Cryoballoon cardioneuroablation: New electrophysiological insights

Abstract

BackgroundCardioneuroablation(CNA) targeting ganglionated plexi has shown promise in treating vasovagal syncope. Only radiofrequency ablation has been used to achieve this goal thus far. ObjectiveWe investigated the utility of cryo-balloon ablation(CBA) of the pulmonary veins as a potential simplified approach to CNA. MethodsWe are reporting our observations of autonomic modulation in a series of 17 patients undergoing CBA for atrial fibrillation and our early experience using CBA of the PVs in 3 patients with malignant vagal syncope. ResultsIn 17 patients undergoing CBA of AF, sinus cycle length was recorded intra-procedurally after ablation of individual PVs. We demonstrated most pronounced shortening of the sinus cycle length after isolation of the right upper PV which was ablated last. There was reduced SNRT and AV nodal ERP after CBA. The elevation in resting heart rate by 6-7 beats/minute following CBA persisted during a follow-up of 12 months. We performed CBA of the PVs in 3 patients with recurrent vagal syncope mediated by sinus arrest (n=2) and AV block (n=1). In all patients, isolation of the right upper PV resulted in marked shortening of sinus cycle length. During a follow-up of 178±43 days (134-219 days) CNA resulted in abolition of pauses, bradycardia related symptoms and syncope in all patients. ConclusionCBA of the PVs (most importantly the right upper PV) may be a predictable anatomic CNA approach in patients with refractory vagal syncope due to sinus arrest and/or AV block and may deserve systematic investigation as a tool to perform CNA.