The cardiac autonomic nervous system: A target for modulation of atrial fibrillation

Figures

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  Figure 1. Atrial fibrillation (AF) was directly induced by high‐frequency stimulation (HFS) (2.4 V) at the pulmonary vein (PV). AV block was also observed before initiation of AF. HFS consisted of trains of high‐frequency electrical stimuli (200 Hz, 0.1 ms in duration of each impulse, train duration 40 ms, 0.6‐12 V), and were delivered at 2 ms after each pacing stimulus (two threshold at a cycle length of 330 ms)6

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  Figure 2. A simplified diagram interpreting the role of sympathetic and parasympathetic components of CANS in AF. Sympathetic stimulation leads to focal ectopic firing via enhanced automaticity, EADs and DADs. While vagal stimulation facilitates the maintenance of reentry by shortening the atrial ERP. And then AF can result from focal or re‐entrant mechanisms. AF, atrial fibrillation; CANS, cardiac autonomic nerve system; DADs, delayed afterdepolarizations; EADs, early afterdepolarizations; ERP, effective refractory period; up arrow: increase; down arrow: decrease

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  Figure 3. Summary of the interactions among extrinsic CANS (ECANS), superior vena cava‐aorta ganglionated plexus (SVC‐Ao GP), right anterior ganglionated plexus (RAGP), left superior ganglionated plexus (LSGP), right inferior ganglionated plexus (RIGP), left inferior ganglionated plexus (LIGP) on SA nodal (SAN), AV nodal (AVN) and atrial electrophysiology (EP). AVN, atrioventricular nodal; ECANS, extrinsic cardiac autonomic nerve system; LA EP, left atrial electrophysiology; LA GPs, left atrial ganglionated plexi; LIGP, left inferior ganglionated plexi; LSGP, left superior ganglionated plexi; RA EP, right atrial electrophysiology; RAGP, right anterior ganglionated plexi; RIGP, right inferior ganglionated plexi; SAN, sinoatrial nodal; SVC‐Ao GP, superior vena cava‐aorta

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  Figure 4. A, Left atrial electroanatomic maps in anteroposterior (AP) view and posteroanterior (PA) view, showing location of sites at which vagal response was elicited (green points) in ostia of left pulmonary vein. Application of radiofrequency energy at these sites induced transient bradycardia (RR interval = 2.4 seconds). B, Left atrial electroanatomic maps in right‐lateral (RL) view and anteroposterior view, showing location of sites at which vagal response was elicited (green points) in ostia of right pulmonary vein. Application of radiofrequency energy at these sites resulted in sinus pause (RR interval N 7.7 seconds), artificial pacing had to use at coronary sinus(red arrow). AP, anteroposterior view; PA, posteroanterior view; RL, right lateral view

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  Figure 5. The location of ganglionated plexuses (GPs) in atrial electro‐anatomic maps. GPs sites are shown as red dots and yellow circles. A, LSGP, LIGP, RIGP distribute in the posterior left atrium near LSPV, LIPV, RIPV, respectively. B, RAGP distribute in the anterior left atrium near RSPV. C, D, Ao‐SVC GP located between the medial superior vena cava and aortic root. Ao‐SVC GP, aorta‐superior vena cava GP; CS, coronary sinus; IVC, inferior vena cava; LAA, left atrial appendage; LIGP, left inferior GP; LSGP, left superior GP; RAGP, right anterior GP; RIGP, right inferior GP; MV, mitral valve; SVC, superior vena cava; TV, tricuspid valve