Vagal response in cryoballoon ablation of atrial fibrillation and autonomic nervous system: Utility of epicardial adipose tissue location

Satoshi Yanagisawa, Yasuya Inden, Yoshiaki Mizutani, Aya Fujii, Yosuke Kamikubo, Yasunori Kanzaki, Monami Ando, Junya Funabiki, Yosuke Murase, Masaki Takenaka, Noriaki Otake, Tetsuyoshi Hattori, Rei Shibata, Toyoaki Murohara, Satoshi Yanagisawa, Yasuya Inden, Yoshiaki Mizutani, Aya Fujii, Yosuke Kamikubo, Yasunori Kanzaki, Monami Ando, Junya Funabiki, Yosuke Murase, Masaki Takenaka, Noriaki Otake, Tetsuyoshi Hattori, Rei Shibata, Toyoaki Murohara

Abstract

Background: Mechanism and effects of vagal response (VR) during cryoballoon ablation procedure on the cardiac autonomic nervous system (ANS) are unclear. The present study aimed to evaluate the relationship between VR during cryoballoon catheter ablation for atrial fibrillation and ANS modulation by evaluating epicardial adipose tissue (EAT) locations and heart rate variability (HRV) analysis.

Methods: Forty-one patients with paroxysmal atrial fibrillation (11 with VR during the procedure and 30 without VR) who underwent second-generation cryoballoon ablation were included. EAT locations and changes in HRV parameters were compared between the VR and non-VR groups, using Holter monitoring before ablation, immediately after ablation and one month after ablation.

Results: The total EAT volume surrounding the left atrium (LA) in the VR and non-VR groups was 29.0±18.4 cm3 vs 27.7±19.7 cm3, respectively (p=0.847). The VR group exhibited greater EAT volume overlaying the LA-left superior pulmonary vein (PV) junction (6.1±3.6 cm3 vs 3.6±3.3 cm3, p=0.039) than the non-VR group. HRV parameters similarly changed following ablation in both the groups. EAT volume overlaying LA-right superior PV junction was significantly correlated with the relative changes in root-mean-square successive differences (r=-0.317, p=0.043) and high frequency (r=-0.331, p=0.034), immediately after the ablation.

Conclusions: Changes in HRV parameters following ablation were similarly observed in both the groups. EAT volume on the LA-PV junction is helpful for interpretation of VR occurrence and ANS modulation.

Keywords: Autonomic nervous system; Cryoballoon ablation; Epicardial adipose tissue; Heart rate variability; Vagal response.

Figures

Fig. 1
Fig. 1
Representative case showing the distribution of EAT on the LA. Fusion between the EAT image and voltage mapping in sinus rhythm after cryoballoon ablation was performed. In the voltage map, areas under 0.05 V were mapped to gray, between 0.05 and 0.5 V to colors between red and purple, and above 0.5 V to purple.
Fig. 2
Fig. 2
Changes in HRV parameters from baseline to post-ablation and one-month after ablation among the VR and non-VR groups. HRV analysis one month after the procedure was conducted with four and 20 patients in the VR and non-VR groups, respectively. Data are presented as mean values. Error bars indicate standard deviation.
Fig. 3
Fig. 3
Distributions of EAT volume on the RSPV, with relative changes in rMSSD and ln HF from baseline to post-ablation.
Fig. 4
Fig. 4
Time course of the cycle length in the sinus rhythm during the ablation procedure (n=30) (A), and between the VR (n=8) and non-VR (n=22) groups (B). Patients with atrial fibrillation rhythms or a change of rhythms during the ablation procedure were excluded. Data is presented as a mean value. Error bars indicate standard deviation.

