Autonomic denervation, myocardial hypoperfusion and fibrosis may predict ventricular arrhythmia in the early stages of Chagas cardiomyopathy.

BACKGROUND: Sudden cardiac death (SCD) can be the first clinical event of Chagas heart disease (CHD). However, current guidelines contain no clear recommendation for early cardioverter-defibrillator implantation. Using imaging modalities, we evaluated associations among autonomic denervation, myocardial hypoperfusion, fibrosis and ventricular arrhythmia in CHD. METHODS AND RESULTS: Twenty-nine patients with CHD and preserved left ventricular function underwent 123I-metaiodobenzylguanidine (MIBG) scintigraphy, 99mTc-methoxyisobutylisonitrile (MIBI) myocardial perfusion and cardiac magnetic resonance imaging (MRI). They were divided into arrhythmic (≥ 6 ventricular premature complexes/h and/or non-sustained ventricular tachycardia on 24-hour Holter, n = 15) and non-arrhythmic (< 6 ventricular premature complexes/h and no ventricular tachycardia; n = 14) groups. The arrhythmic group had higher denervation scores from MIBG imaging (23.2 ± 18.7 vs 5.6 ± 4.9; P < .01), hypoperfusion scores from MIBI SPECT (4.7 ± 6.8 vs 0.29 ± 0.6: P = .02), innervation/perfusion mismatch scores (18.5 ± 17.5 vs 5.4 ± 4.8; P = .01) and fibrosis by late gadolinium enhancement on MRI (14.3% ± 13.5% vs 4.0% ± 2.9%; P = .04) than the non-arrhythmic group. CONCLUSION: These imaging parameters were associated with ventricular arrhythmia in early CHD and may enable risk stratification and the implementation of primary preventive strategies for SCD.

Bowel Motility After Injury to the Superior Mesenteric Plexus During D3 Extended Mesenterectomy.

BACKGROUND: Improvement of lymphadenectomy in right colectomy requires removal of all tissue surrounding the superior mesenteric vessels beneath the pancreatic notch. Short- and long-term bowel motility disorders after D3 extended mesenterectomy with consecutive superior mesenteric plexus transection are studied. METHODS: Patients without pre-existing motility disorders undergoing D3 extended mesenterectomy were examined 3 times using the wireless motility capsule: before, at 3 wk, and 6 mo after surgery. Segmental transit times and contractility were analyzed using mixed effect modeling. Correlation between contractility and transit time was assessed by the Pearson correlation coefficient. RESULTS: Fifteen patients (4 men), with median age 62 y, were included. Mean values for the three consecutive examinations are as follows. Gastric transit time increased from 237 to 402 and 403 min, respectively. Small bowel transit time decreased from 246 to 158 (P < 0.01) and 199 (P = 0.03) min, respectively. Colonic transit time decreased from 1742 to 1450 and 1110 (P = 0.02) min, respectively. Gastric contractions per minute (CPM) varied from 1.73 to 1.05 (P = 0.01) and 2.47 (P < 0.01), respectively. Small bowel CPM decreased from 3.43 to 2.68 and 3.34, respectively. Colonic CPM ranged from 1.59 to 1.45 and 1.91 (P = 0.08), respectively. Correlation between small bowel (SB) transit time and CPM was -0.45 (P = 0.09) preoperatively, and -0.03 (P = 0.91) 6 mo postoperatively. CONCLUSIONS: Extrinsic SB denervation leads to significantly accelerated SB transit, reduced contractility, and disturbed correlation between transit time and contractility early after denervation. Both number of contractions and transit time in the denervated SB show a clear tendency toward normalization at 6 mo.

Percutaneous Radiofrequency Lesion of the Superior Cervical Sympathetic Ganglion in Patients with Tinnitus.

OBJECTIVE: The aim of this study was to determine the efficacy of radiofrequency lesioning of the superior cervical sympathetic ganglion for patients with tinnitus. STUDY DESIGN: This is a retrospective long-term clinical review of patients with tinnitus treated with a blockade of the superior cervical sympathetic ganglion. SETTING: The human subjects were 366 consecutive patients who came to the DC Klinieken in Almere and Amsterdam from January 2010 to January 2014 for consultations on their tinnitus that persisted for 1 month or longer. SUBJECTS AND METHODS: Data were recorded from patients whose charts were reviewed retrospectively to identify the patients who were treated with a blockade of the superior cervical sympathetic ganglion for tinnitus. An independent observer conducted a long-term follow-up assessment of the therapy by telephone interview. RESULTS: Relief of tinnitus at 7-week follow-up was achieved in 64% of the patients treated with a radiofrequency lesion of the superior cervical sympathetic ganglion after a positive test blockade of this structure. Two years after the treatment, the maintenance of a tinnitus relief occurred in almost 40% of the patients with a follow-up period of two years or longer. CONCLUSIONS: A radiofrequency lesion of the superior cervical sympathetic ganglion may be a useful alternative for patients with tinnitus not responding to conventional therapy.

