Predictors of cardiac neuromodulation achieved by cryoballoon ablation performed in patients with atrial fibrillation who were in sinus rhythm before the ablation

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Highlights

  • Cryoballoon ablation may have a role on intrinsic cardiac autonomic nervous system.

  • Vagal denervation with cryoballoon ablation may contribute to the clinical outcome.

  • Clinical and procedural factors can predict heart rate increase after the procedure.

  • Significant heart rate increase is associated with fewer arrhythmic recurrences.

Abstract

Background

The impact of pulmonary vein isolation (PVI) performed with cryoballoon (CB) on the intrinsic cardiac autonomic nervous system (ICANS) remains unclear.

Objective

The purpose of this study was to evaluate the predictors and the clinical meaning of cardiac neuromodulation achieved by CB-ablation as assessed by sinus heart rate (HR) response after the procedure.

Methods

Patients who underwent CB-ablation for drug-resistant atrial fibrillation (AF) from January 2014 to October 2018 were included. Twelve‑leads rest ECG was taken both before and after the procedure. After discharge, patients were scheduled for follow-up visits at 1, 3, 6, and 12 months and 24 h Holter recordings were obtained at each follow-up visit. All documented AF episodes of >30 s were considered as recurrence.

Results

Four-hundred seventy-two patients (62.3% male, age 56.7 ± 13.6 years, 97.2% paroxysmal AF) were included. Mean HR before the procedure was 60.17 ± 10.4 bpm, while the morning after the procedure mean HR was 75.48 ± 12.0 bpm. Age at enrollment (R = −0.26; p < 0.001), baseline HR before the CB-A (R = −0.32; p < 0.001), nadir temperature in each right pulmonary vein (R = −0.11, p = 0.022; R = −0.16; p = 0.001) were significantly associated with the ∆HR. At 2-year follow-up, freedom from recurrences was 83.1% for the patients with HR increase ≥15 bpm after CB-A and 66.3% in patients with HR increase ˂15 bpm (p = 0.021).

Conclusion

Sinus HR increase is a frequent phenomenon after CB-A, that can be predicted by both clinical and procedural factors and that correlates with better outcome after cryo-PVI.

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.

References (33)

  • J.R. Stratton et al.

    Effects of aging on cardiovascular responses to parasympathetic withdrawal

    J. Am. Coll. Cardiol.

    (2003 Jun 4)
  • H. Calkins et al.

    2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation: executive summary

    J. Interv. Card. Electrophysiol.

    (2017 Oct)
  • D. Mörtsell et al.

    Cryoballoon vs. radiofrequency ablation for atrial fibrillation: a study of outcome and safety based on the ESC-EHRA atrial fibrillation ablation long-term registry and the Swedish catheter ablation registry

    Europace.

    (2019 Apr 1)
  • R. Providencia et al.

    Results from a multicentre comparison of cryoballoon vs. radiofrequency ablation for paroxysmal atrial fibrillation: is cryoablation more reproducible?

    Europace.

    (2017 Jan)
  • C. Pappone et al.

    Pulmonary vein denervation enhances long-term benefit after circumferential ablation for paroxysmal atrial fibrillation

    Circulation.

    (2004 Jan 27)
  • H. Yorgun et al.

    Additional benefit of cryoballoon-based atrial fibrillation ablation beyond pulmonary vein isolation: modification of ganglionated plexi

    Europace.

    (2014 May)
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    Maj Riccardo and Borio Gianluca contributed equally to the work as co-first authors.

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