title: Vagal responses induced by endocardial left atrial autonomic ganglion stimulation before and after pulmonary vein antrum isolation for atrial fibrillation.
abstract: BACKGROUND
  Elimination of vagal inputs into the left atrium (LA) may be necessary for successful catheter ablation of atrial fibrillation (AF). These vagal inputs are clustered in autonomic ganglia (AG) that are close to the pulmonary vein antrum (PVA) borders, but whether standard intracardiac echocardiography (ICE)-guided PVA isolation (PVAI) affects these inputs is unknown.
  
  
  OBJECTIVE
  The purpose of this study was to assess whether standard ICE-guided PVAI affects vagal responses induced by endocardial AG stimulation in the LA.
  
  
  METHODS
  Twenty consecutive patients undergoing first-time PVAI (group 1) and 20 consecutive patients undergoing repeat PVAI for AF recurrence (group 2) were enrolled in the study. Before ablation, electrical stimulation (20 Hz, pulse duration 10 ms, voltage range 12-20 V) was performed through an 8-mm-tip ablation catheter. Based on prior data, regions around all four PVA borders were carefully mapped and stimulated to localize AG inputs. A positive stimulated vagal response was defined as atrioventricular (AV) block, asystole, or increase in mean RR interval by >50%. Locations of positive vagal responses were recorded wth biplane fluoroscopy and CARTO. All patients then underwent standard ICE-guided PVAI by an operator blinded to the locations of vagal responses. Stimulation of the AG locations was then repeated postablation.
  
  
  RESULTS
  Patients (age 54 +/- 11 years, 30% female, ejection fraction 54% +/- 7%) had a history of paroxysmal (75%) and persistent (25%) AF. In group 1, vagal responses were induced in all 20 patients around a mean of 3.8 +/- 0.4 PVAs per patient. The most common response was asystole (53%), mean RR slowing >50% (28%), and AV block (20%). Postablation, vagal responses could no longer be induced in all 20 patients. A diminished response was induced (RR slowing <50%) in 2/20 patients around one PVA each. In group 2, vagal responses were not induced in any of the 20 repeat patients. Stimulation capture postablation was confirmed because transient, nonsustained (<30 seconds) AF or atrial flutter was induced in all 40 patients with stimulation, whether vagal responses were induced or not.
  
  
  CONCLUSIONS
  Standard ICE-guided PVAI eliminates vagal responses induced by AG stimulation. Responses are not seen in patients presenting for repeat PVAI, despite clinical recurrence of AF.
authors.affiliation: Cleveland Clinic Foundation, Section of Electrophysiology, Cleveland, Ohio 44195, USA.
authors.forename: Atul
authors.initials: A
authors.lastname: Verma
authors.forename: Walid I
authors.initials: WI
authors.lastname: Saliba
authors.forename: Dhanumjaya
authors.initials: D
authors.lastname: Lakkireddy
authors.forename: J David
authors.initials: JD
authors.lastname: Burkhardt
authors.forename: Jennifer E
authors.initials: JE
authors.lastname: Cummings
authors.forename: Oussama M
authors.initials: OM
authors.lastname: Wazni
authors.forename: William A
authors.initials: WA
authors.lastname: Belden
authors.forename: Sergio
authors.initials: S
authors.lastname: Thal
authors.forename: Robert A
authors.initials: RA
authors.lastname: Schweikert
authors.forename: David O
authors.initials: DO
authors.lastname: Martin
authors.forename: Patrick J
authors.initials: PJ
authors.lastname: Tchou
authors.forename: Andrea
authors.initials: A
authors.lastname: Natale
mesh_terms: D000328:Adult; D000368:Aged; D001281:Atrial Fibrillation / Q000000981:diagnostic imaging / Q000601:surgery*; D016275:Atrial Function; D017115:Catheter Ablation / Q000379:methods*; D003131:Combined Modality Therapy; D004452:Echocardiography / Q000379:methods; D004558:Electric Stimulation; D005260:Female; D005500:Follow-Up Studies; D006329:Heart Conduction System / Q000000981:diagnostic imaging / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D010275:Parasympathetic Nervous System / Q000503:physiopathology; D011667:Pulmonary Veins / Q000000981:diagnostic imaging / Q000601:surgery*; D025321:Surgery, Computer-Assisted / Q000379:methods*; D016896:Treatment Outcome