Cardioneuroablation for treatment of carotid sinus syndrome secondary to oropharyngeal squamous cell cancer.

Head and neck tumors can rarely cause carotid sinus syndrome and this often resolves by surgical intervention or palliative chemoradiotherapy. If these modalities are not an option or are ineffective, the most preferred treatment is permanent pacemaker therapy. Here, we present the first case of cardioneuroablation treatment performed in patient with oropharyngeal squamous cell cancer who developed recurrent asystole and syncope attacks due to compression of the carotid sinus on neck movement.

Decreasing time between first diagnosis of paroxysmal atrial fibrillation and cryoballoon ablation positively affects long-term consequences.

BACKGROUND: Patients with atrial fibrillation (AF) usually experience a worsening of their AF burden over time. We aimed to investigate timing of pulmonary vein isolation (PVI) by cryoballoon (CB-2) after the first clinical diagnosis of AF on ablation-related outcomes. METHODS: A total of 132 consecutive patients with paroxysmal AF undergoing PVI by CB-2 were included in the study. The patients were retrospectively sorted into two groups to evaluate differences in AF recurrence risk associated with early ablation (n = 89), defined as within 365 days of first AF diagnosis, and late ablation (n = 365), defined as > 365 days after first AF diagnosis. AF-free survival during follow-up was compared between groups. RESULTS: Although mean procedure times were comparable between groups, mean fluoroscopy times were lower in the early ablation group. For the whole study group, median (interquartile range) time from AF diagnosis to first ablation was 4.0 (2.0-11.3) months [3.0 (1.0-4.0) vs 14.0 (12.0-22.5) months in the early and late ablation groups, respectively]. Median follow-up for the whole population was 12.0 (12.0-18.0) months, and after the blanking period, 14 (10.6%) patients had arrhythmia recurrence (2 in the early and 12 in the late ablation groups). In the univariable Cox regression analysis and propensity score adjusted penalized Cox regression analysis, there was a significant association between delay in ablation time and AF recurrence (unadjusted hazard ratio = 7.74, 95% CI 2.26-40.1, p < 0.001, adjusted hazard ratio = 7.50, 95% CI 2.23-38.6, p < 0.001). CONCLUSION: Delays in treatment with CB-2 ablation may negatively affect AF-free survival rates among patients with paroxysmal AF.

The benefit of cardioneuroablation to reduce syncope recurrence in vasovagal syncope patients: a case-control study.

BACKGROUND: Adequate and effective therapy for resistant vasovagal syncope patients is lacking and the benefit of cardioneuroablation (CNA) in this cohort is still debated. The aim of this study is to assess the long-term effect of CNA versus conservative therapy (CT) in a retrospectively followed cohort. METHODS: A total of 2874 patients underwent head-up tilt test (HUT) and 554 (19.2 %) were reported as positive, with VASIS type 2B response or > 3 s asystole in 130 patients. After exclusion of 29 patients under 18 years and over 65 years of age, 101 patients were included final analysis. Fifty-one patients (50.4%) underwent CNA and 50 (49.6%) patients received CT. After propensity score matching, 19 pairs of patients were successfully matched. The recurrence rate of syncope was compared between groups. RESULTS: During a median follow-up of 22 months (IQR, 13-35), syncope was seen in 12 (11.8%) cases. In the 19 propensity-matched patients, recurrent syncope was observed in 8 patients in the CT group and in 2 patients in the CNA group, respectively. In mixed effect Cox regression analysis, CNA was associated with less syncope recurrence risk at follow-up (HR 0.23, 95% CI 0.03-0.99, p = 0.049). The 4-year Kaplan-Meier syncope free rate was 0.86 (95% CI, 0.63-1.00) for CNA group and 0.50 (95% CI, 0.30-0.82) for CT group in the matched cohort. CONCLUSIONS: In highly selected patients with HUT-induced cardioinhibitory response, CNA is associated with a significant reduction in syncope recurrence during follow-up when compared to CT.

Medium-term results of cardioneuroablation for clinical bradyarrhythmias and vasovagal syncope: effects on QT interval and heart rate.

