield neuroscience-based therapeutics for cardiac disease.
Collapse
Affiliation(s)
- Peter Hanna
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, Department of Medicine, UCLA, Los Angeles, CA.,UCLA Molecular, Cellular & Integrative Physiology Program, UCLA, Los Angeles, CA
| | - Jeffrey L Ardell
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, Department of Medicine, UCLA, Los Angeles, CA.,UCLA Molecular, Cellular & Integrative Physiology Program, UCLA, Los Angeles, CA
| | - Kalyanam ShivkumarKalyanam
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, Department of Medicine, UCLA, Los Angeles, CA.,UCLA Molecular, Cellular & Integrative Physiology Program, UCLA, Los Angeles, CA
| |
Collapse
|
23
|
Sharma K, Premchand RK, Mittal S, Monteiro R, Libbus I, DiCarlo LA, Ardell JL, Amurthur B, KenKnight BH, Anand IS. Long-term Follow-Up of Patients with Heart Failure and Reduced Ejection Fraction Receiving Autonomic Regulation Therapy in the ANTHEM-HF Pilot Study. Int J Cardiol 2020; 323:175-178. [PMID: 33038408 DOI: 10.1016/j.ijcard.2020.09.072] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 09/14/2020] [Accepted: 09/30/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The ANTHEM-HF pilot study was an open-label study that evaluated the safety and feasibility of autonomic regulation therapy (ART) utilizing cervical vagus nerve stimulation (VNS) for patients with chronic HF with reduced EF (HFrEF). Patients in NYHA class II-III with EF ≤40% (n = 60) received ART for 6 months post-titration. ART was associated with sustained improvement in left ventricular (LV) function and HF symptoms at 6 and 12 months. METHODS Continuously cyclic VNS was maintained to determine longer-term safety and chronic effects of ART. Echocardiographic parameters and HF symptoms were assessed throughout a follow-up period of at least 42 months. RESULTS Between 12 and 42 months after initial titration, there were no device-related SAEs or malfunctions. There were 10 SAEs adjudicated to be unrelated to VNS, including 5 deaths. There were 6 non-serious adverse events that were adjudicated to be device-related (2 oropharyngeal pain, 1 implant site pain, 2 voice alteration, and 1 hoarseness). At 42 months, there was significant improvement from baseline in LVEF, NYHA class, 6-min walk distance, and MLHFQ score. However, these improvements at 42 months were not significantly different from mean values at 6 and 12 months. CONCLUSIONS In a 42-month follow-up, ART was durable, safe, and was associated with beneficial effects on LVEF and 6-min walk distance. Long term, chronic, open-loop ART continued to be well-tolerated in patients with HFrEF. The open label, randomized, controlled, ANTHEM-HFrEF Pivotal Study is currently underway to further evaluate ART in patients with advanced HF.
Collapse
Affiliation(s)
- Kamal Sharma
- Sanjivani Super Specialty Hospitals, Ahmedabad, India
| | | | | | | | - Imad Libbus
- LivaNova PLC, Inc., Houston, TX, United States of America
| | | | - Jeffrey L Ardell
- University of California at Los Angeles, Los Angeles, CA, United States of America
| | - Badri Amurthur
- LivaNova PLC, Inc., Houston, TX, United States of America
| | | | - Inder S Anand
- University of Minnesota, Minneapolis, MN, United States of America.
| |
Collapse
|
24
|
Affiliation(s)
- Jeffrey L. Ardell
- Address for correspondence: Dr. Jeffrey Ardell, University of California-Los Angeles Cardiac Arrhythmia Center, David Geffen School of Medicine, 100 Medical Plaza, Suite 660, Los Angeles, California 90095.
| |
Collapse
|
25
|
Boukens BJD, Dacey M, Meijborg VMF, Janse MJ, Hadaya J, Hanna P, Swid MA, Opthof T, Ardell JL, Shivkumar K, Coronel R. Mechanism of ventricular premature beats elicited by left stellate ganglion stimulation during acute ischaemia of the anterior left ventricle. Cardiovasc Res 2020; 117:2083-2091. [PMID: 32853334 PMCID: PMC8318107 DOI: 10.1093/cvr/cvaa253] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 12/12/2019] [Revised: 07/06/2020] [Accepted: 08/20/2020] [Indexed: 11/13/2022] Open
Abstract
AIMS Enhanced sympathetic activity during acute ischaemia is arrhythmogenic, but the underlying mechanism is unknown. During ischaemia, a diastolic current flows from the ischaemic to the non-ischaemic myocardium. This 'injury' current can cause ventricular premature beats (VPBs) originating in the non-ischaemic myocardium, especially during a deeply negative T wave in the ischaemic zone. We reasoned that shortening of repolarization in myocardium adjacent to ischaemic myocardium increases the 'injury' current and causes earlier deeply negative T waves in the ischaemic zone, and re-excitation of the normal myocardium. We tested this hypothesis by activation and repolarization mapping during stimulation of the left stellate ganglion (LSG) during left anterior descending coronary artery (LAD) occlusion. METHODS AND RESULTS In nine pigs, five subsequent episodes of acute ischaemia, separated by 20 min of reperfusion, were produced by occlusion of the LAD and 121 epicardial local unipolar electrograms were recorded. During the third occlusion, left stellate ganglion stimulation (LSGS) was initiated after 3 min for a 30-s period, causing a shortening of repolarization in the normal myocardium by about 100 ms. This resulted in more negative T waves in the ischaemic zone and more VPBs than during the second, control, occlusion. Following the decentralization of the LSG (including removal of the right stellate ganglion and bilateral cervical vagotomy), fewer VPBs occurred during ischaemia without LSGS. During LSGS, the number of VPBs was similar to that recorded before decentralization. CONCLUSION LSGS, by virtue of shortening of repolarization in the non-ischaemic myocardium by about 100 ms, causes deeply negative T waves in the ischaemic tissue and VPBs originating from the normal tissue adjacent to the ischaemic border.
Collapse
Affiliation(s)
- Bastiaan J D Boukens
- Department of Medical Biology, Amsterdam UMC, University of Amsterdam, Heart Center, Meibergdreef 9, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands.,Department of Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Heart Center, Meibergdreef 9, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands
| | - Michael Dacey
- UCLA Cardiac Arrhythmia Center, Los Angeles, CA, USA
| | - Veronique M F Meijborg
- Department of Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Heart Center, Meibergdreef 9, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands
| | - Michiel J Janse
- Department of Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Heart Center, Meibergdreef 9, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands
| | - Joseph Hadaya
- UCLA Cardiac Arrhythmia Center, Los Angeles, CA, USA
| | - Peter Hanna
- UCLA Cardiac Arrhythmia Center, Los Angeles, CA, USA
| | - M Amer Swid
- UCLA Cardiac Arrhythmia Center, Los Angeles, CA, USA
| | - Tobias Opthof
- Department of Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Heart Center, Meibergdreef 9, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands
| | | | | | - Ruben Coronel
- Department of Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Heart Center, Meibergdreef 9, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands.,L'Institut de RYtmologie et de Modelisation Cardiaque (LIRYC), Universite de Bordeaux, Bordeaux, France
| |
Collapse
|
26
|
Anand I, Ardell JL, Gregory D, Libbus I, DiCarlo L, Premchand RK, Sharma K, Mittal S, Monteiro R. Baseline NT-proBNP and responsiveness to autonomic regulation therapy in patients with heart failure and reduced ejection fraction. Int J Cardiol Heart Vasc 2020; 29:100520. [PMID: 32509959 PMCID: PMC7264752 DOI: 10.1016/j.ijcha.2020.100520] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 04/15/2020] [Indexed: 11/26/2022]
Abstract
Background Recent heart failure studies have associated lower baseline natriuretic peptide levels with improved morbidity/mortality outcomes during pharmaceutical treatment, and better clinical outcomes during neuromodulation (NM) with carotid nerve plexus stimulation for HFrEF when NT-proBNP < 1600 pg/ml. Whether baseline NT-proBNP is associated with HFrEF responsiveness to NM using vagus nerve stimulation (VNS) has not been examined. Hence, we evaluated the interaction of baseline NT-proBNP with changes in symptoms and function that occurred during chronic VNS in the ANTHEM-HF study. Methods A repeated measures, generalized-estimating, equations model evaluated the relationship of baseline NT-proBNP values above and below 1600 pg/ml to symptomatic and functional responses in ANTHEM-HF. Results Median (interquartile range; maximum) NT-proBNP was 868 (322, 1875; 14,656) pg/ml (N = 58). Heart rate (HR), HR variability (SDNN), 6-minute walk distance, MLWHF mean score, and NYHA improved significantly, independent of baseline NT-proBNP. While there was a statistical interaction between baseline NT-proBNP and better LVEF improvement during VNS, LVEF improved overall in the study cohort (N = 60; 32 ± 7 to 37 ± 10%; p = 0.0042), and in those patients whose baseline NT-proBNP was below the median baseline NT-proBNP value (n = 29; 36 ± 6 to 42 ± 10%; p < 0.0025)] or above this value (n = 29; 29 ± 7 to 32 ± 9%; p < 0.05). Conclusions In ANTHEM-HF, overall symptomatic and functional improvement during chronic VNS was independent of baseline NTproBNP. These are preliminary and hypothesis-generating findings, and the reason for a differing interaction between baseline NT-proBNP and response to CNPS and VNS remains unclear. It is anticipated that the ongoing ANTHEM-HFrEF Pivotal Study of VNS will provide additional insight.