Potential consequences of cardioneuroablation for vasovagal syncope: A call for appropriately designed, sham-controlled clinical trials.

Cardioneuroablation (CNA) is being increasingly used to treat patients with vasovagal syncope (VVS). Bradycardia, in the cardioinhibitory subtype of VVS, results from transient parasympathetic overactivity leading to sinus bradycardia and/or atrioventricular block. By mitigating parasympathetic overactivity, CNA has been shown to improve VVS symptoms in clinical studies with relatively small sample sizes and short follow-up periods (<5 years) at selected centers. However, CNA may potentially tip the autonomic balance to a state of sympathovagal imbalance with attenuation of cardiac parasympathetic activity. A higher heart rate is associated with adverse cardiovascular events and increased mortality in healthy populations without cardiovascular diseases. Chronic sympathovagal imbalance may also affect the pathophysiology of spectra of cardiovascular disorders including atrial and ventricular arrhythmias. This review addresses potential long-term pathophysiological consequences of CNA for VVS.

Arriving at SKINTED (Surgery of the Knee, Injury to the Infrapatellar Branch of the Saphenous Nerve, Traumatic Eczematous Dermatitis): A Case Report.

Surgery of the knee, injury to the infrapatellar branch of the saphenous nerve, traumatic eczematous dermatitis (SKINTED) is a postsurgical localized dermatitis specifically linked to total knee arthroplasty (TKA). It is due to autonomic denervation following surgically inflicted nerve injury. It develops several months to years following a surgical trauma. It is being referred to by various names in the literature. Locoregional immune dysfunction due to lymphatic injury after surgery is the currently accepted theory. It must be distinguished from atopic dermatitis, allergic contact dermatitis/sensitization induced by topical medications or implanted metal hypersensitivity dermatitis, and post-traumatic eczema/dermatitis. We present a case of an elderly female patient in her 50s with dry eczematous lesions over the lateral aspect of the surgical incision over both knees developed three months following bilateral total knee replacement (TKR) done in view of osteoarthritis. The patient responded well to topical corticosteroid and emollient treatment. We have also reviewed the literature to provide an overview of potential concepts of etiopathogenesis described in the literature and to clear up any ambiguity surrounding various labels given to this entity.

Cardiac Sympathetic Denervation as a Treatment for Ventricular Arrhythmias Refractory to Conventional Treatment: A Case Series.

Background: Ventricular arrhythmias are a leading cause of sudden death. The objective of this study was to characterise the results of patients with ventricular arrhythmias refractory to standard medical management, undergoing Video-assisted thoracoscopic cardiac sympathetic denervation (VAT-CSD) during 2012-2022 in Cali, Colombia. Methods: This was an observational retrospective study, using the Institutional General Thoracic Surgery Database for patient identification and retrospectively reviewing the clinical charts for data description and analysis. Results: Clinical records of 19 patients who underwent VAT-CSD for ventricular arrhythmia were analysed. The patients were predominantly male (73.7%) with an mean age of 62 years. Ischaemic heart disease was the main underlying condition (52.6%); all individuals had a diagnosis of heart failure, with comorbidities such as hypertension (63.1%), acute MI (57.8%) and diabetes (26.3%) also present. The procedure was performed bilaterally in 89.4% of cases and was successful with minimal perioperative complications. Postoperative follow-up showed improvement in symptoms, including a significant reduction in the number of ICD shocks and emergency department visits. Conclusion: VAT-CSD is a viable, safe and palliative therapeutic option for patients with ventricular arrhythmias who have not responded to conventional treatments, achieving a significant decrease in symptoms with low mortality and perioperative complications.

Recognition of a patient with neck autonomic dysfunction: findings from a rare case report of harlequin syndrome in direct access physiotherapy.

