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Gerstenfeld EP, Mansour M, Whang W, Venkateswaran R, Harding JD, Ellis CR, Ellenbogen KA, Osorio J, DeLurgio DB, Daccarett M, Mangrum M, McElderry T, Richards E, Albrecht EM, Schneider CW, Sutton BS, Reddy VY. Autonomic Effects of Pulsed Field vs Thermal Ablation for Treating Atrial Fibrillation: Subanalysis of ADVENT. JACC Clin Electrophysiol 2024; 10:1634-1644. [PMID: 38869507 DOI: 10.1016/j.jacep.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 05/06/2024] [Accepted: 05/07/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND Autonomic denervation is an ancillary phenomenon during thermal ablation of atrial fibrillation (AF), that may have synergistic effects on symptomatic improvement and long-term freedom from AF. Pulsed field ablation (PFA), a nonthermal ablation modality, was noninferior to thermal ablation in treating AF; however, PFA's relative myocardial selectivity may minimize autonomic effects. OBJECTIVES This study sought to compare heart rate (HR) and heart rate variability (HRV) metrics as markers of autonomic function after ablation using PFA vs thermal ablation. METHODS ADVENT (FARAPULSE ADVENT PIVOTAL Trial PFA System vs SOC Ablation for Paroxysmal Atrial Fibrillation) was a randomized pivotal study comparing PFA (pentaspline catheter) with thermal ablation (radiofrequency [RF] or cryoballoon [CB]) for treating paroxysmal AF. Baseline HR was acquired from a pre-ablation 12-lead electrocardiogram, whereas follow-up HRs, as well as HRV (standard deviation of all normal to normal RR intervals, standard deviation of 5-minute average RR intervals) metrics, were derived from 72-hour Holter monitors at 6 and 12 months. RESULTS This study included 379 paroxysmal AF patients undergoing PFA (n = 194) or thermal ablation (n = 185; n = 102 RF, n = 83 CB) completing 6- and 12-month Holter monitoring. Compared with PFA, thermal patients had significantly greater increases in HR from baseline to 6 months (ΔHR; 10.1 vs 5.9 beats/min; P = 0.02) and 12 months (ΔHR; 8.8 vs 5.2 beats/min; P = 0.03). This increase in HR at 6 and 12 months was similar between CB and RF (P = 0.94 and 0.83, respectively). HRV, both standard deviation of all normal to normal RR intervals and standard deviation of 5-minute average RR intervals, were significantly lower at both 6 and 12 months after thermal ablation compared with PFA (P < 0.01). CONCLUSIONS PFA's effect on the autonomic nervous system was attenuated compared with thermal ablation. Whether this affects long-term freedom from AF or symptomatic bradycardia/pauses after AF ablation requires further study.
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Affiliation(s)
| | - Moussa Mansour
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - William Whang
- Helmsley Electrophysiology Center, Mount Sinai Fuster Heart Hospital, New York, New York, USA
| | | | | | | | | | - Jose Osorio
- Grandview Medical Center, Birmingham, Alabama, USA
| | | | | | - Michael Mangrum
- University of Virginia Medical Center, Charlottesville, Virgina, USA
| | - Tom McElderry
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | | | | | | | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Mount Sinai Fuster Heart Hospital, New York, New York, USA
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Del Monte A, Della Rocca DG, Pannone L, Vetta G, Cespón Fernández M, Marcon L, Doundoulakis I, Mouram S, Audiat C, Zeriouh S, Monaco C, Al Housari M, Betancur A, Mené R, Iacopino S, Sorgente A, Bala G, Ströker E, Sieira J, Almorad A, Sarkozy A, Boveda S, de Asmundis C, Chierchia GB. Pulsed field ablation of the right superior pulmonary vein prevents vagal responses via anterior right ganglionated plexus modulation. Heart Rhythm 2024; 21:780-787. [PMID: 38290688 DOI: 10.1016/j.hrthm.2024.01.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 01/19/2024] [Accepted: 01/22/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND Pulsed field ablation (PFA) is selective for the myocardium. However, vagal responses and reversible effects on ganglionated plexi (GP) are observed during pulmonary vein isolation (PVI). Anterior-right GP ablation has been proven to effectively prevent vagal responses during radiofrequency-based PVI. OBJECTIVE The purpose of this study was to test the hypothesis that PFA-induced transient anterior-right GP modulation when targeting the right superior pulmonary vein (RSPV) before any other pulmonary veins (PVs) may effectively prevent intraprocedural vagal responses. METHODS Eighty consecutive paroxysmal atrial fibrillation patients undergoing PVI with PFA were prospectively included. In the first 40 patients, PVI was performed first targeting the left superior pulmonary vein (LSPV-first group). In the last 40 patients, RSPV was targeted first, followed by left PVs and right inferior PV (RSPV-first group). Heart rate (HR) and extracardiac vagal stimulation (ECVS) were evaluated at baseline, during PVI, and postablation to assess GP modulation. RESULTS Vagal responses occurred in 31 patients (78%) in the LSPV-first group and 5 (13%) in the RSPV-first group (P <.001). Temporary pacing was needed in 14 patients (35%) in the LSPV-first group and 3 (8%) in the RSPV-first group (P = .003). RSPV isolation was associated with similar acute HR increase in the 2 groups (13 ± 11 bpm vs 15 ± 12 bpm; P = .3). No significant residual changes in HR or ECVS response were documented in both groups at the end of the procedure compared to baseline (all P >.05). CONCLUSION PVI with PFA frequently induced vagal responses when initiated from the LSPV. Nevertheless, an RSPV-first approach promoted transient HR increase and reduced vagal response occurrence.
