A Novel Approach to AF Ablation

34 snips

May 16, 2024

In this engaging discussion, Piotr Futima, a cardiac electrophysiologist from Poland, explores innovative approaches to ablate atrial fibrillation (AF). He reveals how pandemic constraints sparked groundbreaking techniques using a single catheter for right atrial ablation, targeting ganglionated plexi without anesthesia. They delve into vagally mediated AF, explaining its link to high vagal tone in younger patients. The conversation raises intriguing questions about the unknown mechanisms of pulmonary vein isolation and the importance of precise patient selection for effective treatment.

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INSIGHT

Ganglionic Plexi Affect AF Beyond Vein Isolation

Ganglionated plexi (GPs) near pulmonary veins mediate parasympathetic input to the heart and can be affected by ablation.
Ablating these GP areas may change vagal tone and explain some PVI benefits beyond electrical isolation.

ADVICE

Select Patients By History And Deceleration Capacity

Identify vagally mediated AF with history (episodes at rest, after meals or sleep) and ECG metrics like deceleration capacity.
Use these criteria to select patients who might benefit from targeted GP ablation instead of full PVI.

INSIGHT

Right-Atrial GP Ablation Is Minimal And Targeted

Right-atrial GP ablation skips transseptal puncture and major left atrial risks while targeting parasympathetic inputs.
The procedure is brief, low-energy, and can produce heart rate acceleration indicating vagal attenuation.

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A few short words about our conversation:

Two decades have passed and electrophysiologists have learned little about how to ablate atrial fibrillation. Now, and then, we simply ablate circles around the orifices of the pulmonary veins.

This works reasonably well. But we don’t—exactly—know why it works. For instance, some patients have total elimination of AF, but when they are restudied, they have reconnection of PV activity.

Observations like these suggest there is something else happening with our ablations—beyond building an electric fence around the veins.

One possibility is that we are affecting the neural input to the heart. Structures called ganglionic plexi sit next to the areas we ablate. We often see heart rate increases after AF ablation. Say, from 60 to 80 bpm. That’s because ablation has reduced parasympathetic input to the heart.

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Piotr and his team had to suspend typical AF ablation during the pandemic. Surgeons would not provide backup. This gave them the idea of a simple approach—only in the right atrium, with one catheter, and no anesthesia. It turns out that there is often a ganglionic plexus in the upper right atrium.

They found patients who had a history of vagally-mediated AF. They documented that these patients had high vagal tone. And… in these patients, simple ablation in the RA yielded a signal of benefit, a reduction of AF. Wow.

It’s a small single-center study. It’s just a signal. A first mile of a marathon. But for the curious regarding AF, it is super-interesting.

Many athletes and young people have vagally-mediated AF.

Here is the link to the paper: Cardioneuroablation of Right Anterior Ganglionated Plexus for Treatment of Vagally Mediated Paroxysmal Atrial Fibrillation

Here is Piotr. He works in Rzeszów, Poland. It’s a beautiful city to visit. I once ran a marathon there. JMM

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