Pulsed field ablation of the right superior pulmonary vein prevents vagal responses via anterior right ganglionated plexus modulation

• Published in: Heart rhythm Vol. 21; no. 6; pp. 780 - 787
• Main Authors: Del Monte, Alvise, Della Rocca, Domenico Giovanni, Pannone, Luigi, Vetta, Giampaolo, Cespón Fernández, María, Marcon, Lorenzo, Doundoulakis, Ioannis, Mouram, Sahar, Audiat, Charles, Zeriouh, Sarah, Monaco, Cinzia, Al Housari, Maysam, Betancur, Andrés, Mené, Roberto, Iacopino, Saverio, Sorgente, Antonio, Bala, Gezim, Ströker, Erwin, Sieira, Juan, Almorad, Alexandre, Sarkozy, Andrea, Boveda, Serge, de Asmundis, Carlo, Chierchia, Gian-Battista
• Format: Journal Article
• Language: English
• Published: United States 01.06.2024
• Subjects: Aged; Atrial Fibrillation - physiopathology; Atrial Fibrillation - surgery; Catheter Ablation - methods; Female; Follow-Up Studies; Ganglia, Autonomic - physiopathology; Ganglia, Autonomic - surgery; Heart Conduction System - physiopathology; Heart Rate - physiology; Humans; Male; Middle Aged; Prospective Studies; Pulmonary Veins - surgery; Treatment Outcome; Vagus Nerve - physiology; Vagus Nerve - physiopathology; Heart rate; Vagal response; Autonomic nervous system; Ganglionated plexi; Atrial fibrillation; Pulsed field ablation
• ISSN: 1547-5271; 1556-3871; 1556-3871
• DOI: 10.1016/j.hrthm.2024.01.040

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. 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. 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. 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). 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.