Collapse
Affiliation(s)
- Inder Anand
- University of Minnesota (Emeritus), Minneapolis, MN, USA
| | | | - Doug Gregory
- Clinical Cardiovascular Science Foundation, Boston, MA, USA
| | | | | | | | - Kamal Sharma
- Sanjivani Super Specialty Hospitals, Ahmedabad, India
| | | | | |
Collapse
|
27
|
Hoover DB, Hanna P, Dacey MJ, Hadaya JE, Swid MA, Smith EH, Peirce SG, Poston MD, Potter JC, Ardell JL, Shivkumar K. SPARC: Autonomic Innervation of Porcine Ventricular Myocardium and Purkinje Fibers. FASEB J 2020. [DOI: 10.1096/fasebj.2020.34.s1.03376] [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] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
28
|
Chan SA, Vaseghi M, Kluge N, Shivkumar K, Ardell JL, Smith C. Fast in vivo detection of myocardial norepinephrine levels in the beating porcine heart. Am J Physiol Heart Circ Physiol 2020; 318:H1091-H1099. [PMID: 32216617 PMCID: PMC7346543 DOI: 10.1152/ajpheart.00574.2019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The sympathetic nervous system modulates cardiac function by controlling key parameters such as chronotropy and inotropy. Sympathetic control of ventricular function occurs through extrinsic innervation arising from the stellate ganglia and thoracic sympathetic chain. In the healthy heart, sympathetic release of norepinephrine (NE) results in positive modulation of chronotropy, inotropy, and dromotropy, significantly increasing cardiac output. However, in the setting of myocardial infarction or injury, sympathetic activation persists, contributing to heart failure and increasing the risk of arrhythmias, including sudden cardiac death. Methodologies for detection of norepinephrine in cardiac tissue are limited. Present techniques rely on microdialysis for analysis by high-performance liquid chromatography coupled to electrochemical detection (HPLC-ED), radioimmunoassay, or other immunoassays, such as enzyme-linked immunosorbent assay (ELISA). Although significant information about the release and action of norepinephrine has been obtained with these methodologies, they are limited in temporal resolution, require large sample volumes, and provide results with a significant delay after sample collection (hours to weeks). In this study, we report a novel approach for measurement of interstitial cardiac norepinephrine, using minimally invasive, electrode-based, fast-scanning cyclic voltammetry (FSCV) applied in a beating porcine heart. The first multispatial and high temporal resolution, multichannel measurements of NE release in vivo are provided. Our data demonstrate rapid changes in interstitial NE profiles with regional differences in response to coronary ischemia, sympathetic nerve stimulation, and alterations in preload/afterload. NEW & NOTEWORTHY Pharmacological, electrical, or surgical regulation of sympathetic neuronal control can be used to modulate cardiac function and treat arrhythmias. However, present methods for monitoring sympathetic release of norepinephrine in the heart are limited in spatial and temporal resolution. Here, we provide for the first time a methodology and demonstration of practice and rapid measures of individualized regional autonomic neurotransmitter levels in a beating heart. We show dynamic, spatially resolved release profiles under normal and pathological conditions.
Collapse
Affiliation(s)
- Shyue-An Chan
- Department of Physiology and Biophysics, Case Western Reserve University, Cleveland, Ohio
| | - Marmar Vaseghi
- UCLA Cardiac Arrhythmia Center, UCLA Health System, University of California Los Angeles, Los Angeles, California.,UCLA Neurocardiology Research Program of Excellence, University of California Los Angeles, Los Angeles, California
| | - Nicholas Kluge
- Department of Physiology and Biophysics, Case Western Reserve University, Cleveland, Ohio
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, UCLA Health System, University of California Los Angeles, Los Angeles, California.,UCLA Neurocardiology Research Program of Excellence, University of California Los Angeles, Los Angeles, California
| | - Jeffrey L Ardell
- UCLA Cardiac Arrhythmia Center, UCLA Health System, University of California Los Angeles, Los Angeles, California.,UCLA Neurocardiology Research Program of Excellence, University of California Los Angeles, Los Angeles, California
| | - Corey Smith
- Department of Physiology and Biophysics, Case Western Reserve University, Cleveland, Ohio
| |
Collapse
|
29
|
Dale EA, Kipke J, Kubo Y, Sunshine MD, Castro PA, Ardell JL, Mahajan A. Spinal cord neural network interactions: implications for sympathetic control of the porcine heart. Am J Physiol Heart Circ Physiol 2020; 318:H830-H839. [PMID: 32108524 DOI: 10.1152/ajpheart.00635.2019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Inherent and acquired factors determine the integrated autonomic response to cardiovascular stressors. Excessive sympathoexcitation to ischemic stress is a major contributor to the potential for sudden cardiac death. To define fundamental aspects of cardiac-related autonomic neural network interactions within the thoracic cord, specifically as related to modulating sympathetic preganglionic (SPN) neural activity. Adult, anesthetized Yorkshire pigs (n = 10) were implanted with penetrating high-density microarrays (64 electrodes) at the T2 level of the thoracic spinal cord to record extracellular potentials concurrently from left-sided dorsal horn (DH) and SPN neurons. Electrical stimulation of the T2 paravertebral chain allowed for antidromic identification of SPNs located in the intermediolateral cell column (57 of total 1,760 recorded neurons). Cardiac stressors included epicardial touch, occlusion of great vessels to transiently alter preload/afterload, and transient occlusion of the left anterior descending coronary artery (LAD). Spatial/temporal assessment of network interactions was characterized by cross-correlation analysis. While some DH neurons responded solely to changes in preload/afterload (8.5 ± 1.9%) or ischemic stress (10.5 ± 3.9%), the majority of cardiovascular-related DH neurons were multimodal (30.2 ± 4.7%) with ischemia sensitivity being one of the modalities (26.1 ± 4.7%). The sympathoexcitation associated with transient LAD occlusion was associated with increased correlations from baseline within DH neurons (2.43 ± 0.61 to 7.30 ± 1.84%, P = 0.04) and between SPN to DH neurons (1.32 ± 0.78 to 7.24 ± 1.84%, P = 0.02). DH to SPN network correlations were reduced during great vessel occlusion. In conclusion, increased intrasegmental network coherence within the thoracic spinal cord contributes to myocardial ischemia-induced sympathoexcitation.NEW & NOTEWORTHY In an in vivo pig model, we demonstrate using novel high-resolution neural electrode arrays that increased intrasegmental network coherence within the thoracic spinal cord contributes to myocardial ischemia-induced sympathoexcitation.
