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

Heart Rhythm. 2024 Jun;21(6):780-787. doi: 10.1016/j.hrthm.2024.01.040. Epub 2024 Jan 28.

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.

Keywords: Atrial fibrillation; Autonomic nervous system; Ganglionated plexi; Heart rate; Pulsed field ablation; Vagal response.

MeSH terms

  • 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