Postgraduate Program in Cardiac Electrophysiology and Pacing, Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium.
J Cardiovasc Electrophysiol. 2023 Nov;34(11):2393-2397. doi: 10.1111/jce.16089. Epub 2023 Oct 4.
Pulmonary vein isolation (PVI) with thermal energy is characterized by concomitant ablation of the surrounding ganglionated plexi (GP). Pulsed-field ablation (PFA) selectively targets the myocardium and seems associated with only negligible effects on the autonomic nervous system (ANS). However, little is known about the dynamic effects of PFA on the GP immediately after PVI. This study sought to investigate the degree and acute vagal modulation induced by the Farapulse PFA system during PVI compared with single-shot thermal ablation.
A total of 76 patients underwent first-time PVI with either Farapulse PFA (PFA group, n = 40) or cryoballoon ablation (thermal ablation group, n = 36) for paroxysmal atrial fibrillation (AF). The effect on the ANS in the two groups was assessed before and after PVI with extracardiac vagal stimulation (ECVS). To capture any transient effects of PFA on the ANS, in a subgroup of PFA patients ECVS was repeated at three predefined timepoints: (1) before PVI (T0); (2) immediately after PVI (T1); and (3) 10 min after the last energy application (T2).
Despite similar baseline values, the vagal response induced by ECVS after PVI almost disappeared in the thermal ablation group but persisted in the PFA group (thermal group: 840 [706-1090] ms, p < .001 compared to baseline; PFA group: 11 466 [8720-12 293] ms, p = .70 compared to baseline). Intraprocedural vagal reactions (defined as RR increase >50%, transitory asystole, or atrioventricular block) occurred more frequently with PFA than thermal ablation (70% vs. 28%, p = .001). Moreover, heart rate 24 h post-PVI increased more with thermal ablation than with PFA (16.5 ± 9.0 vs. 2.6 ± 6.1 beats/min, p < .001). In the subgroup of PFA patients undergoing repeated ANS modulation assessment (n = 11), ECVS demonstrated that PFA determined a significant acute suppression of the vagal response immediately after PVI (p < .001 compared to baseline), which recovered almost completely within 10 min.
PVI with the Farapulse PFA system is associated with only transitory and short-lasting vagal effects on the ANS which recover almost completely within a few minutes after ablation. The impact of this phenomenon on AF outcome needs to be further investigated.
热消融联合肺静脉隔离（PVI）时，消融能量会同时作用于周围的神经节丛（GP）。脉冲场消融（PFA）则选择性地靶向心肌，似乎对自主神经系统（ANS）只有很小的影响。然而，关于 PFA 在 PVI 后即刻对 GP 的动态影响知之甚少。本研究旨在比较 Farapulse PFA 系统与单次热消融治疗阵发性心房颤动（AF）时，PVI 对 GP 产生的程度和急性迷走神经调制作用。
共 76 例首次接受 PVI 的患者被分为 Farapulse PFA 组（n=40）或冷冻球囊消融组（n=36）。在 PVI 前后，采用心外膜迷走神经刺激（ECVS）评估两组患者的 ANS 影响。为了捕捉 PFA 对 ANS 的任何瞬态影响，在 PFA 患者的亚组中，在三个预设时间点重复进行 ECVS：（1）PVI 前（T0）；（2）PVI 后即刻（T1）；和（3）最后一次能量应用后 10 分钟（T2）。
尽管基线值相似，但 PVI 后 ECVS 诱导的迷走神经反应在热消融组几乎消失，但在 PFA 组持续存在（热消融组：840[706-1090]ms，p<0.001 与基线相比；PFA 组：11466[8720-12293]ms，p=0.70 与基线相比）。术中迷走神经反应（定义为 RR 增加>50%、短暂窦性停搏或房室传导阻滞）在 PFA 组比热消融组更常见（70% vs. 28%，p=0.001）。此外，PVI 后 24 小时的心率变化在热消融组比 PFA 组更明显（16.5±9.0 vs. 2.6±6.1 次/分钟，p<0.001）。在接受重复 ANS 调制评估的 PFA 患者亚组（n=11）中，ECVS 显示 PFA 导致 PVI 后即刻出现明显的短暂迷走神经反应抑制（p<0.001 与基线相比），在 10 分钟内几乎完全恢复。
Farapulse PFA 系统联合 PVI 治疗阵发性心房颤动时，仅对 ANS 产生短暂且短暂的迷走神经影响，消融后几分钟内几乎完全恢复。这种现象对 AF 结果的影响需要进一步研究。
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