Anatomic Approach for Ganglionic Plexi Ablation in Patients With Paroxysmal Atrial Fibrillation

doi:10.1016/j.amjcard.2008.03.062

The American Journal of Cardiology

Volume 102, Issue 3, 1 August 2008, Pages 330-334

https://doi.org/10.1016/j.amjcard.2008.03.062 Get rights and content

There is evidence that parasympathetic denervation may prevent atrial fibrillation (AF) recurrences. This study aimed at applying an anatomic approach for ablation of atrial ganglionic plexi (GPs) in patients with paroxysmal AF. Nineteen patients with symptomatic, paroxysmal AF underwent anatomically guided radiofrequency ablation at the location of the 4 main left atrial GPs and were prospectively assessed for recurrence of AF or other atrial arrhythmia. This group was compared with 19 age- and gender-matched patients who previously underwent conventional circumferential pulmonary vein ablation. All ablation procedures were uneventful. Circumferential and GP ablations were accomplished with a radiofrequency delivery time of 28 ± 5 versus 18 ± 3 min (p <0.001) and a fluoroscopy time of 31 ± 5 versus 18 ± 5 min (p <0.001), respectively. Parasympathetic reflexes during radiofrequency ablation were elicited in 4 patients (21%). Arrhythmia recurred in 7 patients (37%) with circumferential ablation and 14 patients (74%) with GP ablation, during 1-year follow-up (p for log-rank test = 0.017). In 2 patients with GP ablation, left atrial flutters were documented in addition to AF during follow-up. Patients who underwent GP ablation had an almost 2.5 times higher risk of AF recurrence compared with those who underwent circumferential ablation (hazard ratio 2.6, 95% confidence interval 1.0 to 6.6, p = 0.038). In conclusion, anatomically guided GP ablation is feasible and safe in the electrophysiology laboratory, but this approach yields inferior clinical results compared with circumferential ablation.

Section snippets

Methods

Patients with symptomatic, paroxysmal AF underwent anatomically guided radiofrequency ablation of the 4 main left atrial GPs and were prospectively assessed for recurrence of AF or other atrial arrhythmia. This group was compared with age and gender-matched patients who previously underwent conventional circumferential PV ablation. The trial was approved by our institutional review board, and all patients were fully aware of the experimental nature of the procedure and had provided written,

Results

Procedural characteristics by type of ablation technique are presented in Table 1, Table 2. Average radiofrequency energy delivery, fluoroscopy, and procedure times were longer in patients undergoing circumferential ablation compared with those who underwent GP ablation. No difference was observed in left atrial size between patients who underwent the 2 different techniques of ablation (40 ± 4 and 42 ± 5 mm for those who underwent circumferential and GP ablations, respectively, p = 0.270).

Discussion

Our results indicated that the described anatomic approach for attempted GP ablation is feasible and safe in the electrophysiology laboratory. However, this approach confers favorable clinical outcome over 1-year follow-up in <30% of patients. It is not known whether systematic search and identification of GPs by high-frequency stimulation might yield better clinical results. Our study also indicated that radiofrequency energy delivery is not an adequate way for the identification of GPs in the

References (27)

S. Oh et al.
Vagal denervation and atrial fibrillation inducibility: epicardial fat pad ablation does not have long-term effects
Heart Rhythm
(2006)
J.E. Cummings et al.
Preservation of the anterior fat pad paradoxically decreases the incidence of postoperative atrial fibrillation in humans
J Am Coll Cardiol
(2004)
H. Nakagawa et al.
Increased inducibility of macroreentrant left atrial tachycardia with addition of autonomic ganglionated plexi ablation to pulmonary vein antrum isolation
Heart Rhythm
(2006)
H. Nakagawa et al.
Localization of left atrial autonomic ganglionated plexuses using endocardial and epicardial high frequency stimulation in patients with atrial fibrillation
Heart Rhythm
(2005)
R. Lemery et al.
Feasibility study of endocardial mapping of ganglionated plexuses during catheter ablation of atrial fibrillation
Heart Rhythm
(2006)
J.R. Mehall et al.
Intraoperative epicardial electrophysiologic mapping and isolation of autonomic ganglionic plexi
Ann Thorac Surg
(2007)
A. Verma et al.
Vagal responses induced by endocardial left atrial autonomic ganglion stimulation before and after pulmonary vein antrum isolation for atrial fibrillation
Heart Rhythm
(2007)
K. Kumagai et al.
Electrophysiologic properties of pulmonary veins assessed using a multielectrode basket catheter
J Am Coll Cardiol
(2004)
H. Calkins et al.
HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-upA report of the Heart Rhythm Society (HRS) task force on catheter and surgical ablation of atrial fibrillation
Heart Rhythm
(2007)
L. Liu et al.
Differing sympathetic and vagal effects on atrial fibrillation in dogs: role of refractoriness heterogeneity
Am J Physiol
(1997)

