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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\u003Cp id=\u0022p-1\u0022\u003ESecondary analysis of a small pilot study has shown that botulinum toxin vs placebo reduces the burden of atrial fibrillation at 1 year after coronary artery bypass graft surgery. An improvement in heart rate variability also suggests that botulinum toxin injected into fat pads is a neuromodulator with effects on the autonomic nervous system.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Eatrial fibrillation\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eautonomic nervous system\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ebotulinum toxin\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ecoronary artery bypass graft surgery\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECABG\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eneuromodulator\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eimplantable loop recorder\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Earrhythmias\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ecardiology \u0026amp; cardiovascular medicine clinical trials\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\u003Cp id=\u0022p-2\u0022\u003EBotulinum toxin injected into the epicardial fat pads during coronary artery bypass graft (CABG) surgery significantly reduced the primary end point of atrial fibrillation (AF) events by 10% compared with placebo (\u003Cem\u003EP\u003C\/em\u003E\u2005=\u2005.024) at 30 days in a randomized pilot study [Pokushalov E et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E. 2014]. New results from a secondary analysis showed this benefit extended to 1 year, along with reduction in heart rate variability (HRV), according to Jonathan S. Steinberg, MD, The University of Rochester, Rochester, New York, and The Valley Health System, New York, New York, USA.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EThe prospective, double-blind study was conducted in 2 centers and randomized 30 patients to botulinum toxin (type A; 50 U\/1 mL per fat pad) and 30 patients to placebo (normal saline; 1 mL per fat pad). The patients were mostly men (about 80%) who were aged about 62 years and had a history of paroxysmal AF and indication for CABG using the American College of Cardiology\/American Heart Association guidelines. An implantable loop recorder was placed on the day of surgery in all patients to capture AF events and burden, and data were collected at 3, 6, 9, and 12 months. Holter recordings were used to obtain serial measurements of HRV to assess the effect of botulinum toxin on the autonomic nervous system, which plays a key role in the initiation and maintenance of AF. This toxin is known to interfere with neurotransmitter release.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EIn the secondary analysis, there was a marked and significant reduction in AF burden with botulinum toxin vs placebo at all assessments except 3 months (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E). All patients would be considered responders, stated Dr Steinberg, because they did not meet the conventional implantable loop recorder criteria for AF burden of \u0026gt;\u2005.5% per month. In the placebo group, 6 patients required additional drug therapy because of clinically frequent AF, and 2 patients required catheter ablation for persistent AF; there were none in the botulinum toxin group. No strokes or other serious clinical events occurred in either group.\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/12\/10\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022AF Burden With 1-Year Follow-upAF, atrial fibrillation.Reprinted with permission from JS Steinberg, MD.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1037445137\u0022 data-figure-caption=\u0022AF Burden With 1-Year Follow-upAF, atrial fibrillation.Reprinted with permission from JS Steinberg, MD.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/12\/10\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/12\/10\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/12\/10\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16699\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \u003Cp id=\u0022p-5\u0022 class=\u0022first-child\u0022\u003EAF Burden With 1-Year Follow-up\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EAF, atrial fibrillation.\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EReprinted with permission from JS Steinberg, MD.\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-8\u0022\u003EHRV, measured as standard deviation of the NN intervals, was reduced substantially in both groups at 1 month after surgery (\u003Cem\u003EP\u003C\/em\u003E\u2005\u0026lt;\u2005.05 vs baseline). With botulinum toxin, HRV was significantly lower at 3 months vs baseline (\u003Cem\u003EP\u003C\/em\u003E\u2005\u0026lt;\u2005.05) and then recovered to near-baseline levels, while HRV recovered to near-baseline levels at 3 months in the placebo group and was maintained. The frequency of HRV in the patients with low and with high frequency was reduced early after surgery with botulinum toxin and placebo, with a similar pattern of rebounding to baseline levels (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E).\u003C\/p\u003E\u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/12\/10\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Frequency of Heart Rate Variability*P\u0026#x2005;\u0026amp;lt;\u0026#x2005;.05 vs baseline; **P\u0026#x2005;\u0026amp;lt;\u0026#x2005;.05 between groups.Reprinted with permission from JS Steinberg, MD.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1037445137\u0022 data-figure-caption=\u0022\u0026amp;lt;div xmlns=\u0026amp;quot;http:\/\/www.w3.org\/1999\/xhtml\u0026amp;quot;\u0026amp;gt;Frequency of Heart Rate Variability*\u0026amp;lt;em\u0026amp;gt;P\u0026amp;lt;\/em\u0026amp;gt;\u0026#x2005;\u0026amp;amp;lt;\u0026#x2005;.05 vs baseline; **\u0026amp;lt;em\u0026amp;gt;P\u0026amp;lt;\/em\u0026amp;gt;\u0026#x2005;\u0026amp;amp;lt;\u0026#x2005;.05 between groups.Reprinted with permission from JS Steinberg, MD.\u0026amp;lt;\/div\u0026amp;gt;\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/12\/10\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/12\/10\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/12\/10\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16700\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \u003Cp id=\u0022p-9\u0022 class=\u0022first-child\u0022\u003EFrequency of Heart Rate Variability\u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003E*\u003Cem\u003EP\u003C\/em\u003E\u2005\u0026lt;\u2005.05 vs baseline; **\u003Cem\u003EP\u003C\/em\u003E\u2005\u0026lt;\u2005.05 between groups.\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003EReprinted with permission from JS Steinberg, MD.\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-12\u0022\u003EAccording to Dr Steinberg, the alterations in HRV with botulinum toxin suggest there were reductions in parasympathetic and sympathetic activity, but the changes dissipated between 3 and 6 months as expected. Among the limitations of this study are the small number of patients, the lack of data on AF burden prior to surgery, no objective testing to confirm the denervation effect, and no confirmation of functional atrial remodeling or its mechanisms. Although these data suggest botulinum toxin may be a neuromodulator, large-scale trials are required to evaluate its possible value to reduce postoperative AF and in other clinical settings.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2015 SAGE Publications\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/15\/12\/10.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzlj5d\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzlj5d\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}