Collapse
Affiliation(s)
- Erica A Dale
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Jasmine Kipke
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Yukiko Kubo
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Michael D Sunshine
- Department of Physical Therapy, University of Florida, Gainesville, Florida
| | - Peter A Castro
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Jeffrey L Ardell
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, California.,Department of Medicine, Cardiac Arrhythmia Center and Cardiac Neurocardiology Research Program of Excellence, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Aman Mahajan
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
| |
Collapse
|
30
|
Anand IS, Konstam MA, Klein HU, Mann DL, Ardell JL, Gregory DD, Massaro JM, Libbus I, DiCarlo LA, Udelson JJE, Butler J, Parker JD, Teerlink JR. Comparison of symptomatic and functional responses to vagus nerve stimulation in ANTHEM-HF, INOVATE-HF, and NECTAR-HF. ESC Heart Fail 2020; 7:75-83. [PMID: 31984682 PMCID: PMC7083506 DOI: 10.1002/ehf2.12592] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 11/11/2019] [Accepted: 11/25/2019] [Indexed: 12/19/2022] Open
Abstract
Aims Clinical studies of vagal nerve stimulation (VNS) for heart failure with reduced ejection fraction have had mixed results to date. We sought to compare VNS delivery and associated changes in symptoms and function in autonomic regulation therapy via left or right cervical vagus nerve stimulation in patients with chronic heart failure (ANTHEM‐HF), increase of vagal tone in heart failure (INOVATE‐HF), and neural cardiac therapy for heart failure (NECTAR‐HF) for hypothesis generation. Methods and results Descriptive statistics were used to analyse data from the public domain for differences in proportions using Pearson's chi‐square test, differences in mean values using Student's unpaired t‐test, and differences in changes of mean values using two‐sample t‐tests. Guideline‐directed medical therapy recommendations were similar across studies. Fewer patients were in New York Heart Association 3, and baseline heart rate (HR) was higher in ANTHEM‐HF. In INOVATE‐HF, VNS was aimed at peripheral neural targets, using closed‐loop delivery that required synchronization of VNS to R‐wave sensing by an intracardiac lead. Pulse frequency was low (1–2 Hz) because of a timing schedule allowing ≤3 pulses of VNS following at most 25% of detected R waves. NECTAR‐HF and ANTHEM‐HF used open‐loop VNS delivery (i.e. independent of any external signal) aimed at both central and peripheral targets. In NECTAR‐HF, VNS delivery at 20 Hz caused off‐target effects that limited VNS up‐titration in a majority of patients. In ANTHEM‐HF, VNS delivery at 10 Hz allowed up‐titration until changes in HR dynamics were confirmed. Six months after VNS titration, significant improvements in both HR and HR variability occurred only in ANTHEM‐HF. When ANTHEM‐HF and NECTAR‐HF were compared, greater improvements from baseline were observed in ANTHEM‐HF in standard deviation in normal‐to‐normal R‐R intervals (94 ± 26 to 111 ± 50 vs. 146 ± 48 to 130 ± 52 ms; P < 0.001), left ventricular ejection fraction (32 ± 7 to 37 ± 0.4 vs. 31 ± 6 to 33 ± 6; P < 0.05), and Minnesota Living with Heart Failure mean score (40 ± 14 to 21 ± 10 vs. 44 ± 22 to 36 ± 21; P < 0.002). When compared with INOVATE‐HF, greater improvement in 6‐min walk distance was observed in ANTHEM‐HF (287 ± 66 to 346 ± 78 vs. 304 ± 111 to 334 ± 111 m; P < 0.04). Conclusions In this post‐hoc analysis, differences in patient demographics were seen and may have caused the differential responses in symptoms and function observed in association with VNS. Major differences in technology platforms, neural targets, VNS delivery, and HR and HR variability responses could have also potentially played a very important role. Further study is underway in a randomized controlled trial with these considerations in mind.
Collapse
Affiliation(s)
- Inder S Anand
- Division of Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - Marvin A Konstam
- The CardioVascular Center at Tufts Medical Center, Boston, MA, USA
| | - Helmut U Klein
- Division of Cardiology, University of Rochester Medical Center, Rochester, NY, USA
| | - Douglas L Mann
- Center for Cardiovascular Research, Washington University School of Medicine, Saint Louis, MO, USA
| | - Jeffrey L Ardell
- UCLA Neurocardiology Program of Excellence, University of California, Los Angeles, CA, USA
| | | | - Joseph M Massaro
- Department of Biostatistics, School of Public Health, Boston University, Boston, MA, USA
| | | | | | | | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - John D Parker
- University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California, San Francisco, CA, USA
| |
Collapse
|
31
|
Ardell JL, Foreman RD, Armour JA, Shivkumar K. Cardiac sympathectomy and spinal cord stimulation attenuate reflex-mediated norepinephrine release during ischemia preventing ventricular fibrillation. JCI Insight 2019; 4:131648. [PMID: 31671074 DOI: 10.1172/jci.insight.131648] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 10/23/2019] [Indexed: 12/15/2022] Open
Abstract
The purpose of this study was to define the mechanism by which cardiac neuraxial decentralization or spinal cord stimulation (SCS) reduces ischemia-induced ventricular fibrillation (VF). Direct measurements of norepinephrine (NE) levels in the left ventricular interstitial fluid (ISF) by microdialysis, in response to transient (15-minute) coronary artery occlusion (CAO), were performed in anesthetized canines. Responses were studied in animals with intact neuraxes and were compared with those in which the intrathoracic component of the cardiac neuraxes (stellate ganglia) or the intrinsic cardiac neuronal (ICN) system was surgically delinked from the central nervous system and those with intact neuraxes with preemptive SCS (T1-T3). With intact neuraxes, animals with exaggerated NE release due to CAO were at increased risk for VF. During CAO, there was a 152% increase in NE when the neuraxes were intact compared with 114% following stellate decentralization and 16% following ICN decentralization. During SCS, CAO NE levels increased by 59%. Risk for CAO-induced VF was 38% in controls, 8% following decentralization, and 11% following SCS. These data indicate that ischemia-related afferent neuronal transmission differentially engages central and intrathoracic sympathetic reflexes and amplifies sympathoexcitation. Differences in regional ventricular NE release are associated with increased risk for VF. Surgical decentralization or SCS reduced NE release and VF.
Collapse
Affiliation(s)
- Jeffrey L Ardell
- UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, California, USA.,Neurocardiology Research Program of Excellence and.,Molecular Cellular and Integrative Physiology, UCLA, Los Angeles, California, USA.,Department of Biomedical Sciences, East Tennessee State University, Johnson City, Tennessee, USA
| | - Robert D Foreman
- Department of Physiology, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, USA
| | - J Andrew Armour
- UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, California, USA.,Neurocardiology Research Program of Excellence and
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, California, USA.,Neurocardiology Research Program of Excellence and.,Molecular Cellular and Integrative Physiology, UCLA, Los Angeles, California, USA.,Neuroscience Interdepartmental Programs, UCLA, Los Angeles, California, USA
| |
Collapse
|
32
|
Konstam MA, Udelson JE, Butler J, Klein HU, Parker JD, Teerlink JR, Wedge PM, Saville BR, Ardell JL, Libbus I, DiCarlo LA. Impact of Autonomic Regulation Therapy in Patients with Heart Failure. Circ Heart Fail 2019; 12:e005879. [DOI: 10.1161/circheartfailure.119.005879] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background:
The ANTHEM-HFrEF (Autonomic Regulation Therapy to Enhance Myocardial Function and Reduce Progression of Heart Failure with Reduced Ejection Fraction) pivotal study is an adaptive, open-label, randomized, controlled study evaluating whether autonomic regulation therapy will benefit patients with advanced HFrEF. While early-phase studies have supported potential use of vagus nerve stimulation to deliver autonomic regulation therapy for HFrEF, results of larger clinical trials have been inconsistent. The ANTHEM-HFrEF study uses a novel design, with adaptive sample size selection, evaluating effects on morbidity and mortality as well as symptoms and function.
Methods:
The ANTHEM-HFrEF study will randomize patients (2:1) to autonomic regulation therapy plus guideline-directed medical therapy, or guideline-directed medical therapy alone. The morbidity and mortality trial utilizes a conventional frequentist approach for analysis of the primary outcome end point—reduction in the composite of cardiovascular death or first HF hospitalization—and a Bayesian adaptive approach toward sample size selection. Embedded within the ANTHEM-HFrEF study is a second trial evaluating improvement in symptoms and function. Symptom/function success will require meeting 2 risk-related conditions (trend for reduced cardiovascular death/HF hospitalization and sufficient freedom from device-related serious adverse events) and 3 efficacy end point components (changes in left ventricular EF, 6-minute walk distance, and Kansas City Cardiomyopathy Questionnaire overall score).
Conclusions:
Vagus nerve stimulation remains a promising, yet unproven treatment in HFrEF. A successful ANTHEM-HFrEF pivotal study would provide an important advance in HFrEF treatment and offer a model for expediting evaluation of new therapies.
Clinical Trial Registration:
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT03425422.
Collapse
Affiliation(s)
- Marvin A. Konstam
- The CardioVascular Center at Tufts Medical Center, Boston, MA (M.A.K., J.E.U.)
| | - James E. Udelson
- The CardioVascular Center at Tufts Medical Center, Boston, MA (M.A.K., J.E.U.)