B.J. Scherlag et al.

Electrical stimulation to identify neural elements on the heart: their role in atrial fibrillation

J Interv Card Electrophysiol

(2005)

M. Scanavacca et al.

Selective atrial vagal denervation guided by evoked vagal reflex to treat patients with paroxysmal atrial fibrillation

Circulation

(2006)

P. Schauerte et al.

Catheter ablation of cardiac autonomic nerves for prevention of vagal atrial fibrillation

Circulation

(2000)

Cited by (100)

Bradyarrhythmia in a marathonist: Cardiac vagal denervation as alternative treatment
2023, Revista Portuguesa de Cardiologia
Although not routinely used, cardioneuroablation or modulation of the cardiac autonomic nervous system has been proposed as an alternative approach to treat young individuals with enhanced vagal tone and significant atrioventricular (AV) disturbances.
We report the case of a 42-year-old athlete with prolonged ventricular pauses associated with sinus bradycardia and paroxysmal episodes of AV block (maximum of 6.6 s) due to enhanced vagal tone who was admitted to our hospital for pacemaker implantation. Cardiac magnetic resonance and stress test were normal. Although he was asymptomatic, safety concerns regarding possible neurological damage and sudden cardiac death were raised, and he accordingly underwent electrophysiological study (EPS) and cardiac autonomic denervation. Mapping and ablation were anatomically guided and radiofrequency pulses were delivered at empirical sites of ganglionated plexi. Modulation of the parasympathetic system was confirmed through changes in heart rate and AV nodal conduction properties associated with a negative cardiac response to atropine administration.
After a follow-up of nine months, follow-up 24-hour Holter revealed an increase in mean heart rate and no AV disturbances, with rare non-significant ventricular pauses, suggesting that this technique may become a safe and efficient procedure in this group of patients.
Ainda que raramente utilizada, a cardioneuroablação ou modulação do sistema nervoso autónomo cardíaco tem vindo a ser proposta como abordagem alternativa ao tratamento de indivíduos jovens com tónus vagal aumentado e, consequentemente, perturbações significativas da condução auriculoventricular (AV).
É apresentado um caso de um homem, atleta de 42 anos, referenciado para implantação de pacemaker por bradicardia sinusal e bloqueio auriculoventricular (BAV) de predomínio noturno por provável hipertonia vagal. As pausas noturnas por bradicardia sinusal associada a BAV atingiam os 6,6 segundos. Exames de imagem e prova de esforço foram normais. O doente foi submetido a estudo eletrofisiológico (EP) e desenervação autonómica cardíaca. O mapeamento e a ablação foram guiados anatomicamente, tendo sido aplicada energia por radiofrequência, de forma empírica, em locais da aurícula esquerda e direita onde previamente tinha sido descrita a existência de plexos ganglionares. A modulação do sistema parassimpático foi confirmada através da variação da frequência cardíaca e das propriedades de condução nodal AV no final do procedimento e ainda através de resposta cardíaca negativa à administração de atropina.
No seguimento de nove meses, o Holter de 24 horas evidenciou aumento da frequência cardíaca média e ausência de perturbações significativos da condução AV, sugerindo que essa técnica poderá vir a constituir uma alternativa à implantação de pacemaker neste subgrupo de doentes.
Percutaneous Neuromodulation for Atrial Fibrillation
2023, Cardiac Electrophysiology Clinics
Neuromodulation therapy for atrial fibrillation
2023, Heart Rhythm
Citation Excerpt :
The efficacy of GPA when performed alone is variable, which is partly influenced by ablation methods. In small observational studies, Lemery et al106 found that HFS-guided GPA alone led to 50% freedom from AF at 8 months (N = 14 patients), whereas Katritsis et al107 used anatomic-guided GPA with less promising results (GPA alone: 26% freedom from AF; PVI: 63%). However, in a larger study of 80 patients randomized to HFS- or anatomic-guided GPA, Pokushalov et al108 demonstrated that anatomic guidance was superior to HFS (77.5% freedom from AF vs 42.5%; P = .02).
