Anatomical Distribution of Ectopy-Triggering Plexuses in Patients With Atrial Fibrillation
2020; Lippincott Williams & Wilkins; Volume: 13; Issue: 9 Linguagem: Inglês
10.1161/circep.120.008715
ISSN1941-3149
AutoresMin-young Kim, Belinda Sandler, Markus B. Sikkel, Chris D. Cantwell, Kevin Leong, Vishal Luther, Louisa Malcolme‐Lawes, Michael Koa‐Wing, Fu Siong Ng, Norman Qureshi, Afzal Sohaib, Zachary I. Whinnett, Michael Fudge, Elaine Lim, Michelle Todd, Ian Wright, Nicholas S. Peters, Phang Boon Lim, Nick Linton, Prapa Kanagaratnam,
Tópico(s)Cardiac electrophysiology and arrhythmias
ResumoHomeCirculation: Arrhythmia and ElectrophysiologyVol. 13, No. 9Anatomical Distribution of Ectopy-Triggering Plexuses in Patients With Atrial Fibrillation Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessLetterPDF/EPUBAnatomical Distribution of Ectopy-Triggering Plexuses in Patients With Atrial Fibrillation Min-Young Kim, MBChB Belinda C. Sandler, MBBS Markus B. Sikkel, PhD Christopher D. Cantwell, PhD Kevin M. Leong, PhD Vishal Luther, PhD Louisa Malcolme-Lawes, PhD Michael Koa-Wing, PhD Fu Siong Ng, PhD Norman Qureshi, PhD Afzal Sohaib, PhD Zachary I. Whinnett, PhD Michael Fudge, BSc Elaine Lim, BSc Michelle Todd, BSc Ian Wright, BSc Nicholas S. Peters, MD Phang Boon Lim, PhD Nicholas W.F. Linton, PhD Prapa KanagaratnamPhD Min-Young KimMin-Young Kim Min-Young Kim, MRCP, Imperial College London, United Kingdom, Email E-mail Address: [email protected] https://orcid.org/0000-0001-6441-1798 Myocardial Function Section, Imperial Centre for Translational and Experimental Medicine (M.-Y.K., B.C.S., M.B.S., C.D.C., F.S.N., N.S.P., P.B.L., N.W.F.L., P.K.), Imperial College London, United Kingdom. Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom. , Belinda C. SandlerBelinda C. Sandler Myocardial Function Section, Imperial Centre for Translational and Experimental Medicine (M.-Y.K., B.C.S., M.B.S., C.D.C., F.S.N., N.S.P., P.B.L., N.W.F.L., P.K.), Imperial College London, United Kingdom. Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom. , Markus B. SikkelMarkus B. Sikkel https://orcid.org/0000-0001-9801-8978 Myocardial Function Section, Imperial Centre for Translational and Experimental Medicine (M.-Y.K., B.C.S., M.B.S., C.D.C., F.S.N., N.S.P., P.B.L., N.W.F.L., P.K.), Imperial College London, United Kingdom. Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom. Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.). , Christopher D. CantwellChristopher D. Cantwell https://orcid.org/0000-0002-2448-3540 Myocardial Function Section, Imperial Centre for Translational and Experimental Medicine (M.-Y.K., B.C.S., M.B.S., C.D.C., F.S.N., N.S.P., P.B.L., N.W.F.L., P.K.), Imperial College London, United Kingdom. Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom. , Kevin M. LeongKevin M. Leong Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom. Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.). , Vishal LutherVishal Luther Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom. Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.). , Louisa Malcolme-LawesLouisa Malcolme-Lawes Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom. Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.). , Michael Koa-WingMichael Koa-Wing Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom. Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.). , Fu Siong NgFu Siong Ng https://orcid.org/0000-0002-8681-4368 Myocardial Function Section, Imperial Centre for Translational and Experimental Medicine (M.-Y.K., B.C.S., M.B.S., C.D.C., F.S.N., N.S.P., P.B.L., N.W.F.L., P.K.), Imperial College London, United Kingdom. Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom. Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.). , Norman QureshiNorman Qureshi Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom. Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.). , Afzal SohaibAfzal Sohaib Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom. Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.). Department of Cardiology, Barts Health NHS Trust, London, United Kingdom (A.S.). , Zachary I. WhinnettZachary I. Whinnett https://orcid.org/0000-0002-2775-5126 Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom. Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.). , Michael FudgeMichael Fudge https://orcid.org/0000-0002-9994-3708 Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom. Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.). , Elaine LimElaine Lim https://orcid.org/0000-0001-6229-6714 Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom. Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.). , Michelle ToddMichelle Todd Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom. Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.). , Ian WrightIan Wright Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom. Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.). , Nicholas S. PetersNicholas S. Peters https://orcid.org/0000-0002-3581-8078 Myocardial Function Section, Imperial Centre for Translational and Experimental Medicine (M.-Y.K., B.C.S., M.B.S., C.D.C., F.S.N., N.S.P., P.B.L., N.W.F.L., P.K.), Imperial College London, United Kingdom. Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom. Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.). , Phang Boon LimPhang Boon Lim Myocardial Function Section, Imperial Centre for Translational and Experimental Medicine (M.-Y.K., B.C.S., M.B.S., C.D.C., F.S.N., N.S.P., P.B.L., N.W.F.L., P.K.), Imperial College London, United Kingdom. Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom. Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.). , Nicholas W.F. LintonNicholas W.F. Linton https://orcid.org/0000-0002-5712-849X Myocardial Function Section, Imperial Centre for Translational and Experimental Medicine (M.-Y.K., B.C.S., M.B.S., C.D.C., F.S.N., N.S.P., P.B.L., N.W.F.L., P.K.), Imperial College London, United Kingdom. Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom. Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.). , Prapa KanagaratnamPrapa Kanagaratnam Correspondence to: Prapa Kanagaratnam, PhD, Cardiology Department, St. Mary's Hospital, Praed St, London W2 1NY, United Kingdom, Email E-mail Address: [email protected] https://orcid.org/0000-0003-3593-2185 Myocardial Function Section, Imperial Centre for Translational and Experimental Medicine (M.-Y.K., B.C.S., M.B.S., C.D.C., F.S.N., N.S.P., P.B.L., N.W.F.L., P.K.), Imperial College London, United Kingdom. Originally published27 Jul 2020https://doi.org/10.1161/CIRCEP.120.008715Circulation: Arrhythmia and Electrophysiology. 2020;13:e008715The autonomic nervous system plays a crucial role in trigger and maintenance of atrial fibrillation (AF). One of the key structures previously targeted for AF treatment are ganglionated plexuses (GPs), which are part of the intrinsic cardiac autonomic nervous system. GPs contain dense clusters of nerves that are abundant in the atrial epicardium. There are common clusters of GP in the human heart, mostly around the pulmonary vein (PV) antrum, interatrial septum, and inferior portion of the posterior left atrial wall.1 Specific localization of the epicardial GP is achieved from the endocardium using a mapping catheter to deliver high frequency stimulation (HFS). There are 2 different functional types of GP previously identified using different HFS techniques: atrioventricular dissociating GP (AVD-GP), which causes significant bradycardia or asystole during AF and atrial (PV or non-PV) ectopy-triggering GP (ET-GP) during sinus rhythm.2 We previously showed that AVD-GPs have anatomically discrete distribution in the left atrium of patients with AF; inferolateral portion of the posterior wall, interatrial septum, and the anterior portion of the right superior PV antrum.3 However, selective mapping and ablation of AVD-GP has limited role in AF.4 The anatomic distribution of ET-GPs and their role in AF is yet to be determined. Our aim was to map ET-GP in the left atrium of patients with AF and compare their anatomic distribution to AVD-GP.Twenty-six patients with paroxysmal AF indicated for catheter ablation were recruited. Patients gave written informed consent, and the study had ethics approval from the Health Research Authority and the Local Research Ethics Committee. All had antiarrhythmics and β-blockers stopped for 5 half-lives before their procedures and had general anesthesia. Transoesophageal echocardiography was performed to exclude cardiac thrombus. Access into the left atrium was achieved by transseptal puncture guided by fluoroscopy and transoesophageal echocardiography. A 3-dimensional electroanatomic map of the left atrium was created using the CARTO system (Biosense Webster). Intracardiac electrograms were recorded at 1000 Hz by an electrophysiology recording system (Bard EP, Lowell, MA). A decapolar catheter was inserted into the coronary sinus, and a PV catheter (Lasso) was inserted into the nearest PV to the site of HFS testing. At a stable spot for testing with a contact force–sensing ablation catheter, the left atrium was paced with high output (10 V) using the Grass S88 stimulator. This confirmed atrial capture and excluded ventricular capture. From the same catheter, short bursts of HFS were delivered immediately after each paced beat, at 10 V, 40 Hz, 100 to 120 ms duration. This ensured that HFS was synchronized to the local atrial refractory period and avoided direct myocardial capture. However, there remained a risk of local myocardial capture if there was enough shortening of local refractory period. These could be identified by the mapping catheter having the earliest signal with no delay from the last pacing artifact. If this occurred, we repeated HFS and reduced the duration of HFS until no further local capture was evident. Up to 15 trains of HFS were performed if there was no response. HFS was performed all around the left atrium, excluding the left atrial appendage, within the PVs, and near the mitral annulus. We aimed to test at least 80 sites overall. A positive response was defined as reproducibly triggering atrial ectopy or atrial arrhythmia and tagged as ET-GP on the 3-dimensional left atrial geometry. All negative responses to HFS were also tagged on the same geometry. Patients completed