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Affiliation(s)
- Alvise Del Monte
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Domenico Giovanni Della Rocca
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Luigi Pannone
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Giampaolo Vetta
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - María Cespón Fernández
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Lorenzo Marcon
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Ioannis Doundoulakis
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Sahar Mouram
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Charles Audiat
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Sarah Zeriouh
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
| | - Cinzia Monaco
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Maysam Al Housari
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Andrés Betancur
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
| | - Roberto Mené
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
| | - Saverio Iacopino
- Electrophysiology Unit, GVM Care & Research, Maria Cecilia Hospital, Cotignola, Italy
| | - Antonio Sorgente
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Gezim Bala
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Erwin Ströker
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Juan Sieira
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Alexandre Almorad
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Andrea Sarkozy
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium.
| | - Gian-Battista Chierchia
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
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Musikantow DR, Neuzil P, Anic A, Balin P, Petru J, Funasako M, Lisica L, Jurisic Z, Jais P, Reddy VY. Long-Term Clinical Outcomes of Pulsed Field Ablation in the Treatment of Paroxysmal Atrial Fibrillation. JACC Clin Electrophysiol 2023; 9:2001-2003. [PMID: 37565951 DOI: 10.1016/j.jacep.2023.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 06/15/2023] [Accepted: 06/18/2023] [Indexed: 08/12/2023]
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O'Brien B, Reilly J, Coffey K, González-Suárez A, Quinlan L, van Zyl M. Cardioneuroablation Using Epicardial Pulsed Field Ablation for the Treatment of Atrial Fibrillation. J Cardiovasc Dev Dis 2023; 10:238. [PMID: 37367403 DOI: 10.3390/jcdd10060238] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/24/2023] [Accepted: 05/26/2023] [Indexed: 06/28/2023] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia affecting millions of people worldwide. The cardiac autonomic nervous system (ANS) is widely recognized as playing a key role in both the initiation and propagation of AF. This paper reviews the background and development of a unique cardioneuroablation technique for the modulation of the cardiac ANS as a potential treatment for AF. The treatment uses pulsed electric field energy to selectively electroporate ANS structures on the epicardial surface of the heart. Insights from in vitro studies and electric field models are presented as well as data from both pre-clinical and early clinical studies.
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Affiliation(s)
- Barry O'Brien
- AtriAN Medical Ltd., Unit 204, Business Innovation Centre, Upper Newcastle, H91 W60E Galway, Ireland
| | - John Reilly
- AtriAN Medical Ltd., Unit 204, Business Innovation Centre, Upper Newcastle, H91 W60E Galway, Ireland
| | - Ken Coffey
- AtriAN Medical Ltd., Unit 204, Business Innovation Centre, Upper Newcastle, H91 W60E Galway, Ireland
| | - Ana González-Suárez
- School of Engineering, University of Galway, H91 TK33 Galway, Ireland
- Translational Medical Device Lab, University of Galway, H91 YR71 Galway, Ireland
| | - Leo Quinlan
- Physiology and Cellular Physiology Research Laboratory, CURAM SFI Centre for Research in Medical Device, University of Galway, H91 TK33 Galway, Ireland
| | - Martin van Zyl
- Cardiac Electrophysiology, Royal Jubilee Hospital, Victoria, BC V8R 1J8, Canada
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