左房内环肺静脉口线性消融治疗阵发性心房颤动对窦性心率震荡及心率变异性影响的研究
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摘要
第一部分左房内环肺静脉口外线性消融术治疗阵发性心房颤动的去迷走效应研究
目的通过观察左房内环肺静脉口外线性消融术对窦性心率震荡的影响，间接反映消融术治疗心房颤动时心脏迷走神经活动即刻的改变。
方法2006年3月至2006年12月间至南京医科大学第一附属医院心脏科行射频消融术的阵发性心房颤动患者44名(男性26例，女性18例)，年龄24～76(53±13)岁，左房直径27～50(36±5)cm，射血分数0.49～0.71(0.65±0.04)。消融前及消融后即刻呈稳定的窦性心律，无任何异常搏动，此时于右室心尖部引入RS2期前刺激，偶联间期为刺激当时窦性周期的60％，输出电压为2倍舒张期阈值，并以5次早搏平均为基础测量术前术后震荡初始(TO)及震荡斜率(TS)。
结果射频消融前后HRT有明显变化，其中TO为-0.0216±0.0236VS0.0009±0.0133(P值＜0.01)；TS 7.3318±6.9835VS2.0553±2.1724(P值＜0.01)，为差异有统计学意义。
结论HRT的变化趋势表明环肺静脉左房线性消融术中发生去迷走效应是普遍的现象，而并非一定表现为生命体征的改变。这种变化本身也提示射频能量引起迷走反射主要为损伤或者刺激了迷走传入支而非传出支。
第二部分左房线性消融治疗阵发性心房颤动对心率变异性的影响
目的通过观察左心房线性消融术治疗阵发性心房颤动术后心率变异性的变化来评价其对自主神经系统的影响。
方法2006年1月至2006年6月于南京医科大学第一附属医院心脏科行射频消融术的阵发性心房颤动患者25名，年龄28-66(51±12)岁，术前及术后三天行24小时动态心电图检查，分别测定最大心率MaxHR，最小心率MinHR，平均心率MeanHR，时域指标NN间期标准差(SDNN)，NN间期平均值的标准差(SDANN)，相邻NN间期差的均方根(RMMSD)，相邻NN间期差值超过50ms的NN间期所占百分数(PNN50)，频域指标低频功率(LF)，高频功率(HF)，低频高频比值(LF／HF)。
结果患者术前MaxHe，MinHR，MeanHR，SDNN，SDANN，RMSSD，PNN50，LF，HF，LF／HF分别为154±40，47±5，69±9，125±26，110±25，27±7，6±5，94±67，110±45，0.9±0.7。术后各指标分别为129±37，66±8，84±9，59±17，53±17，15±7，2±3，17±19，11±10，2.0±2.2。差异有统计学意义。
结论左心房线性消融术造成了心率变异性的明显变化，反映了其对交感和迷走两系统都有损伤作用。而对两神经系统的损伤可能是射频消融治疗心房颤动的机制之一。
Part one Alterations of Heart rate turbulence: immediate vagal reflex during left atrium circumferential pulmonary vein ablation
Purpose To observe the alteration of Heart rate turbulence(HRT) before and after left atrium circumferential ablation surrounding pulmonary veins(LACA) in patients with paroxysmal atrial fibrillation(PAF) to indicate whether concealed vagal denervation happened during the procedure.
Methods Forty four(26 male, aged 53±11 years) patients with paroxysmal atrial fibrillation were included in the study referred for catheter ablation treatment from Mar 2006 to Dec 2006. The left atrium circumferential ablation surrounding pulmonary veins were done in every patients to achieve complete electrical isolation of both ipsilateral pulmonary veins. RS2 extrastimulus were delivered from right ventricular apex to obtain heart rate turbulence with 60％of basic sinus cycle length and at twice diastolic threshold before and after the procedure. Turbulence onset[To(％)] and Turbulence slope[TS(msec/beat)] were obtained averagely from five respective ventricular premature beats.
Results TO and TS significantly changed after LACA[-0.0216±0.0236 to 0.0009±0.0133(P＜0.001)]and [7.3318±6.9835VS2.0553±2.1724 respectively (P＜0.001)].
