Cerebral hypoperfusion and altered neuro-cardiorespiratory coupling in atrial fibrillation

Atrial fibrillation (AF) is associated with an increased risk of neurological morbidity, yet its impact on cerebral perfusion and neuro-cardiorespiratory regulation remains incompletely understood. We used arterial spin labeling, blood oxygenation level-dependent functional MRI (BOLD-fMRI), and a breath-hold challenge to characterize alterations in 14 AF patients compared with 14 age-matched healthy controls. We also examined the changes after catheter ablation with pulmonary vein isolation (PVI) in a subset of patients. Compared with controls, AF patients exhibited widespread reductions in basal cerebral perfusion, including in brainstem regions involved in cardiorespiratory regulation, and a higher prevalence of periodic breathing during wakeful rest. During breath-hold challenge, the coupling between heart rate and BOLD signal changes (ΔBOLD) was smaller in AF, whereas ΔBOLD coupling with breath-by-breath O ₂ -CO ₂ exchange ratio was greater at rest within pontine respiratory centers, indicating altered cardiac and respiratory contributions to cerebral hemodynamic regulation. Follow-up MRI scans 1-6 months after PVI demonstrated that restoration of sinus rhythm was associated with stronger heart rate-ΔBOLD coupling during breath-hold challenge, whereas basal cerebral perfusion showed no significant change. This dissociation suggests distinct temporal responses of neuro-cardiorespiratory coupling and cerebral perfusion after sinus rhythm restoration, while the timing of cerebral perfusion recovery remains unresolved.