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Autonomic Denervation Added to Pulmonary Vein Isolation for Paroxysmal Atrial Fibrillation: A Randomized Clinical Trial
Study Questions:
Does ganglionated plexi (GP) modification have incremental value when added to pulmonary vein isolation (PVI) in patients undergoing radiofrequency catheter ablation of paroxysmal atrial fibrillation (AF)?
Methods:
Two hundred forty-two patients (mean age 56 years) with paroxysmal AF were randomly assigned to undergo circumferential PVI (n = 78), anatomically-guided ablation of the four major left atrial GP (n = 82), or PVI plus GP ablation (n = 82). All patients were treated with a beta-blocker post-ablation and ambulatory monitoring was performed monthly during 2 years of follow-up. One hundred twenty-one patients (50%) received an implantable loop recorder (ILR). The primary endpoint was freedom from AF after a single ablation procedure.
Results:
Freedom from AF at 2 years of follow-up was significantly higher in the PVI + GP ablation group (74%) than in the PVI (56%) and GP ablation (48%) groups. The only complication was cardiac tamponade in one patient in the PVI group.
Conclusions:
The authors concluded that combination of PVI and GP ablation is more effective than either ablation strategy by itself for preventing paroxysmal AF.
Perspective:
The major left atrial GPs are adjacent to the pulmonary veins (PVs), and antral PVI probably often results in some GP injury. The 48% success rate of GP ablation by itself suggests that the efficacy of PVI may be partly attributable to autonomic denervation. The authors concluded that the most effective ablation strategy for paroxysmal AF is PVI plus GP ablation. However, a large proportion of AF recurrences after PVI are attributable to PV reconnection. It is possible that the incremental value of GP ablation, which often is antral in location, is at least partly attributable to more reliable PVI.
Keywords: Recurrence, Follow-Up Studies, Furylfuramide, Autonomic Denervation, Pulmonary Veins, Electrophysiologic Techniques, Cardiac, Catheter Ablation, Cardiac Tamponade, Ovarian Follicle
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