The ectopy-triggering ganglionated plexuses in atrial fibrillation

Epicardial ganglionated plexuses (GP) have an important role in the pathogenesis of atrial fibrillation (AF). The relationship between anatomical, histological and functional effects of GP is not well known. We previously described atrioventricular (AV) dissociating GP (AVD-GP) locations. In this st...

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Published in:Autonomic neuroscience 2020-11, Vol.228, p.102699-102699, Article 102699
Main Authors: Kim, Min-Young, Sandler, Belinda, Sikkel, Markus B., Cantwell, Christopher D., Leong, Kevin M., Luther, Vishal, Malcolme-Lawes, Louisa, Koa-Wing, Michael, Ng, Fu Siong, Qureshi, Norman, Sohaib, Afzal, Whinnett, Zachary I., Fudge, Michael, Lim, Elaine, Todd, Michelle, Wright, Ian, Peters, Nicholas S., Lim, Phang Boon, Linton, Nicholas W.F., Kanagaratnam, Prapa
Format: Article
Language:English
Subjects:
Atrial fibrillation
Autonomic nervous system
Ganglionated plexus
Intrinsic cardiac nerves
Pulmonary vein ectopy
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Summary:Epicardial ganglionated plexuses (GP) have an important role in the pathogenesis of atrial fibrillation (AF). The relationship between anatomical, histological and functional effects of GP is not well known. We previously described atrioventricular (AV) dissociating GP (AVD-GP) locations. In this study, we hypothesised that ectopy triggering GP (ET-GP) are upstream triggers of atrial ectopy/AF and have different anatomical distribution to AVD-GP. We mapped and characterised ET-GP to understand their neural mechanism in AF and anatomical distribution in the left atrium (LA). 26 patients with paroxysmal AF were recruited. All were paced in the LA with an ablation catheter. High frequency stimulation (HFS) was synchronised to each paced stimulus for delivery within the local atrial refractory period. HFS responses were tagged onto CARTO™ 3D LA geometry. All geometries were transformed onto one reference LA shell. A probability distribution atlas of ET-GP was created. This identified high/low ET-GP probability regions. 2302 sites were tested with HFS, identifying 579 (25%) ET-GP. 464 ET-GP were characterised, where 74 (16%) triggered ≥30s AF/AT. Median 97 (IQR 55) sites were tested, identifying 19 (20%) ET-GP per patient. >30% of ET-GP were in the roof, mid-anterior wall, around all PV ostia except in the right inferior PV (RIPV) in the posterior wall. ET-GP can be identified by endocardial stimulation and their anatomical distribution, in contrast to AVD-GP, would be more likely to be affected by wide antral circumferential ablation. This may contribute to AF ablation outcomes. •ET-GP can be stimulated endocardially using high frequency stimulation within the local atrial refractory period.•ET-GP stimulation displays a wide range of responses from single ectopy to sustained AF and occasionally AV block.•ET-GP have distinct anatomical regions in patients with AF, and their distribution contrasts that of AV dissociating GP.•Most ET-GP are in the roof/PV ostia and inadvertently ablated during PVI. This may contribute to AF ablation success.
ISSN:1566-0702
1872-7484
DOI:10.1016/j.autneu.2020.102699