Atrial fibrillation has a multifactorial pathophysiology influenced by cardiac autonomic innervation. Both sympathetic and parasympathetic influences are profibrillatory. Innovative therapies targeting the neurocardiac axis include catheter ablation or pharmacologic suppression of ganglionated plexi, renal sympathetic denervation, low-level vagal stimulation, and stellate ganglion blockade. To date, these therapies have variable efficacy. As our understanding of atrial fibrillation and the cardiac nervous system expands, our approach to therapeutic neuromodulation will continue evolving for the benefit of those with AF.
Autonomic Changes Are More Durable After Radiofrequency Than Pulsed Electric Field Pulmonary Vein Ablation
2022, JACC: Clinical Electrophysiology
Citation Excerpt :
Although some studies have shown a benefit of adding intrinsic ANS modulation to PVI,7,8 others have not.14,16 The ablation of GPs alone has never been superior to PVI.17-19 Nevertheless, if the thermal ablation of GPs has an adjuvant effect on suppression of AF, PEF ablation with the limited collateral damage of neural tissue may be theoretically handicapped in terms of efficacy compared to RF ablation.
Pulmonary vein isolation (PVI) by radiofrequency (RF) energy is associated with a collateral ganglionated plexi ablation. Pulsed electric field (PEF) is a nonthermal energy source that preferentially affects the myocardial cells and spares neural tissue.
This study investigated whether PVI by a PEF compared with RF energy will result in less prominent alteration of the cardiac autonomic nervous system.
A total of 31 patients with atrial fibrillation underwent PVI using a novel lattice-tip catheter and PEF energy (n = 18) or a conventional irrigated-tip catheter and RF energy (n = 13). The response of the sinoatrial node and atrioventricular node to extracardiac high-frequency, high-output, right vagal nerve stimulation was evaluated at baseline and during and at the end of the ablation procedure. Substantial reduction in responsiveness was arbitrarily defined as stimulation-inducible pause <1.5 seconds.
Reduced response of the sinoatrial node was documented in 13 of 13 (100%) and 6 of 18 (33%) patients (P = 0.0001) in RF and PEF groups, respectively. Reduced response of the atrioventricular node was found in 10 of 11 (93%) and 6 of 18 (33%) patients (P = 0.002) in RF and PEF groups, respectively. The major effects were observed predominantly during ablation around the right pulmonary veins. Early recovery of ganglionated plexi function was noticed only in the PEF ablation group. RF ablation resulted in higher acceleration of the sinus rhythm compared with PEF ablation (20 ± 13 beats/min vs 12 ± 10 beats/min; P = 0.04).
PEF compared with RF energy used for PVI induces significantly weaker and less durable suppression of cardiac autonomic regulations.
Anatomic guided ablation of the atrial right ganglionated plexi is enough for cardiac autonomic modulation in patients with significant bradyarrhythmias
2021, Indian Pacing and Electrophysiology Journal
Cardiac autonomic system modulation by endocardial ablation targeting atrial ganglionated plexi (GP) is an alternative strategy in selected patients with severe functional bradyarrhythmias, although no consensus exists on the best ablation strategy. The aim of this study was to evaluate if a simplified approach by a purely anatomical guided ablation of just the atrial right GP is enough for the treatment of these patients.
We prospectively enrolled patients with significant functional bradyarrhythmias and performed endocardial ablation purely guided by 3D electroanatomic mapping directed at the atrial right GP and accessed parameters of parasympathetic modulation and recurrence of bradyarrhythmias.
