Ganglionated plexi ablation with pulmonary vein isolation after testing dormant pulmonary vein conduction and excluding non-pulmonary triggers in patients with paroxysmal atrial fibrillation

Background. Pulmonary vein isolation (PVI) is the gold standard of interventional atrial fibrillation (AF) treatment, however, it doesn't provide a stable clinical effect and durable PVI in the long-term follow-up due to reconnections within the ablation line. To increase the efficacy of surgery, modulation of the autonomic nervous system can be combined with pulmonary vein isolation. Aim. The study was focused on the evaluation of efficacy of ganglionated plexi (GP) ablation combined with PVI, and intraoperative drug testing of dormant pulmonary vein conduction and exclusion of non-pulmonary vein triggers in patients with paroxysmal atrial fibrillation. Methods. There hundred sixty-seven patients with paroxysmal AF scheduled for catheter ablation were initially screened. PVI was performed in all patients. After testing with adenosine triphosphate and isoprenaline for dormant conduction following PVI and exclusion of non-pulmonary vein triggers, 194 patients with a positive response to high-frequency stimulation in the main GP sites of the left atrium were randomized in two groups: PVI (group I, n = 97), PVI with anatomical GP ablation (group II, n = 97). To perform continuous ECG monitoring, 53 patients received implantable cardiac monitors. The primary endpoint of the study was the freedom from any atrial tachyarrhythmias after 12 months of follow- up as recorded by 24-hour Holter monitoring. The secondary endpoints included AF burden based on implantable cardiac monitors data and predictors of AF recurrences. The patients were followed 3, 6, 9, 12 months after the ablation procedure. Results. The mean follow-up was 12.5±2.2 months. By the end of the follow-up, 79 (81.4%) patients in the PVI with GP ablation group and 58 (59.8%) patients in the PVI only group were free from any atrial tachyarrhythmia (р=0.0012; log-rank test, HR 0.41, 95% CI [0.23–0.72], р=0.002; Cox regression). Implantable cardiac monitors data revealed that AF burden was significantly lower in the PVI with GP group as compared with the PVI only group (14.8±1.7% and 5.4±0.7%, р<0.001). According to the multivariable regression analysis, the independent predictors of AF recurrences were AF duration and presence of diabetes mellitus, while GP ablation reduced the risk of AF recurrence by 61%. Conclusion. Ganglionated plexi ablation combined with pulmonary vein isolation confirmed by testing dormant conduction and excluding non-pulmonary triggers provides higher efficacy in maintaining the sinus rhythm as compared with PVI only in patients with paroxysmal atrial fibrillation. Received 17 July 2018. Revised 7 August 2018. Accepted 10 August 2018. Funding: The study did not have sponsorship. Conflict of interest: Authors declare no conflict of interest. Author contributions Conception and study design: Yu.S. Krivosheev, L.I. Vilenskiy, V.N. Kolesnikov Data collection and analysis: Yu.S Krivosheev, D.I. Bashta, A.A. Simonyan Drafting the article: Yu.S. Krivosheev, A.A. Simonyan, D.I. Bashta, S.Yu. Krasilnikova Critical revision of the article: V.N. Kolesnikov Final approval of the version to be published: Yu.S. Krivosheev, D.I. Bashta, A.A. Simonyan, S.Yu. Krasilnikova, L.I. Vilenskiy, T.A. Myznikova, Z.A. Mishodzheva, V.N. Kolesnikov