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS (J.B.)
| | - Helmut U. Klein
- Department of Medicine, University of Rochester Medical Center, NY (H.U.K.)
| | - John D. Parker
- University of Toronto, Mount Sinai Hospital, Division of Cardiology, Sinai Health Systems and University Health Network, Toronto, Canada (J.D.P.)
| | - John R. Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California (J.R.T.)
| | | | - Benjamin R. Saville
- Berry Consultants LLC, Austin TX and Department of Biostatistics, Vanderbilt University, Nashville TN (B.R.S.)
| | - Jeffrey L. Ardell
- Neurocardiology Center, University of California, Los Angeles (J.L.A.)
| | - Imad Libbus
- LivaNova USA Incorporated, Houston, TX (I.L., L.A.D.)
| | | | | |
Collapse
|
33
|
Jungen C, Scherschel K, Flenner F, Jee H, Rajendran P, De Jong KA, Nikolaev V, Meyer C, Ardell JL, Tompkins JD. Increased arrhythmia susceptibility in type 2 diabetic mice related to dysregulation of ventricular sympathetic innervation. Am J Physiol Heart Circ Physiol 2019; 317:H1328-H1341. [PMID: 31625779 DOI: 10.1152/ajpheart.00249.2019] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Patients with type 2 diabetes mellitus (T2DM) have a greater risk of developing life-threatening cardiac arrhythmias. Because the underlying mechanisms and potential influence of diabetic autonomic neuropathy are not well understood, we aimed to assess the relevance of a dysregulation in cardiac autonomic tone. Ventricular arrhythmia susceptibility was increased in Langendorff-perfused hearts isolated from mice with T2DM (db/db). Membrane properties and synaptic transmission were similar at cardiac postganglionic parasympathetic neurons from diabetic and control mice; however, a greater asynchronous neurotransmitter release was present at sympathetic postganglionic neurons from the stellate ganglia of db/db mice. Western blot analysis showed a reduction of tyrosine hydroxylase (TH) from the ventricles of db/db mice, which was confirmed with confocal imaging as a heterogeneous loss of TH-immunoreactivity from the left ventricular wall but not the apex. In vivo stimulation of cardiac parasympathetic (vagus) or cardiac sympathetic (stellate ganglion) nerves induced similar changes in heart rate in control and db/db mice, and the kinetics of pacing-induced Ca2+ transients (recorded from isolated cardiomyocytes) were similar in control and db/db cells. Antagonism of cardiac muscarinic receptors did not affect the frequency or severity of arrhythmias in db/db mice, but sympathetic blockade with propranolol completely inhibited arrhythmogenicity. Collectively, these findings suggest that the increased ventricular arrhythmia susceptibility of type 2 diabetic mouse hearts is due to dysregulation of the sympathetic ventricular control.NEW & NOTEWORTHY Patients with type 2 diabetes mellitus have greater risk of suffering from sudden cardiac death. We found that the increased ventricular arrhythmia susceptibility in type 2 diabetic mouse hearts is due to cardiac sympathetic dysfunction. Sympathetic dysregulation is indicated by an increased asynchronous release at stellate ganglia, a heterogeneous loss of tyrosine hydroxylase from the ventricular wall but not apex, and inhibition of ventricular arrhythmias in db/db mice after β-sympathetic blockade.
Collapse
Affiliation(s)
- Christiane Jungen
- Department of Cardiology-Electrophysiology, cNEP, cardiac Neuro- and Electrophysiology research group, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Katharina Scherschel
- Department of Cardiology-Electrophysiology, cNEP, cardiac Neuro- and Electrophysiology research group, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Frederik Flenner
- DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany.,Department of Experimental Pharmacology and Toxicology, Cardiovascular Research Centre, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Haesung Jee
- University of California, Los Angeles Cardiac Arrhythmia Center, Neurocardiology Research Program of Excellence, Department of Medicine-Cardiology, Los Angeles, California
| | - Pradeep Rajendran
- University of California, Los Angeles Cardiac Arrhythmia Center, Neurocardiology Research Program of Excellence, Department of Medicine-Cardiology, Los Angeles, California
| | - Kirstie A De Jong
- DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany.,Institute of Experimental Cardiovascular Research, University Medical Center Hamburg-Eppendorf, University of Hamburg, Germany
| | - Viacheslav Nikolaev
- DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany.,Institute of Experimental Cardiovascular Research, University Medical Center Hamburg-Eppendorf, University of Hamburg, Germany
| | - Christian Meyer
- Department of Cardiology-Electrophysiology, cNEP, cardiac Neuro- and Electrophysiology research group, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Jeffrey L Ardell
- University of California, Los Angeles Cardiac Arrhythmia Center, Neurocardiology Research Program of Excellence, Department of Medicine-Cardiology, Los Angeles, California
| | - John D Tompkins
- University of California, Los Angeles Cardiac Arrhythmia Center, Neurocardiology Research Program of Excellence, Department of Medicine-Cardiology, Los Angeles, California
| |
Collapse
|
34
|
Salavatian S, Ardell SM, Hammer M, Gibbons D, Armour JA, Ardell JL. Thoracic spinal cord neuromodulation obtunds dorsal root ganglion afferent neuronal transduction of the ischemic ventricle. Am J Physiol Heart Circ Physiol 2019; 317:H1134-H1141. [PMID: 31538809 DOI: 10.1152/ajpheart.00257.2019] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Aberrant afferent signaling drives adverse remodeling of the cardiac nervous system in ischemic heart disease. The study objective was to determine whether thoracic spinal dorsal column stimulation (SCS) modulates cardiac afferent sensory transduction of the ischemic ventricle. In anesthetized canines (n = 16), extracellular activity generated by 62 dorsal root ganglia (DRG) soma (T1-T3), with verified myocardial ischemic (MI) sensitivity, were evaluated with and without 20-min preemptive SCS (T1-T3 spinal level; 50 Hz, 90% motor threshold). Transient MI was induced by 1-min coronary artery occlusion (CAO) of the left anterior descending (LAD) or circumflex (LCX) artery, randomized as to sequence. LAD and LCX CAO activated cardiac-related DRG neurons (LAD: 0.15 ± 0.04-1.05 ± 0.20 Hz, P < 0.00002; LCX: 0.08 ± 0.02-1.90 ± 0.45 Hz, P < 0.0003). SCS decreased basal neuronal activity of neurons that responded to LAD (0.15 ± 0.04 to 0.02 ± 0.01 Hz, P < 0.006) and LCX (0.08 ± 0.02 to 0.02 ± 0.01 Hz, P < 0.003). SCS suppressed responsiveness to transient MI (LAD: 1.05 ± 0.20-0.03 ± 0.01 Hz; P < 0.0001; LCX: 1.90 ± 0.45-0.03 ± 0.01 Hz; P < 0.001). Suprathreshold SCS (1 Hz) did not activate DRG neurons antidromically (n = 10 animals). Ventricular fibrillation (VF) was associated with a rapid increase in DRG activity to a maximum of 4.39 ± 1.07 Hz at 20 s after VF induction and a return to 90% of baseline within 10 s thereafter. SCS obtunds the capacity of DRG ventricular neurites to transduce the ischemic myocardium to second-order spinal neurons, a mechanism that would blunt reflex sympathoexcitation to myocardial ischemic stress, thereby contributing to its capacity to cardioprotect.NEW & NOTEWORTHY Aberrant afferent signaling drives adverse remodeling of the cardiac nervous system in ischemic heart disease. This study determined that thoracic spinal column stimulation (SCS) obtunds the capacity of dorsal root ganglia ventricular afferent neurons to transduce the ischemic myocardium to second-order spinal neurons, a mechanism that would blunt reflex sympathoexcitation to myocardial ischemic stress. This modulation does not reflect antidromic actions of SCS but likely reflects efferent-mediated changes at the myocyte-sensory neurite interface.
