Functional Characterization of Atrial Electrograms in Sinus Rhythm Delineates Sites of Parasympathetic Innervation in Patients With Paroxysmal Atrial Fibrillation

Lellouche, Nicolas; Buch, Éric; Celigoj, Andrew; Siegerman, Carin; Cesario, David A.; Diego, Carlos De; Mahajan, Aman; Boyle, Noel G.; Wiener, Isaac; Garfinkel, Alan; Shivkumar, Kalyanam

doi:10.1016/j.jacc.2007.03.069

Cited by 110 publications

(79 citation statements)

References 29 publications

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“…Interestingly, we were able to measure ICNA directly at the complex fractionated atrial electrograms (CFAE) -like activity. These findings support an association of ICNA and CFAE reported by other investigators [33,34]. Also, this might explain the beneficial effects of catheter ablation targeting GP [35][36][37] and sites with CFAE [38].…”

Section: Intrinsic Cardiac Nervous Activitysupporting

confidence: 91%

How to Map Autonomic Activity

et al. 2012

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Section: Intrinsic Cardiac Nervous Activitysupporting

confidence: 91%

How to Map Autonomic Activity

et al. 2012

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“…Guo et al, in a canine model, found that vagal stimulation shortened the electrogram duration in ischemic myocardium zone in the right atrium, whereas sympathetic stimulation did not alter electrogram duration [34]. In a previous analysis of atrial electrograms during sinus rhythm in patients with PAF, electrograms with ≥ 4 deflections and duration ≥ 40 ms were associated with a parasympathetic response during AF ablation [35]. The explanation for this finding was related with local effects of acetylcholine in atrial tissue, causing conduction block between adjacent fiber bundles.…”

Section: Autonomic Modulation Of Conduction Parameters In Paf Patientsmentioning

confidence: 96%

Effects of acute autonomic modulation on atrial conduction delay and local electrograms duration in paroxysmal atrial fibrillation

Oliveira¹,

Silva²,

Cunha³

et al. 2011

International Journal of Cardiology

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Slowed atrial conduction may contribute to reentry circuits and vulnerability for atrial fibrillation (AF). The autonomic nervous system (ANS) has modulating effects on electrophysiological properties. However, complex interactions of the ANS with the arrhythmogenic substrate make it difficult to understand the mechanisms underlying induction and maintenance of AF. Aim: To determine the effect of acute ANS modulation in atrial activation times in patients (P) with paroxysmal AF (PAF). Methods and results: 16P (9 men; 59 ± 14 years) with PAF, who underwent electrophysiological study before AF ablation, and 15P (7 men; 58 ± 11 years) with atrioventricular nodal reentry tachycardia, without documentation or induction of AF (control group). Each group included 7P with arterial hypertension but without underlying structural heart disease. The study was performed while off drugs. Multipolar catheters were placed at the high right atrium (HRA), right atrial appendage (RAA), coronary sinus (CS) and His bundle area (His). At baseline and with HRA pacing (600 ms, shortest propagated S2) we measured: i) intraatrial conduction time (IACT, between RAA and atrial deflection in the distal His), ii) inter-atrial conduction time (interACT, between RAA and distal CS), iii) left atrial activation time (LAAT, between atrial deflection in the distal His and distal CS), iv) bipolar electrogram duration at four atrial sites (RAA, His, proximal and distal CS). In the PAF group, measurements were also determined during handgrip and carotid sinus massage (CSM), and after pharmacological blockade of the ANS (ANSB). AF was induced by HRA programmed stimulation in 56% (self-limited -6; sustained -3), 68.8% (self-limited -6; sustained -5), and 50% (selflimited -5; sustained -3) of the P, in basal, during ANS maneuvers, and after ANSB, respectively (p = NS). IACT, interACT and LAAT significantly lengthened during HRA pacing in both groups (600 ms, S2). P with PAF have longer IACT (p b 0.05), a higher increase in both IACT, interACT (p b 0.01) and electrograms duration (p b 0.05) with S2, and more fragmented activity, compared with the control group. Atrial conduction times and electrograms duration were not significantly changed during ANS stimulation. Nevertheless, ANS maneuvers increased heterogeneity of the local electrograms duration. Also, P with sustained AF showed longer interACT and LAAT during CSM. Conclusion: Atrial conduction times, electrograms duration and fractionated activity are increased in PAF, suggesting a role for conduction delays in the arrhythmogenic substrate. Acute vagal stimulation is associated with prolonged interACT and LAAT in P with inducible sustained AF and ANS modulation may influence the heterogeneity of atrial electrograms duration.

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“…The diverse GP-mapping strategies used by different authors (1, high-frequency endocardial stimulation [2][3][4][5][6][8][9][10][11][12] ; 2, purely anatomic location 7,13 ; and 3, atrial electrogram characteristics 1,10,14,15 ) emerged as potential alternatives, with each one proposing specific end points (1, evoked reflex abolition; 2, ablation of all anatomic GP sites achieved; and 3, elimination of all fragmented potentials, respectively). However, some important questions still remain whichever technique is chosen:…”

Section: See Editorial By Mulpuru and Shenmentioning

confidence: 99%

Targets and End Points in Cardiac Autonomic Denervation Procedures

Rivarola

Hachul

et al. 2017

Circ: Arrhythmia and Electrophysiology

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Background-Autonomic denervation is an alternative approach for patients with symptomatic bradycardia. No consensus exists on the critical targets and end points of the procedure. The aim of this study was to identify immediate end points and critical atrial regions responsible for vagal denervation. Methods and Results-We enrolled 14 patients (50% men; age: 34.0±13.8 years) with cardioinhibitory syncope, advanced atrioventricular block or sinus arrest, and no structural heart disease. Anatomic mapping of ganglionated plexuses was performed, followed by radiofrequency ablation. Heart rate, sinus node recovery time, Wenckebach cycle length, and atrial-His (AH) interval were measured before and after every radiofrequency pulse. Wilcoxon signed-rank test was used for comparison. Significant shortening of the R-R interval (P=0.0009), Wenckebach cycle length (P=0.0009), and AH intervals (P=0.0014) was observed after ablation. The heart rate elevation was 23.8±12.5%, and the Wenckebach cycle length and AH interval shortening was 18.1±11% and 24.6±19%, respectively. Atropine bolus injection (0.04 mg/kg) did not increase heart rate further. Targeting a single spot of the left side (64% of the patients) or right side (36%) of the interatrial septum was observed to be responsible for ≥80% of the final R-R and AH interval shortening during ablation. Conclusions-Targeting specific sites of the interatrial septum is followed by an increase in heart rate and atrioventricular nodal conduction properties and might be critical for vagal attenuation. The R-R interval, Wenckebach cycle length, and AH interval shortening, associated with a negative response to atropine, could be considered immediate end points of the procedure.

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Functional Characterization of Atrial Electrograms in Sinus Rhythm Delineates Sites of Parasympathetic Innervation in Patients With Paroxysmal Atrial Fibrillation

Abstract: Parasympathetic activation during AF ablation is associated with the presence of pre-ablation high-amplitude fractionated EGMs in sinus rhythm. Local acetylcholine release could potentially explain this phenomenon.

Cited by 110 publications

References 29 publications

How to Map Autonomic Activity

How to Map Autonomic Activity

Effects of acute autonomic modulation on atrial conduction delay and local electrograms duration in paroxysmal atrial fibrillation

Targets and End Points in Cardiac Autonomic Denervation Procedures

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