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

Min-Young Kim ,Phang Boon Lim,Elaine Lim,Markus B Sikkel,Prapa Kanagaratnam,Guy Furniss,Rheeda L Ali,Chris D Cantwell,Dimitrios Panagopoulos,Hanney Gonna,Muzahir H Tayebjee,Gurpreet Dhillon,Guy A Haywood,Ross J Hunter,James O’Neill,Nicholas S Peters,David R Tomlinson,Nicola Hill ,Nick Linton ,Dárrel P Francis ,Gordon A Begg ,Belinda Sandler

doi:10.1111/jce.13723

Abstract

IntroductionThe ganglionated plexuses (GPs) of the intrinsic cardiac autonomic system are implicated in arrhythmogenesis. GP localization by stimulation of the epicardial fat pads to produce atrioventricular dissociating (AVD) effects is well described. We determined the anatomical distribution of the left atrial GPs that influence atrioventricular (AV) dissociation.Methods and ResultsHigh frequency stimulation was delivered through a Smart‐Touch catheter in the left atrium of patients undergoing atrial fibrillation (AF) ablation. Three dimensional locations of points tested throughout the entire chamber were recorded on the CARTO™ system. Impact on the AV conduction was categorized as ventricular asystole, bradycardia, or no effect. CARTO maps were exported, registered, and transformed onto a reference left atrial geometry using a custom software, enabling data from multiple patients to be overlaid. In 28 patients, 2108 locations were tested and 283 sites (13%) demonstrated (AVD‐GP) effects. There were 10 AVD‐GPs (interquartile range, 11.5) per patient. Eighty percent (226) produced asystole and 20% (57) showed bradycardia. The distribution of the two groups was very similar. Highest probability of AVD‐GPs (>20%) was identified in: inferoseptal portion (41%) and right inferior pulmonary vein base (30%) of the posterior wall, right superior pulmonary vein antrum (31%).ConclusionIt is feasible to map the entire left atrium for AVD‐GPs before AF ablation. Aggregated data from multiple patients, producing a distribution probability atlas of AVD‐GPs, identified three regions with a higher likelihood for finding AVD‐GPs and these matched the histological descriptions. This approach could be used to better characterize the autonomic network.

Highlights

The ganglionated plexuses (GPs) of the intrinsic cardiac autonomic system are implicated in arrhythmogenesis
The autonomic nervous system (ANS) regulates normal cardiac function but is implicated in pathological processes such as arrhythmogenesis.[1–5]. Such proarrhythmic changes are likely to be mediated by the intrinsic cardiac ANS, which is a complex network of ganglionated plexuses (GPs) around the epicardium
We have identified three main regions of the left atrium (LA) that are abundant in atrioventricular dissociating (AVD)‐GPs, and all these sites were in close proximity to the right atrium.[7,8]

Summary

| INTRODUCTION

The autonomic nervous system (ANS) regulates normal cardiac function but is implicated in pathological processes such as arrhythmogenesis.[1–5] Such proarrhythmic changes are likely to be mediated by the intrinsic cardiac ANS, which is a complex network of ganglionated plexuses (GPs) around the epicardium. The atria will fibrillate when HFS is applied due to high rate capture, but at atrial GP sites there will be ventricular rate slowing with a more than or equal to 50% increase in the mean RR interval compared to baseline. This response has been described as a “vagal response, vagal reflex, bradycardia, atrioventricular (AV) node block, and asystole” in other studies.[25–29]. We combined their LA geometries to create a probability atlas of AVD‐GPs

| MATERIALS AND METHODS

| LIMITATIONS

Findings

| CONCLUSION