SPC365

Anatomic-guided ablation of the right ganglionated plexi validated by the automatic fractionation map

Session: Comunicações Orais - Sessão 11 - Ablação de fibrilhação auricular
Speaker: Leonor Parreira

Congress: CPC 2024
Topic: C. Arrhythmias and Device Therapy
Theme: 05. Atrial Fibrillation
Subtheme: 05.4 Atrial Fibrillation - Treatment
Session Type: Comunicações Orais
FP Number: ---
Authors: Leonor Parreira; Jeni Quintal; Dinis Mesquita; Lia Marques; Rita Marinheiro; Jose Silva; Duarte Chambel; Claudia Encarnação; Patricia Bernardes; Fabio Costa; Pedro Contreiras; Filipe Seixo

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><strong><span style="font-size:10.0pt"><span style="color:black">Background and aim:</span></span></strong> <span style="font-size:10.0pt"><span style="color:black">Cardiac autonomic modulation through endocardial ablation of atrial ganglionated plexi (GP) is an alternative strategy in selected patients with severe vagal-induced bradyarrhythmias. </span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:10.0pt"><span style="color:black">A strictly anatomical approach targeting the right GPs has demonstrated reasonable success rates but is an empirical approach and has yet to be validated. The presence of fractionated electrograms has been associated with the areas of GPs and can be automatically mapped (fractionation map). This study aimed to compare the empirical ablated area to the automatically assessed sites of GPs based on the presence of fractionated electrograms (FEs). </span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><strong><span style="font-size:10.0pt"><span style="color:black">Methods: </span></span></strong><span style="font-size:10.0pt"><span style="color:black">We studied<strong> </strong>eight consecutive patients referred for parasympathetic modulation. A high-density map of the left and right atria (LA, RA) in sinus rhythm was performed. The settings for the automatic map were as follows: bipolar high pass filter of 500 Hz, a fractionation threshold of 4, and a width of 5 ms. The ablation was empirically performed by an operator blinded to the results of the fractionation map, as per site protocol. The ablation was aimed at the anatomic locations of the right GPs in the LA and RA.&nbsp; At the anterior and inferior aspect of the right superior pulmonary vein and bad aspect of the right inferior pulmonary vein on the LA, and posterior RA opposite to the LA RF applications and around the coronary sinus ostium on the RA (Figure). Before ablation, 2 mg of atropine was administered in bolus, and the increase in heart rate was registered and repeated at the end of the procedure. After the operator completed the ablation, access to the fractionation map was available, and additional radiofrequency (RF) applications were applied as needed (Figure). The number of additional RF applications to cover all the areas with FEs was assessed. Success was defined as an absence of response to atropine after the procedure.</span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><strong><span style="font-size:10.0pt"><span style="color:black">Results:</span></span></strong><span style="font-size:10.0pt"><span style="color:black"> Three patients underwent autonomic system modulation only, and five underwent additional pulmonary vein isolation (PVI). The mean age was 66 (50-77) years, five males. The median mapping time of the LA and RA was 11 (17-7) and 14 (9-18) min. All patients underwent successful parasympathetic modulation. The initial median (Q<sub>1</sub>-Q<sub>3</sub>) increase in heart rate with atropine was 34 (23-39)% versus 0 (0-2)% after ablation, p=0.012. The differences between empiric and FEs map-guided ablation are depicted in the Figure. The additional number of points was low. However, a median of 9 (5-15) extra points were added. </span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><strong><span style="font-size:10.0pt"><span style="color:black">Conclusions: </span></span></strong><span style="font-size:10.0pt"><span style="color:black">A purely anatomic-guided procedure directed only at the atrial right GPs is usually enough as a therapeutic approach for</span></span> <span style="font-size:10.0pt"><span style="color:black">cardiac autonomic modulation; however, the fractionation map tool helped validate the method and ensure success on the first pass. </span></span></span></span></p>