Effects of Different n6/n3 PUFAs Dietary Ratio on Cardiac Diabetic Neuropathy.

We studied the influence of experimentally induced DM1, in combination with different dietary n6:n3 polyunsaturated fatty acid (PUFA) ratios on different types of nerve fibers in rat myocardium, in order to reveal whether protective/unfavorable effects of different PUFAs on myocardial function in diabetic patients could be a (partial) repercussion of their effect on the changes in cardiac innervation. The control group (c) and diabetic group (stz) were fed with an n6/n3 ratio of ≈7; the diet of the stz+n6 group had an n6/n3 ratio ≈60, while the diet for the stz+DHA group contained 2.5% of fish oil (containing 16% eicosapentaenoic acid-EPA and 19% docosahexaenoic acid-DHA), n6/n3 ratio of ≈1. DM1 was induced by i.p. injection of streptozotocin (55 mg/kg) and rats were euthanized 30 days after induction. Immunohistochemistry was used for the detection and quantification of different types of neuronal fibers in the cardiac septum. We found changes in cardiac innervations characteristics for the initial phase of experimental DM1, which manifested as an increase in total number and area density of all neuronal fibers, measured by Pgp9.5 immunoreactivity. By detailed analysis, we found that this increase consisted mostly of heavy myelinated NF200 immunoreactive fibers and TH immunoreactive sympathetic fibers, while the density of ChAT immunoreactive parasympathetic fibers decreased. In the deep (middle) part of the myocardium, where rare fibers (of all studied types) were found, significant differences were not found. Surprisingly, we found a more consistent protective effect of n6 PUFAs, in comparison to n3 PUFAs supplementation. These results may provide a better understanding of the potential impacts of different PUFA ratios in the diet of diabetic patients on cardiac innervation and genesis and outcome of diabetic autonomic cardiomyopathy.

Cardiac sympathetic denervation predicts PD in at-risk individuals.

INTRODUCTION: By the time a person develops the motor manifestations of Parkinson's disease (PD), substantial loss of nigrostriatal dopamine neurons has already occurred. There is great interest in identifying biomarkers that can detect pre-clinical PD. Braak's neuropathological staging concept imputes early autonomic involvement. Here we report results from a small prospective cohort study about the utility of neuroimaging evidence of cardiac sympathetic denervation in predicting PD among individuals with multiple PD risk factors. METHODS: Subjects provided information about family history of PD, olfactory dysfunction, dream enactment behavior, and orthostatic hypotension at a protocol-specific website. From this pool, 27 people with at least 3 risk factors confirmed underwent cardiac 18F-dopamine positron emission tomographic scanning and were followed for at least 3 years. Interventricular septal and left ventricular free wall concentrations of 18F-dopamine-derived radioactivity were measured. RESULTS: Of the 27 subjects, 4 were diagnosed with PD within the 3-year follow-up period (Pre-Clinical PD group); 23 risk-matched (mean 3.2 risk factors) subjects remained disease-free (No-PD group). Compared to the No-PD group, the Pre-Clinical PD group had lower initial values for septal and free wall concentrations of 18F-dopamine-derived radioactivity (p = 0.0248, 0.0129). All 4 Pre-Clinical PD subjects had evidence of decreased cardiac sympathetic innervation in the interventricular septum or left ventricular free wall, in contrast with 3 of 23 (13%) No-PD subjects (p = 0.0020 by Fisher's exact test). CONCLUSION: People with multiple PD risk factors and diagnosed with PD within 3 years have evidence of antecedent cardiac sympathetic denervation. The findings fit with Braak's staging concept.

Atrial septostomy decreases sympathetic overactivity in pulmonary arterial hypertension.