PURPOSE: Although parasympathetic effects of cardioneuroablation (CNA) in vagally mediated bradyarrhythmias (VMB) were studied, sympathetic effects have not been elucidated, yet. We aimed to investigate the acute and medium-term outcomes of CNA as well as the impact of CNA on ventricular repolarization by using corrected QT interval (QTc) measurements. METHODS: Sixty-five patients (58.5% men; age 39.4 ± 14 years) undergoing CNA were included in the study. Patients who underwent CNA due to VMB were divided into two groups: (1) bi-atrial CNA and (2) right-sided CNA. QTc was calculated at 3 time points: before the procedure (time point 1); 24 h post-ablation (time point 2); and at the last follow-up visit (time point 3). RESULTS: The mean follow-up time was 20.0 ± 20 months. Acute success was achieved in 64 (98.4%) of cases. In the whole cohort, from time point 1 to 2, a significant shortening in QTcFredericia, QTcFramingham, and QTcHodges was observed which remained lower than baseline in time point 3. Although the difference between measurements in time point 1 and 2 was not statistically significant for QTcBazett, a significant shortening was detected between time point 1 and 3. There was significant difference between groups for shortening in QTcFredericia and QTcFramingham (p = 0.01). Event-free survival was detected in 90.7% (59/65) of cases. CONCLUSIONS: Our results demonstrate a significant shortening of QTc in addition to high acute and medium-term success rates after CNA. The most likely mechanism is the effect of CNA on the sympathetic system as well as on the parasympathetic system. Bi-atrial ablation was found related to higher QTc shortening effect.

Selective vagal innervation principles of ganglionated plexi: step-by-step cardioneuroablation in a patient with vasovagal syncope.

Cardioneuroablation (CNA) is an endocardial ablation technique aiming to prevent the autonomic imbalance occurring in vasovagal syncope (VVS). A 46-year-old female was referred to our center for pacemaker implantation due to recurrent syncopal episodes despite conventional treatments. A 22-s asystole was detected on head-up tilt testing. After a discussion with the patient and her family, we decided to perform CNA. Positive response was confirmed, and procedural endpoints were defined using pre-procedural atropine response test. Ganglionated plexus (GP) sites were detected and ablated by using fractionated electrogram (FE)-based strategy. During baseline electrophysiological study, AA and PR intervals were calculated as 810 ms and 164 ms, respectively. Based on our ablation order, radiofrequency ablation (RFA) was started from the left inferior and left superior GPs, respectively. A significant vagal response with sinus pauses and atrioventricular (AV) block was detected during RFA. Ablation of the right superior GP caused a significant increase of sinus rate with continuing AV block. After completion of ablation on the right superior and inferior GPs, PR interval was still 164 ms although AA interval decreased to 640 ms. After RFA on the posteromedial left GP which provides mainly vagal innervation of AV node, PR interval and cycle length of sinus node were detected as 134 ms and 540 ms, respectively. Selective parasympathetic innervation principles of the sinus node and AV node were previously demonstrated. We described a case of successful parasympathetic denervation of the sinus node and AV nodes using CNA.

Potential therapeutic effects of electrogram-guided cardioneuroablation in long QT syndrome: case series.

BACKGROUND: A significant shortening of the corrected QT interval (QTc) in addition to parasympathetic denervation after cardioneuroablation (CNA) was recently demonstrated in patients with vagally mediated bradyarrhythmias and normal QTc range. This study assessed the effects of CNA on ventricular repolarization and heart rate by using QTc measurements in 2 patients with long QT syndrome (LQTS). METHODS: The case series included 2 consecutive patients with significant sinus bradycardia and refractory paroxysmal atrial fibrillation (AF). All atrial ganglionated plexus (GP) sites in addition to pulmonary vein isolation were successively targeted by using electrogram-guided strategy. QTc was calculated on 12-lead ECG before the procedure (time point 1), at post-ablation 24 h (time point 2), and at the last follow-up visit (time point 3), respectively. RESULTS: In the first case, QTc (Bazett) shortened from 612 to 551 msec between time points 1 and 2 and was 419 msec in time point 3. Similarly, QTc (Bazett) shortened from 480 to 401 msec between time points 1 and 3 in the second case. In both cases, minimum and mean heart rates were significantly increased after ablation. The parameters of which are used to estimate both sympathetic and parasympathetic changes in heart rate variability were significantly decreased after ablation. There were no arrhythmia-related symptoms during follow-up. CONCLUSIONS: The present case series reports a new ablation strategy systematically targeting autonomic GPs in LQTS patients. CNA shortens QTc (through sympathetic modulation) and increases heart rate. Although promising, these preliminary results need to be confirmed in the larger prospective study.

Initial experience with fractionation mapping-guided ablation strategy in patients with long-standing persistent atrial fibrillation.

