A novel approach to mapping the atrial ganglionated plexus network by generating a distribution probability atlas

Figure 1. (A) Hierarchical stages of the ANS from the central to the peripheral system. First, a mapping catheter is used to pace in the endocardium of the left atrium for four beats to ensure that there is no ventricular capture. HFS is then delivered at 20 Hz, 12 V. Asystole occurs almost immediately after starting HFS. This is due to direct AV dissociation or via stimulation of the RLGP acting as the common “gateway” to the AV node. During HFS and AV dissociation, there is continued atrial activity as observed in CS 3 to 4. Due to the high voltage output, the Map electrogram only shows output signals during pacing and HFS. The RR interval recovers following cessation of HFS. This site was determined as an A‐AVD‐GP site. (B) An intracardiac recording of determination of a B‐AVD‐GP site. We have performed HFS with the same parameters as (A) but for 10 seconds. The mean of 10 RR intervals preceding HFS was 952 milliseconds. We then measured the total time duration between the first R after starting HFS and the first R after cessation of HFS (HFSRR) and averaged this to calculate the mean RR interval (1610 milliseconds). There was increase in more than 50% of the RR interval during HFS from…

Figure 2. An example of a patient’s CARTO left atrial image (posterior‐anterior view) with A‐AVD‐GP (green), B‐AVD‐GP (orange), and high frequency stimulation negative sites (pink) transformed onto a reference left atrial shell. A‐AVD‐GP, asystole atrioventricular dissociating ganglionated plexus; B‐AVD‐GP, bradycardia atrioventricular dissociating ganglionated plexus [Color figure can be viewed at wileyonlinelibrary.com]

Figure 3. Examples of patients with the lowest and the highest number of AVD‐GPs. The left panel shows the highest number of AVD‐GPs (31) and the right panel shows the lowest number (1) of AVD‐GPs. Pink dots indicate negative HFS sites, green dots are A‐AVD‐GPs. Neither patients had B‐AVD‐GP. Clinical characteristics of the patients are as follows: Left panel, patient, 67 years old, male, BMI 28.1, good LVSF, LA size 3 cm, hypertensive, 72 points tested in total, 29 were A‐AVD‐GP; right panel, patient, 77 years old, male, BMI 25.5, good LVSF, LA size 3.9 cm, previous stroke, previous percutaneous coronary intervention, hypertensive, 71 points tested in total. A‐AVD‐GP, asystole atrioventricular dissociating ganglionated plexus; AP, anterior‐posterior; AVD‐GP, atrioventricular dissociating ganglionated plexus; B‐AVD‐GP, bradycardia atrioventricular dissociating ganglionated plexus; INF, inferior; LSPV, left superior pulmonary vein; LAO, left anterior oblique; LIPV, left inferior pulmonary vein; MV, mitral valve; PA, posterior‐anterior; PVI, pulmonary vein isolation; RAO, right anterior oblique; RSPV, right superior pulmonary vein; RIPV, right inferior pulmonary vein; RLGP, right lower…

Figure 4. A scatter plot with 28 patients and the number of AVD‐GPs identified out of the total number of high frequency stimulation sites tested per patient. There was no clear linear relationship between the two variables. AVD‐GP, atrioventricular dissociating ganglionated plexus

Figure 5. A‐AVD‐GP and B‐AVD‐GP distributions in the left atrium. (A) All the A‐AVD‐GPs identified from 28 patients on the reference left atrial shell. The red spots indicate A‐AVD‐GPs and the blue circle around each point represents the 5 mm kernel variance. (B) All the B‐AVD‐GPs identified. The red spots indicate B‐AVD‐GPs and the orange circle around each site represents the 5 mm kernel variance. Areas in white are absent of any AVD‐GPs. (C) The combination of (A) and (B) into one map of AVD‐GPs. A‐AVD‐GP, asystole atrioventricular dissociating ganglionated plexus; AVD‐GP, atrioventricular dissociating ganglionated plexus; AP, anterior‐posterior; B‐AVD‐GP, bradycardia atrioventricular dissociating ganglionated plexus; INF, inferior; LAO, left anterior oblique; LIPV, left inferior pulmonary vein; LSPV, left superior pulmonary vein; MV, mitral valve; PA, posterior‐anterior; RAO, right anterior oblique; RSPV, right superior pulmonary vein; RIPV, right inferior pulmonary vein; RLGP, right lower ganglionated plexus; SUP, superior [Color figure can be viewed at wileyonlinelibrary.com]

Figure 6. A probability distribution atlas of AVD‐GPs. The probabilities are shown in the figure from 0% to 45%, white to dark green. This resulted in clear identification of the highest probability sites of AVD‐GP to the lowest. “High probability AVD‐GP sites” were more than 20% in probability, labeled with yellow dots with corresponding probabilities. These were: inferoseptal posterior wall (41%), the RSPV antrum (31%), and the base of the RIPV in the posterior wall (30%). AP, anterior‐posterior; AVD‐GP, atrioventricular dissociating ganglionated plexus; INF, inferior; LSPV, left superior pulmonary vein; LAO, left anterior oblique; LIPV, left inferior pulmonary vein; MV, mitral valve; PA, posterior‐anterior; RAO, right anterior oblique; RSPV, right superior pulmonary vein; RIPV, right inferior pulmonary vein; RLGP, right lower ganglionated plexus; SUP, superior [Color figure can be viewed at wileyonlinelibrary.com]

Figure 7. All AVD‐GPs and high frequency stimulation negative sites in 28 patients on the reference left atrial shell. Red spots represent high frequency stimulation site tested and the color scale on the left‐hand side represent the density of high frequency stimulation points tested (darkest blue representing highest density) in the left atrium. AVD‐GP, atrioventricular dissociating ganglionated plexus [Color figure can be viewed at wileyonlinelibrary.com]