BACKGROUND: We have reported previously that the sympathetic nervous system is activated in patients with pulmonary arterial hypertension (PAH), and that this is only partly explained by a decrease in arterial oxygenation. Possible causes for increased muscle sympathetic nerve activity (MSNA) in patients with PAH include right atrial distension and decreased cardiac output. Both may be improved by atrial septostomy, but this intervention also further decreases arterial oxygenation. In the present study, we wanted to investigate the effect of atrial septostomy on MSNA in patients with PAH. METHODS: We recorded BP, heart rate (HR), arterial O2 saturation (SaO2), and MSNA before and after atrial septostomy in PAH patients (mean [+/- SE] age, 48 +/- 5 years) and in closely matched control subjects. Measurements were also performed after septostomy, while SaO2 was brought to the preprocedure level by supplemental O2 therapy. RESULTS: Compared to the control subjects (n = 10), the PAH patients (n = 11) had a lower mean BP (75 +/- 2 vs 96 +/- 3 mm Hg, respectively; p < 0.001), lower mean SaO2 (92 +/- 1% vs 97 +/- 0%, respectively; p < 0.001), increased mean HR (84 +/- 4 vs 68 +/- 3 beats/min; p < 0.01), and markedly increased mean MSNA (76 +/- 5 vs 29 +/- 2 bursts per minute; p < 0.001). Atrial septostomy decreased mean SaO2 (to 85 +/- 2%; p < 0.001) and mean MSNA (to 69 +/- 4 bursts per minute; p < 0.01), but did not affect HR or BP. Therapy with supplemental O2 did not affect MSNA, BP, or HR. The decrease in MSNA was correlated to the decrease in right atrial pressure (r = 0.62; p < 0.05). CONCLUSIONS: Atrial septostomy in PAH patients decreases sympathetic hyperactivity despite an associated decrease in arterial oxygenation, and this appears to be related to decreased right atrial distension.

Cryoablation for accessory pathways located near normal conduction tissues or within the coronary venous system in children and young adults.

BACKGROUND: Cryoablation may offer advantages over radiofrequency (RF) ablation for certain arrhythmia substrates, such as septal accessory pathways (APs). Data for young patients, especially regarding recurrence risk, require expansion. OBJECTIVES: The purpose of this study was to study institutional outcomes for cryoablation of APs located in potentially difficult septal regions for children and young adults. METHODS: Cryoablation was attempted in 35 young patients (mean age 15.6 years) with 37 APs that were either close to normal conduction tissues or inside the coronary venous system. Outcomes were compared with previously published institutional data for RF ablation at these same locations. RESULTS: Acute cryoablation success was achieved for 29 (78%) of 37 APs. Apart from permanent PR prolongation in one case and right bundle branch block in one other, there were no detrimental effects on normal conduction. At median follow-up of 207 days (range 2-695 days), AP conduction recurred for 13 (45%) of 29 ablated APs. Younger patient age and midseptal AP location correlated with higher likelihood of recurrence. Acute success rates for cryoablation were similar to RF ablation in our laboratory, but recurrence rates were significantly higher (P <.001). CONCLUSION: Cryoablation yields acute success rates comparable with RF ablation for difficult septal APs in young patients. The risk of AP recurrence appears higher after cryoablation, although safety benefits may provide suitable compensation for this deficiency. Methods for creating more effective cryoablation lesions need to be explored.

Optimization of right ventricular lead position in cardiac resynchronisation therapy.

BACKGROUND: The benefit of biventricular pacing (BiV) may be substantially affected by optimal lead placement. AIM: To evaluate the importance of right ventricular (RV) lead positioning on clinical outcome of BiV. METHODS AND RESULTS: A total of 99 patients with symptomatic heart failure and implantation of BiV system were included. Position of the left-ventricular (LV) lead was selected based on timing of local endocardial signal within the terminal portion of the QRS complex. RV lead was preferably positioned at the midseptum (n=74, RVS group) where the earliest RV endocardial signal was recorded. A subgroup of patients had RV lead placed in the apex (n=25, RVA group). NYHA class, maximum oxygen-uptake (VO(2)max), LV end-diastolic diameter (LVEDD, mm) and ejection fraction were assessed every third month. A trend towards greater improvement in NYHA class and significant increase in VO(2)max was present in the RVS group. Moreover, a significant decrease in LVEDD (DeltaLVEDD) was observed in the RVS group only (-3.4+/-6.5 mm versus +1.7+/-6.4 mm in RVA group at 12 months, p=0.004). No significant correlation between the degree of DeltaLVEDD and QRS narrowing induced by BiV was found. LVEDD reduction was predominantly present in dilated cardiomyopathy. CONCLUSIONS: Midseptal positioning of the RV lead appears to promote reverse LV remodelling during cardiac resynchronisation therapy.

Reliability of retrograde atrial activation patterns during ventricular pacing for localizing accessory pathways.

