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Ganglionated Plexi Ablation for the Treatment of Atrial Fibrillation

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Ganglionated Plexi Ablation for the Treatment of Atrial Fibrillation Journal of Clinical Medicine Review Ganglionated Plexi Ablation for the Treatment of Atrial Fibrillation 1, 1, 2 2 3,4 Sahar Avazzadeh y , Shauna McBride y, Barry O’Brien , Ken Coffey , Adnan Elahi , Martin O’Halloran 3, Alan Soo 5 and Leo. R Quinlan 1,* 1 Physiology and Human Movement Laboratory, CÚRAM SFI Centre for Research in Medical Devices, School of Medicine, Human biology building, National University of Ireland (NUI) Galway, H91 TK33 Galway, Ireland; [email protected] (S.A.); [email protected] (S.M.) 2 AtriAN Medical Limited, Unit 204, NUIG Business Innovation Centre, Upper Newcastle, H91 TK33 Galway, Ireland; [email protected] (B.O.); ken.coff[email protected] (K.C.) 3 Translational Medical Devise Lab (TMD Lab), Lambe Institute of Translational Research, University College Hospital Galway, H91 ERW1 Galway, Ireland; [email protected] (A.E.); [email protected] (M.O.) 4 Electrical & Electronic Engineering, School of Engineering, National University of Ireland Galway, H91 TK33 Galway, Ireland 5 Department of Cardiothoracic Surgery, University Hospital Galway, Saolta Hospital HealthCare Group, H91 YR71 Galway, Ireland; [email protected] * Correspondence: [email protected]; Tel.: +35-3-9149-3710 Joint first author. y Received: 7 August 2020; Accepted: 23 September 2020; Published: 24 September 2020 Abstract: Atrial fibrillation (AF) is the most common type of cardiac arrhythmia and is associated with significant morbidity and mortality. The autonomic nervous system (ANS) plays an important role in the initiation and development of AF, causing alterations in atrial structure and electrophysiological defects. The intrinsic ANS of the heart consists of multiple ganglionated plexi (GP), commonly nestled in epicardial fat pads. These GPs contain both parasympathetic and sympathetic afferent and efferent neuronal circuits that control the electrophysiological properties of the myocardium. Pulmonary vein isolation and other cardiac catheter ablation targets including GP ablation can disrupt the fibers connecting GPs or directly damage the GPs, mediating the benefits of the ablation procedure. Ablation of GPs has been evaluated over the past decade as an adjunctive procedure for the treatment of patients suffering from AF. The success rate of GP ablation is strongly associated with specific ablation sites, surgical techniques, localization techniques, method of access and the incorporation of additional interventions. In this review, we present the current data on the clinical utility of GP ablation and its significance in AF elimination and the restoration of normal sinus rhythm in humans. Keywords: atrial fibrillation; ganglionated plexi; autonomic nervous system; ablation 1. Introduction Atrial Fibrillation presents clinically as chaotic electrical excitation that is detrimental to normal atrial contractility [1]. AF is the most common form of cardiac dysrhythmia and is categorized as a supraventricular tachyarrhythmia, which will affect 18 million people in Europe and 6–12 million in the United States by 2060 and 2050, respectively [2–5]. AF is generally classified as either paroxysmal, persistent, or long-standing persistent, and its presentation can in fact evolve and change over time [6]. The effects of AF can be life-threatening, as insufficient contraction of the atria results in blood stasis which promotes the formation of thromb-oemboli which effect the heart but can also propagate to other vital organs [7,8]. Despite many advances in recent years, no specific etiological J. Clin. Med. 2020, 9, 3081; doi:10.3390/jcm9103081 www.mdpi.com/journal/jcm J. Clin. Med. 2020, 9, x FOR PEER REVIEW 2 of 21 J. Clin. Med. 2020, 9, 3081 2 of 21 vital organs [7,8]. Despite many advances in recent years, no specific etiological factor has been factorpinpointed has beenas the pinpointed main cause as of theAF. mainSome causeepidemio of AF.logical Some and epidemiological clinical factors such and as clinical abnormalities factors suchassociated as abnormalities with metabolism, associated endocrine with function metabolism, and genetics, endocrine are functionknown to and predispose genetics, patients are known to AF to[6,9]. predispose Furthermore, patients pathophysiological to AF [6,9]. Furthermore, factors pathophysiologicalsuch as electrical factorsand structural such as electricalremodelling, and structuralinflammation, remodelling, and local inflammation, autonomic system and local regulation autonomic are system also seen regulation with AF are [10]. also Evidence seen with from AF [ 10the]. Evidenceliterature fromhighlights the literature the role highlights of the intrinsic the role and of ex thetrinsic