vagal avnode modulation in afecc-conference.com/1/mam2017/mam2017-d2-s5-1-bianchi.pdffbf isola...
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STEFANO BIANCHI
FBF ISOLA TIBERINA
Rome
Vagal
AVNode
Modulation in AF
Amor e Psiche, A. Canova
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FBF ISOLA TIBERINA
Rome
P. Hanna
Autonomic Neuroscience:
Basic and Clinical (2017)
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Exstrinsic and Intrinsic Autonomus nervous system
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FBF ISOLA TIBERINA
Rome
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Pauza,Anat-Embryol 2006
Intrinsic Autonomic System
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Intrinsic Autonomic System
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Armour J.A. The Anatomical record 1997
Testo
Intrinsic Autonomic System
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Jennifer E. Cummings et al. JACC 2004;43:994-1000JACC 2004;43:994-1000
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Low-Level Electrical Stimulation of Aortic Root Ventricular Ganglionated Plexi Attenuates Autonomic Nervous System
WANG 2015
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11
LV Summit
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Armour J.A. The Anatomical record 1997
Testo
Intrinsic Autonomic System
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CardioStim Congress, June 2012
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Chronic Atrioventricular Nodal Vagal Stimulation First Evidence for Long-Term Ventricular Rate Control in Canine Atrial Fibrillation ModelY.Zhang, T N. Mazgalev.
(Circulation. 2005;112:2904-2911.)
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J Cardiovasc Electrophysiol. 2012 Jul 9.
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J Interv Card Electrophysiol. 2009 Jan;24(1):37-45.
Start stim.
A-V block
Stop stim.
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Start stim.
Stop stim.
A-V block
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Bianchi S. Endocardial transcatheter stimulation of the AV nodal fat pad: stabilization of rapid ventricular rate response during atrial fibrillation in left ventricular failure. J Cardiovasc Electrophysiol 2009
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Endocardial vagal atrioventricular node stimulation in
humans: reproducibility on 18-month follow-up P Rossi, S Bianchi, S Valsecchi, D Porcelli, F Sgreccia, A Lucifiero, S Canonaco, M Campoli, M Malavasi, G
Piccirillo, R Quaglione and P Azzolini Europace (2010) 12, 1719–1724
Ventricular rate control during AF was obtained under HFS 18 months after implantation in patients with the atrial lead
positioned at a location suitable for AVNS
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Bianchi S et al. Atrioventricular (AV) node vagal stimulation by transvenous permanent lead implantation to modulate AV node function: safety and feasibility in humans. Heart Rhythm. 2009
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months
J Cardiovasc Electrophysiol. 2010 Feb;21(2):193-9.
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Rome, 04 december 2012
Start stimulation
Stop stimulation
Ventricular rate control by AVNS directly from the implanted ICD
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Automatic intervention from the AICD-AVNS download software
Start Stimulation
Atrial Flutter
Ventricular rate control during AVNS
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Clinical Applications
• In patients with an ICD, AVNS could reduce inappropriate shocks.
• In HF patients, AVNS may decrease rapid, irregular VR during AF and prevent CRT discontinuation.
• In pacemaker patients, ventricular rate could be controlled during AF to reduce symptoms.
Both ventricular rate control and reduction cardiac inflammation might prevent AF and heart failure deterioration.
⇓
AVNS may represent an alternative to irreversible Ablate & Pace approach for AF patients indicated to rate-control therapy
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Background 2
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Epicardial ganglionated plexus stimulation decreases postoperative inflammatory
response in humans
HEART RYTHM 2012
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Wires placement and intra-operative protocol
Start stim.
Stop
stim.
A-V block
Frequency:50 Hz
Burst duration:180 ms
Pulse duration: 1 ms
Bursts/min: 90
1 to 9 V
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Aims of the study
• Feasibility and safety of postoperative bursts IVC-IAGP stimulation (6 hours)
• To verify if bursts IVC-IAGP stimulation modulates postoperative releasing curves of inflammatory cytokines
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Blood samples collection
10 cc of venous blood samples (Jugular line) were collected at the following times:T1 before skin incisionT2 at the arrive in the intensive care unit (ICU)T3 three hours after arriving in the ICUT4 six hours after arriving in the ICUT5 nine hours after arriving in the ICUT6 twelve hours after arriving in the ICU
IL-6TNF-alphaVEGFEGFMCP-1IL-10
Measured cytoKines :
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Results
*p< 0,05 ** p < 0,01
TNF-α VEGF
IL-6 EGF
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Results
IL-10
MCP-1
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Results
Number of grafts, n 3±1 3±1 1.000
Operative time, min 230±37 229±33 0.935
Max. serum Trop. I level, pg/ml 0.76±1.22 1.08±1.33 0.465
Max. Leucocites number, n/mm3 18005±5780 19923±7016 0.382
Intensive Care Unit length of stay, hours 31±16 29±19 0.738
Post-operative atrial fibrillation, n (%) 5 (25) 1 (7) 0.207
Control
Group
Study
GroupP value
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Conclusions
• Temporary bipolar wire implanted in the IVC-IAGP area allows both standard atrial pacing and GP stimulation
• Post-operative GP stimulation is feasible and safe
• IVC-GP stimulation can control AF ventricular response in Postop period
• IVC-IAGP stimulation decreases inflammatory cytokines secretion with potential clinical benefits
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As such, although often using some reductionistic models,
I do my best to remain a pupil at the school of complexity
Alberto Malliani (1935–2006)