Definitive localization of accessory pathways is based on atrial activation patterns during orthodromic supraventricular tachycardia when retrograde conduction occurs exclusively through the accessory pathway. In some patients, supraventricular tachycardia cannot be induced or is deleterious. To determine whether accessory pathway sites can be identified accurately during ventricular pacing, retrograde atrial activation was assessed during orthodromic supraventricular tachycardia and ventricular pacing at multiple cycle lengths in 41 patients with a single accessory pathway. To obviate retrograde fusion due to concomitant conduction through the normal atrioventricular (AV) conduction system that may obscure the location of the accessory pathway, the difference in conduction time from the site of earliest atrial activation to the His bundle atrial electrogram (delta A-SVT) was measured during orthodromic supraventricular tachycardia and compared with values observed during ventricular pacing (delta A-VP). Characteristic values for the delta A-SVT interval were identified for left lateral (66 +/- 17 ms), left posterior (50 +/- 8 ms), posteroseptal (33 +/- 7 ms), right free wall (22 +/- 15 ms) and anteroseptal (0 +/- 0 ms) accessory pathway sites. During ventricular pacing, the site with the earliest atrial electrogram was used to define the accessory pathway location only if the maximal value of the delta A-VP interval over the range of cycle lengths assessed was comparable with the value of the delta A-SVT interval characteristic of that region. Values of the delta A-SVT interval correlated closely with the maximal values of the delta A-VP interval (r = 0.91). With this approach, 40 (98%) of 41 accessory pathway sites were identified correctly during ventricular pacing.(ABSTRACT TRUNCATED AT 250 WORDS)

Differentiation of atypical atrioventricular node re-entrant tachycardia from orthodromic reciprocating tachycardia using a septal accessory pathway by the response to ventricular pacing.

OBJECTIVES: The purpose of this study was to determine whether the response to ventricular pacing during tachycardia is useful for differentiating atypical atrioventricular node re-entrant tachycardia (AVNRT) from orthodromic reciprocating tachycardia (ORT) using a septal accessory pathway. BACKGROUND: Although it is usually possible to differentiate atypical AVNRT from ORT using a septal accessory pathway, a definitive diagnosis is occasionally elusive. METHODS: In 30 patients with atypical AVNRT and 44 patients with ORT using a septal accessory pathway, the right ventricle was paced at a cycle length 10 to 40 ms shorter than the tachycardia cycle length (TCL). The ventriculo-atrial (VA) interval and TCL were measured just before pacing. The interval between the last pacing stimulus and the last entrained atrial depolarization (stimulus-atrial [S-A] interval) and the post-pacing interval (PPI) at the right ventricular apex were measured on cessation of ventricular pacing. RESULTS: All 30 patients with atypical AVNRT and none of the 44 patients with ORT using a septal accessory pathway had an S-A-VA interval >85 ms and PPI-TCL >115 ms. CONCLUSIONS: The S-A-VA interval and PPI-TCL are useful in distinguishing atypical AVNRT from ORT using a septal accessory pathway.

Paraseptal accessory pathway in Wolff-Parkinson- White-Syndrom: ablation from the right, from the left or within the coronary sinus/middle cardiac vein?

AIMS: In 1999 the consensus statement "living anatomy of the atrioventricular junctions" was published. With that new nomenclature the former posteroseptal accessory pathway (APs) are termed paraseptal APs. The aim of this study was to identify ECG features of manifest APs located in this complex paraseptal space. METHODS AND RESULTS: ECG characteristics of all patients who underwent radiofrequency ablation of an AP during a 3 year period were analyzed. Of the 239 patients with one or more APs, 30 patients had a paraseptal AP with preexcitation. Compared to APs within the coronary sinus (CS) or the middle cardiac vein (MCV) the right sided paraseptal APs significantly more often showed an isoelectric delta wave in lead II and/or a negative delta wave in aVR. The left sided paraseptal APs presented a negative delta wave in II significantly more often compared to the right sided APs. CONCLUSIONS: According to the site of radiofrequency ablation, paraseptal APs are classified into 4 subgroups: paraseptal right, paraseptal left, inside the CS or inside the MCV. Subtle differences in preexcitation patterns of the delta wave as well as of the QRS complex exist. However, the definitive localization of APs remains reserved to the periinterventional intracardiac electrogram analysis.

Co-expression of four muscarinic receptor genes by the intrinsic neurons of the rat and guinea-pig heart.