Conclusion Though vagal reflex with significant bradycardia and hypotension might happen during LACA procedure, HRT alteration, which indicates the concealed vagal denervation, is more common. This might contribute to the long term success of LACA treatment of PAF to some extent. Alteration itself also illustrates that the ablation damages or stimulates not the efferent but the afferent limb of the vagal reflex.
Part two The effect of left atrium linear lesion encircling Pulmonary veins on the heart rate variability
Purpose To evaluate the effect of left atrium linear lesion encircling pulmonary veins on the autonomic nervous system via the alternations of the heart rate variability.
Methods Twenty five patients with paroxysmal atrial fibrillation were referred for catheter ablation treatment from Jan 2006 to Jun 2006. The left atrium linear lesion encircling pulmonary veins were done in every patients to achieve the disappearance of the pulmonary vein potentials. The maximal heart rate, minimal heart rate, mean heart rate, time domain and frequency domain analyses of HRV were obtained by use of 24-hour ambulatory electrocardiogram before and 3 days after the procedure.
Results The parameters of MaxHR, MinHR, MeanHR, SDNN, SDANN, RMSSD, PNNS0, LF, HF, LF/HF were151, 47, 70, 126, 111, 27, 6, 98, 86, 2.4 before theprocedure, and 136, 66, 84, 57, 53, 16, 2, 18, 16, 1.2 after the ablation(P＜0.05).
Conclusion The left atrium linear lesion encircling pulmonary veins significantly altered the heart rate variability which demonstrated the damage to the cardiac nervous system and this "neurogenic substrate modification" might be one of the mechanism of catheter ablation of atrial fibrillation.
目的通过观察左房内环肺静脉口外线性消融术对窦性心率震荡的影响，间接反映消融术治疗心房颤动时心脏迷走神经活动即刻的改变。
方法2006年3月至2006年12月间至南京医科大学第一附属医院心脏科行射频消融术的阵发性心房颤动患者44名(男性26例，女性18例)，年龄24～76(53±13)岁，左房直径27～50(36±5)cm，射血分数0.49～0.71(0.65±0.04)。消融前及消融后即刻呈稳定的窦性心律，无任何异常搏动，此时于右室心尖部引入RS2期前刺激，偶联间期为刺激当时窦性周期的60％，输出电压为2倍舒张期阈值，并以5次早搏平均为基础测量术前术后震荡初始(TO)及震荡斜率(TS)。
结果射频消融前后HRT有明显变化，其中TO为-0.0216±0.0236VS0.0009±0.0133(P值＜0.01)；TS 7.3318±6.9835VS2.0553±2.1724(P值＜0.01)，为差异有统计学意义。
结论HRT的变化趋势表明环肺静脉左房线性消融术中发生去迷走效应是普遍的现象，而并非一定表现为生命体征的改变。这种变化本身也提示射频能量引起迷走反射主要为损伤或者刺激了迷走传入支而非传出支。
第二部分左房线性消融治疗阵发性心房颤动对心率变异性的影响
目的通过观察左心房线性消融术治疗阵发性心房颤动术后心率变异性的变化来评价其对自主神经系统的影响。
方法2006年1月至2006年6月于南京医科大学第一附属医院心脏科行射频消融术的阵发性心房颤动患者25名，年龄28-66(51±12)岁，术前及术后三天行24小时动态心电图检查，分别测定最大心率MaxHR，最小心率MinHR，平均心率MeanHR，时域指标NN间期标准差(SDNN)，NN间期平均值的标准差(SDANN)，相邻NN间期差的均方根(RMMSD)，相邻NN间期差值超过50ms的NN间期所占百分数(PNN50)，频域指标低频功率(LF)，高频功率(HF)，低频高频比值(LF／HF)。
结果患者术前MaxHe，MinHR，MeanHR，SDNN，SDANN，RMSSD，PNN50，LF，HF，LF／HF分别为154±40，47±5，69±9，125±26，110±25，27±7，6±5，94±67，110±45，0.9±0.7。术后各指标分别为129±37，66±8，84±9，59±17，53±17，15±7，2±3，17±19，11±10，2.0±2.2。差异有统计学意义。
结论左心房线性消融术造成了心率变异性的明显变化，反映了其对交感和迷走两系统都有损伤作用。而对两神经系统的损伤可能是射频消融治疗心房颤动的机制之一。
Part one Alterations of Heart rate turbulence: immediate vagal reflex during left atrium circumferential pulmonary vein ablation
Purpose To observe the alteration of Heart rate turbulence(HRT) before and after left atrium circumferential ablation surrounding pulmonary veins(LACA) in patients with paroxysmal atrial fibrillation(PAF) to indicate whether concealed vagal denervation happened during the procedure.