BACKGROUND: Harlequin syndrome is a rare autonomic condition consisting of unilateral facial flushing and sweating induced by heat, emotion or physical activity. The affected side presents anhidrosis and midline facial pallor due to denervation of the sympathetic fibers. CASE DESCRIPTION: This case describes a patient who reported right-side redness of the face associated with hyperhidrosis during physical activity. She had two previous major motor vehicle accidents. The patient demonstrated difficulties in the visual accommodation of the left eye, but cranial nerve assessment was unremarkable; the patient was then referred to an ophthalmologist, who excluded any autonomic dysfunction as the primary cause of convergence and visual acuity. OUTCOMES: A left-sided sympathetic dysfunction with Harlequin sign diagnosis was made followed by a progressive compensatory adaptation of the right face. The patient was educated and reassured about the benign nature of her problem. DISCUSSION: Knowledge of the autonomic nervous system is still limited in clinical practice. Although challenging, physiotherapists should develop the knowledge and ability needed to perform appropriate assessment of autonomic dysfunctions. CONCLUSION: A dispositional reasoning model should be considered in differential diagnosis.

Neuropathy Dermatitis: An Underdocumented Complication Following Total Knee Arthroplasty.

Background: Midline surgical incision used in Total Knee Arthroplasty (TKA) is associated with iatrogenic injury to the infrapatellar branch of the saphenous nerve, which leads to neuropathic dermatitis around the healed surgical scar. There are very few studies with a limited number of cases that have reported this complication. We evaluated the incidence of neuropathic dermatitis and its implication for the functional outcome in TKA patients. Methodology: Patients who underwent primary TKA between 1 January 2010 and 31 August 2019 and presented in follow-up with sensory disturbances and skin lesions adjacent to the surgical incision were evaluated in this study. Results: A total of 3318 patients with 4282 TKAs were included, of which 188 patients presented with the clinical picture of neuropathic dermatitis. There were 136 females and 52 males with a mean age of 67.13 years (range 37-92 years). The mean duration from surgery to the appearance of skin lesions was 4.4 months (range 2-6 months), and they resolved at a mean duration of 7.67 (range 6-12) weeks. In our study, we found an incidence of 5.52%. All these patients had a stable and well-functioning knee at the time of presentation of the lesion with a mean Knee Society Score (KSS) of 92 (range 84-96). Conclusion: In our study, we found the incidence of neuropathic dermatitis to be 5.52%, without any long-term implication on the functional outcome of operated knees. For a self-limiting complication of midline knee incision of TKA, it either resolves on its own or requires a short duration of topical steroid application.

Incidental parasympathetic cardiac denervation during atrial fibrillation ablation using high power short duration: a marker of long-term success.

BACKGROUND: There are multiple factors in both technique and substrate that lead to recurrence of atrial fibrillation after ablation. We sought to examine whether the degree of heart rate increase (HRI) caused by concurrent high-power-short-duration (HPSD) incidental parasympathetic denervation during AF ablation predicts long term success. Between December 2018 and December 2021, prospectively enrolled 214 patients who presented in sinus rhythm at AF ablation. Used 50 W of power and contact force (CF) of 5-15 g and 10-20 g at a flow rate of 40 mL/min on the anterior and posterior left atrial walls, respectively. RESULTS: Males were 143 (66.8%) and paroxysmal was 124 (57.9%) patients. Mean age 61.1 ± 12.3 years and follow-up time was 32.8 ± 13.2 months. Arrhythmia occurred after 90 days in 39 (18.2%) patients, 19 (48.7%) from the paroxysmal and 20 (51.3%) from the persistent AF patients. Recurrence group showed a lower HRI from a mean of 57 ± 7.7 to 64.4 ± 10.4 bpm (12.3%) while in success group HRI was from 53.8 ± 9.7 to 66.8 ± 11.6 bpm [(24.2%) p = 0.04]. We divided HRI in 3 percentiles of ≤ 8%, > 8 ≤ 37% and > 37%. A predictor of recurrence was identified in those in the first (< 8%, p = 0.006) and a predictor of success in the later (> 37%, p = 0.01) HRI percentile. CONCLUSION: Atrial fibrillation ablation with HPSD incidental cardiac parasympathetic denervation identified that patients with lower heart rate increase are prone to recurrence while those with higher heart rate increase had higher maintenance of sinus rhythm at a long-term follow-up.

The benefit of cardioneuroablation to reduce syncope recurrence in vasovagal syncope patients: a case-control study.

