Selective atrial vagal denervation guided by evoked vagal reflex to treat patients with paroxysmal atrial fibrillation

Background-The aim of this study was to evaluate whether selective radiofrequency (RF) catheter ablation of the atrial sites in which high-frequency stimulation induces vagal reflexes prevents paroxysmal atrial fibrillation (AF). Methods and Results-Ten patients with episodes suggestive of vagal-induced paroxysmal AF and no heart disease were selected for percutaneous epicardial and endocardial mapping of the atria to search for sites in which high-frequency transcatheter stimulation (20 Hz,) induced vagal reflexes. A vagal response defined as AV block of > 2 seconds was elicited in 7 of 10 patients (70%) with an average of 5 +/- 2.4 (range, 2 to 9) sites per patient, and RF pulses (21.0 +/- 12.0 per patient) were applied at those sites to eliminate all evoked vagal reflexes. The 3 patients in whom evoked vagal reflexes were not obtained underwent circumferential pulmonary vein ablation with an average of 58.0 +/- 13.9 RF pulses per patient (P = 0.022). Autonomic evaluation was performed before and 48 hours and 3 months after the procedure and was consistent with vagal withdrawal in all patients. Two of the 7 patients who underwent denervation remained asymptomatic without the use of antiarrhythmic medication at a mean follow-up of 8.3 +/- 2.8 months (range, 5 to 15 months); 4 had frequent recurrences and were referred for circumferential pulmonary vein ablation; and 1 had few AF episodes without antiarrhythmic medication. The 3 patients without evoked vagal reflexes who underwent circumferential pulmonary vein ablation remained asymptomatic without antiarrhythmic medication. One patient had acute delayed gastric emptying after atrial vagal denervation. Conclusions-RF catheter ablation of selected atrial sites in which high-frequency stimulation induced vagal reflexes may prevent AF recurrences in selected patients with apparently vagal-induced paroxysmal AF.