Recent insights into the role of the autonomic nervous system in the creation of substrate for atrial fibrillation implications for therapies targeting the atrial autonomic nervous system

The studies presented above indicate that autonomic influences contribute to the creation of AF substrate not only in normal hearts but also in the setting of structural heart disease. Current ablative and surgical methods are, therefore, attempting to anatomically target autonomic GPs in patients with AF to achieve autonomic denervation of the atria. Recent studies suggest that characteristic of AF electrograms (eg, CFAEs) may also define autonomic inputs in the fibrillating atria and may, therefore, be a suitable target for ablation. However, significant further investigation is necessary to optimize current ablation approaches to the atrial autonomic nervous system. Other new developments in our understanding of the role of the autonomic signaling in AF include radionuclide imaging studies in patients with AF; these studies indicate that 123-I-MIBG imaging may have prognostic value in patients with AF, including in the setting of AF ablation. Last, because of the varying efficacy of current ablation approaches targeting the autonomic innervation of the atria, we also describe recent biological (gene therapy) attempts to selectively disrupt parasympathetic signaling in the atria using novel G-protein inhibitory peptides; further studies are needed to fully investigate the potential of these new biological approaches to AF.