Pulsed field ablation-guided cardioneuroablation – experience from the University Hospital Centre Split

    Authors

    Keywords

    cardioneuroablation, pulsed field ablation, vagal denervation, syncope

    DOI

    https://doi.org/10.15836/ccar2024.399

    Full Text

    **Introduction**: Endocardial vagal denervation, known as cardioneuroablation (CNA), is an emerging treatment option for treating conditions associated with symptomatic periods of increased vagal tone such as refractory vasovagal syncope (VVS), functional atrioventricular block, and sinus node dysfunction (SND) (1). The cornerstone of CNA is targeting groups of autonomic ganglia known as ganglionated plexi (GP) (1). Pulsed field ablation (PFA) is a non-thermal form of energy during which a strong electric field delivered to the underlying tissue leads to the opening of pores on the cell membrane, resulting in the destruction of the cell (2). **Patients and Methods**: Cardioneuroablation was performed in symptomatic patients with proven cardioinhibitory reflex. The procedure was performed in deep sedation with propofol, fentanyl and midazolam. Standard transseptal approach was obtained and 3D electroanatomical mapping of the left atrium was preformed prior to the ablation. The presumed anatomical location of the right superior vagal GP was verified by the delivery of focal PFA lesion in anterosuperior aspect of right superior pulmonary vein ostium. The proximity to the ganglion was verified by the induction of transitory sinus bradycardia after PFA delivery. Once the anatomical position was verified, further ablation was performed using radiofrequency energy. Additional consolidation lesions were applied from the right side of interatrial septum. The ablation was considered successful by the lack of vagal response after repeated PFA delivery at the initial position (**Figure 1**) (3). FIGURE 1. An example of the use of pulse field ablation (PFA)-guided cardioneuroablation (CNA) in one patient. *Panel A*: application of PFA (yellow dot) to the anterior superior ostium of the right superior pulmonary vein causes transient sinus bradycardia, indicating proximity to the right superior vagal ganglion. *Panel B*: set of radiofrequency ablation lesions surrounding the initial PFA application site. *Panel C*: after ablation, application of PFA does not induce sinus bradycardia. **Results**: The PFA-guided CNA was performed in 4 patients. In 2 the indication was SND and in other 2 VVS. Acute endpoint was obtained in all patients. During the median follow up period of 12 months all patients remained symptom free (**Table 1**). ### TABLE 1: Cohort of patients treated with cardioneuroablation guided by pulsed field ablation at University Hospital Centre Split. | **Pt.** | **Sex** | **Age** | **Indication** | **Follow up period (months)** | **Recurrence** | | --- | --- | --- | --- | --- | --- | | 001 | F | 35 | Sinus arrest | 14 | NO | | 002 | F | 40 | Vasovagal syncope | 12 | NO | | 003 | M | 42 | Vasovagal syncope | 12 | NO | | 004 | M | 44 | Sinus arrest | 1 | NO | **Conclusion**: A PFA-guided CNA is a safe procedure with promising acute success rate and could be the treatment option for patients with pronounced drug-refractory cardioinhibitory reflex. Larger randomized studies are warranted to assess the procedural success rate and further optimize ablation strategy.

    Literature

    1. Pachon JC, Pachon EI, Aksu T, Gopinathannair R, Kautzner J, Yao Y, et al. Cardioneuroablation: Where are we at? Heart Rhythm O2. 2023 March 21;4(6):401–13. https://doi.org/10.1016/j.hroo.2023.02.007
    2. Davalos RV, Mir IL, Rubinsky B. Tissue ablation with irreversible electroporation. Ann Biomed Eng. 2005 February;33(2):223–31. https://doi.org/10.1007/s10439-005-8981-8
    3. Sikiric I, Jurisic Z, Breskovic T, Juric-Paic M, Berovic N, Kedzo J, et al. Focal pulsed field ablation for guiding and assessing the acute effect of cardioneuroablation. J Interv Card Electrophysiol. 2024 January 29;. https://doi.org/10.1007/s10840-023-01716-4
    Cardiologia Croatica
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    Pulsed field ablation-guided cardioneuroablation – experience from the University Hospital Centre Split

    Extended Abstract
    Issue11-12
    Published
    Pages399-400
    PDF via DOIhttps://doi.org/10.15836/ccar2024.399
    cardioneuroablation
    pulsed field ablation
    vagal denervation
    syncope