Expression of the messenger RNAs encoding the five different muscarinic acetylcholine receptor subtypes was examined in intracardiac neurons from the rat and guinea-pig heart by in situ hybridization techniques. Newborn guinea-pig intracardiac neurons were studied in dissociated cell culture preparations employing both 35S- and digoxigenin-labelled oligonucleotide probes specific for the m1, m2, m3, m4 or m5 muscarinic receptor messenger RNAs. When 35S-tailed oligonucleotides were used, all intracardiac neurons in culture were found to express m1, m2, m3 and m4, but not m5 messenger RNAs. However after hybridization with digoxigenin-tailed probes, only m1 and m2 transcripts were detected. This may reflect differences in the sensitivity of the two techniques. Further to these experiments, intracardiac ganglia in sections of adult rat heart were studied employing m1-, m2-, m3- or m4-specific, 35S-labelled oligonucleotides, and again, all intracardiac neurons expressed messenger RNA for each of these four muscarinic receptor subtypes. Atrial myocytes in culture were only labelled by [35S]- and digoxigenin-tailed m2 oligonucleotides. No other heart cell type seen expressed messenger RNA for any of the muscarinic receptors. The expression of four different muscarinic receptor transcripts by intrinsic neurons of the heart provides the molecular basis for the diverse muscarinic actions observed in these and other autonomic ganglia.

Localization of accessory pathways from the 12-lead electrocardiogram using a new algorithm.

A new algorithm (St. George's algorithm), based on the polarity and morphology of QRS complexes rather than delta waves, was developed for localizing accessory pathways to 1 of 9 sites on the atrioventricular annuli. This was compared with algorithms previously proposed by Skeberis et al (localizing to 1 of 7 sites) and Milstein et al (localizing to 1 of 4 sites). The preexcited 12-lead electrocardiograms recorded during sinus rhythm in 106 consecutive patients (including 60 retrospectively analyzed patients and 46 prospectively analyzed patients) who underwent successful radiofrequency catheter ablation of a single accessory pathway were analyzed by 3 blinded observers using all 3 algorithms. The results were compared with the actual localization of accessory pathways as derived from endocardial mapping during catheter ablation. In all 106 patients, the accuracy of the 3 algorithms for 4 sites on the atrioventricular annuli (as considered by Milstein's method) was 72%, 79%, and 92% for Milstein's, Skeberis', and St. George's algorithms, respectively. For 7 sites (as considered by Skeberis' method), the accuracy was 65% (Skeberis' algorithm) and 88% (St. George's algorithm), and for 9 sites (as considered by our method) the accuracy was 86% (St. George's algorithm). In 46 prospectively analyzed patients, the accuracy of the 3 algorithms for 4 sites was 70% (Milstein's), 67% (Skeberis'), and 87% (St. George's); for 7 sites the accuracy was 61% (Skeberis') and 85% (St. George's), and for 9 sites the accuracy was 85% (St. George's). The reproducibility of St. George's and Skeberis' methods was better than that of Milstein's method.(ABSTRACT TRUNCATED AT 250 WORDS)

Unmasking the trifascicular left intraventricular conduction system by ablation of the right bundle branch.

Twenty-five patients underwent transcatheter right bundle ablation either for bundle branch reentrant tachycardias or inadvertent or deliberate right bundle ablation during atrioventricular junctional ablation for rate control. Electrophysiologic data and 12-lead electrocardiograms before and after right bundle ablation were available in all patients. Eleven of the patients had no significant intraventricular conduction abnormalities by surface electrocardiograms (group I), whereas 14 patients had underlying intraventricular conduction delays (group II). All group I patients had typical electrocardiographic changes of right bundle branch block after right bundle ablation, with minimal changes in initial or mean QRS axis. In group II, 5 patients had an initial 40 ms QRS axis shift of > 45 degrees, in 7 patients the mean QRS axis changed significantly (leftward in 4 and rightward in 3), and a qR pattern in V1 was seen in 12 of 14 patients including 2 with structurally normal hearts. These changes, namely new Q waves, and rightward and leftward axis shifts are most likely the result of septal fascicular, left posterior fascicular, and left anterior fascicular delay/block, which were exposed by exclusive conduction via a diseased left bundle and its fascicles. The trifascicular nature of left intraventricular conduction is more apparent when diseased and unmasked by concomitant block in the right bundle branch.

A cadmium-sensitive, tetrodotoxin-resistant sodium channel in bullfrog autonomic axons.

The major component of the compound action potential of the bullfrog cardiac nerve was not blocked by TTX (10(-5) M) although the conduction velocity of these fibers was decreased by 50%. The TTX-resistant compound action potential was completely blocked by 100-300 microM CdCl2 but not by 5 mM CoCl2 or NiCl2. This cadmium-sensitive action potential was only partially reduced by removal of calcium from the medium but was abolished by replacement of sodium with sucrose, tetramethylammonium or choline. Therefore, in addition to the classical TTX-sensitive sodium channels, the parasympathetic axons of the bullfrog may also utilize a TTX-insensitive, cadmium-sensitive sodium channel.