Methods Forty four(26 male, aged 53±11 years) patients with paroxysmal atrial fibrillation were included in the study referred for catheter ablation treatment from Mar 2006 to Dec 2006. The left atrium circumferential ablation surrounding pulmonary veins were done in every patients to achieve complete electrical isolation of both ipsilateral pulmonary veins. RS2 extrastimulus were delivered from right ventricular apex to obtain heart rate turbulence with 60％of basic sinus cycle length and at twice diastolic threshold before and after the procedure. Turbulence onset[To(％)] and Turbulence slope[TS(msec/beat)] were obtained averagely from five respective ventricular premature beats.
Results TO and TS significantly changed after LACA[-0.0216±0.0236 to 0.0009±0.0133(P＜0.001)]and [7.3318±6.9835VS2.0553±2.1724 respectively (P＜0.001)].
Conclusion Though vagal reflex with significant bradycardia and hypotension might happen during LACA procedure, HRT alteration, which indicates the concealed vagal denervation, is more common. This might contribute to the long term success of LACA treatment of PAF to some extent. Alteration itself also illustrates that the ablation damages or stimulates not the efferent but the afferent limb of the vagal reflex.
Part two The effect of left atrium linear lesion encircling Pulmonary veins on the heart rate variability
Purpose To evaluate the effect of left atrium linear lesion encircling pulmonary veins on the autonomic nervous system via the alternations of the heart rate variability.
Methods Twenty five patients with paroxysmal atrial fibrillation were referred for catheter ablation treatment from Jan 2006 to Jun 2006. The left atrium linear lesion encircling pulmonary veins were done in every patients to achieve the disappearance of the pulmonary vein potentials. The maximal heart rate, minimal heart rate, mean heart rate, time domain and frequency domain analyses of HRV were obtained by use of 24-hour ambulatory electrocardiogram before and 3 days after the procedure.
Results The parameters of MaxHR, MinHR, MeanHR, SDNN, SDANN, RMSSD, PNNS0, LF, HF, LF/HF were151, 47, 70, 126, 111, 27, 6, 98, 86, 2.4 before theprocedure, and 136, 66, 84, 57, 53, 16, 2, 18, 16, 1.2 after the ablation(P＜0.05).
Conclusion The left atrium linear lesion encircling pulmonary veins significantly altered the heart rate variability which demonstrated the damage to the cardiac nervous system and this "neurogenic substrate modification" might be one of the mechanism of catheter ablation of atrial fibrillation.
引文
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14. Raj SR, Sheldon RS, Koshman M. Role of hypotension in heart rate turbulence physiology. Heart Rhythm. 2005 Aug;2(8):820-827.
15. Marine JE, Watanabe MA, Smith TW, Monahan KMEffect of atropine on heart rate turbulenceAm J Cardiol. 2002 Mar 15;89(6):767-769.
16. Guettler N, Vukajlovic D, Berkowitsch A. Effect of vagus blockade with atropine on heart rate turbulence. Pacing Clin Electrophysiol 2001;24(Pt II):625.
17. Lin LY, Lai LP, Lin JL, Du CC, Shau WY, Chan HL, Tseng YZ, Huang SK. Tight mechanism correlation between heart rate turbulence and baroreflex sensitivity: sequential autonomic blockade analysis. J Cardiovasc Electrophysiol. 2002 May;13(5):427-407.
18. Levy MN, Warner MR. Parasympathetic effects on cardiac function.In: Armour JA, Ardell JL, Neurocardiology. New York: Oxford University Press, 1994:53.
19. Lawler HC. Turnover time of acetylcholine esterase. J Biol Chem 1961;236:2296-2301.
20. Borst C, Wieling W. Baroreceptor functions: the paradoxical contribution of arterial baroreceptors to the temporary blood pressure drop upon standing. In: Adrenergic Blood Pressure Regulation: Proceedings of a Symposium. Amsterdam: Excerpta Medica, 1985:40.
21. Lin LY, Hwang JJ, Lai LP. Restoration of heart rate turbulence by titrated beta-blocker therapy in patients with advanced congestive heart failure: positive correlation with enhanced vagal modulation of heart rate. J Cardiovasc Electrophysiol. 2004 Jul;15(7):752-756.
