title: Autonomic denervation added to pulmonary vein isolation for paroxysmal atrial fibrillation: a randomized clinical trial.
abstract: OBJECTIVE
  The aim of this study was to investigate whether the combination of conventional pulmonary vein isolation (PVI) by circumferential antral ablation with ganglionated plexi (GP) modification in a single ablation procedure, yields higher success rates than PVI or GP ablation alone, in patients with paroxysmal atrial fibrillation (PAF).
  
  
  BACKGROUND
  Conventional PVI transects the major left atrial GP, and it is possible that autonomic denervation by inadvertent GP ablation plays a central role in the efficacy of PVI.
  
  
  METHODS
  A total of 242 patients with symptomatic PAF were recruited and randomized as follows: 1) circumferential PVI (n = 78); 2) anatomic ablation of the main left atrial GP (n = 82); or 3) circumferential PVI followed by anatomic ablation of the main left atrial GP (n = 82). The primary endpoint was freedom from atrial fibrillation (AF) or other sustained atrial tachycardia (AT), verified by monthly visits, ambulatory electrocardiographic monitoring, and implantable loop recorders, during a 2-year follow-up period.
  
  
  RESULTS
  Freedom from AF or AT was achieved in 44 (56%), 39 (48%), and 61 (74%) patients in the PVI, GP, and PVI+GP groups, respectively (p = 0.004 by log-rank test). PVI+GP ablation strategy compared with PVI alone yielded a hazard ratio of 0.53 (95% confidence interval: 0.31 to 0.91; p = 0.022) for recurrence of AF or AT. Fluoroscopy duration was 16 ± 3 min, 20 ± 5 min, and 23 ± 5 min for PVI, GP, and PVI+GP groups, respectively (p < 0.001). Post-ablation atrial flutter did not differ between groups: 5.1% in PVI, 4.9% in GP, and 6.1% in PVI+GP. No serious adverse procedure-related events were encountered.
  
  
  CONCLUSIONS
  Addition of GP ablation to PVI confers a significantly higher success rate compared with either PVI or GP alone in patients with PAF.
authors: Department of Cardiology, Athens Euroclinic, Athens, Greece. Electronic address: dkatritsis@euroclinic.gr.
authors: Demosthenes G
authors: DG
authors: Katritsis
authors: Arrhythmia Department, State Research Institute of Circulation Pathology, Novosibirsk, Russia.
authors: Evgeny
authors: E
authors: Pokushalov
authors: Arrhythmia Department, State Research Institute of Circulation Pathology, Novosibirsk, Russia.
authors: Alexander
authors: A
authors: Romanov
authors: Department of Cardiology, Athens Euroclinic, Athens, Greece.
authors: Eleftherios
authors: E
authors: Giazitzoglou
authors: Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece.
authors: George C M
authors: GC
authors: Siontis
authors: Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.
authors: Sunny S
authors: SS
authors: Po
authors: Cardiac and Vascular Sciences, St. George's, University of London, London, United Kingdom.
authors: A John
authors: AJ
authors: Camm
authors: Stanford Prevention Research Center, Department of Medicine, and Department of Health Research and Policy, Stanford University School of Medicine, and Department of Statistics, Stanford University School of Humanities and Sciences, Stanford, California.
authors: John P A
authors: JP
authors: Ioannidis
mesh_terms: D055011:Ablation Techniques; D000328:Adult; D000368:Aged; D001281:Atrial Fibrillation / Q000601:surgery*; D017763:Autonomic Denervation / Q000379:methods*; D022062:Electrophysiologic Techniques, Cardiac; D005260:Female; D005725:Ganglia, Autonomic / Q000000981:diagnostic imaging / Q000601:surgery; D006325:Heart Atria / Q000294:innervation; D006801:Humans; D008297:Male; D008875:Middle Aged; D011667:Pulmonary Veins / Q000601:surgery*; D013614:Tachycardia, Paroxysmal / Q000601:surgery*; D036542:Tomography, Spiral Computed
keywords: AF; AT; CI; GP; HFS; ILR; PAF; PV; PVI; RF; atrial fibrillation; atrial tachycardia; catheter ablation; confidence interval; ganglionated plexi; high-frequency stimulation; implantable loop recorder; paroxysmal atrial fibrillation; pulmonary vein; pulmonary vein isolation; radiofrequency