Nitric oxide synthase immunoreactivity and NADPH-diaphorase activity in a subpopulation of intrinsic neurones of the guinea-pig heart.

This is the first report of the presence of nitric oxide synthase (NOS) immunoreactivity and NADPH-diaphorase (NADPH-d) activity in a subpopulation of the intrinsic neurones that innervate the heart. A cytochemical technique to detect NADPH-d and antisera raised against purified rat cerebellar NOS were employed to examine the expression of these enzymes by cells in a dissociated cell culture preparation from newborn guinea-pig atria and interatrial septum. Comparison of the results obtained by these two techniques and double-labelling experiments indicate that a subpopulation of intracardiac neurones contain both NADPH-d and NOS. These results indicate that some intracardiac neurones are capable of synthesizing nitric oxide. This raises the possibility that nitric oxide plays a role in the neural control of the heart.

The vagal origin of preganglionic fibers containing nitric oxide synthase in the guinea-pig heart.

The origin of nerve fibers projecting to the guinea pig heart that contain nitric oxide synthase (NOS) were studied by unilateral cervical vagotomy. Three kinds of NOS-immunoreactive (NOS-ir) nerve fibers are distributed in the control guinea pig heart: the sparse network covering the right atrium, the basket-like endings around intracardiac neuronal cell bodies in the small ganglia located in the left atrium and the interatrial septum, and the axons situated in the septal region. The sparse network in the right atrium did not change after vagotomy of right or left side. In the whole mount preparations of right atrium, we often traced labeled axons from the somata to join the network covering the right atrium. Therefore, most of this network of labeled fibers must be of intrinsic origin. Because the basket-like endings around neuronal cell bodies in the ganglia in the left atrium and the septum disappeared completely after vagotomy of left side, we conclude that they are parasympathetic preganglionic fibers originating from the left vagus nerve. NOS-ir cell bodies and the positive fibers in the atrioventricular nodal region survived after vagotomy. All of such nerve fibers were unmyelinated axons. Therefore, they seem to be the postganglionic fibers arising from the ganglia located in the left atrium or the septum.

Cardiac sympathetic activity in the asymmetrically hypertrophied septum in patients with hypertension or hypertrophic cardiomyopathy.

BACKGROUND: In patients with essential hypertension (HT), proportional (symmetric) left ventricular hypertrophy (LVH) is common. In contrast, hypertrophic cardiomyopathy (HCM) is characterized by disproportional LVH and, in particular, asymmetric septal hypertrophy (ASH); however, some hypertensive patients also develop ASH. It has not been determined whether such cases represent a distinct type of hypertensive LVH or HCM combined with hypertension. HYPOTHESIS: The study was undertaken to evaluate sympathetic activity in the interventricular septum in patients with HT and ASH or in patients with HCM. METHODS: The patients were evaluated by I-123 meta-iodobenzylguanidine (MIBG) and thallium-201 (201Tl) single-photon emission computed tomography (SPECT), respectively. They were divided into three groups: patients with essential HT and symmetric septal hypertrophy (Group A), patients with HT and ASH (Group B), and patients with HCM and ASH (Group C). RESULTS: Compared with the lateral wall, early uptake of MIBG in the septum was significantly higher in Group B than in Group A, but not significantly different between Groups A and C. Compared with the lateral wall, early uptake of 201Tl in the septum did not differ among the three groups. No significant difference in the MIBG clearance in the lateral wall was seen among the three groups. By contrast, MIBG clearances in the septum and apex were significantly greater in Group C than in Groups A and B. There was an inverse correlation between systolic thickening and MIBG clearance in the septum. CONCLUSION: These findings suggest that sympathetic activity in the septum differs between patients with HT and ASH and patients with HCM.

Cardiac afferents to the nucleus of the tractus solitarius: A WGA-HRP study in the rat.

Central distribution of the sensory fibers of the heart was investigated in the rat by the use of transganglionic transport of horseradish peroxidase (HRP). After the left intercostal thoracotomy was done under deep anesthesia and artificial respiration, wheat germ agglutinin-conjugated HRP (WGA-HRP) was injected into the left and right ventricular walls and the apex of the heart. HRP-labeled fibers were observed to be distributed to the dorsomedial portion of the medulla oblongata through the vagal nerve. The labeled fibers were present in various subnuclei of the nucleus of the tractus solitarius (NTS) bilaterally at the level of +0.36 to -1.74 mm to the obex. However, the most conspicuous feature in the present study was that the labeled fibers were exclusively confined to the medial, ventrolateral and commissural NTS with some distribution to the dorsolateral NTS. Although the labeling in the medial and ventrolateral NTS was observed to extend rostrocaudally, it was of interest that the labeling in the medial NTS was divided into the ventral and dorsal parts at the level around the obex. Accumulation of the labeled fibers in the commissural NTS was found at the level caudal to the obex and these fibers were traced to the caudal portion of its subnucleus with a gradual decrease in number. This pattern of distribution of cardiac afferents in the NTS was considered to be peculiar to the rat, because it was quite different from that reported previously in the cat.