22. Yang A, Schafer H, Manka R. Influence of obstructive sleep apnea on heart rate turbulence. Basic Res Cardiol. 2005 Sep;100(5):439-45. Epub 2005 Jun 10.
23. Lombardi F. Clinical implications of present physiological understanding of HRV components. Card Electrophysiol Rev 2002;6:245-249.
24. Folino AF, Buja G, Bauce B, et al. Heart rate variability in arrhythmogenic right ventricular cardiomyopathy correlation with clinical and prognostic features. PACE 2002;25:1285-1292.
25. Ghuran A, Reid F, La Rovere MT. Heart rate turbulence-based predictors of fatal and nonfatal cardiac arrest (The Autonomic Tone and Reflexes After Myocardial Infarction substudy). Am J Cardiol. 2002 Jan 15;89(2):184-190.
26. Sestito A, Valsecchi S, Infusino F. Differences in heart rate turbulence between patients with coronary artery disease and patients with ventricular arrhythmias but structurally normal hearts. Am J Cardiol. 2004 May 1;93(9):1114-1118.
27. Iwasa A, Hwa M, Hassankhani A, Liu T, Narayan SM. Abnormal heart rate turbulence predicts the initiation of ventricular arrhythmias Pacing Clin Electrophysiol. 2005 Nov;28(11):1189-1197.
28. Grimm W, Schmidt G, Maisch B. Prognostic significance of heart rate turbulence following ventricular premature beats in patients with idiopathic dilated cardiomyopathy. J Cardiovasc Electrophysiol. 2003 Aug;14(8):819-824.
29. Makarov LM, Komoliatova VN, Gorlitskaia OV.Heart rate turbulence in patients with ventricular tachy arrhythmias of noncoronary genesis Kardiologiia. 2005;45(4):21-26.
30. Tai CT, Chiou CW, Wen ZC, et al. Effect of phenylephrine on focal atrial fibrillation originating in the pulmonary veins and superior vena cava. J Am Coll Cardiol 2000; 36:788-793.
31. Liu L, Nattel S. Differing sympathetic and vagal effects on atrial fibrillation in dogs: Role of refractoriness heterogeneity. Am J Physiol 1997; 273:H805-816.
32. Page RL, Wharton JM, Prystowsky EN. Effect of continuous vagal enhancement on concealed conduction and refractoriness within the atrioventricular node. Am J Cardiol 1996; 77:260-265.
33. Takei M, Tsuboi M, Usui T, et al. Vagal stimulation prior to atrial rapid pacing protects the atrium from electrical remodeling in anesthetized dogs. Jpn Circ J 2001; 65:1077-1081.
34. Jayachandran JV, Sih HJ, Winkle W, et al. Atrial fibrillation produced by prolonged rapid atrial pacing is associated with heterogeneous changes in atrial sympathetic innervation. Circulation 2000; 101:1185-1191.
35. Chang CM, Wu TJ, Zhou S, et al. Nerve sprouting and sympathetic hyperinnervation in a canine model of atrial fibrillation produced by prolonged right atrial pacing. Circulation 2001; 103:22-25.
36. Hsieh MH, Chiou CW, Wen ZC.Alterations of heart rate variability after radiofrequency catheter ablation of focal atrial fibrillation originating from pulmonary veins. Circulation 1999;100:2237-2243.
37. Pappone C, Santinelli V, Manguso F, et al. Pulmonary vein denervation enhances long-term benefit after circumferential ablation for paroxysmal atrial fibrillation. Circulation 2004; 109:327-334.
38. Vikman S, Lindgren K, Makikallio TH, Yli-Mayry S, Heart rate turbulence after atrial premature beats before spontaneous onset of atrial fibrillation. J Am Coll Cardiol. 2005 Jan 18;45(2):278-284.
39. Lown B, Verrier RL. Neural activity and ventricular fibrillation. N Engl J Med 1976; 294:1165-1170.
40. Levy MN, Blattberg B. Effect of vagal stimulation on the overflow of norepinephrine into the coronary sinus during cardiac sympathetic nerve stimulation in the dog. Circ Res 1976;38:81-84.
41. Lampert R, Joska T, Burg MM, et al. Emotional and physical precipitants of ventricular arrhythmia. Circulation 2002; 106:1800-1805.
