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Catheter Ablation of Right Atrial Ganglionated Plexi in Patients With Vagal Paroxysmal Atrial Fibrillation
Study Questions:
Does radiofrequency catheter ablation (RFCA) of right atrial (RA) ganglionated plexi (GP) eliminate vagotonic atrial fibrillation (AF)?
Methods:
Thirty-four patients (mean age 49 years) with vagotonic paroxysmal AF were randomly assigned to undergo selective RFCA of RA GP guided by high-frequency stimulation (HFS) at the posterior and septal right atrium (n = 17) or anatomic ablation at known RA GP sites on the posterior wall and near the superior vena cava and coronary sinus ostium. Serial 24-hour Holter monitoring with assessment of heart rate variability (HRV) was performed during follow-up. The primary endpoint was freedom from AF/flutter.
Results:
In the selective GP ablation group, a mean of six RA GP sites were identified by a vagal response to HFS, and the vagal responses were successfully abolished by RFCA using a mean of 21 minutes of RF energy. In the anatomic GP ablation group, a mean of 39 minutes of RF energy was delivered at key RA sites. The mean duration of follow-up was 20 months. Freedom from AF/flutter at 1 year was significantly lower in the selective ablation group (35%) than in the anatomic ablation group (88%). At 2 years, freedom from AF was 35% versus 70% in the two groups, respectively. HRV parameters were consistent with parasympathetic denervation that was more prominent among patients in the anatomic ablation group and in patients with a successful clinical outcome.
Conclusions:
The authors concluded that anatomic RFCA of RA GP often eliminates vagotonic paroxysmal AF.
Perspective:
The elimination of vagotonic AF without any pulmonary vein isolation provides strong evidence of a major role for RA GP in the pathogenesis of this type of AF.
Keywords: Follow-Up Studies, Coronary Sinus, Pulmonary Veins, Parasympathectomy, Electrocardiography, Autonomic Pathways, Heart Rate, Catheter Ablation, Atrial Flutter, Vena Cava, Superior
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