their ablation protocols, and their left atrial geometry was exported from the system. A custom-built software was used to merge all patients' maps together and create a single probability distribution atlas of ET-GP, using methods described from our previous AVD-GP mapping study.3Two thousand three hundred and two sites were tested with HFS, identifying 579 (25%) ET-GP. Four hundred sixty-four ET-GPs were characterized, where 74 (16%) triggered ≥30-s AF or atrial tachycardia. Median 97 (interquartile range, 55) sites were tested, identifying 19 (20%) ET-GPs per patient. The highest probability of ET-GP (>30%) was in the roof, mid-anterior wall, around all PV ostia except the right inferior PV in the posterior wall. There was marked contrast when comparing the anatomic probability distribution of ET-GP and AVD-GP3 (Figure). The biggest difference was observed in the roof, around the PV antra, and the posterior wall.Download figureDownload PowerPointFigure. Comparison of the anatomic probability distribution of ectopy-triggering ganglionated plexuses (ET-GP) and atrioventricular dissociating ganglionated plexuses (AVD-GP). The purple and the green atlases represent ET-GP and AVD-GP, respectively. The probability ranges from 0% to 45%, lowest (white) to highest probability (darkest purple/green). The same projection views of ET-GP and AVD-GP atlases are displayed next to each for comparison. The biggest differences are seen in posterior-anterior (PA), inferior (INF), and superior (SUP) views. The AVD-GP atlas is from our previous published work.3 AP indicates anterior-posterior; LAO, left anterior oblique; LIPV, left inferior pulmonary vein; LSPV, left superior pulmonary vein; MV, mitral valve; RAO, right anterior oblique; RIPV, right inferior pulmonary vein; and RSPV, right superior pulmonary vein.The preponderance of ET-GP to the roof and around the PVs suggests that ET-GPs are inadvertently ablated during conventional PV isolation procedures for AF, while majority of AVD-GPs lie outside the PV isolation target regions. It is possible that ET-GP ablation may contribute to the success of PV isolation procedures and explain why some patients remain symptom free with reconnected PVs.5 The results from this study also highlight the 2 different functional subtypes of GP are anatomically discrete and may have a differentiating role in AF. Further studies are warranted to investigate the role of ET-GP in AF specifically.Nonstandard Abbreviations and AcronymsAFatrial fibrillationAVD-GPatrioventricular dissociating ganglionated plexusET-GPectopy-triggering ganglionated plexusGPganglionated plexusHFShigh frequency stimulationPVpulmonary veinSources of FundingThis study was supported by the British Cardiac Trust; Rosetrees Trust; British Heart Foundation, Centre of Research Excellence; British Heart Foundation, grant/award number FS/13/73/30352; and St. Mary's Coronary Flow Trust.DisclosuresNone.Footnotes*M.-Y. Kim and B. Sandler contributed equally to this work as first authors.For Sources of Funding and Disclosures, see page 1046.Correspondence to: Prapa Kanagaratnam, PhD, Cardiology Department, St. Mary's Hospital, Praed St, London W2 1NY, United Kingdom, Email p.[email protected]ac.ukMin-Young Kim, MRCP, Imperial College London, United Kingdom, Email min-young.[email protected]ac.ukReferences1. Pauziene N, Pauza DH, Stropus R. Morphology of human intracardiac nerves: an electron microscope study.J Anat. 2000; 197(pt 3):437–459. doi: 10.1046/j.1469-7580.2000.19730437.xCrossrefMedlineGoogle Scholar2. Kim MY, Sandler B, Sikkel MB, Cantwell CD, Leong KM, Luther V, Malcolme-Lawes L, Koa-Wing M, Siong FS, Qureshi N, Sohaib A, Whinnett ZI, Fudge M, Lim E, Todd M, Wright I, Peters NS, Lim PB, Linton NWF, Kanagarantam P. Auton Neurosci. 2020 Jul; 21;228:102699. doi: 10.1016/j.autneu.2020.102699Google Scholar3. Kim MY, Sikkel MB, Hunter RJ, Haywood GA, Tomlinson DR, Tayebjee MH, Ali RL, Cantwell CD, Gonna H, Sandler BC, et al.. A novel approach to mapping the atrial ganglionated plexus network by generating a distribution probability atlas.J Cardiovasc Electrophysiol. 2018; 29:1624–1634. doi: 10.1111/jce.13723CrossrefMedlineGoogle Scholar4. Pokushalov E, Romanov A, Shugayev P, Artyomenko S, Shirokova N, Turov A, Katritsis DG. Selective ganglionated plexi ablation for paroxysmal atrial fibrillation.Heart Rhythm. 2009; 6:1257–1264. doi: 10.1016/j.hrthm.2009.05.018CrossrefMedlineGoogle Scholar5. Kuck KH, Hoffmann BA, Ernst S, Wegscheider K, Treszl A, Metzner A, Eckardt L, Lewalter T, Breithardt G, Willems S. Impact of complete versus incomplete circumferential lines around the pulmonary veins during catheter ablation of paroxysmal atrial fibrillation.Circ Arrhythmia Electrophysiol. 2016; 9:1–10. doi: 10.1161/CIRCEP.115.003337LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails September 2020Vol 13, Issue 9Article InformationMetrics Download: 95 © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.120.008715PMID: 32718187 Originally publishedJuly 27, 2020 Keywordsautonomic nervous systematrial fibrillationheart blockheart atriaendocardiumPDF download
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