Ganglionic Plexus Ablation: A Step-by-step Guide for Electrophysiologists and Review of Modalities for Neuromodulation for the Management of Atrial Fibrillation

Abstract

As the most common sustained arrhythmia, AF is a complex clinical entity which remains a difficult condition to durably treat in the majority of patients. Over the past few decades, the management of AF has focused mainly on pulmonary vein triggers for its initiation and perpetuation. It is well known that the autonomic nervous system (ANS) has a significant role in the milieu predisposing to the triggers, perpetuators and substrate for AF. Neuromodulation of ANS – ganglionated plexus ablation, vein of Marshall ethanol infusion, transcutaneous tragal stimulation, renal nerve denervation, stellate ganglion block and baroreceptor stimulation – constitute an emerging therapeutic approach for AF. The purpose of this review is to summarise and critically appraise the currently available evidence for neuromodulation modalities in AF.

A case report of cardiac neuromodulation in a young patient with a third-degree atrioventricular block

“…The main locations of the GPs include the following: the superior paraseptal ganglionated plexus (SPSGP, located in the upper area of the right atrium, medial to the outlet of the superior vena cava and lateral to the aortic root) which is the final common pathway of the right vagus that innervates the sinus node; the aorta-superior vena cava ganglionated plexus (Ao-SVC GP), anterior to the previous one; the inferior paraseptal ganglionated plexus (IPSGP, located in the posteroinferior area of the right interatrial septum, near the proximal coronary sinus, and around its ostium) which is the final common pathway of the left vagus that innervates the AV node; the left superior ganglionated plexus (LSGP); the left lateral ganglionated plexus (LLGP), also called GP of Marshall's ligament; right and left inferior ganglionated plexuses (RIGP and LIGP), sometimes identified as oblique sinus GP (OSGP) (1,(5)(6)(7)(8)(9)(10)(11).…”

Cardioneuroablation Using Epicardial Pulsed Field Ablation for the Treatment of Atrial Fibrillation

“…In this context, the use of electroanatomical mapping is already being widely used for GP localization in the treatment of syncope [ 116 , 117 ] and sinus bradycardia [ 118 ]. Initial work has also been performed in relation to AF [ 119 , 120 ]. There will be some technical challenges with alignment of these endocardial maps with epicardial anatomy and navigation, but these seem to be resolvable.…”