Pulmonary Vein Denervation Enhances Long-Term Benefit After Circumferential Ablation for Paroxysmal Atrial Fibrillation

Abstract

Background-There are no data to evaluate the relationship between autonomic nerve function modification and recurrent atrial fibrillation (AF) after circumferential pulmonary vein ablation (CPVA). This study assesses the incremental benefit of vagal denervation by radiofrequency in preventing recurrent AF in a large series of patients undergoing CPVA for paroxysmal AF. Methods and Results-Data were collected on 297 patients undergoing CPVA for paroxysmal AF. Abolition of all evoked vagal reflexes around all pulmonary vein ostia was defined as complete vagal denervation (CVD) and was obtained in 34.3% of patients. Follow-up ended at 12 months. Heart rate variability attenuation, consistent with vagal withdrawal, was detectable for up to 3 months after CPVA, particularly in patients with reflexes and CVD, who were less likely to have recurrent AF than those without reflexes (Pϭ0.0002, log-rank test). Only the percentage area of left atrial isolation and CVD were predictors of AF recurrence after CPVA (PϽ0.001 and Pϭ0.025, respectively). Conclusions-This study suggests that adjunctive CVD during CPVA significantly reduces recurrence of AF at 12 months.

Neural mechanisms of atrial fibrillation

“…20 However, the effectiveness of autonomic modulation as an adjunctive therapeutic strategy to catheter ablation of AF has been inconsistent. Although favorable results has been obtained by Nakagawa and Pappone et al, 21,22 others found no beneficial 23 or deleterious 24 outcomes in patients who had denervation compared to those who did not. These findings are also underlined by animal studies by Hirose et al, 25 where partial vagal denervation of the high right atrium was found to increase inducibility of AF.…”

2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Patient Selection, Procedural Techniques, Patient Management and Follow-up, Definitions, Endpoints, and Research Trial Design

“…246 The latter might include interruption of crucial pathways of conduction between pulmonary-atrial junctions, which play a role in sustenance of AF, reduction of the amount of mass available for the number of simultaneously circulating wavelets (atrial debulking), or partial vagal denervation by interruption of vagal stimulation from the autonomic ganglia. 109,247,248,249 Adjuvant substrate modification is targeted at patient-specific AF sources in the RA and LA. 250 AF recurrences after an initially successful AF ablation procedure are typically associated with PVI reconnection.…”

Differences in atrial fibrillation properties under vagal nerve stimulation versus atrial tachycardia remodeling

“…An interesting correlation of CFAEs with DFs and consequently vagal ganglia was also suggested by the electroanatomical mapping performed in our study. Therefore, based also on previous observations 72,73,138,143 , ablation of vagal ganglia during AF ablation could also be advantageous.…”