PURPOSE: We aimed to define the role of extended pulmonary vein isolation (PVI), posterior wall isolation, and mitral isthmus lines to eliminate electrograms exhibiting fractionation pattern during stepwise ablation on acute atrial fibrillation (AF) termination rate in patients with long-standing persistent AF (LSPAF). METHODS: Twelve patients with LSPAF underwent ablation during AF. Using the fractionation mapping tool of the Ensite™ (Abbott Medical, Chicago, USA) system, sites exhibiting discrete atrial complexes and consistent activation sequence were mapped. The areas with a fractionation score above 4 were accepted as potential drivers for AF. During stepwise ablation consisting of circumferential PVI, roof and floor lines for posterior wall isolation, and mitral isthmus lines, ablation lines were extended toward potential AF drivers on the fractionation map as much as possible until sinus was achieved by ablation. RESULTS: Fractionation-guided ablation caused acute AF termination in 8 of 12 patients. In 6 of 12 cases, AF returned to sinus rhythm during the extended ablation. In 2 patients, AF shifted to sinus after cavotricuspid isthmus ablation. Sinus was achieved by cardioversion in 3 of cases. Procedural failure was seen in one case with significant scar tissue. During a mean follow-up of 31.5 ± 11 months, overall arrhythmia-free survival was 92% with 2 procedures. CONCLUSIONS: This pilot study demonstrates that fractionation mapping-guided ablation may provide an adjunctive benefit in terms of acute AF termination in patients with LSPAF. These results should be confirmed by larger, randomized, comparison studies between linear ablation and extended ablation without elimination of electrograms (EGMs) with fractionation.

Usefulness of post-procedural heart rate response to predict syncope recurrence or positive head up tilt table testing after cardioneuroablation.

AIMS: Previous reports have suggested that cardioneuroablation (CNA) can be effective in reducing syncopal recurrences in patients with vasovagal syncope (VVS). This study assessed the efficacy of CNA in preventing a positive response to head-up tilt testing (HUT). METHODS AND RESULTS: This is a single-centre retrospective study reviewing prospectively collected data. Fifty-one consecutive patients with VVS were included in the study. After confirmation of >3 s asystole on HUT, all patients underwent CNA. Head-up tilt testing was repeated 1 month after CNA. The main outcome measures were recurrence of syncope episode and positive response on HUT. During a median follow-up period of 11 months (interquartile range 3-27 months), all but 3 (5.8%) of 51 patients were free of syncope. Repeated HUTs were negative in 44 (86.2%) patients. When patients with recurrent syncope were excluded, vasodepressor response was seen in three cases and cardioinhibitory response in one case, respectively. Cardioneuroablation caused significant and durable shortening of RR interval in all cases. This effect was significantly higher in patients without positive HUT responses. CONCLUSION: This pilot study shows that CNA can effectively prevent recurrent syncopal episodes in patients with refractory VVS. Head-up tilt testing seems as a valuable diagnostic tool not only to select suitable candidates and but also to evaluate success of CNA.

Why is pulmonary vein isolation not enough for vagal denervation in all cases?

Pulmonary vein isolation (PVI) may cause vagal response during radiofrequency application or increase on heart rate after ablation. All those responses are related to inadvertent ablation effect on ganglionated plexi. In the present case, we aimed to explain why vagal response effects of PVI are not same in all cases.

Usage of a new mapping algorithm to detect possible critical substrate for continuity of atrial fibrillation: fractionation mapping in preliminary experience.

Although treatment of atrial fibrillation (AF) classically focuses on eliminating the pulmonary vein (PV) triggers, isolation of PVs is associated with limited success rates in patients with persistent AF. The role of the left atrial appendage (LAA) as both trigger and driver in arrhythmogenesis of AF was previously demonstrated. In the present case, fractionation mapping software of Ensite system was firstly tested to detect critical substrate during AF. Focusing on the width and continuity of fractionation pattern, the LAA was accepted as main driver for maintenance of AF. Ablation in fractionated electrograms around the LAA caused acute AF termination. After isolation of the LAA, no AF was inducible with atrial stimulation with and without isoproterenol infusion. Fractionation mapping may be used to detect potential importance of the LAA in AF continuity.

Catheter Ablation of Atrioventricular Block: From Diagnosis to Selection of Proper Treatment.

A 39-year-old man presented with recurrent syncope. A 12-lead electrocardiogram and a 24-h Holter recording demonstrated atypical persistent Mobitz type I and high-degree atrioventricular block, respectively. The functional nature of the atrioventricular block was confirmed by atropine challenge, exercise testing, and electrophysiological study. The patient was successfully treated with a cardioneuroablation procedure. (Level of Difficulty: Intermediate.).

Vagal responses during cardioneuroablation on different ganglionated plexi: Is there any role of ablation strategy?

