Targeting the autonomic nervous system during AF ablation: should we
fight or take flight?
Abstract
Demonstration that the myocardial sleeves of the pulmonary veins (PVs)
are the main triggering and maintaining foci for paroxysmal atrial
fibrillation (AF) have stimulated studies investigating
electrophysiological properties of PVs and the adjacent left atrial (LA)
myocardium. It has been shown that PV myocytes have a shorter action
potential duration and are more prone to effects of local autonomic
nerve stimulation in terms of shortening of action potential duration,
early after depolarization formation and triggered firing compared to
left atrial myocytes (1). The intrinsic cardiac autonomic nervous system
(ICANS) forms clusters of neurons called ganglionic plexi (GPs), and
studies using histologic examination of heart sections have shown that
these GPs are localized preferentially at certain epicardial sites
adjacent to the left and right atria (2). The precise role of ICANS in
AF continues to be an area of intense research (3), and matters are not
helped by the uncertainty regarding the best way to identify and target
ICANS peri-procedurally. As there can be significant variability of GP
sites in individual patients, endocardial high-frequency stimulation
(HFS) has been used to aid their localization in the electrophysiology
laboratory (4).