BACKGROUND: Adequate and effective therapy for resistant vasovagal syncope patients is lacking and the benefit of cardioneuroablation (CNA) in this cohort is still debated. The aim of this study is to assess the long-term effect of CNA versus conservative therapy (CT) in a retrospectively followed cohort. METHODS: A total of 2874 patients underwent head-up tilt test (HUT) and 554 (19.2 %) were reported as positive, with VASIS type 2B response or > 3 s asystole in 130 patients. After exclusion of 29 patients under 18 years and over 65 years of age, 101 patients were included final analysis. Fifty-one patients (50.4%) underwent CNA and 50 (49.6%) patients received CT. After propensity score matching, 19 pairs of patients were successfully matched. The recurrence rate of syncope was compared between groups. RESULTS: During a median follow-up of 22 months (IQR, 13-35), syncope was seen in 12 (11.8%) cases. In the 19 propensity-matched patients, recurrent syncope was observed in 8 patients in the CT group and in 2 patients in the CNA group, respectively. In mixed effect Cox regression analysis, CNA was associated with less syncope recurrence risk at follow-up (HR 0.23, 95% CI 0.03-0.99, p = 0.049). The 4-year Kaplan-Meier syncope free rate was 0.86 (95% CI, 0.63-1.00) for CNA group and 0.50 (95% CI, 0.30-0.82) for CT group in the matched cohort. CONCLUSIONS: In highly selected patients with HUT-induced cardioinhibitory response, CNA is associated with a significant reduction in syncope recurrence during follow-up when compared to CT.

Cryoballoon ablation for atrial fibrillation: Effects on neuromodulation.

Pulmonary vein isolation (PVI) represents the mainstay of atrial fibrillation (AF) ablation, and PVI with cryoballoon catheter (CB) ablation (CB-A) has proven to be as effective and safe as radiofrequency ablation (RF-A). Although AF is initiated by triggers arising from the pulmonary veins (PV) and non-PV foci, the intrinsic cardiac nervous system (ICNS) plays a significant role in the induction and maintenance of AF. The ICNS is an epicardial neural system composed of ganglionated plexi (GPs) and a complex network of interconnecting neurons. In the left atrium, the major GPs are located in proximity to the PV-left atrial junction. Vagal reactions have been described as markers of autonomic modulation during PVI with both RF-A and CB-A. The occurrence of neuromodulation during PVI with CB-A may be explained by both the anatomical relationship between the GPs and the PVs and the characteristics of the CB. Due to the CB/PV size mismatch, the CB creates a wide ablation area that extends from the PV ostium toward the antrum, possibly including the GPs. Although targeted GPs ablation, as a supplemental strategy to PVI, has been associated with a better AF outcome in patients undergoing RF-A, the additional clinical benefit of neuromodulation during PVI with CB-A remains a matter of debate. In this review, we provide an overview of the anatomy of the ICNS, the relationship between the ICNS and AF pathophysiology, and the current evidence on the clinical relevance of neuromodulation during PVI with CB-A.

Adding six short lines on pulmonary vein isolation circumferences reduces recurrence of paroxysmal atrial fibrillation: Results from a multicenter, single-blind, randomized trial.

BACKGROUND: Pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (AF) is associated with a non-negligible long-term recurrence rate. OBJECTIVES: The purpose of this study was to investigate whether PVI combined with 6 short ablation lines on the PVI circumferences (PVI+6L group) yields higher success rates than PVI alone (PVI group). METHODS: In this multicenter, single-blind, randomized trial, a total of 390 patients with paroxysmal AF were randomly assigned to the PVI group (n = 193) or the PVI+6L group (n = 197). The primary endpoint was freedom from AF/atrial tachycardia recurrence between 91 and 365 days. Secondary endpoints included AF burden, procedural parameters, and complications. RESULTS: Freedom from atrial tachyarrhythmia was achieved in 160 of 197 patients (81.2%) in the PVI+6L group and 142 of 193 patients (73.6%) in the PVI group (hazard ratio 0.61; 95% confidence interval 0.39-0.97; P = .040). Mean AF burden tended to be lower in the PVI+6L group compared to the PVI group (1.95% vs 0.53%, P = .097). Procedural and ablation times were slightly longer in the PVI+6L group than in the PVI group (130 ± 25 minutes vs 121 ± 28 minutes; P = .002; and 46 ± 14 minutes vs 41 ± 16 minutes, P = .001, respectively). X-ray exposure was similar (60 ± 54 seconds vs 61 ± 60 seconds; P = .964). Complications occurred in 3 patients (1.6%) in the PVI group and 3 patients (1.5%) in the PVI+6L group. CONCLUSION: In patients with paroxysmal AF undergoing catheter ablation, adding 6 short ablation lines on the PVI circumferences could reduce the AF recurrence rate.

