Sao Paulo University, Brazil (E.I.P.-M., J.C.P.-M., J.P.-M., R.C.A.).
Heart Hospital, Sao Paulo, Brazil (E.I.P.-M., J.C.P.-M., C.H., T.G.S-P., T.L., C.P., J.P.-M., J.Z.,F.O., R.F.S, R.C.A.).
Circ Arrhythm Electrophysiol. 2020 Apr;13(4):e007900. doi: 10.1161/CIRCEP.119.007900. Epub 2020 Mar 19.
Vagal hyperactivity is directly related to several clinical conditions as reflex/functional bradyarrhythmias and vagal atrial fibrillation (AF). Cardioneuroablation provides therapeutic vagal denervation through endocardial radiofrequency ablation for these cases. The main challenges are neuromyocardium interface identification and the denervation control and validation. The finding that the AF-Nest (AFN) ablation eliminates the atropine response and decreases RR variability suggests that they are related to the vagal innervation.
Prospective, controlled, longitudinal, nonrandomized study enrolling 62 patients in 2 groups: AFN group (AFN group 32 patients) with functional or reflex bradyarrhythmias or vagal AF treated with AFN ablation and a control group (30 patients) with anomalous bundles, ventricular premature beats, atrial flutter, atrioventricular nodal reentry, and atrial tachycardia, treated with conventional ablation (non-AFN ablation). In AFN group, ablation delivered at AFN detected by fragmentation/fractionation of the endocardial electrograms and by 3-dimensional anatomic location of the ganglionated plexus. Vagal response was evaluated before, during, and postablation by 5 s noncontact vagal stimulation at the jugular foramen, through the internal jugular veins (extracardiac vagal stimulation [ECVS]), analyzing 15 s mean heart rate, longest RR, pauses, and atrioventricular block. All patients had current guidelines arrhythmia ablation indication.
Preablation ECVS induced sinus pauses, asystole, and transient atrioventricular block in both groups showing a strong vagal response (=0.96). Postablation ECVS in the AFN group showed complete abolishment of the cardiac vagal response in all cases (pre/postablation ECVS=<0.0001), demonstrating robust vagal denervation. However, in the control group, vagal response remained practically unchanged postablation (=0.35), showing that non-AFN ablation promotes no significant denervation.
AFN ablation causes significant vagal denervation. Non-AFN ablation causes no significant vagal denervation. These results suggest that AFNs are intrinsically related to vagal innervation. ECVS was fundamental to stepwise vagal denervation validation during cardioneuroablation. Visual Overview A visual overview is available for this article.
迷走神经活性与多种临床情况直接相关，如反射/功能性心动过缓以及迷走性心房颤动（AF）。心脏神经消融术通过心内膜射频消融术为这些病例提供治疗性迷走神经切断。主要挑战是神经心肌界面的识别以及去神经支配的控制和验证。AF-Nest（AFN）消融消除了阿托品反应并降低了 RR 变异性的发现表明，它们与迷走神经支配有关。
前瞻性、对照、纵向、非随机研究纳入了 62 例患者，分为 2 组：AFN 组（AFN 组 32 例），接受 AFN 消融治疗功能性或反射性心动过缓或迷走性 AF；对照组（30 例），接受异常束支、室性早搏、心房扑动、房室结折返性心动过速和房性心动过速治疗，接受常规消融（非-AFN 消融）。在 AFN 组中，通过碎裂/分化解剖心内膜电图和通过神经节丛的三维解剖位置来消融 AFN。通过在颈静脉孔处经颈内静脉（心外膜迷走神经刺激 [ECVS]）进行 5 s 无接触迷走神经刺激，在消融前、期间和之后评估迷走神经反应，分析 15 s 平均心率、最长 RR、暂停和房室传导阻滞。所有患者均符合当前指南心律失常消融适应证。
在两组中，ECVS 均引起窦性暂停、停搏和短暂性房室传导阻滞，表明存在强烈的迷走神经反应（=0.96）。在 AFN 组中，消融后所有病例的 ECVS 均完全消除了心脏迷走神经反应（消融前后 ECVS<0.0001），表明有效的迷走神经切断。然而，在对照组中，消融后迷走神经反应基本不变（=0.35），表明非-AFN 消融不会导致明显的去神经支配。
AFN 消融可导致明显的迷走神经切断。非-AFN 消融不会导致明显的迷走神经切断。这些结果表明，AFN 与迷走神经支配有关。ECVS 在心神经消融术中对逐步验证迷走神经去神经支配至关重要。