Collapse
Affiliation(s)
- Siamak Salavatian
- Neurocardiology Research Program of Excellence, University of California, Los Angeles, California.,Cardiac Arrhythmia Center, University of California, Los Angeles, California
| | - Sarah M Ardell
- Neurocardiology Research Program of Excellence, University of California, Los Angeles, California.,Cardiac Arrhythmia Center, University of California, Los Angeles, California
| | - Mathew Hammer
- Neurocardiology Research Program of Excellence, University of California, Los Angeles, California.,Cardiac Arrhythmia Center, University of California, Los Angeles, California
| | - David Gibbons
- Department of Biomedical Sciences, East Tennessee State University, Johnson City, Tennessee
| | - J Andrew Armour
- Neurocardiology Research Program of Excellence, University of California, Los Angeles, California.,Cardiac Arrhythmia Center, University of California, Los Angeles, California
| | - Jeffrey L Ardell
- Neurocardiology Research Program of Excellence, University of California, Los Angeles, California.,Cardiac Arrhythmia Center, University of California, Los Angeles, California
| |
Collapse
|
35
|
Anand IS, Konstam MA, Udelson JE, Butler J, Klein HU, Parker JD, Teerlink JR, Libbus I, Amurthur B, KenKnight BH, Ardell JL, Gregory DD, Massaro JM, DiCarlo LA. Vagus Nerve Stimulation for Chronic Heart Failure: Differences in Therapy Delivery and Clinical Efficacy in ANTHEM-HF, INOVATE-HF, and NECTAR-HF. J Card Fail 2019. [DOI: 10.1016/j.cardfail.2019.07.505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
36
|
Premchand RK, Sharma K, Mittal S, Monteiro R, Libbus I, Ardell JL, Gregory DD, KenKnight BH, Amurthur B, DiCarlo LA, Anand IS. Background pharmacological therapy in the ANTHEM-HF: comparison to contemporary trials of novel heart failure therapies. ESC Heart Fail 2019; 6:1052-1056. [PMID: 31339232 PMCID: PMC6816059 DOI: 10.1002/ehf2.12484] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 05/06/2019] [Accepted: 06/01/2019] [Indexed: 12/11/2022] Open
Abstract
AIMS Clinical trials of new heart failure (HF) therapies administer guideline-directed medical therapy (GDMT) as background pharmacologic treatment (BPT). In the ANTHEM-HF Pilot Study, addition of autonomic regulation therapy to GDMT significantly improved left ventricular function, New York Heart Association (NYHA) class, 6 min walk distance, and quality of life in patients with HF with reduced ejection fraction (HFrEF). A post hoc analysis was performed to compare BPT in ANTHEM-HF with two other trials of novel HF therapies: the PARADIGM-HF study of sacubitril-valsartan and the SHIFT study of ivadrabine. All three studies evaluated patients with HFrEF, and the recommendations for use of GDMT were similar. A left ventricular ejection fraction ≤40% was required for entry into ANTHEM-HF and PARADIGM-HF and ≤35% for SHIFT. NYHA 2 or 3 symptoms were required for entry into ANTHEM-HF, and patients with predominantly NYHA 2 or 3 symptoms were enrolled in PARADIGM-HF and SHIFT. METHODS AND RESULTS Data on BPT were obtained from peer-reviewed publications and the public domain. Pearson's χ2 test was used to evaluate differences in proportions, and Student's unpaired t-test was used to evaluate differences in mean values. The minimum period of stable GDMT required before randomization was longer in ANTHEM-HF: 3 months vs. 1 month in PARADIGM-HF and SHIFT, respectively. When compared with PARADIGM-HF and SHIFT, more patients in ANTHEM-HF received beta-blockers (100% vs. 93% and 89%, P < 0.04 and P < 0.007) and mineralocorticoid receptor antagonists (75% vs. 55% and 61%, P < 0.002 and P < 0.03). More patients in PARADIGM-HF received an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker than in ANTHEM-HF or SHIFT (100% vs. 85%, P < 0.0001, and 100% vs. 91%, P < 0.001), which was related to PARADIGM's design. When beta-blocker doses in ANTHEM-HF and SHIFT were compared, significantly fewer patients in ANTHEM-HF received doses ≥100% of target (10% vs. 23%, P < 0.02), and fewer patients tended to receive doses ≥50% of target (17% vs. 26%, P = 0.11). When ANTHEM-HF and PARADIGM-HF were compared, more patients in ANTHEM-HF tended to receive doses ≥100% of target (10% vs. 7%, P = 0.36), and fewer patients tended to receive doses ≥50% of target (17% vs. 20%, P = 0.56). CONCLUSIONS Background treatment with GDMT in ANTHEM-HF compared favourably with that in two other contemporary trials of new HF therapies. The minimum period of stable GDMT required before randomization was longer, and GDMT remained unchanged for the study's duration. These findings serve to further support the potential role of autonomic regulation therapy as an adjunct to GDMT for patients with HFrEF.
Collapse
Affiliation(s)
| | - Kamal Sharma
- Sanjivani Super Specialty Hospitals, Ahmedabad, India
| | | | | | | | | | | | | | | | | | - Inder S Anand
- University of Minnesota (Emeritus), Minneapolis, MN, USA
| |
Collapse
|
37
|
Salavatian S, Yamaguchi N, Hoang J, Lin N, Patel S, Ardell JL, Armour JA, Vaseghi M. Premature ventricular contractions activate vagal afferents and alter autonomic tone: implications for premature ventricular contraction-induced cardiomyopathy. Am J Physiol Heart Circ Physiol 2019; 317:H607-H616. [PMID: 31322427 DOI: 10.1152/ajpheart.00286.2019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Mechanisms behind development of premature ventricular contraction (PVC)-induced cardiomyopathy remain unclear. PVCs may adversely modulate the autonomic nervous system to promote development of heart failure. Afferent neurons in the inferior vagal (nodose) ganglia transduce cardiac activity and modulate parasympathetic output. Effects of PVCs on cardiac parasympathetic efferent and vagal afferent neurotransmission are unknown. The purpose of this study was to evaluate effects of PVCs on vagal afferent neurotransmission and compare these effects with a known powerful autonomic modulator, myocardial ischemia. In 16 pigs, effects of variably coupled PVCs on heart rate variability (HRV) and vagal afferent neurotransmission were evaluated. Direct nodose neuronal recordings were obtained in vivo, and cardiac-related afferent neurons were identified based on their response to cardiovascular interventions, including ventricular chemical and mechanical stimuli, left anterior descending (LAD) coronary artery occlusion, and variably coupled PVCs. On HRV analysis before versus after PVCs, parasympathetic tone decreased (normalized high frequency: 83.6 ± 2.8 to 72.5 ± 5.3; P < 0.05). PVCs had a powerful impact on activity of cardiac-related afferent neurons, altering activity of 51% of neurons versus 31% for LAD occlusion (P < 0.05 vs. LAD occlusion and all other cardiac interventions). Both chemosensitive and mechanosensitive neurons were activated by PVCs, and their activity remained elevated even after cessation of PVCs. Cardiac afferent neural responses to PVCs were greater than any other intervention, including ischemia of similar duration. These data suggest that even brief periods of PVCs powerfully modulate vagal afferent neurotransmission, reflexly decreasing parasympathetic efferent tone.NEW & NOTEWORTHY Premature ventricular contractions (PVCs) are common in many patients and, at an increased burden, are known to cause heart failure. This study determined that PVCs powerfully modulate cardiac vagal afferent neurotransmission (exerting even greater effects than ventricular ischemia) and reduce parasympathetic efferent outflow to the heart. PVCs activated both mechano- and chemosensory neurons in the nodose ganglia. These peripheral neurons demonstrated adaptation in response to PVCs. This study provides additional data on the potential role of the autonomic nervous system in PVC-induced cardiomyopathy.
Collapse
Affiliation(s)
- Siamak Salavatian
- University of California, Los Angeles Cardiac Arrhythmia Center, Los Angeles, California.,University of California, Los Angeles Neurocardiology Research Center of Excellence, Los Angeles, California
| | - Naoko Yamaguchi
- University of California, Los Angeles Cardiac Arrhythmia Center, Los Angeles, California.,University of California, Los Angeles Neurocardiology Research Center of Excellence, Los Angeles, California
| | - Jonathan Hoang
- University of California, Los Angeles Cardiac Arrhythmia Center, Los Angeles, California.,University of California, Los Angeles Neurocardiology Research Center of Excellence, Los Angeles, California
| | - Nicole Lin
- University of California, Los Angeles Cardiac Arrhythmia Center, Los Angeles, California.,University of California, Los Angeles Neurocardiology Research Center of Excellence, Los Angeles, California
| | - Saloni Patel
- University of California, Los Angeles Cardiac Arrhythmia Center, Los Angeles, California.,University of California, Los Angeles Neurocardiology Research Center of Excellence, Los Angeles, California
| | - Jeffrey L Ardell
- University of California, Los Angeles Cardiac Arrhythmia Center, Los Angeles, California.,University of California, Los Angeles Neurocardiology Research Center of Excellence, Los Angeles, California
| | - J Andrew Armour
- University of California, Los Angeles Cardiac Arrhythmia Center, Los Angeles, California.,University of California, Los Angeles Neurocardiology Research Center of Excellence, Los Angeles, California
| | - Marmar Vaseghi
- University of California, Los Angeles Cardiac Arrhythmia Center, Los Angeles, California.,University of California, Los Angeles Neurocardiology Research Center of Excellence, Los Angeles, California
| |
Collapse
|
38
|
Abstract
Autonomic nerves are attractive targets for medical therapies using electroceutical devices because of the potential for selective control and few side effects. These devices use novel materials, electrode configurations, stimulation patterns, and closed-loop control to treat heart failure, hypertension, gastrointestinal and bladder diseases, obesity/diabetes, and inflammatory disorders. Critical to progress is a mechanistic understanding of multi-level controls of target organs, disease adaptation, and impact of neuromodulation to restore organ function.
