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Funding Acknowledgements Type of funding sources: None. Background. The  differentiation  between  vagally  and  non-vagally mediated  atrial fibrillation (AF)  could be useful  to decide  adding  ganglionated  plexi  ablation  (GPA)  to  pulmonary vein isolation (PVI)  in  patients with vagally mediated  AF  onset. The role of the autonomic nervous system in triggering paroxysmal AF can be analyzed through heart rate variability (HRV) parameters. The low frequency/high frequency ratio (LF/HF) is used as an index of sympatho-vagal interaction. Based on clinical criteria, values of LF/HF &amp;lt;1.5 are considered to reflect an increase of vagal modulation.  Purpose Identify  patients with paroxysmal AF who may benefit from GPA in addition to PVI, based on analysis of HRV parameters Material and methods From our database of unselected Holter recordings containing paroxysmal AF episodes, 199 analyzable AF onsets were labelled. We analyzed HRV frequential parameters by segments every 300 RR intervals to identify adrenergic and vagal onsets of AF episodes. We categorized AF onsets, depending of their respective values of LF/HF. We also checked the relationship of these parameters to heart rate (HR). We followed the evolution of the mean normalized values of LF/HF from the beginning of the recordings to the AF onsets (see figure). Results We found a progressive increase of LF/HF  in normalized units  (mean [95% confidence interval]) from  2.44  [2.12-2.76]  to 3.12  [2.85-3.39]  in the adrenergic group  (n = 113)  and a  progressive decrease of LF/HF from  1.51 [1.28-1.75]  to 1.02 [0.95-1.09]  in the  vagal group (n = 86). Differences between adrenergic and vagal AF were highly significant using Mann-Whitney test (p &amp;lt; 0.001). A given patient shows the same type of AF in 80% of cases.  We found no correlation between frequential parameters and HR. Conclusions Our data show  potential  added value of  frequential  HRV  analysis  to  guide additional ganglionated  plexi ablation  to PVI. This  remains  to be demonstrated in a prospective study. The ratio LF/HF should be  considered  to optimize the decision-making process for  the ablation procedure. Abstract Figure. Frequential HRV parameters before AF

Potential value of the low frequency/high frequency ratio of heart rate variability to guide atrial fibrillation ablation procedures