Cardioneuroablation changes the type of vasovagal response in patients with asystolic reflex syncope.

BACKGROUND: Cardioneuroablation (CNA) has been recently proposed as a new therapy in patients with asystolic vasovagal syncope (VVS) caused by parasympathetic overactivity. OBJECTIVE: To assess the impact of CNA on the type of VV response during tilt testing (TT). METHODS: The study group consisted of 20 patients (7 males, mean age 38 ± 9). All patients had a history of syncope due to asystole and confirmed asystolic VVS at baseline TT (TT1). CNA was performed in the right and left atrium. The second TT (TT2) and Holter ECG were performed three months later. All patients completed one-year follow up. RESULTS: At TT1, twenty patients had cardioinhibitory syncope and 1 had mixed VVS with asystole > 3 s. During one-year follow-up no spontaneous syncopal episodes were noted. At TT2, 6 patients had no syncope whereas the remaining 13 had syncope - twelve due to vasodepressor mechanism and only one due to asystole. Mean heart rate after CNA was significantly faster and heart rate variability parameter (SDNN) lower than before the procedure (82 ± 9 vs 69 ± 11 beats/min, p = 0.0003 and 74 ± 22 vs 143 ± 40 ms, p = 000001, respectively). These changes were similar in those who fainted during TT2 and those who did not (84 ± 10 vs 81 ± 5 beats/min, p = NS and 72 ± 24 vs 72 ± 19 ms, p = NS, respectively). CONCLUSIONS: CNA profoundly affects type of VV reaction causing normalization of the response to tilting or changing cardiodepression to vasodepression. Changes in heart rate and heart rate variability are consistent with attenuation of parasympathetic activity.

Perioperative management of patients with arrhythmogenic syndromes refractory to medical treatment: A clinical case report.

Family heart diseases related to sudden death are a group of cardiovascular diseases (cardiomyopathies, channelopathies, aortic diseases …) that require familiarity of the anesthesiologist with the perioperative treatment of complex hemodynamic disorders, as well as their surgical treatment.1 We present the case of a 12-year-old man diagnosed with non-obstructive hypertrophic cardiomyopathy (MHNO), after cardiorespiratory arrest (PCR), who underwent video-guided thoracoscopy-guided left sympathectomy (VATS) for frequent syncope, despite pharmacological treatment and implantation of an implantable automatic defibrillator (ICD). Whenever arrhythmic syncope occurs in the setting of familial heart disease, left heart denervation should be considered as the next step in the treatment plan.2.

Perioperative management of patients with arrhythmogenic syndromes refractory to medical treatment: A clinical case report. / Valoración y tratamiento perioperatorio de los pacientes con síndromes arritmogénicos refractarios a tratamiento médico: a propósito de un caso clínico.

Family heart diseases related to sudden death are a group of cardiovascular diseases (cardiomyopathies, channelopathies, aortic diseases...) that require familiarity of the anesthesiologist with the perioperative treatment of complex hemodynamic disorders, as well as their surgical treatment1. We present the case of a 12-year-old man diagnosed with non-obstructive hypertrophic cardiomyopathy, after cardiorespiratory arrest, who underwent video-guided thoracoscopy-guided left sympathectomy for frequent syncope, despite pharmacological treatment and implantation of an implantable automatic defibrillator. Whenever arrhythmic syncope occurs in the setting of familial heart disease, left heart denervation should be considered as the next step in the treatment plan2.

Effect of Renal Denervation on Suppression of PVC and QT Prolongation in a Porcine Model of Acute Myocardial Infarction.

BACKGROUND AND OBJECTIVES: Antiarrhythmic effect of renal denervation (RDN) after acute myocardial infarction (AMI) remains unclear. The goal of this study was to evaluate the effect of RDN on ventricular arrhythmia (VA) after AMI in a porcine model. METHODS: Twenty pigs were randomly divided into 2 groups based on RDN (RDN, n=10; Sham, n=10). After implanting a loop recorder, AMI was induced by occlusion of the middle left anterior descending coronary artery. Catheter-based RDN was performed for each renal artery immediately after creating AMI. Sham procedure used the same method, but a radiofrequency current was not delivered. Electrocardiography was monitored for 1 hour to observe VA. One week later, the animals were euthanized and the loop recorder data were analyzed. RESULTS: Ventricular fibrillation event rate and the interval from AMI creation to first VA in acute phase were not different between the 2 groups. However, the incidence of premature ventricular complex (PVC) was lower in the RDN than in the Sham. Additionally, RDN inhibited prolongation of the corrected QT (QTc) interval after AMI. The frequency of non-sustained or sustained ventricular tachycardia, arrhythmic death was lower in the RDN group in the early period. CONCLUSIONS: RDN reduced the incidence of PVC, inhibited prolongation of the QTc interval, and reduced VA in the early period following an AMI. These results suggest that RDN might be a therapeutic option in patients with electrical instability after AMI.