Collapse
Affiliation(s)
- Charles C Horn
- Biobehavioral Oncology Program, UPMC Hillman Cancer Center , Pittsburgh, Pennsylvania.,Department of Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.,Center for Neuroscience, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Jeffrey L Ardell
- University of California- Los Angeles (UCLA) Cardiac Arrhythmia Center, Los Angeles, California.,UCLA Neurocardiology Research Program of Excellence, David Geffen School of Medicine , Los Angeles, California
| | - Lee E Fisher
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.,Department of Bioengineering, University of Pittsburgh , Pittsburgh, Pennsylvania
| |
Collapse
|
39
|
Chen J, Hanna P, Ardell JL, Hoover DB, Vadigepalli R, Schwaber J, Shivkumar K, Cheng ZJ. Intrinsic Cardiac Ganglionic Neurons Projecting to the SA node in the Rat and Pig Hearts: Retrograde Labeling and Neurolucida 3‐D Reconstruction. FASEB J 2019. [DOI: 10.1096/fasebj.2019.33.1_supplement.773.2] [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] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jin Chen
- Neuroscience DivisionCollege of Medicine, University of Central FloridaOrlandoFL
| | - Peter Hanna
- Cardiac Arrhythmia Center and Neurocardiology Research Program of ExcellenceUniversity of California Los AngelesLos AngelesCA
| | - Jeffrey L Ardell
- Cardiac Arrhythmia Center and Neurocardiology Research Program of ExcellenceUniversity of California Los AngelesLos AngelesCA
| | - Donald B Hoover
- Department of Biomedical SciencesEast Tennessee State UniversityJohnson CityTN
| | | | - James Schwaber
- Department of PathologyThomas Jefferson UniversityPhiladelphiaPA
| | - Kalyanam Shivkumar
- Cardiac Arrhythmia Center and Neurocardiology Research Program of ExcellenceUniversity of California Los AngelesLos AngelesCA
| | - Zixi J Cheng
- Neuroscience DivisionCollege of Medicine, University of Central FloridaOrlandoFL
| |
Collapse
|
40
|
Shivkumar K, Ardell JL. Cardiac Innervation: Pathophysiology and Therapeutics. FASEB J 2019. [DOI: 10.1096/fasebj.2019.33.1_supplement.74.1] [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] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
41
|
Affiliation(s)
- Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Center of Excellence, Los Angeles, CA, USA
| | - Jeffrey L Ardell
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Center of Excellence, Los Angeles, CA, USA
| |
Collapse
|
42
|
Bardsley EN, Davis H, Ajijola OA, Buckler KJ, Ardell JL, Shivkumar K, Paterson DJ. RNA Sequencing Reveals Novel Transcripts from Sympathetic Stellate Ganglia During Cardiac Sympathetic Hyperactivity. Sci Rep 2018; 8:8633. [PMID: 29872217 PMCID: PMC5988725 DOI: 10.1038/s41598-018-26651-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 05/15/2018] [Indexed: 12/15/2022] Open
Abstract
Cardiovascular disease is the most prevalent age-related illness worldwide, causing approximately 15 million deaths every year. Hypertension is central in determining cardiovascular risk and is a strong predictive indicator of morbidity and mortality; however, there remains an unmet clinical need for disease-modifying and prophylactic interventions. Enhanced sympathetic activity is a well-established contributor to the pathophysiology of hypertension, however the cellular and molecular changes that increase sympathetic neurotransmission are not known. The aim of this study was to identify key changes in the transcriptome in normotensive and spontaneously hypertensive rats. We validated 15 of our top-scoring genes using qRT-PCR, and network and enrichment analyses suggest that glutamatergic signalling plays a key role in modulating Ca2+ balance within these ganglia. Additionally, phosphodiesterase activity was found to be altered in stellates obtained from the hypertensive rat, suggesting that impaired cyclic nucleotide signalling may contribute to disturbed Ca2+ homeostasis and sympathetic hyperactivity in hypertension. We have also confirmed the presence of these transcripts in human donor stellate samples, suggesting that key genes coupled to neurotransmission are conserved. The data described here may provide novel targets for future interventions aimed at treating sympathetic hyperactivity associated with cardiovascular disease and other dysautonomias.
Collapse
Affiliation(s)
- Emma N Bardsley
- Wellcome Trust OXION Initiative in Ion Channels and Disease, Burdon Sanderson Cardiac Science Centre, Department of Physiology, Anatomy and Genetics, Sherrington Building, University of Oxford, Oxford, OX1 3PT, UK.
| | - Harvey Davis
- Wellcome Trust OXION Initiative in Ion Channels and Disease, Burdon Sanderson Cardiac Science Centre, Department of Physiology, Anatomy and Genetics, Sherrington Building, University of Oxford, Oxford, OX1 3PT, UK
| | - Olujimi A Ajijola
- UCLA Cardiac Arrhythmia Center, 100 Medical Plaza, Suite 660, Los Angeles, CA, 90095, USA
| | - Keith J Buckler
- Wellcome Trust OXION Initiative in Ion Channels and Disease, Burdon Sanderson Cardiac Science Centre, Department of Physiology, Anatomy and Genetics, Sherrington Building, University of Oxford, Oxford, OX1 3PT, UK
| | - Jeffrey L Ardell
- UCLA Cardiac Arrhythmia Center, 100 Medical Plaza, Suite 660, Los Angeles, CA, 90095, USA
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, 100 Medical Plaza, Suite 660, Los Angeles, CA, 90095, USA
| | - David J Paterson
- Wellcome Trust OXION Initiative in Ion Channels and Disease, Burdon Sanderson Cardiac Science Centre, Department of Physiology, Anatomy and Genetics, Sherrington Building, University of Oxford, Oxford, OX1 3PT, UK.
| |
Collapse
|
43
|
Shivkumar K, Ardell JL. Vagal Neuromodulation for Atrial Arrhythmias. JACC Clin Electrophysiol 2018; 3:939-941. [PMID: 29759718 DOI: 10.1016/j.jacep.2017.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 06/13/2017] [Accepted: 06/30/2017] [Indexed: 12/21/2022]
Affiliation(s)
- Kalyanam Shivkumar
- University of California-Los Angeles Cardiac Arrhythmia Center, David Geffen School of Medicine, Los Angeles, California; University of California-Los Angeles Neurocardiology Research Center of Excellence, David Geffen School of Medicine, Los Angeles, California.
| | - Jeffrey L Ardell
- University of California-Los Angeles Cardiac Arrhythmia Center, David Geffen School of Medicine, Los Angeles, California; University of California-Los Angeles Neurocardiology Research Center of Excellence, David Geffen School of Medicine, Los Angeles, California
| |
Collapse
|
44
|
Liu K, Li D, Hao G, McCaffary D, Neely O, Woodward L, Ioannides D, Lu CJ, Brescia M, Zaccolo M, Tandri H, Ajijola OA, Ardell JL, Shivkumar K, Paterson DJ. Phosphodiesterase 2A as a therapeutic target to restore cardiac neurotransmission during sympathetic hyperactivity. JCI Insight 2018; 3:98694. [PMID: 29720569 DOI: 10.1172/jci.insight.98694] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 04/05/2018] [Indexed: 12/17/2022] Open
Abstract
Elevated levels of brain natriuretic peptide (BNP) are regarded as an early compensatory response to cardiac myocyte hypertrophy, although exogenously administered BNP shows poor clinical efficacy in heart failure and hypertension. We tested whether phosphodiesterase 2A (PDE2A), which regulates the action of BNP-activated cyclic guanosine monophosphate (cGMP), was directly involved in modulating Ca2+ handling from stellate ganglia (SG) neurons and cardiac norepinephrine (NE) release in rats and humans with an enhanced sympathetic phenotype. SG were also isolated from patients with sympathetic hyperactivity and healthy donor patients. PDE2A activity of the SG was greater in both spontaneously hypertensive rats (SHRs) and patients compared with their respective controls, whereas PDE2A mRNA was only high in SHR SG. BNP significantly reduced the magnitude of the calcium transients and ICaN in normal Wistar Kyoto (WKY) SG neurons, but not in the SHRs. cGMP levels stimulated by BNP were also attenuated in SHR SG neurons. Overexpression of PDE2A in WKY neurons recapitulated the calcium phenotype seen in SHR neurons. Functionally, BNP significantly reduced [3H]-NE release in the WKY rats, but not in the SHRs. Blockade of overexpressed PDE2A with Bay 60-7550 or overexpression of catalytically inactive PDE2A reestablished the modulatory action of BNP in SHR SG neurons. This suggests that PDE2A may be a key target in modulating the action of BNP to reduce sympathetic hyperactivity.
