Predictors of cardiac neuromodulation achieved by cryoballoon ablation performed in patients with atrial fibrillation who were in sinus rhythm before the ablation
Introduction
Cryoballoon ablation (CB-A) is nowadays an established treatment option for patients with atrial fibrillation (AF) who are refractory to drug-based treatment [1], showing satisfying results also as a first-line treatment for symptomatic AF [2]. Data on both safety and outcomes of pulmonary vein isolation (PVI) performed with CB-A has shown similar complication rates and no difference in terms of freedom from arrhythmia recurrence when compared to radiofrequency (RF) energy [3], with more reproducible results in the setting of paroxysmal AF ablation compared to RF ablation [4]. Still, although some grade of vagal denervation during PVI performed with RF energy has been described since few years [5], the impact of CB-A on the intrinsic cardiac autonomic nervous system (ICANS) (i.e., the ganglionated plexi [GPs]) is still not yet perfectly understood. Moreover, the GPs located between the left atrium (LA) and the pulmonary vein (PV) junction, which are part of the cardiac autonomic nervous system (ANS), may have an important role in the initiation and maintenance of AF [6]. Despite some initial evidences on the effect of CB-A on the cardiac ANS [[7], [8]], still, to the best of our knowledge, data on clinical and procedural predictors of vagal denervation during CB-A are lacking. In the present study, we retrospectively analyzed the acute response of sinus heart rate (HR) after CB-A performed with the second-generation version of the CB-A (Arctic Front Advance, Medtronic, Minneapolis, USA) in a large cohort of patients.
Section snippets
Aim of the study
The main aim of the study was to analyze the acute response (≈24 h) of sinus HR, as a marker of considerable effect on cardiac autonomic nervous system, after PVI performed with the second-generation cryoballoon (CB) in a series of consecutive patients with drug-resistant paroxysmal or persistent AF.
Inclusion criteria
Patients having undergone CB-A for paroxysmal or persistent AF from January 2014 to October 2018 were consecutively included in our analysis.
Exclusion criteria
The exclusion criteria were any contraindication for the
Baseline population characteristics
Four-hundreds seventy-two patients with a diagnosis of either paroxysmal or persistent AF, who had failed at least one AAD before undergoing CB-A AF ablation were analyzed (294 males [62.3%], mean age 56.7 ± 13.6 years). Most patients were diagnosed with paroxysmal AF (459 patients [97.2%]). Mean LA diameter was 40.2 ± 6.6 mm, mean LV ejection fraction (EF) was 60.3 ± 7.0%; 21 patients showed reduced LV systolic function at the pre-procedural TTE. No patient was excluded due to anatomical
Discussion
To the best of our knowledge, this is the first study reporting the clinical and procedural predictors of the acute response of sinus HR after CB-A performed with the second-generation CB in patients affected by paroxysmal or persistent AF. The main findings of our study are that CB-A is associated with a mean increase of 15.31 ± 10.3 bpm measured on the surface ECG the next day of the procedure and that this increase in sinus HR is correlated with clinical and procedural factors such as age of
Limitations
First, this study represents a large, nonrandomized retrospective single-center analysis of patients undergoing CB-A using second-generation CB in the conventional approach this procedure has been performed throughout these years in our center; the acute effect of cardiac neuromodulation results therefore as a secondary purpose gained with the procedure, whose main goal was PVI. Second and consequently, the LA GPs were not identified before the applications nor specifically targeted during the
Conclusions
Sinus HR increase is a frequent phenomenon after CB-A, most probably related to the involvement of GPs during cryo-applications. Both clinical (age at enrollment, baseline HR before the CB-A) and procedural factors (nadir temperature in each right PVs) can predict the acute response of HR after CB-A. Post-AF ablation increased sinus HR may also be associated with lower AF recurrence after catheter ablation. Future studies are needed to enlighten the durability and the clinical impact of the
Declaration of competing interest
Prof. de Asmundis, Prof Brugada, and Prof Chierchia have received consulting fees and speaker honoraria from Medtronic. G.B.C. and C.d.A. have received compensation for teach-ing and proctoring purposes from AF solutions Medtronic.
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Maj Riccardo and Borio Gianluca contributed equally to the work as co-first authors.