RADIOFREQUENCY ABLATION OF GANGLION PLEXUSES AND AREAS OF COMPLEX FRACTIONATED ATRIAL ELECTROGRAMS IN PATIENTS WITH ATRIAL FIBRILLATION

To assess safety and effectiveness of ablation of ganglion plexuses and areas of complex fractionated atrial electrograms revealed during overdrive pacing in patients with paroxysmal atrial fibrillation (AF), 84 patients aged 59±7 years were included into the study. The ablation sites were defined as areas where vagus reflexes developed in response to overdrive pacing conducted with the frequency of 20 Hz, amplitude of 15 V, and impulse duration of 10 ms. Areas of complex fractionated atrial electrograms were defined as fractionated atrial electrograms which consisted of two or more deviations from baseline, with the persistent deviation from the prolonged activation complex. Radiofrequency ablation was performed in all areas with the positive vagus response during overdrive pacing and additionally continued in the area of complex fractionated atrial electrograms. In all study subjects, by the end of ablative procedure, the recorders Reveal XT (Medtronic Inc.) have been implanted according to the commonly accepted technique for persistent cardiac rhythm analysis. During the follow-up period, the patients were free of therapy with antiarrhythmics and β-blockers. Sustained AF was inducible by overdrive pacing in all study subjects. The number of overdrive suppressions made was 41±7 per patient. The number of radiofrequency applications sufficient to eliminate completely the vagus response was 5.4±2.5 ones per area revealed. In addition, 8.7±5.2 radiofrequency applications were performed in each area of complex fractionated atrial electrograms. In total, 68.2±9.4 radiofrequency applications were made. During the follow-up period, AF recurrence (i.e., AF burden >0.5%) was observed in 24 patients of 84 (28.6%). Thus, the expanded ablation of ganglion plexuses can be performed safely and provides the sinus node maintenance in a majority of patients with paroxysmal AF during a 12 month of follow-up. Effectiveness of the procedure can be caused by more pronounced autonomic denervation.

atrial fibrillation, ganglion plexuses, complex fractionated atrial electrograms, overdrive suppression, radiofrequency catheter ablation

1. Scherlag B., Nakagawa H., Jackman W. et al. Electrical Stimulation to Identify Neural Elements on the Heart: Their Role in Atrial Fibrillation // J Cardiovasc Electrophysiol 2005; 13: 37-42.

2. Hou Y., Scherlag BJ., Lin J. et al. Ganglionated plexi modulate extrinsic cardiac autonomic nerve input: effects on sinus rate, atrioventricular conduction, refractoriness, and inducibility of atrial fibrillation // J Am Coll Cardiol. 2007; 50:61-68.

3. Schauerte P., Scherlag BJ., Pitha J., et al. Catheter ablation of cardiac autonomic nerves for prevention of vagal atrial fibrillation // Circulation 2000;102:2774-2780.

4. Lemola K., Chartier D., Yeh Y.H. et al. Pulmonary vein region ablation in experimental vagal atrial fibrillation: role of pulmonary veins versus autonomic ganglia // Circulation 2008;117:470-477.

5. Scanavacca M., Pisani C., Hachul D. et al. Selective Atrial Vagal Denervation Guided by Evoked Vagal Reflex to Treat Patients With Paroxysmal Atrial Fibrillation // Circulation 2006; 114:876-885.

6. Lemery R., Birnie D., Tang A. et al. Feasibility study of endocardial mapping of ganglionated plexuses during catheter ablation of atrial fibrillation // Heart Rhythm 2006; 3:387-396.

7. Katritsis D., Giazitzoglou E., Sougiannis D. et al. Anatomic approach for ganglionic plexi ablation in patients with paroxysmal atrial fibrillation // Am J Cardiol. 2008;102:330-334.

8. Pokushalov E., Romanov A., Shugayev P. et al. Selective ganglionated plexi ablation for paroxysmal atrial fibrillation // Heart Rhythm 2009; 6: 1257-64

9. Hou YL., Scherlag BJ., Lin J. et al. Interactive atrial neural network: determining the connection between ganglionated plexi // Heart Rhythm 2007; 4: 56-63.