Collapse
Affiliation(s)
- Kun Liu
- Burdon Sanderson Cardiac Science Centre and BHF Centre of Research Excellence, Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, United Kingdom
| | - Dan Li
- Burdon Sanderson Cardiac Science Centre and BHF Centre of Research Excellence, Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, United Kingdom
| | - Guoliang Hao
- Burdon Sanderson Cardiac Science Centre and BHF Centre of Research Excellence, Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, United Kingdom
| | - David McCaffary
- Burdon Sanderson Cardiac Science Centre and BHF Centre of Research Excellence, Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, United Kingdom
| | - Oliver Neely
- Burdon Sanderson Cardiac Science Centre and BHF Centre of Research Excellence, Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, United Kingdom
| | - Lavinia Woodward
- Burdon Sanderson Cardiac Science Centre and BHF Centre of Research Excellence, Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, United Kingdom
| | - Demetris Ioannides
- Burdon Sanderson Cardiac Science Centre and BHF Centre of Research Excellence, Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, United Kingdom
| | - Chieh-Ju Lu
- Burdon Sanderson Cardiac Science Centre and BHF Centre of Research Excellence, Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, United Kingdom
| | - Marcella Brescia
- Burdon Sanderson Cardiac Science Centre and BHF Centre of Research Excellence, Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, United Kingdom
| | - Manuela Zaccolo
- Burdon Sanderson Cardiac Science Centre and BHF Centre of Research Excellence, Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, United Kingdom
| | - Harikrishna Tandri
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Olujimi A Ajijola
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA Health System, Los Angeles, California, USA
| | - Jeffrey L Ardell
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA Health System, Los Angeles, California, USA
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA Health System, Los Angeles, California, USA
| | - David J Paterson
- Burdon Sanderson Cardiac Science Centre and BHF Centre of Research Excellence, Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
45
|
Dale EA, Kipke JP, Sunshine MD, Kubo Y, Castro PA, Ardell JL, Mahajan A. Characterization of neuronal discharge in the thoracic spinal cord during cardiac stress in a porcine model. FASEB J 2018. [DOI: 10.1096/fasebj.2018.32.1_supplement.717.22] [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] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Erica A. Dale
- Anesthesiology and Perioperative MedicineUniversity of California‐Los AngelesLos AngelesCA
| | - Jasmine P. Kipke
- Anesthesiology and Perioperative MedicineUniversity of California‐Los AngelesLos AngelesCA
| | | | - Yukiko Kubo
- Anesthesiology and Perioperative MedicineUniversity of California‐Los AngelesLos AngelesCA
| | - Peter A. Castro
- Anesthesiology and Perioperative MedicineUniversity of California‐Los AngelesLos AngelesCA
| | | | - Aman Mahajan
- Anesthesiology and Perioperative MedicineUniversity of California‐Los AngelesLos AngelesCA
| |
Collapse
|
46
|
Yoshie K, Rajendran PS, Massoud L, Kwon O, Tadimeti V, Salavatian S, Ardell JL, Shivkumar K, Ajijola OA. Cardiac vanilloid receptor-1 afferent depletion enhances stellate ganglion neuronal activity and efferent sympathetic response to cardiac stress. Am J Physiol Heart Circ Physiol 2018; 314:H954-H966. [PMID: 29351450 DOI: 10.1152/ajpheart.00593.2017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Afferent fibers expressing the vanilloid receptor 1 (VR1) channel have been implicated in cardiac nociception; however, their role in modulating reflex responses to cardiac stress is not well understood. We evaluated this role in Yorkshire pigs by percutaneous epicardial application of resiniferatoxin (RTX), a toxic activator of the VR1 channel, resulting in the depletion of cardiac VR1-expressing afferents. Hemodynamics, epicardial activation recovery intervals, and in vivo activity of stellate ganglion neurons (SGNs) were recorded in control and RTX-treated animals. Stressors included inferior vena cava or aortic occlusion and rapid right ventricular pacing (RVP) to induce dyssynchrony and ischemia. In the epicardium, stellate ganglia, and dorsal root ganglia, immunostaining for the VR1 channel, calcitonin gene-related peptide, and substance P was significantly diminished by RTX. RTX-treated animals exhibited higher basal systolic blood pressures and contractility than control animals. Reflex responses to epicardial bradykinin and capsaicin were mitigated by RTX. Cardiovascular reflex function, as assessed by inferior vena cava or aortic occlusion, was similar in RTX-treated versus control animals. RTX-treated animals exhibited resistance to hemodynamic collapse induced by RVP. Activation recovery interval shortening during RVP, a marker of cardiac sympathetic outflow, was greater in RTX-treated animals and exhibited significant delay in returning to baseline values after cessation of RVP. The basal firing rate of SGNs and firing rates in response to RVP were also greater in RTX-treated animals, as was the SGN network activity in response to cardiac stressors. These data suggest that elimination of cardiac nociceptive afferents reorganizes the central-peripheral nervous system interaction to enhance cardiac sympathetic outflow. NEW & NOTEWORTHY Our work demonstrates a role for cardiac vanilloid receptor-1-expressing afferents in reflex processing of cardiovascular stress. Current understanding suggests that elimination of vanilloid receptor-1 afferents would decrease reflex cardiac sympathetic outflow. We found, paradoxically, that sympathetic outflow to the heart is instead enhanced at baseline and during cardiac stress.
Collapse
Affiliation(s)
- Koji Yoshie
- University of California, Los Angeles (UCLA) Cardiac Arrhythmia Center and UCLA Neurocardiology Research Center of Excellence, UCLA, Los Angeles, California
| | - Pradeep S Rajendran
- University of California, Los Angeles (UCLA) Cardiac Arrhythmia Center and UCLA Neurocardiology Research Center of Excellence, UCLA, Los Angeles, California
| | - Louis Massoud
- University of California, Los Angeles (UCLA) Cardiac Arrhythmia Center and UCLA Neurocardiology Research Center of Excellence, UCLA, Los Angeles, California
| | - OhJin Kwon
- University of California, Los Angeles (UCLA) Cardiac Arrhythmia Center and UCLA Neurocardiology Research Center of Excellence, UCLA, Los Angeles, California
| | - Vasudev Tadimeti
- University of California, Los Angeles (UCLA) Cardiac Arrhythmia Center and UCLA Neurocardiology Research Center of Excellence, UCLA, Los Angeles, California
| | - Siamak Salavatian
- University of California, Los Angeles (UCLA) Cardiac Arrhythmia Center and UCLA Neurocardiology Research Center of Excellence, UCLA, Los Angeles, California
| | - Jeffrey L Ardell
- University of California, Los Angeles (UCLA) Cardiac Arrhythmia Center and UCLA Neurocardiology Research Center of Excellence, UCLA, Los Angeles, California
| | - Kalyanam Shivkumar
- University of California, Los Angeles (UCLA) Cardiac Arrhythmia Center and UCLA Neurocardiology Research Center of Excellence, UCLA, Los Angeles, California
| | - Olujimi A Ajijola
- University of California, Los Angeles (UCLA) Cardiac Arrhythmia Center and UCLA Neurocardiology Research Center of Excellence, UCLA, Los Angeles, California
| |
Collapse
|
47
|
Abstract
Heart failure (HF) is associated with significant morbidity and mortality. The disease is characterised by autonomic imbalance with increased sympathetic activity and withdrawal of parasympathetic activity. Despite the use of medical therapies that target, in part, the neurohormonal axis, rates of HF progression, morbidity and mortality remain high. Emerging therapies centred on neuromodulation of autonomic control of the heart provide an alternative device-based approach to restoring sympathovagal balance. Preclinical studies have proven favourable, while clinical trials have had mixed results. This article highlights the importance of understanding structural/functional organisation of the cardiac nervous system as mechanistic-based neuromodulation therapies evolve.
