Cryoballoon ablation for atrial fibrillation: Effects on neuromodulation

Abstract

Pulmonary vein isolation (PVI) represents the mainstay of atrial fibrillation (AF) ablation, and PVI with cryoballoon catheter (CB) ablation (CB-A) has proven to be as effective and safe as radiofrequency ablation (RF-A). Although AF is initiated by triggers arising from the pulmonary veins (PV) and non-PV foci, the intrinsic cardiac nervous system (ICNS) plays a significant role in the induction and maintenance of AF. The ICNS is an epicardial neural system composed of ganglionated plexi (GPs) and a complex network of interconnecting neurons. In the left atrium, the major GPs are located in proximity to the PV-left atrial junction. Vagal reactions have been described as markers of autonomic modulation during PVI with both RF-A and CB-A. The occurrence of neuromodulation during PVI with CB-A may be explained by both the anatomical relationship between the GPs and the PVs and the characteristics of the CB. Due to the CB/PV size mismatch, the CB creates a wide ablation area that extends from the PV ostium toward the antrum, possibly including the GPs. Although targeted GPs ablation, as a supplemental strategy to PVI, has been associated with a better AF outcome in patients undergoing RF-A, the additional clinical benefit of neuromodulation during PVI with CB-A remains a matter of debate. In this review, we provide an overview of the anatomy of the ICNS, the relationship between the ICNS and AF pathophysiology, and the current evidence on the clinical relevance of neuromodulation during PVI with CB-A.

Quantitative assessment of transient autonomic modulation after single‐shot pulmonary vein isolation with pulsed‐field ablation

“…The cardiac autonomic nervous system (ANS) is composed of interconnected clusters of autonomic ganglia, known as ganglionated plexi (GP), which have been implicated in the initiation and maintenance of atrial fibrillation (AF) 1,2 . Pulmonary vein isolation (PVI) with thermal ablation, namely radiofrequency and cryoballoon ablation (CB), has been demonstrated to concomitantly affect the surrounding GP, as documented by intraprocedural vagal reactions and postprocedural heart rate (HR) increase 3,4 . Unlike thermal energy sources, pulsed‐field ablation (PFA) is a nonthermal ablative modality characterized by selectivity for the cardiac tissue 5–7 .…”

“…1,2 Pulmonary vein isolation (PVI) with thermal ablation, namely radiofrequency and cryoballoon ablation (CB), has been demonstrated to concomitantly affect the surrounding GP, as documented by intraprocedural vagal reactions and postprocedural heart rate (HR) increase. 3,4 Unlike thermal energy sources, pulsed-field ablation (PFA) is a nonthermal ablative modality characterized by selectivity for the cardiac tissue. [5][6][7] Recent evidence suggested that the Farapulse TM PFA system (Boston Scientific) induces minimal effects on the ANS, compared with thermal singleshot technologies.…”