42. Fries R, Konig J, Schafers HJ, et al. Triggering effect of physical and mental stress on spontaneous ventricular tachyarrhythmias in patients with implantable cardioverter-defibrillators. Clin Cardiol 2002;25:474-478.
43. Kovach JA, Nearing BD, Verrier RL. Angerlike behavioral state potentiates myocardial ischemia induced T-wave alternans in canines. J Am Coll Cardiol 2001;37:1719-1725.
44. Kop WJ, Nearing BD, Krantz DS. Increased T-wave alternans with mental stress and exercise in implantable cardioverter defibrillator patients. Circulation 1999;100:I-581.
45. Mittleman MA, Maclure M, Sherwood JB, et al. Triggering of acute myocardial infarction onset by episodes of anger. Determinants of Myocardial Infarction Onset Study Investigators. Circulation 1995;92: 1720-1725.
46. Chen PS, Chen LS, Cao JM, et al. Sympathetic nerve sprouting, electrical remodeling and the mechanisms of sudden cardiac death. Cardiovasc Res 2001;50:409-416.
47. Miyazaki T, Mitamura H, Miyoshi S, et al. Autonomic and antiarrhythmic drug modulation of ST segment elevation in patients with Brugada syndrome. J Am Coll Cardiol 1996;27:1061-1070
48. Liu YB, Wu CC, Lu LS, et al. Sympathetic nerve sprouting, electrical remodeling, and increased vulnerability to ventricular fibrillation in hypercholesterolemic rabbits. Circ Res 2003;92:1145-1152.
49. Antzelevitch C, Dumaine R. Electrical heterogeneity in the heart: Physiological, pharmacological and clinical implications. In: Page E, Fozzard HA, Solaro RJ, editors. Handbook of Physiology. The Heart. New York: Oxford University Press, 2002:654-692.
50. Avolio A, O'Rourke M. Effects of ventricular premature stimulus coupling interval on blood pressure and heart rate turbulence.Circulation. 2003 Feb 11;107(5):E38-8;
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8. Liu L, Nattel S. Differing sympathetic and vagal effects on atrial fibrillation in dogs: Role of refractoriness heterogeneity. Am J Physiol 1997; 273:H805-816.
9. Page RL, Wharton JM, Prystowsky EN. Effect of continuous vagal enhancement on concealed conduction and refractoriness within the atrioventricular node. Am J Cardiol 1996; 77:260-265.
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12. Takei M, Tsuboi M, Usui T, et al. Vagal stimulation prior to atrial rapid pacing protects the atrium from electrical remodeling in anesthetized dogs. JpnCirc J 2001; 65:1077-1081.
13. Jayachandran JV, Sih HJ, Winkle W, et al. Atrial fibrillation produced by prolonged rapid atrial pacing is associated with heterogeneous changes in atrial sympathetic innervation. Circulation 2000; 101:1185-1191.
14. Chang CM, Wu TJ, Zhou S, et al. Nerve sprouting and sympathetic hyperinnervation in a canine model of atrial fibrillation produced by prolonged right atrial pacing. Circulation 2001; 103:22-25.
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21. Sestito A, Valsecchi S, Infusino F, Sgueglia GA, Bellocci F, Zecchi P, Crea F, Lanza GA. Differences in heart rate turbulence between patients with coronary artery disease and patients with ventricular arrhythmias but structurally normal hearts. Am J Cardiol. 2004 May 1;93(9):1114-1118.
22. Iwasa A, Hwa M, Hassankhani A, Liu T, Narayan SM. Abnormal heart rate turbulence predicts the initiation of ventricular arrhythmias Pacing Clin Electrophysiol. 2005 Nov;28(11): 1189-97. 13
23. Heart rate turbulence in patients with ventricular tachy arrhythmias of noncoronary genesis Kardiologiia. 2005;45(4): 21-26.
24. Vikman S, Lindgren K, Makikallio TH, Yli-Mayry S, Airaksinen KE, Huikuri HV. Heart rate turbulence after atrial premature beats before spontaneous onset of atrial fibrillation. J Am Coll Cardiol. 2005 Jan 18;45(2):278-284.
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5. Pappone C, Santinelli V, Manguso F, et al. Pulmonary vein denervation enhances long-term benefit after circumferential ablation for paroxysmal atrial fibrillation. Circulation 2004; 109:327-334.
