Catheter Ablation as a Treatment for Vasovagal Syncope: Long-Term Outcome of Endocardial Autonomic Modification of the Left Atrium

Wei Sun, Lihui Zheng, Yu Qiao, Rui Shi, Bingbo Hou, Lingmin Wu, Jinrui Guo, Shu Zhang, Yan Yao, Wei Sun, Lihui Zheng, Yu Qiao, Rui Shi, Bingbo Hou, Lingmin Wu, Jinrui Guo, Shu Zhang, Yan Yao

Abstract

Background: Autonomic modification through catheter ablation of ganglionated plexi (GPs) in the left atrium has been reported previously as a treatment for vasovagal syncope. This study aimed to observe the long-term outcome in a larger cohort.

Methods and results: A total of 57 consecutive patients (aged 43.2±13.4 years; 35 women) with refractory vasovagal syncope were enrolled, and high-frequency stimulation and anatomically guided GP ablation were performed in 10 and 47 cases, respectively. A total of 127 GP sites with positive vagal response were successfully elicited and ablated, including 52 left superior, 19 left lateral, 18 left inferior, 27 right anterior, and 11 right inferior GPs. During follow-up of 36.4±22.2 months (range 12-102 months), 52 patients (91.2%) remained free from syncope. Prodromes recurred in 16 patients. No statistical differences were found between the high-frequency stimulation and anatomically guided ablation groups in either freedom from syncope (100% versus 89.4%, P=0.348) or recurrent prodromes (50% versus 76.6%, P=0.167). The deceleration capacity, heart rate, and heart rate variability measurements demonstrated a reduced vagal tone lasting for at least 12 months after the procedure, with improved tolerance of repeated head-up tilt testing. No complications were observed except for transient sinus tachycardia that occurred in 1 patient.

Conclusions: Left atrial GP ablation showed excellent long-term clinical outcomes and might be considered as a therapeutic option for patients with symptomatic vasovagal syncope.

Keywords: autonomic modification; catheter ablation; ganglionated plexi; vasovagal syncope.

© 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Figures

Figure 1
Figure 1
A 3‐dimensional computed tomography image of the left atrium showing the anatomical locations of the GPs. The blue balls represent the presumptive GP areas. A, The RAGP was well exposed in the right anterior oblique projection using electroanatomic guidance. B, The anteroposterior plus cranial projections helped identify the location of the LSGP. C, The LLGP between the LAA and LIPV was clearly exposed in the left lateral projection. D, The posteroanterior projection helped identify the locations of the LIGP and RIGP. GP indicates ganglionated plexus; LAA, left auricular appendage; LIGP, left inferior ganglionated plexus; LIPV, left inferior pulmonary vein; LLGP, left lateral ganglionated plexus; LSGP, left superior ganglionated plexus; LSPV, left superior pulmonary vein; MVA, mitral valve annulus; RAGP, right anterior ganglionated plexus; RIGP, right inferior ganglionated plexus; RIPV, right inferior pulmonary vein; RSPV, right superior pulmonary vein.
Figure 2
Figure 2
Illustration of the vagal response induced by radiofrequency energy delivery at the LSGP. The geometry of the left atrium was constructed using the Ensite Navx mapping system. The blue balls represent the ablated lesions with a positive vagal response at each GP site. The green dots represent the real‐time shadow of the catheter tip on the left atrial geometry. Radiofrequency ablation at the LSGP induced sinus arrest lasting 2609 ms. LAA indicates left auricular appendage; LIPV, left inferior pulmonary vein; LSGP, left superior ganglionated plexus; LSPV, left superior pulmonary vein; RIPV, right inferior pulmonary vein; RSPV, right superior pulmonary vein.
Figure 3
Figure 3
Kaplan–Meier curves of recurrent syncope and recurrent prodromes in HFS‐ and anatomically guided ablation groups. A, Syncope recurrence in HFS‐ and anatomically guided ablation groups (0% vs 10.6%, P=0.348). B, Prodrome recurrence in HFS‐ and anatomically guided ablation groups (50% vs 23.4%, P=0.167). GP indicates ganglionated plexus; HFS, high‐frequency stimulation.
Figure 4
Figure 4
Chronological changes in the deceleration capacity in patients with (n=5) and without (n=30) recurrent syncope.

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