STEFANO BIANCHI

FBF ISOLA TIBERINA

Rome

Vagal

AVNode

Modulation in AF

Amor e Psiche, A. Canova

FBF ISOLA TIBERINA

Rome

P. Hanna

Autonomic Neuroscience:

Basic and Clinical (2017)

Exstrinsic and Intrinsic Autonomus nervous system

FBF ISOLA TIBERINA

Rome

Pauza,Anat-Embryol 2006

Intrinsic Autonomic System

Intrinsic Autonomic System

Armour J.A. The Anatomical record 1997

Testo

Intrinsic Autonomic System

Jennifer E. Cummings et al. JACC 2004;43:994-1000JACC 2004;43:994-1000

Low-Level Electrical Stimulation of Aortic Root Ventricular Ganglionated Plexi Attenuates Autonomic Nervous System

WANG 2015

11

LV Summit

Armour J.A. The Anatomical record 1997

Testo

Intrinsic Autonomic System

CardioStim Congress, June 2012

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.)

J Cardiovasc Electrophysiol. 2012 Jul 9.

J Interv Card Electrophysiol. 2009 Jan;24(1):37-45.

Start stim.

A-V block

Stop stim.

Start stim.

Stop stim.

A-V block

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

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

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

months

J Cardiovasc Electrophysiol. 2010 Feb;21(2):193-9.

Rome, 04 december 2012

Start stimulation

Stop stimulation

Ventricular rate control by AVNS directly from the implanted ICD

Automatic intervention from the AICD-AVNS download software

Start Stimulation

Atrial Flutter

Ventricular rate control during AVNS

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

Background 2

Epicardial ganglionated plexus stimulation decreases postoperative inflammatory

response in humans

HEART RYTHM 2012

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

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

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 :

Results

*p< 0,05 ** p < 0,01

TNF-α VEGF

IL-6 EGF

Results

IL-10

MCP-1

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

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

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)