Thirteen patients enrolled (76.9% male, median age 51, 42–63 years). After ablation, a median RR interval shortening of 28.3 (25.6–40.3)% occurred (1111, 937.5–1395.4 ms to 722.9, 652.2–882.4 ms, p = 0.0002). The AH interval also shortened (19, 10.5–35.7%) significantly after the procedure (115, 105–122 ms to 85, 71–105 ms, p = 0.0023) as well as Wenckebach cycle length (11.1, 5.9–17.8% shortening) from 450, 440–510 ms to 430, 400–460 ms, p = 0.0127. On 24-h Holter monitoring there was significant increase in heart rates (HR) of patients after ablation (minimal HR increased from 34 (26–43)bpm to 49 (43–56)bpm, p = 0,0102 and mean HR from 65 (47–72)bpm to 78 (67–87)bpm, p = 0.0004). No patients had recurrence of symptoms or significant bradyarrhythmias during a median follow-up of 8.4 months.
A purely anatomic guided procedure directed only at the atrial right ganglionated plexi seems to be enough as a therapeutic approach for cardioneuroablation in selected patients with significant functional bradyarrhythmias.
Effect of ganglionated plexi ablation by high-density mapping on long-term suppression of paroxysmal atrial fibrillation – The first clinical survey on ablation of the dorsal right plexus
2021, Heart Rhythm O2
Long-term outcomes of suppressing paroxysmal atrial fibrillation (PAF) with additive ganglionated plexus (GP) ablation (GPA) remains unknown.
The aim of the study is to assess potential role of additional GPA for PAF suppression.
This study consisted of 225 patients; 68 (group A: 58 male, aged 60 ± 11 years) underwent pulmonary vein isolation (PVI) alone and 157 (group B: 137 male, aged 61 ± 11 years) GPA followed by PVI. GPA was performed based on the high-density mapping with high-frequency stimulation (HFS) delivered to left atrial (LA) major GP. The latter 85 group B patients (54%) underwent ablation to a posteromedial area within superior vena cava as a part of dorsal right atrial GP (SVC-Ao GP).
In group B, HFS was applied to 126 ± 32 sites, with a median of 47 GP sites (40.0%) being ablated. In patients undergoing an SVC-Ao GPA, HFS and the SVC-Ao GPA were applied at a median of 15 and 4 sites (29.4%), respectively. The PVI with a GPA provided higher PAF suppression than a PVI alone during more than 4 years of follow-up (56.7% vs 38.2%, odds ratio: 0.42, 95% confidence interval: 0.23–0.76, P < .05), but the SVC-Ao GPA did not provide further suppressive effects. Multivariate analyses revealed that tachycardia-bradycardia syndrome and non-PV foci were independent predictors of PAF recurrence after PVI with a GPA (P < .01).
GPA to LA major GP by high-density mapping provides long-term benefits for PAF suppression over 4 years of follow-up, but the effect of an empiric SVC-Ao GPA could not be appreciated, suggesting little effect on suppressing non-PV foci.

View all citing articles on Scopus

View full text

Arrhythmias and conduction disturbanceAnatomic Approach for Ganglionic Plexi Ablation in Patients With Paroxysmal Atrial Fibrillation

Section snippets

Methods

Results

Discussion

Heart Rhythm

J Am Coll Cardiol

Heart Rhythm

Heart Rhythm

Heart Rhythm

Ann Thorac Surg

Heart Rhythm

J Am Coll Cardiol

Heart Rhythm

Differing sympathetic and vagal effects on atrial fibrillation in dogs: role of refractoriness heterogeneity

Am J Physiol

Electrical stimulation to identify neural elements on the heart: their role in atrial fibrillation

J Interv Card Electrophysiol

Selective atrial vagal denervation guided by evoked vagal reflex to treat patients with paroxysmal atrial fibrillation

Circulation

Catheter ablation of cardiac autonomic nerves for prevention of vagal atrial fibrillation

Circulation

Arrhythmias and conduction disturbance
Anatomic Approach for Ganglionic Plexi Ablation in Patients With Paroxysmal Atrial Fibrillation