BACKGROUND: Cardioneuroablation has been used to treat vagally mediated bradyarrhythmias (VMB). The aim of this study is to assess vagal response (VR) characteristics during radiofrequency catheter ablation (RFCA) with different ganglionated plexus (GP) order. METHODS: A total of 49 consecutive patients with VMB who underwent cardioneuroablation were enrolled. GPs were identified by electroanatomic-mapping-guided strategy. After all GP targets have been identified, patients were divided into 2 groups according to GP ablation strategy. In the left side first group, ablation order of GPs were left superior GP (LSGP), left inferior GP (LIGP), right superior GP (RSGP), and right inferior GP (RIGP). In the right side first group, ablation order was RSGP, RIGP, LSGP, and LIGP. RESULTS: In the left side first group, LSGP was the most common GP site at which a VR was observed (36 of 40 cases, 90%). LIGP causes a VR in 9 of 40 (22.5%) cases. In the right side first group, VR was seen only 2 of 9 (22.2%) cases. Comparison of ablation strategy demonstrated a significant difference in VR during ablation on LSGP between groups. Despite, LSGP was the most common GP site at which a VR was observed both groups (90% in left side first group vs 11.1% in right side first group, p < 0.0001). In remaining GPs, VRs were not dependent on the ablation strategy and were not statistically different between groups. CONCLUSION: The present study demonstrates that the characteristics of VR during RFCA might change according to ablation order of GPs.

Step-by-Step Cardioneuroablation Approach in Two Patients with Functional Atrioventricular Block

Parasympathetic overactivity may cause functional atrioventricular block episodes and necessitate pacemaker implantation in symptomatic cases and those refractory to conventional therapies. In these patients, if it can be clearly demonstrated that there is no structural damage in the conduction system, elimination of the vagal activity based on radiofrequency catheter ablation of main ganglionated plexi around the heart, which is called as cardioneuroablation, might be a rational approach. In this review article, we try to discuss patient selection and procedural steps suitable for cardioneuroablation based on two patients with functional atrioventricular block.

Ultrasound-guided combined pectoral nerve block and axillary venipuncture for the implantation of cardiac implantable electronic devices.

BACKGROUND: Combined ultrasound (US)-guided pectoral nerves (PECS) block and axillary vein (AV) puncture for cardiac implantable electronic devices can be effective to achieve optimal perioperative pain management and prevent access-related complications. METHODS: A total of 36 patients who underwent combined US-guided PECS block and AV puncture were included. All routinely recorded parameters, including clinical and demographic characteristics, periprocedural medical administrations, the time taken for both PECS block and AV puncture, procedure time, postprocedural pain score, and procedure-related complications, were collected and analyzed. RESULTS: In total, 54 leads were placed in 36 patients. The combined US-guided PECS block and AV puncture was performed successfully in 35 (97.2%) patients without the need for fluoroscopy or venography. AV access for each lead was achieved in a single attempt in 80.6% of cases. The time for both PECS block and AV puncture was 223.6 ± 52.1 s, including the time to apply incision site anesthesia. Additional sedatives and/or local anesthetics were required in two patients during procedure. Visual analog scale average of the patients in the 1st, 6th, and 24th h was 3.7 ± 1.14. 1.61 ± 1.29, and 0.08 ± 0.28, respectively. After the procedure, four patients (three of them woman) needed analgesics. There were no venous access-related complications. CONCLUSIONS: This new combined technique maintains both surgical and postoperative analgesia and prevents vascular access-related complications without significant increase on procedure time.

Potential usage of cardioneuroablation in vagally mediated functional atrioventricular block.

An increase in parasympathetic tone may be the main cause of some transient or permanent atrioventricular block cases. Some of these patients, defined as vagally mediated functional atrioventricular block, may be severely symptomatic and refractory to conventional therapies and may necessitate cardiac pacing. Cardioneuroablation is a relatively new strategy for management of patients with excessive vagal activation based on radiofrequency catheter ablation of main ganglionated plexi around the heart. Present review was dedicated to discuss potential usage of cardioneuroablation in patients with vagally mediated functional atrioventricular block.

What role might cardioneuroablation strategy have in syncope guidelines?

Vasovagal syncope (VVS) is the most common type of syncope. Although it is not related to an increase in mortality, recurrent syncope episodes may be disabling and reduce the quality of life. There are no optimal treatment strategies currently available, especially for the cardioinhibitory type of VVS. Cardioneuroablation (CNA) is a relatively novel technique that aims to eliminate vagal efferent output during VVS. The objective of this review was to explore the potential role of CNA strategy in syncope guidelines.