Vagal responses during cardioneuroablation on different ganglionated plexi: Is there any role of ablation strategy?

BACKGROUND: Cardioneuroablation has been used to treat vagally mediated bradyarrhythmias (VMB). The aim of this study is to assess vagal response (VR) characteristics during radiofrequency catheter ablation (RFCA) with different ganglionated plexus (GP) order. METHODS: A total of 49 consecutive patients with VMB who underwent cardioneuroablation were enrolled. GPs were identified by electroanatomic-mapping-guided strategy. After all GP targets have been identified, patients were divided into 2 groups according to GP ablation strategy. In the left side first group, ablation order of GPs were left superior GP (LSGP), left inferior GP (LIGP), right superior GP (RSGP), and right inferior GP (RIGP). In the right side first group, ablation order was RSGP, RIGP, LSGP, and LIGP. RESULTS: In the left side first group, LSGP was the most common GP site at which a VR was observed (36 of 40 cases, 90%). LIGP causes a VR in 9 of 40 (22.5%) cases. In the right side first group, VR was seen only 2 of 9 (22.2%) cases. Comparison of ablation strategy demonstrated a significant difference in VR during ablation on LSGP between groups. Despite, LSGP was the most common GP site at which a VR was observed both groups (90% in left side first group vs 11.1% in right side first group, p < 0.0001). In remaining GPs, VRs were not dependent on the ablation strategy and were not statistically different between groups. CONCLUSION: The present study demonstrates that the characteristics of VR during RFCA might change according to ablation order of GPs.

Domino living donor liver transplantation of familial amyloid polyneuropathy patient - A case report.

BACKGROUND: Familial amyloid polyneuropathy (FAP) is caused by mutation in a gene transcribing transport protein produced mainly by the liver. Liver transplantation is required to stop FAP progression, but the pathology causes anesthetic management challenges. CASE: We report a case of domino living donor liver transplantation in an FAP patient. No intraoperative events occurred; however, during postoperative day 1 in the intensive care unit (ICU), the FAP patient underwent multiple cardiopulmonary resuscitation (CPR) sessions due to pulseless electrical activity following a sudden drop in blood pressure and ventricular tachycardia. Despite ICU management, the patient died after the third CPR session. CONCLUSIONS: Various anesthetic management techniques should be considered for FAP patients. Anesthetic management was carefully assessed with the use of isoflurane, isoproterenol, and an external patch. The cause of deterioration in the ICU is unclear, but further investigation is needed to prevent and better manage postoperative morbidity and mortality.

Relation of Fractionated Atrial Potentials With the Vagal Innervation Evaluated by Extracardiac Vagal Stimulation During Cardioneuroablation.

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.

Right anterior ganglionated plexus: The primary target of cardioneuroablation?

BACKGROUND: Catheter ablation of ganglionated plexus (GP) as cardioneuroablation in the left atrium (LA) has been used to treat vasovagal syncope (VVS). OBJECTIVE: The purpose of this study was to assess the effects of ablation of GPs on heart rate and to observe the acute, short-term, and long-term effects after cardioneuroablation. METHODS: A total of 115 consecutive patients with VVS who underwent cardioneuroablation were enrolled. GPs of the LA were identified by high-frequency stimulation and/or anatomic landmarks being targeted by radiofrequency catheter ablation. RESULTS: During ablation of right anterior ganglionated plexus (RAGP), heart rate increased from 61.3 ± 12.2 bpm to 82.4 ± 14.7 bpm (P <.001), whereas during ablation of other GPs only vagal responses were observed. During follow-up of 21.4 ± 13.1 months (median 18 months), 106 participants (92.2%) had no recurrence of syncope or presyncope. Holter data showed that minimal heart rate significantly increased at all follow-up time points (all P<.05), and mean heart rate remained higher than baseline 12 months after ablation (P = .001). CONCLUSION: Cardioneuroablation via GP ablation in the LA effectively inhibited the recurrence of VVS. Ablation of RAGP could increase heart rate immediately and for the long term. This unique phenomenon may provide a new potential approach for treatment of neural reflex syncope or bradyarrhythmias.