6．陈明龙，邹建刚，徐东杰，等。EnSite-NavX和双LASSO指导下的左心房线性消融治疗阵发性心房颤动[J]．中华心血管病杂志，2005，33：971-974．
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8. Schmidt G, Malik M, Barthel P, et al .Heart-rate turbulence after ventricular premature beats as a predictor of mortality after acute myocardial infarction. Lancet. 1999 Apr 24;353(9162):1390-1396.
9. Marine JE, Watanabe MA, Smith TW, et al .Effect of atropine on heart rate turbulenceAm J Cardiol. 2002 Mar 15;89(6):767-769.
10. Guettler N, Vukajlovic D, Berkowitsch A. Effect of vagus blockade with atropine on heart rate turbulence. Pacing Clin Electrophysiol 2001;24(Pt II):625.
11. Lin LY, Lai LP, Lin JL. Tight mechanism correlation between heart rate turbulence and baroreflex sensitivity: sequential autonomic blockade analysis. J Cardiovasc Electrophysiol. 2002 May;13(5):427-407.
12. Watanabe MA, Marine JE, Robert S, Effects of Ventricular Premature Stimulus Coupling Interval on Blood Pressure and Heart Rate Turbulence Circulation. 2002; 106:325-330.
13. Vikman S, Lindgren K, Makikallio TH, et al . Heart rate turbulence after atrial premature beats before spontaneous onset of atrial fibrillation. J Am Coll Cardiol. 2005 Jan 18;45(2):278-284.
14. Hsieh MH, Chiou CW, Wen ZC, et al. Alterations of heart rate variability after radiofrequency catheter ablation of focal atrial fibrillation originating from pulmonary veins. Circulation. 1999 Nov 30;100(22):2237-2243.
15. Tan AY, Li H, Wachsmann-Hogiu S, et al. Autonomic innervation and segmental muscular disconnections at the human pulmonary vein-atrial junction: implications for catheter ablation of atrial-pulmonary vein junction. J Am Coll Cardiol 2006;48:132-143.
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1. Schmidt G, Malik M, Barthel P, Schneider R, Ulm K, Rolnitzky L, Camm AJ, Bigger JT Jr, Schomig AHeart-rate turbulence after ventricular premature beats as a predictor of mortality after acute myocardial infarction. Lancet. 1999 Apr 24;353(9162):1390-1396.
2. Schwab JO, Eichner G, Shlevkov N Impact of age and basic heart rate on heart rate turbulence in healthy persons. Pacing Clin Electrophysiol. 2005 Jan;28 Suppl 1:S198-201.
3. Schwab JO, Eichner G, Veit G, Influence of basic heart rate and sex on heart rate turbulence in healthy subjects. Pacing Clin Electrophysiol. 2004 Dec;27(12):1625-1631.
4. Cygankiewicz I, Wranicz JK, Bolinska H, Circadian changes in heart rate turbulence parameters. J Electrocardiol. 2004 Oct;37(4):297-303.
5. Lin LY, Hwang JJ, Lai LP , Restoration of heart rate turbulence by titrated beta-blocker therapy in patients with advanced congestive heart failure: positive correlation with enhanced vagal modulation of heart rate. J Cardiovasc Electrophysiol. 2004 Jul;15(7):752-756.
6. Avolio A, O'Rourke M. Effects of ventricular premature stimulus coupling interval on blood pressure and heart rate turbulence. Circulation. 2003 Feb 11;107(5):E38-8
7. Mari A Watanabe Heart Rate Turbulence: A Review Indian Pacing Electrophysiol J. 2003 January-March; 3(1): 10-22.
8. Mari A. Watanabe, MD, PhD; Joseph E. Marine, MD; Robert Sheldon, Effects of Ventricular Premature Stimulus Coupling Interval on Blood Pressure and Heart Rate Turbulence Circulation. 2002;106:325-330.
9. Wichterle D, Camm AJ, Malik M. Turbulence slope after atrial premature complexes is an independent predictor of mortality in survivors of acute myocardial infarction. J Cardiovasc Electrophysiol. 2004 Dec;15(12): 1350-1356.
10. Roach D, Koshman ML, Duff H. Induction of heart rate and blood pressure turbulence in the electrophysiologic laboratory. Am J Cardiol 2002;90:1098-1102.