    Authors

    Lucija Lisica Kordić*ORCIDUniversity Hospital Centre Split, Split, Croatia
    Ivan SikirićORCIDUniversity Hospital Centre Split, Split, Croatia
    Zrinka JurišićORCIDUniversity Hospital Centre Split, Split, Croatia
    Ante AnićORCIDUniversity Hospital Centre Split, Split, Croatia
    Toni BreškovićORCIDUniversity Hospital Centre Split, Split, Croatia

    *Correspondence email: lucijalisica21@gmail.com

    Full Text

    Introduction: Endocardial vagal denervation, known as cardioneuroablation (CNA), is an emerging treatment option for treating conditions associated with symptomatic periods of increased vagal tone such as refractory vasovagal syncope (VVS), functional atrioventricular block, and sinus node dysfunction (SND) (1). The cornerstone of CNA is targeting groups of autonomic ganglia known as ganglionated plexi (GP) (1). Pulsed field ablation (PFA) is a non-thermal form of energy during which a strong electric field delivered to the underlying tissue leads to the opening of pores on the cell membrane, resulting in the destruction of the cell (2).

    Patients and Methods: Cardioneuroablation was performed in symptomatic patients with proven cardioinhibitory reflex. The procedure was performed in deep sedation with propofol, fentanyl and midazolam. Standard transseptal approach was obtained and 3D electroanatomical mapping of the left atrium was preformed prior to the ablation. The presumed anatomical location of the right superior vagal GP was verified by the delivery of focal PFA lesion in anterosuperior aspect of right superior pulmonary vein ostium. The proximity to the ganglion was verified by the induction of transitory sinus bradycardia after PFA delivery. Once the anatomical position was verified, further ablation was performed using radiofrequency energy. Additional consolidation lesions were applied from the right side of interatrial septum. The ablation was considered successful by the lack of vagal response after repeated PFA delivery at the initial position (Figure 1) (3).

    FIGURE 1. An example of the use of pulse field ablation (PFA)-guided cardioneuroablation (CNA) in one patient. Panel A: application of PFA (yellow dot) to the anterior superior ostium of the right superior pulmonary vein causes transient sinus bradycardia, indicating proximity to the right superior vagal ganglion. Panel B: set of radiofrequency ablation lesions surrounding the initial PFA application site. Panel C: after ablation, application of PFA does not induce sinus bradycardia.

    Results: The PFA-guided CNA was performed in 4 patients. In 2 the indication was SND and in other 2 VVS. Acute endpoint was obtained in all patients. During the median follow up period of 12 months all patients remained symptom free (Table 1).

    TABLE 1: Cohort of patients treated with cardioneuroablation guided by pulsed field ablation at University Hospital Centre Split.

    001
    Sex
    F
    Age
    35
    Indication
    Sinus arrest
    Follow up period (months)
    14
    Recurrence
    NO
    002
    Sex
    F
    Age
    40
    Indication
    Vasovagal syncope
    Follow up period (months)
    12
    Recurrence
    NO
    003
    Sex
    M
    Age
    42
    Indication
    Vasovagal syncope
    Follow up period (months)
    12
    Recurrence
    NO
    004
    Sex
    M
    Age
    44
    Indication
    Sinus arrest
    Follow up period (months)
    1
    Recurrence
    NO

    Conclusion: A PFA-guided CNA is a safe procedure with promising acute success rate and could be the treatment option for patients with pronounced drug-refractory cardioinhibitory reflex. Larger randomized studies are warranted to assess the procedural success rate and further optimize ablation strategy.

    Literature

    1. 1.
      Pachon JC, Pachon EI, Aksu T, Gopinathannair R, Kautzner J, Yao Y, et al. Cardioneuroablation: Where are we at? Heart Rhythm O2. 2023 March 21;4(6):401–13.DOI
    2. 2.
      Davalos RV, Mir IL, Rubinsky B. Tissue ablation with irreversible electroporation. Ann Biomed Eng. 2005 February;33(2):223–31.DOI
    3. 3.
      Sikiric I, Jurisic Z, Breskovic T, Juric-Paic M, Berovic N, Kedzo J, et al. Focal pulsed field ablation for guiding and assessing the acute effect of cardioneuroablation. J Interv Card Electrophysiol. 2024 January 29;.DOI