Collapse
Affiliation(s)
- Peter Hanna
- David Geffen School of Medicine, University of California Los Angeles (UCLA) Los Angeles, CA, USA
| | - Kalyanam Shivkumar
- David Geffen School of Medicine, University of California Los Angeles (UCLA) Los Angeles, CA, USA
| | - Jeffrey L Ardell
- David Geffen School of Medicine, University of California Los Angeles (UCLA) Los Angeles, CA, USA
| |
Collapse
|
48
|
DiCarlo LA, Libbus I, Kumar HU, Mittal S, Premchand RK, Amurthur B, KenKnight BH, Ardell JL, Anand IS. Autonomic regulation therapy to enhance myocardial function in heart failure patients: the ANTHEM-HFpEF study. ESC Heart Fail 2017; 5:95-100. [PMID: 29283224 PMCID: PMC5793957 DOI: 10.1002/ehf2.12241] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 09/27/2017] [Accepted: 11/14/2017] [Indexed: 01/06/2023] Open
Abstract
Background Approximately half of the patients presenting with new‐onset heart failure (HF) have HF with preserved left ventricular ejection fraction (HFpEF) and HF with mid‐range left ventricular ejection fraction (HFmrEF). These patients have neurohormonal activation like that of HF with reduced ejection fraction; however, beta‐blockers and angiotensin‐converting enzyme inhibitors have not been shown to improve their outcomes, and current treatment for these patients is symptom based and empiric. Sympathoinhibition using parasympathetic stimulation has been shown to improve central and peripheral aspects of the cardiac nervous system, reflex control, induce myocyte cardioprotection, and can lead to regression of left ventricular hypertrophy. Beneficial effects of autonomic regulation therapy (ART) using vagus nerve stimulation (VNS) have also been observed in several animal models of HFpEF, suggesting a potential role for ART in patients with this disease. Methods The Autonomic Neural Regulation Therapy to Enhance Myocardial Function in Patients with Heart Failure and Preserved Ejection Fraction (ANTHEM‐HFpEF) study is designed to evaluate the feasibility, tolerability, and safety of ART using right cervical VNS in patients with chronic, stable HFpEF and HFmrEF. Patients with symptomatic HF and HFpEF or HFmrEF fulfilling the enrolment criteria will receive chronic ART with a subcutaneous VNS system attached to the right cervical vagus nerve. Safety parameters will be continuously monitored, and cardiac function and HF symptoms will be assessed every 3 months during a post‐titration follow‐up period of at least 12 months. Conclusions The ANTHEM‐HFpEF study is likely to provide valuable information intended to expand our understanding of the potential role of ART in patients with chronic symptomatic HFpEF and HFmrEF.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Inder S Anand
- Minneapolis VA Health Care System, University of Minnesota, Cardiology 111 C, One Veterans Drive, Minneapolis, MN, 55417, USA
| |
Collapse
|
49
|
Ardell JL, Nier H, Hammer M, Southerland EM, Ardell CL, Beaumont E, KenKnight BH, Armour JA. Defining the neural fulcrum for chronic vagus nerve stimulation: implications for integrated cardiac control. J Physiol 2017; 595:6887-6903. [PMID: 28862330 DOI: 10.1113/jp274678] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 08/14/2017] [Indexed: 12/12/2022] Open
Abstract
KEY POINTS The evoked cardiac response to bipolar cervical vagus nerve stimulation (VNS) reflects a dynamic interaction between afferent mediated decreases in central parasympathetic drive and suppressive effects evoked by direct stimulation of parasympathetic efferent axons to the heart. The neural fulcrum is defined as the operating point, based on frequency-amplitude-pulse width, where a null heart rate response is reproducibly evoked during the on-phase of VNS. Cardiac control, based on the principal of the neural fulcrum, can be elicited from either vagus. Beta-receptor blockade does not alter the tachycardia phase to low intensity VNS, but can increase the bradycardia to higher intensity VNS. While muscarinic cholinergic blockade prevented the VNS-induced bradycardia, clinically relevant doses of ACE inhibitors, beta-blockade and the funny channel blocker ivabradine did not alter the VNS chronotropic response. While there are qualitative differences in VNS heart control between awake and anaesthetized states, the physiological expression of the neural fulcrum is maintained. ABSTRACT Vagus nerve stimulation (VNS) is an emerging therapy for treatment of chronic heart failure and remains a standard of therapy in patients with treatment-resistant epilepsy. The objective of this work was to characterize heart rate (HR) responses (HRRs) during the active phase of chronic VNS over a wide range of stimulation parameters in order to define optimal protocols for bidirectional bioelectronic control of the heart. In normal canines, bipolar electrodes were chronically implanted on the cervical vagosympathetic trunk bilaterally with anode cephalad to cathode (n = 8, 'cardiac' configuration) or with electrode positions reversed (n = 8, 'epilepsy' configuration). In awake state, HRRs were determined for each combination of pulse frequency (2-20 Hz), intensity (0-3.5 mA) and pulse widths (130-750 μs) over 14 months. At low intensities and higher frequency VNS, HR increased during the VNS active phase owing to afferent modulation of parasympathetic central drive. When functional effects of afferent and efferent fibre activation were balanced, a null HRR was evoked (defined as 'neural fulcrum') during which HRR ≈ 0. As intensity increased further, HR was reduced during the active phase of VNS. While qualitatively similar, VNS delivered in the epilepsy configuration resulted in more pronounced HR acceleration and reduced HR deceleration during VNS. At termination, under anaesthesia, transection of the vagi rostral to the stimulation site eliminated the augmenting response to VNS and enhanced the parasympathetic efferent-mediated suppressing effect on electrical and mechanical function of the heart. In conclusion, VNS activates central then peripheral aspects of the cardiac nervous system. VNS control over cardiac function is maintained during chronic therapy.
Collapse
Affiliation(s)
- Jeffrey L Ardell
- UCLA Neurocardiology Research Center of Excellence and UCLA Cardiac Arrhythmia Center, Los Angeles, Los Angeles, CA, USA
| | - Heath Nier
- Biomedical Sciences, East Tennessee State University, Johnson City, TN, USA
| | - Matthew Hammer
- UCLA Neurocardiology Research Center of Excellence and UCLA Cardiac Arrhythmia Center, Los Angeles, Los Angeles, CA, USA
| | | | | | - Eric Beaumont
- Biomedical Sciences, East Tennessee State University, Johnson City, TN, USA
| | | | - J Andrew Armour
- UCLA Neurocardiology Research Center of Excellence and UCLA Cardiac Arrhythmia Center, Los Angeles, Los Angeles, CA, USA
| |
Collapse
|
50
|
Ajijola OA, Hoover DB, Simerly TM, Brown TC, Yanagawa J, Biniwale RM, Lee JM, Sadeghi A, Khanlou N, Ardell JL, Shivkumar K. Inflammation, oxidative stress, and glial cell activation characterize stellate ganglia from humans with electrical storm. JCI Insight 2017; 2:94715. [PMID: 28931760 DOI: 10.1172/jci.insight.94715] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 08/08/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Neuronal remodeling in human heart disease is not well understood. METHODS Stellate ganglia from patients with cardiomyopathy (CMY) and refractory ventricular arrhythmias undergoing cardiac sympathetic denervation (n = 8), and from organ donors with normal hearts (n = 8) collected at the time of organ procurement were compared. Clinical data on all subjects were reviewed. Electron microscopy (EM), histologic, and immunohistochemical assessments of neurotransmitter profiles, glial activation and distribution, and lipofuscin deposition, a marker of oxidative stress, were quantified. RESULTS In CMY specimens, lipofuscin deposits were larger, and present in more neurons (26.3% ± 6.3% vs. 16.7% ± 7.6%, P < 0.043), than age-matched controls. EM analysis revealed extensive mitochondrial degeneration in CMY specimens. T cell (CD3+) infiltration was identified in 60% of the CMY samples, with one case having large inflammatory nodules, while none were identified in controls. Myeloperoxidase-immunoreactive neutrophils were also identified at parenchymal sites distinct from inflammatory foci in CMY ganglia, but not in controls. The adrenergic phenotype of pathologic samples revealed a decrease in tyrosine hydroxylase staining intensity compared with controls. Evaluation of cholinergic phenotype by staining for the vesicular acetylcholine transporter revealed a low but comparable number of cholinergic neurons in ganglia from both groups and demonstrated that preganglionic cholinergic innervation was maintained in CMY ganglia. S100 staining (a glial cell marker) demonstrated no differences in glial distribution and relationship to neurons; however, glial activation demonstrated by glial fibrillary acidic protein (GFAP) staining was substantially increased in pathologic specimens compared with controls. CONCLUSIONS Stellate ganglia from patients with CMY and arrhythmias demonstrate inflammation, neurochemical remodeling, oxidative stress, and satellite glial cell activation. These changes likely contribute to excessive and dysfunctional efferent sympathetic tone, and provide a rationale for sympathectomy as a treatment for arrhythmias in this population. FUNDING This work was made possible by support from NIH grants HL125730 to OAA, GM107949 to DBH, and HL084261 and OT2OD023848 to KS.
Collapse
Affiliation(s)
- Olujimi A Ajijola
- UCLA Cardiac Arrhythmia Center and.,UCLA Neurocardiology Research Center of Excellence, University of California, Los Angeles, California, USA
| | - Donald B Hoover
- Department of Biomedical Sciences.,Center for Inflammation, Infectious Disease, and Immunity, Quillen College of Medicine, East Tennessee State University, Johnson City, Tennessee, USA. Departments of
| | - Thomas M Simerly
- Department of Biomedical Sciences.,Center for Inflammation, Infectious Disease, and Immunity, Quillen College of Medicine, East Tennessee State University, Johnson City, Tennessee, USA. Departments of
| | - T Christopher Brown
- Department of Biomedical Sciences.,Center for Inflammation, Infectious Disease, and Immunity, Quillen College of Medicine, East Tennessee State University, Johnson City, Tennessee, USA. Departments of
| | | | | | | | | | - Negar Khanlou
- Pathology, University of California, Los Angeles, California, USA
| | - Jeffrey L Ardell
- UCLA Cardiac Arrhythmia Center and.,UCLA Neurocardiology Research Center of Excellence, University of California, Los Angeles, California, USA
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center and.,UCLA Neurocardiology Research Center of Excellence, University of California, Los Angeles, California, USA
| |
Collapse
|