Neuromodulation therapy for atrial fibrillation

Abstract

Atrial fibrillation has a multifactorial pathophysiology influenced by cardiac autonomic innervation. Both sympathetic and parasympathetic influences are profibrillatory. Innovative therapies targeting the neurocardiac axis include catheter ablation or pharmacologic suppression of ganglionated plexi, renal sympathetic denervation, low-level vagal stimulation, and stellate ganglion blockade. To date, these therapies have variable efficacy. As our understanding of atrial fibrillation and the cardiac nervous system expands, our approach to therapeutic neuromodulation will continue evolving for the benefit of those with AF.

Keywords: Atrial fibrillation; Autonomics; Ganglionated plexi; Neurocardiac axis; Neuromodulation.

Figure 1.

Vagal versus Adrenergic Atrial Fibrillation, adapted from Coumel, et al. and de Vos, et al.

Figure 2.

The anatomy of the cardiac autonomic ganglionated plexi, as discovered through anatomic dissection of canines (Armour et al., black ), anatomic dissection of human hearts (Pauza et al., blue ^, ), and electroanatomic mapping of human hearts (Po et al., green ). (A) Posterior, (B) Cross-sectional, (C) Right, (D) Left. Abbreviations: Armour et al., PL-LAGP=posterolateral left atrial, OMGP=obtuse marginal, SLAGP=superior left atrial, PDGP=posterior descending, PM-LAGP=posteromedial left atrial, PRAGP=posterior right atrial, SRAGP=superior right atrial; Po et al., SLGP=superior left, ILGP=inferior left, ARGP=anterior right, IRGP=inferior right; Pauza et al., MDsGP=middle dorsal ganglionated subplexus, LDsGP=left dorsal ganglionated subplexus, VLAsGP=ventral left atrial ganglionated subplexus, DRAsGP=dorsal right atrial ganglionated subplexus, VRAsGP=ventral right atrial ganglionated subplexus, LCsGP=left coronary ganglionated subplexus, RCsGP=right coronary ganglionated subplexus. Anatomy: SVC=superior vena cava, PA=pulmonary artery, LAA=left atrial appendage, VOM=vein of Marshall, LSPV=left superior pulmonary vein, LIPV=left inferior pulmonary vein, RSPV=right superior pulmonary vein, RIPV=right inferior pulmonary vein, IVC=inferior vena cava, SA=sinoatrial, AV=atrioventricular.

Figure 3.

Therapeutic Modulation of the Neurocardiac Axis.