title: Selective atrial vagal denervation guided by spectral mapping to treat advanced atrioventricular block.
abstract: OBJECTIVE
  Asymptomatic nocturnal long ventricular pauses are usually detected accidentally and it has been suggested that they may lead to sudden death. Identification of predisposing factors could prevent cardiovascular events.
  
  
  RESULTS
  We report the case of a patient with frequent asymptomatic nocturnal ventricular pauses of 3-11 s, characteristic of a vagally mediated atrioventricular (AV) block. Echocardiography, treadmill test, thyroid function test levels, and polysomnogram were normal. In an attempt to reduce the risk, it was decided that an atrial vagal denervation induced by radiofrequency (RF) ablation (cardioneuroablation) could be useful. Spectral mapping was used to localize endocardial vagal innervation in the right and left aspects of the inter-atrial septum, responsible for the sinus node and AV node modulation, and RF pulses were applied in those sites only. After finishing the procedure, significant changes were observed in the heart rate (66-90 b.p.m.), atrial-His interval (115-74 ms), Wenckebach cycle length (820-570 ms), and sinus node recovery time (1100-760 ms). Follow-up Holter recording demonstrated that the number of ventricular pauses had reduced from 438 to 0. Heart rate and time domain characteristics were compatible with vagal denervation.
  
  
  CONCLUSIONS
  Ablation of the endocardial vagal innervation sites seems to be safe and efficient in reducing the frequency and the length of the ventricular pauses. It was possible by identifying certain spectral components of the atrial electrogram, resulting in a conservative approach.
authors.affiliation: Unidade Clínica de Arritmia, Heart Institute, University of São Paulo Medical School, Av Dr Eneas Carvalho de Aguiar 44, CEP 05403-000 São Paulo, Brazil Totalcor Hospital, São Paulo, Brazil esteban.rivarola@incor.usp.br.
authors.forename: Esteban
authors.initials: E
authors.lastname: Rivarola
authors.affiliation: Unidade Clínica de Arritmia, Heart Institute, University of São Paulo Medical School, Av Dr Eneas Carvalho de Aguiar 44, CEP 05403-000 São Paulo, Brazil Totalcor Hospital, São Paulo, Brazil.
authors.forename: Carina
authors.initials: C
authors.lastname: Hardy
authors.affiliation: Unidade Clínica de Arritmia, Heart Institute, University of São Paulo Medical School, Av Dr Eneas Carvalho de Aguiar 44, CEP 05403-000 São Paulo, Brazil Totalcor Hospital, São Paulo, Brazil.
authors.forename: Eduardo
authors.initials: E
authors.lastname: Sosa
authors.affiliation: Unidade Clínica de Arritmia, Heart Institute, University of São Paulo Medical School, Av Dr Eneas Carvalho de Aguiar 44, CEP 05403-000 São Paulo, Brazil Totalcor Hospital, São Paulo, Brazil.
authors.forename: Denise
authors.initials: D
authors.lastname: Hachul
authors.affiliation: Totalcor Hospital, São Paulo, Brazil.
authors.forename: Valter
authors.initials: V
authors.lastname: Furlan
authors.affiliation: Unidade Clínica de Arritmia, Heart Institute, University of São Paulo Medical School, Av Dr Eneas Carvalho de Aguiar 44, CEP 05403-000 São Paulo, Brazil.
authors.forename: Fabrizio
authors.initials: F
authors.lastname: Raimundi
authors.affiliation: Unidade Clínica de Arritmia, Heart Institute, University of São Paulo Medical School, Av Dr Eneas Carvalho de Aguiar 44, CEP 05403-000 São Paulo, Brazil Totalcor Hospital, São Paulo, Brazil.
authors.forename: Mauricio
authors.initials: M
authors.lastname: Scanavacca
mesh_terms: D000200:Action Potentials; D000328:Adult; D054537:Atrioventricular Block / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D017115:Catheter Ablation; D015716:Electrocardiography, Ambulatory; D022062:Electrophysiologic Techniques, Cardiac; D004699:Endocardium / Q000294:innervation*; D006325:Heart Atria / Q000294:innervation*; D006339:Heart Rate; D006801:Humans; D008297:Male; D011237:Predictive Value of Tests; D012815:Signal Processing, Computer-Assisted; D013997:Time Factors; D016896:Treatment Outcome; D014628:Vagotomy / Q000379:methods*; D014630:Vagus Nerve / Q000503:physiopathology / Q000601:surgery*
keywords: Atrioventricular block; Cardioneuroablation; Spectral mapping; Vagal denervation