10. Nakagawa H., Scherlag B., Patterson E. et al. Pathophysiologic basis of autonomic ganglionated plexus ablation in patients with atrial fibrillation // Heart Rhythm 2009; 6:S26-34

11. Po S., Nakagawa H., Jackman W. Localization of Left Atrial Ganglionated Plexi in Patients with Atrial Fibrillation // J Cardiovasc Electrophysiol. 2009; 20: 1186-1189.

12. Lemery R. How to perform ablation of the parasym pathetic ganglia of the left atrium //Heart Rhythm 2006; 3:1237-1239.

13. Nakagawa H., Scherlag BJ., Wu R. Addition of selective ablation of autonomic ganglia to pulmonary vein antrum isolation for treatment of paroxysmal and persistent atrial fibrillation (abstr) // Circulation 2004;110; III-543.

14. Nademanee K., Schwab M., Porath J. et al. How to perform electrogram-guided atrial fibrillation ablation // Heart Rhythm 2006. 3(8):981-984.

15. Hanke T., Charitos EI., Stierle U. et al. Twenty-Four-Hour Holter Monitor Follow-Up Does Not Provide Accurate Heart Rhythm Status After Surgical Atrial Fibrillation Ablation Therapy Up to 12 Months Experience With a Novel Permanently Implantable Heart Rhythm Monitor Device // Circulation 2009;120[suppl 1]:S177-184.

16. Hindricks G., Pokushalov E., Urban L. et al. Performance of a new Implantable Cardiac Monitor in Detecting and Quantifying Atrial Fibrillation. Results of the XPECT Trial //Circulation: Arrhythmias and Electrophysiology 2010; 3:141-147.

17. Pokushalov E., Romanov A., Corbucci G. et al. Ablation of Paroxysmal and Persistent Atrial Fibrillation: 1-Year Follow-Up Through Continuous Subcutaneous Monitoring // J Cardiovasc Electrophysiol. 2011; 22: 369-375.

18. Glotzer TV, Daoud EG., Wyse DG. et al. The Relationship Between Daily Atrial Tachyarrhythmia Burden From Implantable Device Diagnostics and Stroke Risk. The TRENDS Study // Circ Arrhythmia Electrophysiol. 2009; 2: 474-480.

19. Botto GL., Padeletti L., Santini M. et al. Presence and duration of atrial fibrillation detected by continuous monitoring: crucial implications for the risk of thromboembolic events // J Cardiovasc Electrophysiol. 2009; 20(3): 241-248.

20. Oh S, Zhang Y, Bibevski S, et al. Vagal denervation and atrial fibrillation inducibility: Epicardial fat pad ablation does not have long-term effects. Heart Rhythm 2006; 3:701-708.

21. Hirose M, Leatmanoratn Z, Laurita KR, et al. Partial vagal denervation increases vulnerability to vagally induced atrial fibrillation. J Cardiovasc Electrophysiol 2002; 13:1272-1279.

22. Pokushalov E, Turov A, Shugayev P, et al. Catheter ablation of left atrial ganglionated plexi for atrial fibrillation.Asian Cardiovasc Thorac Ann 2008; 16:194-201

23. Katritsis DG, Giazitzoglou E, Zografos T et al. Rapid pulmonary vein isolation combined with autonomic ganglia modification: A randomized study. Heart Rhythm 2011; 8:672-678.

24. Oral H, Chugh A, Good E, et al. Randomized comparison of encircling and nonencircling left atrial ablation for chronic atrial fibrillation. Heart Rhythm 2005; 2:1165-1172.

25. Zhou J, Scherlag BJ, Edwards J et al. Gradients of atrial refractoriness and inducibility of atrial fibrillation due to stimulation of ganglionated plexi. J Cardiovasc

26. Kalifa J., Tanaka K., Zaitsev AV et al. Mechanisms of wave fractionation at boundaries of high-frequency excitation in the posterior left atrium of the isolated sheep heart during atrial fibrillation // Circulation 2006; 113(5): 626-33.

27. Ouyang F, Tilz R, Chun J, et al. Long-term results of catheter ablation in paroxysmal atrial fibrillation: lessons from a 5-year follow-up. Circulation 2010; 122:2368-2277.

28. Weerasooriya R, Khairy P, Litalien J et al. Catheter ablation for atrial fibrillation: are results maintained at 5 years of follow-up? J Am Coll Cardiol 2011; 57:160-166.