AP-452681-2 6 MONTH FOLLOW-UP OF A SUCCESSFUL FLUOROLESS PEDIATRIC GANGLIONATED PLEXI ABLATION

Abstract

Cardioneuroablation (CNA) has been shown to treat vagally mediated bradyarrhythmias and vasovagal syncope. In this case, an 8-year-old female with Down’s Syndrome, duodenal atresia, and intermittent nocturnal AV block status post pacemaker without significant cardiopathy underwent successful ganglionated plexi ablation. To discuss the novel use of CNA in pediatric patients for symptomatic vasovagal syncope which can significantly reduce the volume of pacemakers implanted and obviate the need for subsequent lifelong generator replacements and lead revisions. CNA and GP locations were described and reviewed by Garcia et al for cardioinhibitory syncope treatment and prevention.1 Guidelines followed for CNA were well defined by Pachon2 and Aksu3. Localized assessments were performed at areas of complex fractionated signals at main ganglionated plexi (GP) locations. GP/cardiac insertion points are defined through high frequency (HF) EGM analysis with fractionation mapping software (NAVX, Abbott), as 3-5 deflections within the atrial cardiac cycle. Higher frequency signals were localized during mapping and correlated with traditional EGM analysis of 30-500Hz. All catheter positions were visualized with vascular ultrasound and NAVX 3-D mapping. Pacing the vagus nerve 50 Hz/50 microseconds provoked sinus slowing on the left and AV block on the right (figure 2). Fluoroscopy was not utilized. Standard RF targets were set at 60°C with maximum power of 50W. RF lesions were applied to previously defined GP1-4, targeting areas of HF signals4 for a maximum of 60 seconds. HR increase was noted with RF at GP1(18%), and this persisted throughout the case. Wenckebach cycle length change was 13%. Post ablation, HR remained unchanged during stimulation of bilateral vagal nerves. Additionally, there was no change in HR with atropine administration. At 6 month follow up, device check shows 0% pacing. Holter monitor demonstrated transient Wenckebach during sleep. Successful fluoroless GP ablation was performed for recurrent severe cardioinhibitory bradycardia. 6 month follow-up device check 0% pacing burden re-demonstrates sustained success of CNA. Future plans include another 6 months of monitoring followed by pacemaker deactivation and extraction discussion.