Electrical stimulation to identify neural elements on the heart: Their role in atrial fibrillation
Electrical stimulation to identify neural elements on the heart: Their role in atrial fibrillation
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DOI：
10.1007/s10840-005-2492-2
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发表时间：
2005-08-01
影响因子：
1.8
通讯作者：
Lazzara, R
中科院分区：
文献类型：
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作者：
Scherlag, BJ;Nakagawa, H;Lazzara, R
实验研究：麻醉后的狗分别进行右开胸和左开胸。采用两种电刺激方式激活心房心外膜上的神经节丛（GP）：(1)在每条肺静脉（PV）底部附近，将高频刺激（HFS）序列与每次心房有节奏搏动耦合，使其落在不应期内，实现无心房兴奋的神经刺激；(2)通过斑块电极缝合在右上（RS）和左上（LS） pv附近的心外膜脂肪垫（含GP）上，连续应用HFS。然后将胸腔闭合。经皮穿刺消融导管，在透视下放置于右心房，在靠近RSPV的心外膜斑块电极对面，经间隔穿刺在LSPV左心房交界处放置消融导管。应用于每个心外膜脂肪垫的HFS可诱发心房颤动（AF），并且由于副交感神经对房室结的强烈作用，也可引起高级别房室传导阻滞。右心内膜和左心内膜射频消融术分别消除了向靠近RSPV和LSPV的脂肪垫斑块电极递送HFS的迷走神经反应。临床研究：60（60）例阵发性或持续性房颤患者接受左心房前庭隔离（27例）或左心房前庭隔离加左心房GP消融（33例）。靠近4个GPs的PV腔内边界的心内膜HFS在AF期间产生AF和高级别AV阻滞（迷走神经反应）。这些部位的RFA消除了迷走神经反应。在少数随访时间很短的患者中进行的试验表明，在PV窦腔隔离的基础上增加GP消融可将消融成功率（房颤无复发）从70%提高到91%。结论：这些基础和临床研究表明，局部心脏自主神经节（GPs）可能在房颤的发生和维持中起关键作用。
Experimental Studies: Anesthetized dogs were subjected to a right then left thoracotomy. Two modes of electrical stimulation were used to activate ganglionated plexi (GP) on the epicardium of the atria: (1) Near the base of each pulmonary vein (PV), trains of high frequency stimuli (HFS) were coupled to each atrial paced beat so as to fall within the refractory period to achieve nerve stimulation without atrial excitation; and (2) Continuous HFS was applied via plaque electrodes sutured to epicardial fat pads (containing a GP) near the right superior (RS) and left superior (LS) PVs. The chest was then closed. An ablation catheter, inserted percutaneously, was positioned fluoroscopically in the right atrium across from the epicardial plaque electrode near the RSPV Transeptal puncture was used to place an ablation catheter at the LSPV left atrial junction. HFS applied to each of the epicardial fat pads induced atrial fibrillation (AF) and also caused high grade AV block due to a strong parasympathetic effect on the AV node. Radiofrequency ablation from the right and left atrial endocardium abolished the vagal response to HFS delivered to the plaque electrodes on the fat pads close to the RSPV and LSPV, respectively.Clinical Studies: Sixty (60) patients with paroxysmal or persistent AF underwent PV antrum isolation (27 patients) or PV antrum isolation plus left atrial GP ablation (33 patients). Endocardial HFS at the border of the PV antra near the 4 GPs produced AF and high grade AV block (vagal response) during AF. RFA at these sites abolished the vagal response. Testing in a small number of patients with very short follow-up suggests that adding GP ablation to PV antrum isolation may increase ablation success (absence of AF recurrence) from 70% to 91%.Conclusions: These basic and clinical studies suggest that localized cardiac autonomic ganglia (GPs) may play a critical role in the initiation and maintenance of AF.