Regional cardiac sympathetic denervation and systolic compression of a septal perforator branch in a sudden death survivor with hypertrophic cardiomyopathy.

Hypertrophic cardiomyopathy is a heterogeneous primary cardiac disease with a broad clinical spectrum, including a high risk for sudden death in a certain subgroup of patients. However, the precise criteria for identifying the subgroup at high risk have not been established. The authors describe a 41-year-old man with hypertrophic cardiomyopathy who was examined after an episode of aborted sudden death. Extensive invasive and noninvasive investigations did not reveal a cardiac abnormality other than severe sympathetic denervation in the midbasal septal wall on iodine-123 MIBG SPECT imaging and concentric left ventricular hypertrophy on echocardiography. A retrospective review of the cardiac catheterization findings, however, revealed systolic compression of a septal perforator artery. The aborted sudden death of the patient was most likely associated with systolic compression of a septal branch or sympathetic denervation, which may have precipitated a ventricular arrhythmia in this patient.

[Cardioinhibitory vagal response not related to pain, and induced by radiofrequency application during ablation of right posteroseptal accessory pathway]. / Respuesta vagal cardioinhibidora, no mediada por dolor, secundaria a la aplicación de radiofrecuencia durante la ablación de una vía accesoria posteroseptal derecha.

Inappropriate sinus tachycardia is the most common arrhythmia induced by radiofrequency energy delivery in the posteroseptal area. It has been suggested that this could be secondary to parasymphathetic nerve injury. We report a patient with extreme sinus bradycardia and PR interval prolongation induced by radiofrequency energy delivered in the coronary sinus ostium area, but not related to any other stimulus. The most probable mechanism of the disorder was transient stimulation of the vagal afferent nerve fibers located in this anatomical area.

[A study of autonomic innervation of the atrial septum by iso-integral mapping in dogs]. / Etude de l'innervation autonomique du septum inter-auriculaire par cartographie iso-intégrale chez le chien.

Although neuronal cell bodies have been identified in the upper part of the atrial septum, the functional anatomy of its autonomic innervation remains unknown. To study parasympathetic inputs to the atrial septum, we performed isointegral distribution mapping using a 64-electrode balloon array inserted in the right atrium under cardiopulmonary bypass in 9 anesthetized mongrel dogs. Unipolar electrograms were recorded during stimulation of either the right or left vagus nerve or right atrialpulmonary vein ganglionated plexus before and after surgical ablation of tissues along the superior vena cava, of the right atrial-pulmonary vein ganglionated plexus, the aorto-pulmonary tissues and the inferior vena cava fat pad. Local neural effects were estimated from integral changes of each electrogram which were plotted on a septal grid to generate isointegral distribution maps. Changes were considered significant whenever integral differences exceeded twice the standard deviation of control values. Stimulation of the right and left vagi induced significant effects in the high atrial septum in 5 preparations and in the low septum in 6. These effects were suppressed by the dissection of tissues around the superior vena cava and ablation of the right atrial-pulmonary vein ganglionated plexus, but not by that of the inferior vena cava or the aorto-pulmonary tissues. Direct stimulation of the right atrial-pulmonary vein ganglionated plexus produced effects in the high and low septum in 8 and 4 preparations, respectively, which persisted after dissection around the superior vena cava, suggesting the existence of local circuit neural elements. We conclude that the canine atrial septum is innervated by axons from both vagi which course near the superior vena cava and converge through the right atrial-pulmonary vein ganglionated plexus and also by intrinsic neural elements independent of central parasympathetic efferents.

Wolff-Parkinson-White syndrome.

This article discusses a patient with Wolff-Parkinson-White syndrome who recently underwent surgical ablation of her accessory pathway at West Virginia University Health Sciences Center. Surgical cure of this arrhythmia is possible in a high percentage of cases and should be strongly considered for those with life-threatening arrhythmias or poorly controlled symptoms.