Background: Vagal hyperactivity is directly related to several clinical conditions as reflex/functional bradyarrhythmias and vagal atrial fibrillation (AF). Cardioneuroablation provides therapeutic vagal denervation through endocardial radiofrequency ablation for these cases. The main challenges are neuromyocardium interface identification and the denervation control and validation. The finding that the AF-Nest (AFN) ablation eliminates the atropine response and decreases RR variability suggests that they are related to the vagal innervation. Method: Prospective, controlled, longitudinal, nonrandomized study enrolling 62 patients in 2 groups: AFN group (AFN group 32 patients) with functional or reflex bradyarrhythmias or vagal AF treated with AFN ablation and a control group (30 patients) with anomalous bundles, ventricular premature beats, atrial flutter, atrioventricular nodal reentry, and atrial tachycardia, treated with conventional ablation (non-AFN ablation). In AFN group, ablation delivered at AFN detected by fragmentation/fractionation of the endocardial electrograms and by 3-dimensional anatomic location of the ganglionated plexus. Vagal response was evaluated before, during, and postablation by 5 s noncontact vagal stimulation at the jugular foramen, through the internal jugular veins (extracardiac vagal stimulation [ECVS]), analyzing 15 s mean heart rate, longest RR, pauses, and atrioventricular block. All patients had current guidelines arrhythmia ablation indication. Results: Preablation ECVS induced sinus pauses, asystole, and transient atrioventricular block in both groups showing a strong vagal response ( P =0.96). Postablation ECVS in the AFN group showed complete abolishment of the cardiac vagal response in all cases (pre/postablation ECVS= P <0.0001), demonstrating robust vagal denervation. However, in the control group, vagal response remained practically unchanged postablation ( P =0.35), showing that non-AFN ablation promotes no significant denervation. Conclusions: AFN ablation causes significant vagal denervation. Non-AFN ablation causes no significant vagal denervation. These results suggest that AFNs are intrinsically related to vagal innervation. ECVS was fundamental to stepwise vagal denervation validation during cardioneuroablation. Visual Overview A visual overview is available for this article.

Background - Several disorders present reflex or persistent increase in vagal tone that may cause refractory symptoms even in a normal heart patient. Cardioneuroablation (CNA), the vagal denervation by RF ablation of the neuromyocardial interface, was developed to treat these conditions without pacemaker implantation. A theoretical limitation could be the reinnervation, that naturally grows in the first year, that could recover the vagal hyperactivity. This study aims to verify the vagal denervation degree in the chronic phase after CNA. Additionally, it intends to investigate the arrhythmias behavior after CNA. Methods - prospective longitudinal study with intra-patient comparison of 83 very symptomatic cases without significant cardiopathy, submitted to CNA, 49(59%) male, 47.3±17 years-old, having vagal paroxysmal atrial fibrillation 58(70%) or neurocardiogenic syncope 25(30%), NYHA Class < II and absence of significant comorbidities. CNA was performed in both atria by interatrial septum puncture, with irrigated conventional catheter and electroanatomic reconstruction. Ablation targeted the neuromiocardial interface by fragmentation mapping (AF-Nests) using the Velocity Fractionation software, conventional recording and anatomical localization of the ganglionated plexi. There were compared the time and frequency domain of the heart rate variability (HRV) and arrhythmias in 24h Holter pre-, 1-year-post- and 2-year-post-CNA. Clinical outpatient follow-up and serial Holter showed 80% asymptomatic cases at 40 months. Results - Time and frequency domain HRV demonstrated significant decrease in all autonomic parameters, showing an important parasympathetic and sympathetic activity reduction at 2 years-post-CNA (p<0.001). There was no difference in HRV between the 1-year- and 2-post-CNA (p>0.05) suggesting that the reinnervation has halted. There was also an important reduction in all brady- and tachyarrhythmias pre- vs. post-CNA, (p <0.01). Conclusions - There is an important and significant vagal and sympathetic denervation after 2 years of CNA with a significant reduction in brady and tachyarrhythmia in the whole group. There were no complications.

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Background Paroxysmal atrial fibrillation (PAF) can be triggered by non-pulmonary vein foci, like the superior vena cava (SVC). The latter is correlated with improved result in terms of freedom from atrial tachycardias (ATs), when electrical isolation of this vessel utilizing radiofrequency energy (RF) is achieved. Objectives Evaluate the clinical impact, in patients with PAF, of the SVC isolation (SVCi) in addition to ordinary pulmonary vein isolation (PVI) by means of the second-generation cryoballoon (CB) Methods A total of 100 consecutive patients that underwent CB ablation for PAF were retrospectively selected. Fifty consecutive patients received PVI followed by SVCi by CB application, and the following 50 consecutive patients received standard PVI. All patients were followed 12 months. Results The mean time to SVCi was 36.7 ± 29.0 s and temperature at SVC isolation was − 35 (− 18 to − 40) °C. Real-time recording (RTR) during SVCi was observed in 42 (84.0%) patients. At the end of 12 months of follow-up, freedom from ATs was achieved in 36 (72%) patients in the PVI only group and in 45 (90%) patients of the SVC and PV isolation group (Fisher’s exact test p = 0.039, binary logistic regression: p = 0.027, OR = 0.28, 95%CI = 0.09–0.86). In survival analysis, SVC and PV isolation group was also associated with improved freedom from ATs (log-rank test: p = 0.017, Cox regression: p = 0.026, HR = 0.31, 95%CI = 0.11–0.87). Conclusion Superior vena cava isolation with the CB in addition to PVI might improve freedom from ATs if compared to PVI alone at 1-year follow-up.

Background A left common pulmonary vein (LCPV) accounts as the most frequent pulmonary vein (PV) variation. Our aim was to compare the performance of radiofrequency (RF) versus second‐generation cryoballoon (CB‐A) ablation in patients with atrial fibrillation (AF) and LCPVs. Methods In a total cohort of 716 patients undergoing PV isolation with preprocedural CT‐scanning, LCPV+ patients were selected with measurement of PV ostial area and trunk distance. All LCPV+ patients were matched between RF and CB‐A group in a 1:1 ratio based on propensity scores, and compared for outcome. Results Left common pulmonary veins were found in 31% (88/283) RF versus 34% (146/433) CB‐A patients, respectively, (P = .44). In the matched population of 83 LCPV+ patients in each group, electrical isolation could be achieved in all left‐sided PVs. No significant difference was noted for the rate of AF/left atrial tachyarrhythmia (LAT) recurrence between RF and CB‐A group (30% vs 28%, P = .86), with similar AF/LAT‐free survival (log rank, P = .71). There were 48 patients with AF/LAT recurrence (29%) during the follow‐up. Recurrence rate between paroxysmal versus persistent AF was 27/120 (22.5%) versus 21/46 (46%), P = .004. Cox proportional regression analysis withheld LA volume and persistent AF as independent variables to predict AF/LAT recurrence. No increased hazard for AF/LAT recurrence was observed for patients with a long (>15 mm) vs short (5‐15 mm) LCPV trunk (OR 1.14, 95% CI 0.6‐2.2, P = .7). Conclusions In our study, equal efficacy and outcome was noted in LCPV+ patients between RF and CB‐A technology.

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