Decreased Postoperative Atrial Fibrillation Following Cardiac Transplantation: The Significance of Autonomic Denervation

Noheria, Amit; Patel, Sandeep M.; Mirzoyev, Sultan A.; Madhavan, Malini; Friedman, Paul A.; Packer, Douglas L.; Daly, Richard C.; Kushwaha, Sudhir S.; Edwards, Brooks S.; Asirvatham, Samuel J.

doi:10.1111/pace.12102

Cited by 22 publications

(18 citation statements)

References 53 publications

(104 reference statements)

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“…Consistently, the OHT group had uncommon AT (4.6 % AF + 2.9 % AFL) when compared with the two other thoracic surgeries (18.9 % AF + 7.4 % AFL and 19.8 % AF + 3.8 % AFL, respectively). In a similar study, Noheria et al 7 also found that POAF occurred only in 6.5 % of OHT patients, and was much more frequent after maze (22.7 %) or CBAG (16.4 %) surgery. POAF is usually benign and thought to be secondary to the immediate post-operative inflammatory state.…”

Section: Supraventricular Tachycardiamentioning

confidence: 66%

“…Moreover, AF episodes occurring long after transplantation are only associated with rejection or ischaemia, which alter the normal atrial substrate. 17 As expected, during the acute post-operative state, only denervation is likely to decrease AF in OHT patients, as suggested by the higher rates after maze 7 or double-lung transplantation 6 both of which require pulmonary vein isolation.…”

Section: Interesting Pathophysiological Findings Associated With Arrhmentioning

confidence: 74%

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Arrhythmias in the Heart Transplant Patient

Hamon

Taleski

Vaseghi

et al. 2014

Arrhythm Electrophysiol Rev

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Orthotopic heart transplantation (OHT) is the most effective long-term therapy for end-stage heart disease, with implanted left ventricular assist devices ('destination therapy') as an alternative for selected patients. The denervation of the transplanted heart with complete loss of autonomic nervous system modulation, the use of immunosuppressant drugs, as well as the risk of allograft rejection (AR) and vasculopathy, all change the incidence, prognosis and treatment of tachyarrhythmias and bradyarrhythmias, as well as the mechanisms of sudden cardiac death (SCD).Arrhythmias post-OHT can be classified according to their underlying mechanisms (see Table 1). Tachyarrhythmias and bradyarrythmias can come from the transplanted heart, be due to the surgery itself or result from AR or vasculopathy. In addition, bradyarrhythmias may be caused by drugs taken by the recipient patient before surgery. This review aims to present the most common causes of arrhythmias in OHT patients, and to highlight the importance of ruling out and treating AR and vasculopathy -transplant coronary artery disease (TCAD), which should always be the first concern. The causative mechanisms represent different risk factors, and overlap is possible, which may increase the occurrence of such arrhythmias.With the increasing success of radiofrequency (RF) ablation techniques, it is important that cardiologists are familiar with tachycardias and bradycardias in this context, which may benefit from a multidisciplinary approach in the management of the patient starting with the underlying mechanisms. Tachyarrhythmias Supraventricular TachycardiaThe most common atrial arrhythmia in OHT patients is atrial flutter AbstractOrthotopic heart transplantation (OHT) is currently the most effective long-term therapy for patients with end-stage cardiac disease, even as left ventricular devices show markedly improved outcomes. As surgical techniques and immunosuppressive regimens have been refined, short-term mortality caused by sepsis has decreased, while morbidity caused by repeated rejection episodes and vasculopathy has increased, and is often manifested by arrhythmias. These chronic transplant complications require early and aggressive multidisciplinary treatment. Understanding the relationship between arrhythmias and these complications in the acute and chronic stages following OHT is critical in improving patient prognosis, as arrhythmias may be the earliest or sole presentation. Finally, decentralised/ denervated hearts represent a unique opportunity to investigate the underlying mechanisms of arrhythmias.