11. Davies LC, Francis DP, Ponikowski P. Relation of heart rate and blood pressure turbulence following premature ventricular complexes to baroreflex sensitivity in chronic congestive heart failure. Am J Cardiol 2001;87:737-742.
12. Voss A, Baier V, Schumann A. Postextrasystolic regulation patterns of blood pressure and heart rate in patients with idiopathic dilated cardiomyopathy. J Physiol 2002;538:271-278.
13. Bauer A, Barthel P, Schneider R,et al. Impact of coupling interval on heart rate turbulence.Eur Heart J,2001 ;22(suppl):438.
14. Raj SR, Sheldon RS, Koshman M. Role of hypotension in heart rate turbulence physiology. Heart Rhythm. 2005 Aug;2(8):820-827.
15. Marine JE, Watanabe MA, Smith TW, Monahan KMEffect of atropine on heart rate turbulenceAm J Cardiol. 2002 Mar 15;89(6):767-769.
16. Guettler N, Vukajlovic D, Berkowitsch A. Effect of vagus blockade with atropine on heart rate turbulence. Pacing Clin Electrophysiol 2001;24(Pt II):625.
17. Lin LY, Lai LP, Lin JL, Du CC, Shau WY, Chan HL, Tseng YZ, Huang SK. Tight mechanism correlation between heart rate turbulence and baroreflex sensitivity: sequential autonomic blockade analysis. J Cardiovasc Electrophysiol. 2002 May;13(5):427-407.
18. Levy MN, Warner MR. Parasympathetic effects on cardiac function.In: Armour JA, Ardell JL, Neurocardiology. New York: Oxford University Press, 1994:53.
19. Lawler HC. Turnover time of acetylcholine esterase. J Biol Chem 1961;236:2296-2301.
20. Borst C, Wieling W. Baroreceptor functions: the paradoxical contribution of arterial baroreceptors to the temporary blood pressure drop upon standing. In: Adrenergic Blood Pressure Regulation: Proceedings of a Symposium. Amsterdam: Excerpta Medica, 1985:40.
21. Lin LY, Hwang JJ, Lai LP. Restoration of heart rate turbulence by titrated beta-blocker therapy in patients with advanced congestive heart failure: positive correlation with enhanced vagal modulation of heart rate. J Cardiovasc Electrophysiol. 2004 Jul;15(7):752-756.
22. Yang A, Schafer H, Manka R. Influence of obstructive sleep apnea on heart rate turbulence. Basic Res Cardiol. 2005 Sep;100(5):439-45. Epub 2005 Jun 10.
23. Lombardi F. Clinical implications of present physiological understanding of HRV components. Card Electrophysiol Rev 2002;6:245-249.
24. Folino AF, Buja G, Bauce B, et al. Heart rate variability in arrhythmogenic right ventricular cardiomyopathy correlation with clinical and prognostic features. PACE 2002;25:1285-1292.
25. Ghuran A, Reid F, La Rovere MT. Heart rate turbulence-based predictors of fatal and nonfatal cardiac arrest (The Autonomic Tone and Reflexes After Myocardial Infarction substudy). Am J Cardiol. 2002 Jan 15;89(2):184-190.
26. Sestito A, Valsecchi S, Infusino F. Differences in heart rate turbulence between patients with coronary artery disease and patients with ventricular arrhythmias but structurally normal hearts. Am J Cardiol. 2004 May 1;93(9):1114-1118.
27. Iwasa A, Hwa M, Hassankhani A, Liu T, Narayan SM. Abnormal heart rate turbulence predicts the initiation of ventricular arrhythmias Pacing Clin Electrophysiol. 2005 Nov;28(11):1189-1197.
28. Grimm W, Schmidt G, Maisch B. Prognostic significance of heart rate turbulence following ventricular premature beats in patients with idiopathic dilated cardiomyopathy. J Cardiovasc Electrophysiol. 2003 Aug;14(8):819-824.
29. Makarov LM, Komoliatova VN, Gorlitskaia OV.Heart rate turbulence in patients with ventricular tachy arrhythmias of noncoronary genesis Kardiologiia. 2005;45(4):21-26.
30. Tai CT, Chiou CW, Wen ZC, et al. Effect of phenylephrine on focal atrial fibrillation originating in the pulmonary veins and superior vena cava. J Am Coll Cardiol 2000; 36:788-793.
