Musikantow Daniel R, Neuzil Petr, Petru Jan, Koruth Jacob S, Kralovec Stepan, Miller Marc A, Funasako Mortioshi, Chovanec Milan, Turagam Mohit K, Whang William, Sediva Lucie, Dukkipati Srinivias R, Reddy Vivek Y
Icahn School of Medicine at Mount Sinai, New York, New York, USA.
Homolka Hospital, Prague, Czech Republic.
JACC Clin Electrophysiol. 2023 Apr;9(4):481-493. doi: 10.1016/j.jacep.2022.10.028. Epub 2022 Nov 30.
During atrial fibrillation ablations using thermal energy, the treatment effect is attributed to not just pulmonary vein isolation (PVI), but also to modulation of the autonomic nervous system by ablation of cardiac ganglionated plexi (GP).
This study sought to assess the impact of pulsed field ablation (PFA) on the GP in patients undergoing PVI.
In the retrospective phase, heart rate was assessed pre- versus post-PVI using PFA, cryoballoon ablation, or radiofrequency ablation. In the prospective phase, a pentaspline PFA catheter was used in a protocol: 1) pre-PFA, high-frequency stimulation (HFS) identified GP sites by vagal effects; 2) PVI was performed assessing for repetitive vagal effects over each set of PF applications; 3) mapping defined PVI extent to identify those GP in the ablation zone; and 4) repeat HFS at GP sites to assess for persistence of vagal effects.
Between baseline and 3 months, heart rates in the retrospective radiofrequency ablation (n = 40), cryoballoon (n = 40), and PFA (n = 40) cohorts increased by 8.9 ± 11.4, 11.1 ± 9.4, and -0.1 ± 9.2 beats/min, respectively (P= 0.01 PFA vs radiofrequency ablation; P= 0.01 PFA vs cryoballoon ablation). In the prospective phase, pre-PFA HFS in 20 additional patients identified 65 GP sites. During PFA, vagal effects were noted in 45% of first PF applications, persisting through all applications in 83%. HFS post-PFA reproduced vagal effects in 29 of 38 sites (76%) in low-voltage tissue.
PFA has minimal effect on GP. Unlike with thermal ablation, the mechanism by which PFA treats atrial fibrillation is mediated solely by durable PVI.
在使用热能进行心房颤动消融期间，治疗效果不仅归因于肺静脉隔离（PVI），还归因于心房神经节丛（GP）消融对自主神经系统的调节作用。
本研究旨在评估脉冲场消融（PFA）对接受PVI治疗患者的GP的影响。
在回顾性阶段，使用PFA、冷冻球囊消融或射频消融评估PVI前后的心率。在前瞻性阶段，按照以下方案使用五边形PFA导管：1）在PFA前，通过迷走效应高频刺激（HFS）识别GP部位；2）进行PVI，评估每组PF应用中的重复性迷走效应；3）标测确定PVI范围，以识别消融区内的GP；4）在GP部位重复HFS，以评估迷走效应的持续性。
在基线和3个月之间，回顾性射频消融组（n = 40）、冷冻球囊组（n = 40）和PFA组（n = 40）的心率分别增加了8.9±11.4、11.1±9.4和-0.1±9.2次/分钟（P = 0.01，PFA与射频消融相比；P = 0.01，PFA与冷冻球囊消融相比）。在前瞻性阶段，另外20例患者在PFA前进行HFS，识别出65个GP部位。在PFA期间，45%的首次PF应用中出现迷走效应，83%的应用中迷走效应持续存在。PFA后，HFS在低电压组织中的38个部位中的29个（76%）重现了迷走效应。
PFA对GP的影响最小。与热消融不同，PFA治疗心房颤动的机制仅由持久的PVI介导。