intrinsic autonomic and extrinsic nervous autonomic system (ANS) nervous in systemcardiac (ANS)function, in cardiacthe underlying function, mechanism the underlying of altered mechanism electrical of alteredactivity electricalin AF is not activity fully in understood AF is not fully[11]. understoodAltered autonomic [11]. Altered activity autonomic is recognised activity as isa recognisedsignificant ascomponent a significant in componentboth the initiation in both and the initiationmaintenance and of maintenance AF [12,13]. ofThe AF incidence [12,13]. The of incidenceatrial arrhythmias of atrial arrhythmiasis reported to is reportedreduce when to reduce ANS wheninnervation ANS innervation is significantly is significantly decreased [14,15]. decreased The [acti14,15vity]. Theof the activity intrinsic of thecardiac intrinsic ANS cardiac is found ANS to be is founddisrupted to be in disruptedcases of AF, in with cases studies of AF, associating with studies vagal associating interference vagal with interference networks of with GPs networks [16,17]. GPs of GPsare normally [16,17]. GPs found are in normally close proximit found iny with close epicardial proximity fat with pads epicardial and resi fatde padsin discrete and reside locations in discrete on the locationsatria and onventricles, the atria andparticularly ventricles, surrounding particularly th surroundinge pulmonary the veins pulmonary (PV) and veins great (PV) vessels and great [18]. vesselsNumerous [18]. trials Numerous employing trials employinga variety aof variety therapeu of therapeutictic interventions interventions for cardiac for cardiac disease disease have havebeen beencompleted completed to date, to date, with with some some targeting targeting GPs GPs for for AF AF treatment. treatment. The The complex complex anatomical anatomical layout andand physiologicalphysiological interconnectivity of of these these GP GP sites sites is is important important in in understanding understanding the the pathophysiology pathophysiology of ofAF AF [19]. [19 ].Our Our aim aim is isto to address address the the association association of of GPs GPs with with AF andand documentdocument thethe extantextant literatureliterature reportingreporting thethe impactimpact of GP ablation proced proceduresures recorded recorded in in human human clinical clinical studies. studies. 2.2. CardiacCardiac AutonomicAutonomic NervousNervous SystemSystem ComponentsComponents ofof thethe peripheral,peripheral, centralcentral andand intrinsicintrinsic cardiaccardiac innervationinnervation systemssystems formform aa complexcomplex interconnectedinterconnected networknetwork thatthat managesmanages cardiovascularcardiovascular functionfunction [[19,20].19,20]. TheThe cardiaccardiac ANSANS isis organisedorganised intointo extrinsicextrinsic andand intrinsic components that that are are su suppliedpplied by by the the autonomic autonomic nerves. nerves. The The intrinsic intrinsic ANS ANS is iscomprised comprised of of clusters clusters of of neurons neurons known known as as GPs GPs that that interconnect interconnect not not only only to to the atria and ventricles,ventricles, butbut alsoalso toto the extrinsic cardiac ANS. ANS. The The extrinsic extrinsic sy sympatheticmpathetic innervation innervation arises arises in in the the grey grey matter matter of ofthe the thoracic thoracic spinal spinal cord cord segments segments T1–T6 T1–T6 and and are aregenerally generally myelinated myelinated fibres, fibres, that that increase increase heart heart rate rateand andmyocardial myocardial contractility contractility by byreleasing releasing noradren noradrenaline,aline, stimulating stimulating inotropy inotropy in in the the heart [[18,20]18,20] (Figure(Figure1 ).1). Noradrenaline Noradrenaline (NE)(NE) binds binds to toβ β1-adrenoceptors1-adrenoceptors increasingincreasing sodiumsodium permeability,permeability, therebythereby increasingincreasing heartheart raterate [[20].20]. ParasympatheticParasympathetic fibresfibres arisearise inin thethe medullamedulla oblongata,oblongata, ponspons andand midbrainmidbrain ofof thethe brainstem,brainstem, withwith somesome fibresfibres arisingarising fromfrom thethe sacralsacral portionportion ofof thethe spinalspinal cordcord (S2–S4).(S2–S4). TheThe restingresting heartheart isis dominateddominated byby parasympatheticparasympathetic tone,tone, whichwhich actsacts toto reducereduce heartheart raterate andand slowslow cardiaccardiac impulsesimpulses fromfrom thethe atriaatria toto thethe ventriclesventricles (Figure(Figure1 1)) through through the the release release of of acetylcholine acetylcholine (ACh).The (ACh).The binding binding of of ACh ACh toto G-proteinG-protein coupledcoupled muscarinicmuscarinic receptorsreceptors (M2)(M2) activatesactivates inhibitoryinhibitory GG proteins,proteins, reducingreducing bothboth
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