31. Liu L, Nattel S. Differing sympathetic and vagal effects on atrial fibrillation in dogs: Role of refractoriness heterogeneity. Am J Physiol 1997; 273:H805-816.
32. Page RL, Wharton JM, Prystowsky EN. Effect of continuous vagal enhancement on concealed conduction and refractoriness within the atrioventricular node. Am J Cardiol 1996; 77:260-265.
33. Takei M, Tsuboi M, Usui T, et al. Vagal stimulation prior to atrial rapid pacing protects the atrium from electrical remodeling in anesthetized dogs. Jpn Circ J 2001; 65:1077-1081.
34. Jayachandran JV, Sih HJ, Winkle W, et al. Atrial fibrillation produced by prolonged rapid atrial pacing is associated with heterogeneous changes in atrial sympathetic innervation. Circulation 2000; 101:1185-1191.
35. Chang CM, Wu TJ, Zhou S, et al. Nerve sprouting and sympathetic hyperinnervation in a canine model of atrial fibrillation produced by prolonged right atrial pacing. Circulation 2001; 103:22-25.
36. Hsieh MH, Chiou CW, Wen ZC.Alterations of heart rate variability after radiofrequency catheter ablation of focal atrial fibrillation originating from pulmonary veins. Circulation 1999;100:2237-2243.
37. Pappone C, Santinelli V, Manguso F, et al. Pulmonary vein denervation enhances long-term benefit after circumferential ablation for paroxysmal atrial fibrillation. Circulation 2004; 109:327-334.
38. Vikman S, Lindgren K, Makikallio TH, Yli-Mayry S, Heart rate turbulence after atrial premature beats before spontaneous onset of atrial fibrillation. J Am Coll Cardiol. 2005 Jan 18;45(2):278-284.
39. Lown B, Verrier RL. Neural activity and ventricular fibrillation. N Engl J Med 1976; 294:1165-1170.
40. Levy MN, Blattberg B. Effect of vagal stimulation on the overflow of norepinephrine into the coronary sinus during cardiac sympathetic nerve stimulation in the dog. Circ Res 1976;38:81-84.
41. Lampert R, Joska T, Burg MM, et al. Emotional and physical precipitants of ventricular arrhythmia. Circulation 2002; 106:1800-1805.
42. Fries R, Konig J, Schafers HJ, et al. Triggering effect of physical and mental stress on spontaneous ventricular tachyarrhythmias in patients with implantable cardioverter-defibrillators. Clin Cardiol 2002;25:474-478.
43. Kovach JA, Nearing BD, Verrier RL. Angerlike behavioral state potentiates myocardial ischemia induced T-wave alternans in canines. J Am Coll Cardiol 2001;37:1719-1725.
44. Kop WJ, Nearing BD, Krantz DS. Increased T-wave alternans with mental stress and exercise in implantable cardioverter defibrillator patients. Circulation 1999;100:I-581.
45. Mittleman MA, Maclure M, Sherwood JB, et al. Triggering of acute myocardial infarction onset by episodes of anger. Determinants of Myocardial Infarction Onset Study Investigators. Circulation 1995;92: 1720-1725.
46. Chen PS, Chen LS, Cao JM, et al. Sympathetic nerve sprouting, electrical remodeling and the mechanisms of sudden cardiac death. Cardiovasc Res 2001;50:409-416.
47. Miyazaki T, Mitamura H, Miyoshi S, et al. Autonomic and antiarrhythmic drug modulation of ST segment elevation in patients with Brugada syndrome. J Am Coll Cardiol 1996;27:1061-1070
48. Liu YB, Wu CC, Lu LS, et al. Sympathetic nerve sprouting, electrical remodeling, and increased vulnerability to ventricular fibrillation in hypercholesterolemic rabbits. Circ Res 2003;92:1145-1152.
49. Antzelevitch C, Dumaine R. Electrical heterogeneity in the heart: Physiological, pharmacological and clinical implications. In: Page E, Fozzard HA, Solaro RJ, editors. Handbook of Physiology. The Heart. New York: Oxford University Press, 2002:654-692.
50. Avolio A, O'Rourke M. Effects of ventricular premature stimulus coupling interval on blood pressure and heart rate turbulence.Circulation. 2003 Feb 11;107(5):E38-8;