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Section: Supraventricular Tachycardiamentioning

confidence: 66%

Section: Interesting Pathophysiological Findings Associated With Arrhmentioning

confidence: 74%

Arrhythmias in the Heart Transplant Patient

Hamon

Taleski

Vaseghi

et al. 2014

Arrhythm Electrophysiol Rev

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“…Conversely, blockade of the ganglion stellatum or renal sympathetic denervation should reduce the risk of ventricular arrhythmias in patients with prolonged-QT syndromes [7]. It is noteworthy in this context that extensive cardiac denervation, which may be present after orthotopic heart transplantation, is associated with a lower risk of supra ventricular rhythm disturbances, especially atrial fibrillation [8]. In these cases, the denervation should have protective effects and protect the myocardium from the autonomic imbalances of the extrinsic system before transmission.…”

Section: Extrinsic Systemmentioning

confidence: 99%

Cardiac Arrhythmia following Stroke

Kallmünzer

Schwab

2017

Neurology International Open

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The autonomous innervation of the heart is based on a complex interaction of central and peripheral mechanisms in sympathetic and parasympathetic parts of the autonomic nervous system (▶Fig. 1). An extrinsic cardiac innervation is distinguished from an intrinsic one. Extrinsic systemTo put it simply, a center of the efferent parasympathetic innervation of the heart is found in the nucleus of the medulla oblongata, especially in the nucleus dorsalis [1]. The preganglionic fibers leave the central nervous system along with the vagus nerve and are connected to the second neuron in cardiac ganglion cells. Sympath etic fibers, on the other hand, originate from the nucleus intermediolateralis of the upper thoracic cord [2]. They reach the plexus cardiacus by means of the so-called "cardiac nerves" (usually 4 right-sided and 3 left-sided nervi cardiaci), after interposition in the border ganglia, especially in the ganglion stellatum. For the control of cardiac functions, the profound part of the plexus cardiacus is decisive; it extends between the tracheal bifurcation and the aortic arch, divides into a right and left half and in its further course follows the right or left coronary artery. The function of the efferent limb is modified by afferents from various organ systems, including the gastrointestinal tract or the carotissinus, by means of multisynaptic reflex arcs (e. g., baroreflex) [1]. In addition, in the blood circulating catecholamine, the release of which in the adrenal system is also subject to the autonomic system, mediates beta-adrenergic effects on the myocardium. It is postulated that dysbalances in the extrinsic system, in particular the pathological disinhibition of sympathetic activity, are relevant to the development of cardiac arrhythmias [1,[3][4][5]. For example, extensive brain stem damage can lead to suppression of central parasympathetic functions and overcoming of sympathetic tone [6], thus promoting the occurrence of cardiac arrhythmias. Conversely, blockade of the ganglion stellatum or renal sympathetic denervation should reduce the risk of ventricular arrhythmias in patients with prolonged-QT syndromes [7]. It is noteworthy in this context that extensive cardiac denervation, which may be present after orthotopic heart transplantation, is associated with a lower risk of supra ventricular rhythm disturbances, especially atrial fibrillation [8]. In these cases, the denervation should have protective effects and protect the myocardium from the autonomic imbalances of the extrinsic system before transmission. It should be noted, however, that organ donors are usually much younger and the vascular damage to the donor organs is often less pronounced, which significantly reduces the risk of atrial fibrillation independent of cardiac denervation [9].

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“…Part of the basis for this focus is the observation that in denervated hearts (such as after orthotopic heart transplant) there tends to be much less atrial fibrillation [68]. In turn, part of the theory behind which pulmonary vein isolation is an effective ablation technique for atrial fibrillation lies in that the act of isolating the pulmonary veins also leads to partial autonomic denervation.…”

Section: Clinical Correlatesmentioning

confidence: 99%

Innervation of the heart: An invisible grid within a black box

Kapa

DeSimone

Asirvatham

2016

Trends in Cardiovascular Medicine

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Autonomic control of cardiovascular function is mediated by a complex interplay between central, peripheral, and innate cardiac components. This interplay is what mediates the normal cardiovascular response to physiologic and pathologic stressors, including blood pressure, cardiac contractile function, and arrhythmias. However, in order to understand how modern therapies directly affecting autonomic function may be harnessed to treat various cardiovascular disease states requires an intimate understanding of anatomic and physiologic features of the innervation of the heart. Thus, in this review, we focus on defining features of the central, peripheral, and cardiac components of cardiac innervation, how each component may contribute to dysregulation of normal cardiac function in various disease states and how modulation of these components may offer therapeutic options for these diseases.

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Decreased Postoperative Atrial Fibrillation Following Cardiac Transplantation: The Significance of Autonomic Denervation

Cited by 22 publications

References 53 publications

Arrhythmias in the Heart Transplant Patient

Arrhythmias in the Heart Transplant Patient

Cardiac Arrhythmia following Stroke

Innervation of the heart: An invisible grid within a black box

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