Abstract 3504: Feasibility of Ablation of Ganglionated Plexi with Pulmonary Vein Antrum Isolation for Ablation of Paroxysmal and Persistent Atrial Fibrillation
Canine studies suggest that activity from autonomic ganglionated plexi (GP) plays an important role in initiation and maintenance of atrial fibrillation (AF). Endocardial ablation of left atrial (LA) GP in dogs eliminates shortening of atrial refractoriness and AF inducibility produced by high frequency stimulation (HFS) of GP. In man, the 4 LA GP are located in epicardial fat pads outside the pulmonary vein (PV) antra. Wide PV antrum isolation does not include all GP areas. The purpose of this study was to test the feasibility of GP ablation by adding it to PV antrum isolation.
Methods and Results: Study population consisted of 72 pts undergoing catheter ablation of paroxysmal (47 pts) or persistent (25 pts) AF. 57 (79%) pts had structural heart disease. Median LA size was 4.7 cm. An electroanatomical map of the LA and each PV was obtained during AF or coronary sinus pacing. HFS (cycle length 50 ms, 12 Volts, pulse width 1–10 ms) localized the 4 LA GP at sites of vagal response (>50% increase of mean R-R interval during AF). The vagal response to HFS was eliminated at all GP sites by 1–11 (median 4) RF applications using an irrigated electrode at 20–35 Watts. GP ablation eliminated PV firing in 46/65 (71%) pts. Left and right PV antrum isolation was then achieved in all 72 pts with 9–69(median 24) and 5–51 (median 21) RFs. The absence of PV potentials was confirmed by Lasso recordings. Ablation of typical atrial flutter (AFL) and atrial tachycardia (AT) was also performed in 38/72 and 35/72 pts, respectively. Following the single ablation procedure, the number of pts free of symptomatic AF at 1, 3, 6 and 12 months was 58/72 (81%), 52/64 (81%), 47/56 (84%), and 35/38 (92%), respectively, and the number of pts free of symptomatic AF, AT and AFL was 47/72 (65%), 44/64 (69%), 42/56 (75%), and 33/38 (87%), respectively. Number of pts free of AF/AT/AFL off antiarrhythmic drugs was 43/47, 40/44, 39/42 and 31/33 pts, respectively.
Conclusions: The 4 LA GP can be identified by HFS and vagal response to HFS and can be consistently eliminated by endocardial RF ablation in pts with paroxysmal and persistent AF. A single procedure of GP ablation plus antrum isolation is highly effective in eliminating symptomatic AF/AT/AFL. Symptomatic AF/AT/AFL recurrences decreased progressively at 1, 3, 6, and 12 months.