References

    1. Kuck K.H., Brugada J., Furnkranz A. Cryoballoon or radiofrequency ablation for paroxysmal atrial fibrillation. N Engl J Med. 2016;374:2235–2245.
    1. Okumura K., Matsumoto K., Kobayashi Y. Safety and efficacy of cryoballoon ablation for paroxysmal atrial fibrillation in Japan – results from the Japanese prospective post-market surveillance study. Circ J. 2016;80:1744–1749.
    1. Oswald H., Klein G., Koenig T. Cryoballoon pulmonary vein isolation temporarily modulates the intrinsic cardiac autonomic nervous system. J Interv Card Electrophysiol. 2010;29:57–62.
    1. Yorgun H., Aytemir K., Canpolat U. Additional benefit of cryoballoon-based atrial fibrillation ablation beyond pulmonary vein isolation: modification of ganglionated plexi. Europace. 2014;16:645–651.
    1. Aytemir K., Gurses K.M., Yalcin M.U. Safety and efficacy outcomes in patients undergoing pulmonary vein isolation with second-generation cryoballoondagger. Europace. 2015;17:379–387.
    1. Miyazaki S., Nakamura H., Taniguchi H. Impact of the order of the targeted pulmonary vein on the vagal response during second-generation cryoballoon ablation. Heart Rhythm. 2016;13:1010–1017.
    1. Scherlag B.J., Yamanashi W., Patel U. Autonomically induced conversion of pulmonary vein focal firing into atrial fibrillation. J Am Coll Cardiol. 2005;45:1878–1886.
    1. Lim P.B., Malcolme-Lawes L.C., Stuber T. Intrinsic cardiac autonomic stimulation induces pulmonary vein ectopy and triggers atrial fibrillation in humans. J Cardiovasc Electrophysiol. 2011;22:638–646.
    1. Venteclef N., Guglielmi V., Balse E. Human epicardial adipose tissue induces fibrosis of the atrial myocardium through the secretion of adipo-fibrokines. Eur Heart J. 2015;36:795–805a.
    1. Nakatani Y., Kumagai K., Minami K. Location of epicardial adipose tissue affects the efficacy of a combined dominant frequency and complex fractionated atrial electrogram ablation of atrial fibrillation. Heart Rhythm. 2015;12:257–265.
    1. Takahashi K., Okumura Y., Watanabe I. Anatomical proximity between ganglionated plexi and epicardial adipose tissue in the left atrium: implication for 3D reconstructed epicardial adipose tissue-based ablation. J Interv Card Electrophysiol. 2016;47:203–212.
    1. Group JCSJW Guidelines for non-pharmacotherapy of cardiac arrhythmias (JCS 2011) Circ J. 2013;77:249–274.
    1. Murakawa Y., Nogami A., Shoda M. Report of periprocedural oral anticoagulants in catheter ablation for atrial fibrillation: the Japanese Catheter Ablation Registry of Atrial Fibrillation (J-CARAF) J Arrhythm. 2016
    1. Lakhani M., Saiful F., Parikh V. Recordings of diaphragmatic electromyograms during cryoballoon ablation for atrial fibrillation accurately predict phrenic nerve injury. Heart Rhythm. 2014;11:369–374.
    1. Perrotta L., Konstantinou A., Bordignon S. What is the acute antral lesion size after pulmonary vein isolation using different balloon ablation technologies? Circ J. 2017;81:172–179.
    1. Tukek T., Yildiz P., Atilgan D. Effect of diurnal variability of heart rate on development of arrhythmia in patients with chronic obstructive pulmonary disease. Int J Cardiol. 2003;88:199–206.
    1. Kang K.W., Kim T.H., Park J. Long-term changes in heart rate variability after radiofrequency catheter ablation for atrial fibrillation: 1-year follow-up study with irrigation tip catheter. J Cardiovasc Electrophysiol. 2014;25:693–700.
    1. Ketels S., Houben R., Van Beeumen K. Incidence, timing, and characteristics of acute changes in heart rate during ongoing circumferential pulmonary vein isolation. Europace. 2008;10:1406–1414.
    1. Hsieh M.H., Chiou C.W., Wen Z.C. Alterations of heart rate variability after radiofrequency catheter ablation of focal atrial fibrillation originating from pulmonary veins. Circulation. 1999;100:2237–2243.
    1. Hou Y., Scherlag B.J., Lin J. Ganglionated plexi modulate extrinsic cardiac autonomic nerve input: effects on sinus rate, atrioventricular conduction, refractoriness, and inducibility of atrial fibrillation. J Am Coll Cardiol. 2007;50:61–68.
    1. Peyrol M., Barraud J., Koutbi L. Vagal reactions during cryoballoon-based pulmonary vein isolation: a clue for autonomic nervous system modulation? Biomed Res Int. 2016;2016:7286074.
    1. Tsai C.F., Chen S.A., Tai C.T. Bezold-Jarisch-like reflex during radiofrequency ablation of the pulmonary vein tissues in patients with paroxysmal focal atrial fibrillation. J Cardiovasc Electrophysiol. 1999;10:27–35.
    1. Chugh A., Makkar A., Yen Ho S. Manifestations of coronary arterial injury during catheter ablation of atrial fibrillation and related arrhythmias. Heart Rhythm. 2013;10:1638–1645.
    1. Kitamura T., Fukamizu S., Arai K. Transient sinus node dysfunction following sinus node artery occlusion due to radiofrequency catheter ablation of the septal superior vena cava-right atrium junction. J Electrocardiol. 2016;49:18–22.
    1. Pappone C., Santinelli V., Manguso F. Pulmonary vein denervation enhances long-term benefit after circumferential ablation for paroxysmal atrial fibrillation. Circulation. 2004;109:327–334.
    1. Tan A.Y., Li H., Wachsmann-Hogiu S. Autonomic innervation and segmental muscular disconnections at the human pulmonary vein-atrial junction: implications for catheter ablation of atrial-pulmonary vein junction. J Am Coll Cardiol. 2006;48:132–143.
    1. Marron K., Wharton J., Sheppard M.N. Distribution, morphology, and neurochemistry of endocardial and epicardial nerve terminal arborizations in the human heart. Circulation. 1995;92:2343–2351.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe