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Penela D, Berruezo A, Roten L, Futyma P, Richter S, Falasconi G, Providencia R, Chun J. Cardioneuroablation for vasovagal syncope: insights on patients' selection, centre settings, procedural workflow and endpoints-results from an European Heart Rhythm Association survey. Europace 2024; 26:euae106. [PMID: 38781099 PMCID: PMC11114473 DOI: 10.1093/europace/euae106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 04/18/2024] [Indexed: 05/25/2024] Open
Abstract
AIMS Cardioneuroablation (CNA) is a catheter-based intervention for recurrent vasovagal syncope (VVS) that consists in the modulation of the parasympathetic cardiac autonomic nervous system. This survey aims to provide a comprehensive overview of current CNA utilization in Europe. METHODS AND RESULTS A total of 202 participants from 40 different countries replied to the survey. Half of the respondents have performed a CNA during the last 12 months, reflecting that it is considered a treatment option of a subset of patients. Seventy-one per cent of respondents adopt an approach targeting ganglionated plexuses (GPs) systematically in both the right atrium (RA) and left atrium (LA). The second most common strategy (16%) involves LA GP ablation only after no response following RA ablation. The procedural endpoint is frequently an increase in heart rate. Ganglionated plexus localization predominantly relies on an anatomical approach (90%) and electrogram analysis (59%). Less utilized methods include pre-procedural imaging (20%), high-frequency stimulation (17%), and spectral analysis (10%). Post-CNA, anticoagulation or antiplatelet therapy is prescribed, with only 11% of the respondents discharging patients without such medication. Cardioneuroablation is perceived as effective (80% of respondents) and safe (71% estimated <1% rate of procedure-related complications). Half view CNA emerging as a first-line therapy in the near future. CONCLUSION This survey offers a snapshot of the current implementation of CNA in Europe. The results show high expectations for the future of CNA, but important heterogeneity exists regarding indications, procedural workflow, and endpoints of CNA. Ongoing efforts are essential to standardize procedural protocols and peri-procedural patient management.
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Affiliation(s)
- Diego Penela
- Humanitas Research Center, Milano, Italy
- Heart Institute, Teknon Medical Center Barcelona, Spain
| | | | - Laurent Roten
- Department of Cardiology, Inselspital-Bern University Hospital, University of Bern, Bern, Switzerland
| | - Piotr Futyma
- St. Joseph’s Heart Rhythm Center Rzeszow and Medical College, University of Rzeszow, Rzeszow, Poland
| | - Sergio Richter
- Heart Center Dresden, University Hospital, Technical University Dresden, Dresden, Germany
| | - Giulio Falasconi
- Humanitas Research Center, Milano, Italy
- Heart Institute, Teknon Medical Center Barcelona, Spain
| | - Rui Providencia
- St Bartholomew’s Hospital, Barts Heart Centre, Barts Health NHS Trust, London, UK
| | - Julian Chun
- Cardioangiologisches Centrum Bethanien, Agaplesion Bethanien Krankenhaus, Frankfurt, Germany
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Aksu T, Tung R, De Potter T, Markman TM, Santangeli P, du Fay de Lavallaz J, Winterfield JR, Baykaner T, Alyesh D, Joza JE, Gopinathannair R, Badertscher P, Do DH, Hussein A, Osorio J, Dewland T, Perino A, Rodgers AJ, DeSimone C, Alfie A, Atwater BD, Singh D, Kumar K, Salcedo J, Bradfield JS, Upadhyay G, Sood N, Sharma PS, Gautam S, Kumar V, Forno ARJD, Woods CE, Rav-Acha M, Valeriano C, Kapur S, Enriquez A, Sundaram S, Glikson M, Gerstenfeld E, Piccini J, Tzou WS, Sauer W, d'Avila A, Shivkumar K, Huang HD. Cardioneuroablation for the management of patients with recurrent vasovagal syncope and symptomatic bradyarrhythmias: the CNA-FWRD Registry. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01789-9. [PMID: 38499825 DOI: 10.1007/s10840-024-01789-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 03/13/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Cardioneuroablation has been emerging as a potential treatment alternative in appropriately selected patients with cardioinhibitory vasovagal syncope (VVS) and functional AV block (AVB). However the majority of available evidence has been derived from retrospective cohort studies performed by experienced operators. METHODS The Cardioneuroablation for the Management of Patients with Recurrent Vasovagal Syncope and Symptomatic Bradyarrhythmias (CNA-FWRD) Registry is a multicenter prospective registry with cross-over design evaluating acute and long-term outcomes of VVS and AVB patients treated by conservative therapy and CNA. RESULTS The study is a prospective observational registry with cross-over design for analysis of outcomes between a control group (i.e., behavioral and medical therapy only) and intervention group (Cardioneuroablation). Primary and secondary outcomes will only be assessed after enrollment in the registry. The follow-up period will be 3 years after enrollment. CONCLUSIONS There remains a lack of prospective multicentered data for long-term outcomes comparing conservative therapy to radiofrequency CNA procedures particularly for key outcomes including recurrence of syncope, AV block, durable impact of disruption of the autonomic nervous system, and long-term complications after CNA. The CNA-FWRD registry has the potential to help fill this information gap.
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Affiliation(s)
- Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, 34100, Istanbul, Turkey
| | - Roderick Tung
- The University of Arizona College of Medicine, Banner-University Medical Center, 755 E McDowell Road, Phoenix, AZ, 85006, USA
| | - Tom De Potter
- Department of Cardiology, OLV Hospital, Aalst, Belgium
| | - Timothy M Markman
- Division of Cardiology, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Pasquale Santangeli
- Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | | | - Tina Baykaner
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, CA, USA
| | - Daniel Alyesh
- South Denver Cardiology Associates, 1000 SouthPark Drive, Littleton, CO, 80120, USA
| | | | | | | | - Duc H Do
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Ayman Hussein
- Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jose Osorio
- Arrhythmia Institute at Grandview, Birmingham, AL, USA
- Heart Rhythm Clinical Research Solutions, Birmingham, AL, USA
| | - Thomas Dewland
- Electrophysiology Section, Division of Cardiology, Department of Internal Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Alexander Perino
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, CA, USA
| | - Albert J Rodgers
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, CA, USA
| | | | - Alberto Alfie
- Electrophysiology Section, Cardiology Division, Hospital Nacional Profesor Alejandro Posadas, Av. Illia y Marconi S/N 1684, El Palomar, Moron, Province of Buenos Aires, Argentina
| | | | - David Singh
- The Queens Medical Center, Honolulu, HI, USA
| | | | | | - Jason S Bradfield
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Gaurav Upadhyay
- Center for Arrhythmia Care, Section of Cardiology, Pritzker School of Medicine, The University of Chicago Medicine, 5841 S. Maryland Avenue, MC 9024, Chicago, IL, 60637, USA
| | - Nitesh Sood
- Arrhythmia Services, Southcoast Health, Fall River, MA, USA
| | - Parikshit S Sharma
- Department of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Sandeep Gautam
- Department of Cardiac Electrophysiology, University of Missouri-Columbia, Columbia, MO, USA
| | - Vineet Kumar
- Inova Heart and Vascular Institute, Falls Church, VA, USA
| | | | - Christopher E Woods
- Department of Cardiology, California Pacific Medical Center, San Francisco, CA, USA
| | - Moshe Rav-Acha
- Jesselson Integrated Heart Center, Shaare Zedek Hospital, 9112102, Jerusalem, Israel
| | | | - Sunil Kapur
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andres Enriquez
- Division of Cardiology, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Sri Sundaram
- South Denver Cardiology Associates, 1000 SouthPark Drive, Littleton, CO, 80120, USA
| | - Michael Glikson
- Jesselson Integrated Heart Center, Shaare Zedek Hospital, 9112102, Jerusalem, Israel
| | - Edward Gerstenfeld
- Electrophysiology Section, Division of Cardiology, Department of Internal Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Jonathan Piccini
- Duke Clinical Research Institute, Duke University Hospital, Durham, USA
| | - Wendy S Tzou
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - William Sauer
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Kalyanam Shivkumar
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Henry D Huang
- Department of Cardiology, Rush University Medical Center, Chicago, IL, USA.
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Vandenberk B, Haemers P, Morillo C. The autonomic nervous system in atrial fibrillation-pathophysiology and non-invasive assessment. Front Cardiovasc Med 2024; 10:1327387. [PMID: 38239878 PMCID: PMC10794613 DOI: 10.3389/fcvm.2023.1327387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 12/13/2023] [Indexed: 01/22/2024] Open
Abstract
The autonomic nervous system plays a crucial role in atrial fibrillation pathophysiology. Parasympathetic hyperactivity result in a shortening of the action potential duration, a reduction of the conduction wavelength, and as such facilitates reentry in the presence of triggers. Further, autonomic remodeling of atrial myocytes in AF includes progressive sympathetic hyperinnervation by increased atrial sympathetic nerve density and sympathetic atrial nerve sprouting. Knowledge on the pathophysiological process in AF, including the contribution of the autonomic nervous system, may in the near future guide personalized AF management. This review focuses on the role of the autonomic nervous system in atrial fibrillation pathophysiology and non-invasive assessment of the autonomic nervous system.
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Affiliation(s)
- Bert Vandenberk
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Peter Haemers
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Carlos Morillo
- Department of Cardiac Sciences, Cumming School of Medicine, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
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Traykov V, Shalganov T. Cardioneuroablation for the Treatment of Vasovagal Syncope: Current Status and Impact on Quality of Life. Curr Cardiol Rep 2023; 25:1839-1849. [PMID: 37982935 DOI: 10.1007/s11886-023-01997-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/08/2023] [Indexed: 11/21/2023]
Abstract
PURPOSE OF REVIEW Vasovagal syncope (VVS) is a common entity causing transient loss of consciousness and affecting quality of life. Guideline-recommended therapy involves conservative measures and pacing in selected patients. Cardioneuroablation (CNA) targeting the ganglionated plexi in the heart has been shown to reduce excessive vagal excitation, which plays a major role in the pathophysiology of VVS and functional bradycardia. RECENT FINDINGS The introduction of CNA has fueled research into its value for the treatment of VVS. Multiple observational studies and one randomized trial have demonstrated the safety and efficacy of CNA and the positive impact on quality of life. This review describes the rationale and CNA procedural techniques and outcomes. Patient selection and future directions have also been described. Cardioneuroablation is a promising treatment for patients with recurrent VVS and functional bradycardia. Further large-scale randomized studies are needed to further verify the safety and efficacy of this approach.
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Affiliation(s)
- Vassil Traykov
- Department of Invasive Electrophysiology, Clinic of Cardiology, Acibadem City Clinic Tokuda Hospital, 1407 N. Vaptzarov blvd 51B, Sofia, Bulgaria.
| | - Tchavdar Shalganov
- Department of Electrophysiology, Clinic of Cardiology, National Heart Hospital, Sofia, Bulgaria
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Vassallo F, Corcino L, Cunha C, Serpa E, Lovatto C, Simoes A, Carloni H, Hespanhol D, Gasparini D, Barbosa LF, Schmidt A. Incidental parasympathetic cardiac denervation during atrial fibrillation ablation using high power short duration: a marker of long-term success. J Interv Card Electrophysiol 2023:10.1007/s10840-023-01653-2. [PMID: 37773556 DOI: 10.1007/s10840-023-01653-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 09/17/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND There are multiple factors in both technique and substrate that lead to recurrence of atrial fibrillation after ablation. We sought to examine whether the degree of heart rate increase (HRI) caused by concurrent high-power-short-duration (HPSD) incidental parasympathetic denervation during AF ablation predicts long term success. Between December 2018 and December 2021, prospectively enrolled 214 patients who presented in sinus rhythm at AF ablation. Used 50 W of power and contact force (CF) of 5-15 g and 10-20 g at a flow rate of 40 mL/min on the anterior and posterior left atrial walls, respectively. RESULTS Males were 143 (66.8%) and paroxysmal was 124 (57.9%) patients. Mean age 61.1 ± 12.3 years and follow-up time was 32.8 ± 13.2 months. Arrhythmia occurred after 90 days in 39 (18.2%) patients, 19 (48.7%) from the paroxysmal and 20 (51.3%) from the persistent AF patients. Recurrence group showed a lower HRI from a mean of 57 ± 7.7 to 64.4 ± 10.4 bpm (12.3%) while in success group HRI was from 53.8 ± 9.7 to 66.8 ± 11.6 bpm [(24.2%) p = 0.04]. We divided HRI in 3 percentiles of ≤ 8%, > 8 ≤ 37% and > 37%. A predictor of recurrence was identified in those in the first (< 8%, p = 0.006) and a predictor of success in the later (> 37%, p = 0.01) HRI percentile. CONCLUSION Atrial fibrillation ablation with HPSD incidental cardiac parasympathetic denervation identified that patients with lower heart rate increase are prone to recurrence while those with higher heart rate increase had higher maintenance of sinus rhythm at a long-term follow-up.
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Affiliation(s)
- Fabricio Vassallo
- School of Medicine, Hospital Santa Casa Misericordia Vitoria, Dr. Joao Dos Santos Neves St, 143, Vila Rubim, Vitoria, Espirito Santo, 29025-023, Brazil.
- Internal Medicine Department of Ribeirao Preto Medical School, University of Sao Paulo (USP), Ribeirao Preto, Brazil.
| | - Lucas Corcino
- School of Medicine, Hospital Santa Casa Misericordia Vitoria, Dr. Joao Dos Santos Neves St, 143, Vila Rubim, Vitoria, Espirito Santo, 29025-023, Brazil
- Internal Medicine Department of Ribeirao Preto Medical School, University of Sao Paulo (USP), Ribeirao Preto, Brazil
| | - Christiano Cunha
- School of Medicine, Hospital Santa Casa Misericordia Vitoria, Dr. Joao Dos Santos Neves St, 143, Vila Rubim, Vitoria, Espirito Santo, 29025-023, Brazil
| | - Eduardo Serpa
- School of Medicine, Hospital Santa Casa Misericordia Vitoria, Dr. Joao Dos Santos Neves St, 143, Vila Rubim, Vitoria, Espirito Santo, 29025-023, Brazil
| | - Carlos Lovatto
- School of Medicine, Hospital Santa Casa Misericordia Vitoria, Dr. Joao Dos Santos Neves St, 143, Vila Rubim, Vitoria, Espirito Santo, 29025-023, Brazil
| | - Aloyr Simoes
- School of Medicine, Hospital Santa Casa Misericordia Vitoria, Dr. Joao Dos Santos Neves St, 143, Vila Rubim, Vitoria, Espirito Santo, 29025-023, Brazil
| | - Hermes Carloni
- School of Medicine, Hospital Santa Casa Misericordia Vitoria, Dr. Joao Dos Santos Neves St, 143, Vila Rubim, Vitoria, Espirito Santo, 29025-023, Brazil
| | - Dalton Hespanhol
- School of Medicine, Hospital Santa Casa Misericordia Vitoria, Dr. Joao Dos Santos Neves St, 143, Vila Rubim, Vitoria, Espirito Santo, 29025-023, Brazil
| | - Dalbian Gasparini
- School of Medicine, Hospital Santa Casa Misericordia Vitoria, Dr. Joao Dos Santos Neves St, 143, Vila Rubim, Vitoria, Espirito Santo, 29025-023, Brazil
| | - Luiz Fernando Barbosa
- School of Medicine, Hospital Santa Casa Misericordia Vitoria, Dr. Joao Dos Santos Neves St, 143, Vila Rubim, Vitoria, Espirito Santo, 29025-023, Brazil
| | - Andre Schmidt
- Internal Medicine Department of Ribeirao Preto Medical School, University of Sao Paulo (USP), Ribeirao Preto, Brazil
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Stec S, Wileczek A, Reichert A, Śledź J, Kosior J, Jagielski D, Polewczyk A, Zając M, Kutarski A, Karbarz D, Zyśko D, Nowarski Ł, Stodółkiewicz-Nowarska E. Shared Decision Making and Cardioneuroablation Allow Discontinuation of Permanent Pacing in Patients with Vagally Mediated Bradycardia. J Cardiovasc Dev Dis 2023; 10:392. [PMID: 37754821 PMCID: PMC10532162 DOI: 10.3390/jcdd10090392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/24/2023] [Accepted: 08/31/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND Safe discontinuation of pacemaker therapy for vagally mediated bradycardia is a dilemma. The aim of the study was to present the outcomes of a proposed diagnostic and therapeutic process aimed at discontinuing or not restoring pacemaker therapy (PPM) in patients with vagally mediated bradycardia. METHODS The study group consisted of two subgroups of patients with suspected vagally mediated bradycardia who were considered to have PPM discontinued or not to restore their PPM if cardioneuroablation (CNA) would successfully treat their bradycardia. A group of 3 patients had just their pacemaker explanted but reimplantation was suggested, and 17 patients had preexisting pacemakers implanted. An invasive electrophysiology study was performed. If EPS was negative, extracardiac vagal nerve stimulation (ECVS) was performed. Then, patients with positive ECVS received CNA. Patients with an implanted pacemaker had it programmed to pace at the lowest possible rate. After the observational period and control EPS including ECVS, redo-CNA was performed if pauses were induced. The decision to explant the pacemaker was obtained based on shared decision making (SDM). RESULTS After initial clinical and electrophysiological evaluation, 17 patients were deemed eligible for CNA (which was then performed). During the observational period after the initial CNA, all 17 patients were clinically asymptomatic. The subsequent invasive evaluation with ECVS resulted in pause induction in seven (41%) patients, and these patients underwent redo-CNA. Then, SDM resulted in the discontinuation of pacemaker therapy or a decision to not perform pacemaker reimplantation in all the patients after CAN. The pacemaker was explanted in 12 patients post-CNA, while in 2 patients explantation was postponed. During a median follow-up of 18 (IQR: 8-22) months, recurrent syncope did not occur in the CNA recipients. CONCLUSIONS Pacemaker therapy in patients with vagally mediated bradycardia could be discontinued safely after CNA.
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Affiliation(s)
- Sebastian Stec
- Division of Electrophysiology, Cardioneuroablation, Catheter Ablation and Cardiac Stimulation, Subcarpathian Center for Cardiovascular Intervention, 38-500 Sanok, Poland
| | - Antoni Wileczek
- Division of Electrophysiology, Cardioneuroablation, Catheter Ablation and Cardiac Stimulation, Subcarpathian Center for Cardiovascular Intervention, 38-500 Sanok, Poland
| | - Agnieszka Reichert
- Department of Invasive Cardiology, County Specialistic Hospital, 37-450 Stalowa Wola, Poland
| | - Janusz Śledź
- El-Medica, EP-NETWORK, 26-110 Skarzysko-Kamienna, Poland
| | - Jarosław Kosior
- Department of Cardiology, Masovian Specialist Hospital, 26-617 Radom, Poland
| | - Dariusz Jagielski
- Department of Cardiology, Centre for Heart Diseases, 4th Military Hospital, 50-981 Wroclaw, Poland
- Faculty of Medicine, Wrocław University of Science and Technology, 50-370 Wroclaw, Poland
| | - Anna Polewczyk
- Department of Physiology, Pathophysiology and Clinical Immunology, Institute of Medical Sciences, Jan Kochanowski University, 25-369 Kielce, Poland
- Department of Cardiac Surgery, Świętokrzyskie Center of Cardiology, 25-736 Kielce, Poland
| | - Magdalena Zając
- Department of Special Pedagogy and Speech Therapy, Kazimierz Wielki University, 85-064 Bydgoszcz, Poland
| | - Andrzej Kutarski
- Department of Cardiology, Medical University, 20-059 Lublin, Poland
| | | | - Dorota Zyśko
- Department of Emergency Medicine, Wrocław Medical University, 50-367 Wroclaw, Poland
| | - Łukasz Nowarski
- Vascular Surgery Department, The Brothers of Saint John of God Hospital, 31-061 Krakow, Poland
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Li L, Po S, Yao Y. Cardioneuroablation for Treating Vasovagal Syncope: Current Status and Future Directions. Arrhythm Electrophysiol Rev 2023; 12:e18. [PMID: 37457436 PMCID: PMC10345939 DOI: 10.15420/aer.2023.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 04/05/2023] [Indexed: 07/18/2023] Open
Abstract
Syncope is defined by transient and spontaneous loss of consciousness with rapid recovery. Vasovagal syncope (VVS) is the most common form of syncope and is strongly associated with hypervagotonia. There is, however, a lack of effective therapies for VVS. Cardioneuroablation (CNA) is an emerging and promising intervention for VVS with favourable outcomes. CNA has been shown to suppress excessive excitation of vagal activity through ablating the cardiac ganglionated plexi. CNA in the management of VVS requires more structured and comprehensive studies and several issues concerning patient selection, selection of ablation targets, ablation endpoints and the long-term effect of CNA are yet to be determined. This review describes its clinical applications and future directions based on current research data and the authors' own experiences.
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Affiliation(s)
- Le Li
- Cardiac Arrhythmia Center, Chinese Academy of Medical Sciences, Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
| | - Sunny Po
- University of Oklahoma Health Sciences Center, Oklahoma City, OK, US
| | - Yan Yao
- Cardiac Arrhythmia Center, Chinese Academy of Medical Sciences, Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China
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Fialho GL, Nearing BD, Waks JW, Maher TR, Clarke JR, Shepherd A, D'Avila A, Verrier RL. Reduction in atrial and ventricular electrical heterogeneity following pulmonary vein isolation in patients with atrial fibrillation. J Interv Card Electrophysiol 2023:10.1007/s10840-023-01543-7. [PMID: 37074510 DOI: 10.1007/s10840-023-01543-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 03/28/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND Pulmonary vein isolation (PVI) modulates the intrinsic cardiac autonomic nervous system and reduces atrial fibrillation (AF) recurrence. METHODS In this retrospective analysis, we investigated the impact of PVI on ECG interlead P-wave, R-wave, and T-wave heterogeneity (PWH, RWH, TWH) in 45 patients in sinus rhythm undergoing clinically indicated PVI for AF. We measured PWH as a marker of atrial electrical dispersion and AF susceptibility and RWH and TWH as markers of ventricular arrhythmia risk along with standard ECG measures. RESULTS PVI acutely (16 ± 8.9 h) reduced PWH by 20.7% (from 31 ± 1.9 to 25 ± 1.6 µV, p < 0.001) and TWH by 27% (from 111 ± 7.8 to 81 ± 6.5 µV, p < 0.001). RWH was unchanged after PVI (p = 0.068). In a subgroup of 20 patients with longer follow-up (mean = 47 ± 3.7 days after PVI), PWH remained low (25 ± 1.7 µV, p = 0.01), but TWH partially returned to the pre-ablation level (to 93 ± 10.2, p = 0.16). In three individuals with early recurrence of atrial arrhythmia in the first 3 months after ablation, PWH increased acutely by 8.5%, while in patients without early recurrence, PWH decreased acutely by 22.3% (p = 0.048). PWH was superior to other contemporary P-wave metrics including P-wave axis, dispersion, and duration in predicting early AF recurrence. CONCLUSION The rapid time course of decreased PWH and TWH after PVI suggests a beneficial influence likely mediated via ablation of the intrinsic cardiac nervous system. Acute responses of PWH and TWH to PVI suggest a favorable dual effect on atrial and ventricular electrical stability and could be used to track individual patients' electrical heterogeneity profile.
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Affiliation(s)
- Guilherme L Fialho
- Federal University of Santa Catarina, Florianopolis, Brazil
- Departments of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Bruce D Nearing
- Departments of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Jonathan W Waks
- Departments of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Timothy R Maher
- Departments of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - John-Ross Clarke
- Departments of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Alyssa Shepherd
- Departments of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Andre D'Avila
- Departments of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Richard L Verrier
- Departments of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA.
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9
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Aksu T, Skeete JR, Huang HH. Ganglionic Plexus Ablation: A Step-by-step Guide for Electrophysiologists and Review of Modalities for Neuromodulation for the Management of Atrial Fibrillation. Arrhythm Electrophysiol Rev 2023; 12:e02. [PMID: 36845167 PMCID: PMC9945432 DOI: 10.15420/aer.2022.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 11/29/2022] [Indexed: 02/01/2023] Open
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.
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Affiliation(s)
- Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, Istanbul, Turkey
| | | | - Henry H Huang
- Department of Cardiology, Rush Medical College, Chicago, IL, US
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10
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Cardioneuroablation: Don't forget atrioventricular node innervation. HeartRhythm Case Rep 2022; 9:70-71. [PMID: 36860753 PMCID: PMC9968891 DOI: 10.1016/j.hrcr.2022.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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11
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Zerpa Acosta JC, Oliveira de Souza K, Ortencio FA, Cunha Pachon CT, Pachon Mateos EI, Pachon Mateos JC. Carotid sinus syndrome treated by cardioneuroablation: Is sinus node denervation enough? Insights from a syncope recurrence report. HeartRhythm Case Rep 2022; 9:48-52. [PMID: 36685681 PMCID: PMC9845552 DOI: 10.1016/j.hrcr.2022.10.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Juan Carlos Zerpa Acosta
- HCor, São Paulo Heart Hospital, São Paulo, Brazil,Address reprint requests and correspondence: Dr Juan Carlos Zerpa Acosta, 550 Rua Muniz de Sousa, Aclimacao, São Paulo, SP 01534-000, Brazil.
| | | | | | | | | | - Jose Carlos Pachon Mateos
- HCor, São Paulo Heart Hospital, São Paulo, Brazil,USP, São Paulo University, São Paulo, Brazil,IDPC – Sao Paulo Dante Pazzanese Cardiology Institute, São Paulo, Brazil
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12
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Huang T, Chen J, Müller-Edenborn B, Mayer L, Eichenlaub M, Moreno Weidmann Z, Allgeier J, Bohnen M, Lehrmann H, Trenk D, Schoechlin S, Westermann D, Arentz T, Jadidi A. Validating left atrial fractionation and low-voltage substrate during atrial fibrillation and sinus rhythm-A high-density mapping study in persistent atrial fibrillation. Front Cardiovasc Med 2022; 9:1000027. [PMID: 36330001 PMCID: PMC9622778 DOI: 10.3389/fcvm.2022.1000027] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/26/2022] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Low-voltage-substrate (LVS)-guided ablation for persistent atrial fibrillation (AF) has been described either in sinus rhythm (SR) or AF. Prolonged fractionated potentials (PFPs) may represent arrhythmogenic slow conduction substrate and potentially co-localize with LVS. We assess the spatial correlation of PFP identified in AF (PFP-AF) to those mapped in SR (PFP-SR). We further report the relationship between LVS and PFPs when mapped in AF or SR. MATERIALS AND METHODS Thirty-eight patients with ablation naïve persistent AF underwent left atrial (LA) high-density mapping in AF and SR prior to catheter ablation. Areas presenting PFP-AF and PFP-SR were annotated during mapping on the LA geometry. Low-voltage areas (LVA) were quantified using a bipolar threshold of 0.5 mV during both AF and SR mapping. Concordance of fractionated potentials (CFP) (defined as the presence of PFPs in both rhythms within a radius of 6 mm) was quantified. Spatial distribution and correlation of PFP and CFP with LVA were assessed. The predictors for CFP were determined. RESULTS PFPs displayed low voltages both during AF (median 0.30 mV (Q1-Q3: 0.20-0.50 mV) and SR (median 0.35 mV (Q1-Q3: 0.20-0.56 mV). The duration of PFP-SR was measured at 61 ms (Q1-Q3: 51-76 ms). During SR, most PFP-SRs (89.4 and 97.2%) were located within LVA (<0.5 mV and <1.0 mV, respectively). Areas presenting PFP occurred more frequently in AF than in SR (median: 9.5 vs. 8.0, p = 0.005). Both PFP-AF and PFP-SR were predominantly located at anterior LA (>40%), followed by posterior LA (>20%) and septal LA (>15%). The extent of LVA < 0.5 mV was more extensive in AF (median: 25.2% of LA surface, Q1-Q3:16.6-50.5%) than in SR (median: 12.3%, Q1-Q3: 4.7-29.4%, p = 0.001). CFP in both rhythms occurred in 80% of PFP-SR and 59% of PFP-AF (p = 0.008). Notably, CFP was positively correlated to the extent of LVA in SR (p = 0.004), but not with LVA in AF (p = 0.226). Additionally, the extent of LVA < 0.5 mV in SR was the only significant predictor for CFP, with an optimal threshold of 16% predicting high (>80%) fractionation concordance in AF and SR. CONCLUSION Substrate mapping in SR vs. AF reveals smaller areas of low voltage and fewer sites with PFP. PFP-SR are located within low-voltage areas in SR. There is a high degree of spatial agreement (80%) between PFP-AF and PFP-SR in patients with moderate LVA in SR (>16% of LA surface). These findings should be considered when substrate-based ablation strategies are applied in patients with the left atrial low-voltage substrate with recurrent persistent AF.
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Affiliation(s)
- Taiyuan Huang
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Juan Chen
- Department of Cardiology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Björn Müller-Edenborn
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Louisa Mayer
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Martin Eichenlaub
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Zoraida Moreno Weidmann
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
- Arrhythmia Unit, Department of Cardiology, Hospital Universitario Sant Pau, Barcelona, Spain
| | - Juergen Allgeier
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Marius Bohnen
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Heiko Lehrmann
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Dietmar Trenk
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Simon Schoechlin
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Dirk Westermann
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Thomas Arentz
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Amir Jadidi
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
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13
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Pachon-M JC, Ortencio FA, Pachon-M EI, Lobo T, Santillana-P TG, Pachon CT, Cunha-P MZ, Pachon-M JCM, Zerpa-A JC, Amarante RC. Treatment of Symptomatic Functional Atrioventricular Block by Cardioneuroablation as an Alternative to Pacemaker Implantation. JACC Case Rep 2022; 4:990-995. [PMID: 35935156 PMCID: PMC9350888 DOI: 10.1016/j.jaccas.2022.04.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/28/2022] [Accepted: 04/27/2022] [Indexed: 10/28/2022]
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14
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Fixed complex electrograms during sinus rhythm and local pacing: potential ablation targets for persistent atrial fibrillation. Sci Rep 2022; 12:10697. [PMID: 35739217 PMCID: PMC9225993 DOI: 10.1038/s41598-022-14824-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 06/13/2022] [Indexed: 12/01/2022] Open
Abstract
In atrial fibrillation (AF) patients, complex electrograms during sinus rhythm (C-EGMs) could be pathological or not. We aimed to demonstrate whether local pacing was helpful to discern pathological C-EGMs. 126 persistent AF patients and 27 patients with left-side accessory pathway (LAP) underwent left atrial mapping during sinus rhythm. If C-EGMs were detected, local pacing was performed. If the electrograms turned normal, we defined them as non-fixed C-EGMs, otherwise as fixed C-EGMs. No difference was detected in the incidence and proportion of non-fixed C-EGMs between AF patients and LAP patients (101/126 vs. 19/27, P = 0.26; 9.1 ± 6.0% vs. 7.7 ± 5.7%, P = 0.28). However, the incidence and proportion of fixed C-EGMs were higher in persistent AF patients (87/126 vs. 1/27, P < 0.01; 4.3 ± 3.4% vs. 0.1 ± 0.5%, P < 0.01). Compared with non-fixed C-EGMs, fixed C-EGMs had lower amplitudes, longer electrogram durations and longer Stimuli-P wave internals. All AF patients received circumferential pulmonary vein isolation. Among AF patients with fixed C-EGMs, 45 patients received fixed C-EGMs ablation and 42 patients underwent linear ablation. Compared with linear ablation, fixed C-EGMs ablation reduced recurrence (HR: 0.43; 95% CI 0.21‐0.81; P = 0.011). Among patients without fixed C-EGMs ablation, the proportion of fixed C-EGMs was an independent predictor of ablation outcomes (HR for per percent: 1.13, 95% CI 1.01–1.28, P = 0.038). C-EGMs could be classified into fixed and non-fixed C-EGMs through local pacing. Fixed rather than non-fixed C-EGMs might indicate abnormal atrial substrates and fixed C-EGMs ablation improve outcomes of persistent AF ablation.
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15
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Chen W, Liu Z, Xiao P, Xu Y, Li D, Xiong Q, Zou L, Qin F, Tao X, Chen J, Lan X, Du H, Yin Y, Ling Z. Extracardiac Vagal Stimulation-Assisted Cardioneuroablation: Dynamically Evaluating the Impact of Sequential Ganglionated Plexus Ablation on Vagal Control of SAN and AVN in Patients with Sinoatrial Node Dysfunction. J Cardiovasc Dev Dis 2022; 9:jcdd9060188. [PMID: 35735817 PMCID: PMC9225033 DOI: 10.3390/jcdd9060188] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/05/2022] [Accepted: 06/07/2022] [Indexed: 11/16/2022] Open
Abstract
Cardioneuroablation (CNA) is proposed as a promising therapy for patients with sinoatrial node dysfunction (SND) that is mediated by excessive vagal tone. However, a series of urgent questions about CNA remain unanswered. From December 2020 to March 2022, six patients with symptomatic SND who underwent CNA were summarized in this report. Sequential CNA targeting Ao-SVC GP, PMLGP, RAGP, and LSGP was performed in patients, guided by fractionated intracardiac electrograms and dynamically evaluated by extracardiac vagal stimulation (ECVS). The results showed that Ao-SVC GP ablation led to a significant increase in heart rate (HR) and the elimination of sinus arrest evoked by ECVS, while the vagal responses of atrial ventricular block were eliminated by the ablation of PMLGP and LSGP. Post-procedure HR increased up to 64-86% of the maximum HR of an atropine test at baseline. The median HR from Holter monitoring increased from 52.8 ± 2.1 bpm at baseline to 73.0 ± 10.4 bpm after the procedure (p = 0.012) and to 71.3 ± 10.1 bpm at the six-month follow-up (p = 0.011). Bradycardia-related symptoms disappeared in all patients at the six-month follow-up. This case series reveals the feasibility of using the ECVS-assisted sequential CNA technique and indicates the critical role of ECVS in dynamically evaluating the impact of sequential CNA on the vagal control of SAN and AVN.
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16
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Pachon-M JC, Pachon-M EI. Atropine: Hero or Villain in Cardioneuroablation (CNA)? HeartRhythm Case Rep 2022; 8:541. [PMID: 35860773 PMCID: PMC9289067 DOI: 10.1016/j.hrcr.2022.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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17
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Mateo EIP. Role of the Autonomic Nervous System in Atrial Fibrillation. Arq Bras Cardiol 2021; 117:1008-1009. [PMID: 34817010 PMCID: PMC8682107 DOI: 10.36660/abc.20210771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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18
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Nishida T, Takitsume A, Sugiura J, Keshi A, Kanaoka K, Hirai K, Yano H, Hashimoto Y, Ueda T, Nakagawa H, Onoue K, Soeda T, Watanabe M, Kawakami R, Saito Y. Catheter ablation of ganglionated plexi in patients with adenosine triphosphate-induced atrial fibrillation after pulmonary vein isolation. Heart Vessels 2021; 37:854-866. [PMID: 34741632 DOI: 10.1007/s00380-021-01979-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 10/22/2021] [Indexed: 11/24/2022]
Abstract
Intravenous ATP may induce atrial fibrillation (AF). ATP shares similar receptor-effector coupling systems with acetylcholine. However, the association between an ATP injection and the hyperactivity of the intrinsic cardiac autonomic nervous system, known as ganglionated plexi (GPs), is not well understood. We describe a series of patients with non-pulmonary vein (PV) trigger sites provoked by an ATP injection, and assess the feasibility of a ganglionated plexus (GP) ablation. We retrospectively analyzed 547 patients (69% male; mean age 67.4 ± 10.4 years; 38.5% non-paroxysmal AF) who underwent a total of 604 ablation procedures. Intravenous ATP was administered with an isoproterenol infusion during sinus rhythm after a pulmonary vein isolation in 21.3%, Box isolation in 78.6%, and SVC isolation in 52.0% of the procedures, respectively. We reviewed the incidence, the distribution of the foci, and the ablation outcomes in patients with ATP-induced AF. A total of seven patients (1.3%) had ATP-induced AF. Foci were identified in the coronary sinus (CS) in six patients, right atrial posterior wall (RAPW) adjacent to the interatrial groove in two, mitral annulus in two, ligament of Marshall in one, right septum below the foramen ovale in one and left atrial posterior wall in one, respectively. Among these trigger foci, we confirmed the vagal response by high-frequency stimulation in the CS and RAPW in six and two patients, respectively. After a median RF time of 2.9 min (range 2.5-11.3) targeting these foci, in five of six patients who received a repeat ATP injection, the AF became non-inducible. ATP-provoked trigger foci were distributed among certain sites that overlapped with the distribution of the GPs. The GP ablation was effective for this rare, but challenging situation.
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Affiliation(s)
- Taku Nishida
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan.
| | - Akihiro Takitsume
- Department of Cardiology, Nara Prefecture General Medical Center, Kashihara, Japan
| | - Junichi Sugiura
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Ayaka Keshi
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Koshiro Kanaoka
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Kaeko Hirai
- Department of Cardiology, Nara Prefecture Seiwa Medical Center, Kashihara, Japan
| | - Hiroki Yano
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Yukihiro Hashimoto
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Tomoya Ueda
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Hitoshi Nakagawa
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Kenji Onoue
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Tsunenari Soeda
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Makoto Watanabe
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Rika Kawakami
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Yoshihiko Saito
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
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19
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Gorev MV, Nardaia SG, Sergeeva OA, Vasilieva EY, Shpektor AV, Rzaev FG. Long-term Success of Cardioneuroablation in a Patient with Tachycardia-bradycardia Syndrome and Syncope. J Innov Card Rhythm Manag 2021; 12:4715-4719. [PMID: 34712506 PMCID: PMC8545437 DOI: 10.19102/icrm.2021.121001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 05/03/2021] [Indexed: 11/26/2022] Open
Abstract
A case of successful treatment for syncopal episodes caused by intermittent atrioventricular block in a patient with paroxysmal atrial fibrillation/atrial flutter using cardioneuroablation is presented.
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Affiliation(s)
- Maxim V Gorev
- Cardiology Department, Davydovsky City Hospital, Moscow, Russia
| | | | - Olga A Sergeeva
- Cardiology Department, Davydovsky City Hospital, Moscow, Russia
| | - Elena Yu Vasilieva
- Cardiology Department, Davydovsky City Hospital, Moscow, Russia.,Cardiology Department, Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - Alexander V Shpektor
- Cardiology Department, Davydovsky City Hospital, Moscow, Russia.,Cardiology Department, Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - Farkhad G Rzaev
- Cardiology Department, Davydovsky City Hospital, Moscow, Russia.,Cardiology Department, Moscow State University of Medicine and Dentistry, Moscow, Russia
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20
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Electrocardiographic Patterns in Patients with Neurally Mediated Syncope. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57080808. [PMID: 34441014 PMCID: PMC8399501 DOI: 10.3390/medicina57080808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/02/2021] [Accepted: 08/04/2021] [Indexed: 12/27/2022]
Abstract
The baseline electrocardiogram (ECG) is less informative in neurally mediated syncope (NMS) than in arrhythmic syncope. However, some of the ECG patterns present in NMS can have diagnostic and prognostic value in such patients. Electrocardiographic documentation of a syncopal spell and thus identification of the ECG changes can be performed during tilt table test (TTT) or during prolonged ECG monitoring. This work reviews the specific ECG patterns in NMS, which are primarily related to the cardioinhibitory reflex. In addition, there are other ECG findings present in patients with NMS that are being analyzed, such as increased heart rate variability as well as specific QRS voltage patterns. In addition to the diagnostic and prognostic value, these ECG patterns in NMS may help improving the selection of patients for pacemaker implant.
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21
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John LA, Mullis A, Payne J, Tung R, Aksu T, Winterfield JR. Fractionation Mapping of the Ganglionated Plexi for Cardioneuroablation. J Innov Card Rhythm Manag 2021; 12:4473-4476. [PMID: 33936863 PMCID: PMC8081457 DOI: 10.19102/icrm.2021.120405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 12/28/2020] [Indexed: 11/06/2022] Open
Abstract
Cardioneuroablation (CNA) is an emerging technique used to treat patients with vasovagal syncope (VVS). We herein describe a case of CNA targeting the atrial ganglionated plexi (GPs) based upon anatomical landmarks and fractionated electrogram (EGM) localization in a 20-year-old healthy female who presented to our center with malignant VVS and symptomatic sinus pauses, the longest of which measured 10 seconds. She underwent acutely successful CNA with a demonstration of vagal response noted following ablation of the left-sided GPs, and tachycardia was noted with right-sided GP ablation. All GP sites were defined by anatomical landmarks and EGM analysis. By using the fractionation mapping software of the EnSite Precision™ cardiac mapping system (Abbott, Chicago, IL, USA) with high-density mapping, fragmented EGMs were successfully detected in each GP site. One month after vagal denervation, no recurrent syncopal episodes or sinus pauses had been recorded. Longer-term follow-up with an implantable loop recorder is planned. Broadly, we performed CNA in a patient with VVS by combining high-density mapping and fractionation mapping software in a novel approach, which allowed us to detect fractionation in all GP sites and demonstrate an acute vagal response. This workflow may facilitate the introduction of a standardized technique suitable for widespread use.
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Affiliation(s)
- Leah A. John
- Division of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Andin Mullis
- Division of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Joshua Payne
- Division of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Roderick Tung
- The University of Chicago Medicine Center for Arrhythmia Care, Pritzker School of Medicine, Chicago, IL, USA
| | - Tolga Aksu
- Department of Cardiology, Kocaeli Derince Training and Research Hospital, University of Health Sciences, Kocaeli, Turkey
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22
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Pachon-M JC, Pachon-M EI, Pachon CTC, Santillana-P TG, Lobo TJ, Pachon-M JC, Zerpa-A JC, Cunha-P MZ, Higuti C, Ortencio FA, Amarante RC, Silva RF, Osorio TG. Long-Term Evaluation of the Vagal Denervation by Cardioneuroablation Using Holter and Heart Rate Variability. Circ Arrhythm Electrophysiol 2020; 13:e008703. [DOI: 10.1161/circep.120.008703] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background:
Several disorders present reflex or persistent increase in vagal tone that may cause refractory symptoms even in a normal heart patient. Cardioneuroablation, the vagal denervation by radiofrequency ablation of the neuromyocardial interface, was developed to treat these conditions without pacemaker implantation. A theoretical limitation could be the reinnervation, that naturally grows in the first year, that could recover the vagal hyperactivity. This study aims to verify the vagal denervation degree in the chronic phase after cardioneuroablation. Additionally, it intends to investigate the arrhythmias behavior after cardioneuroablation.
Methods:
Prospective longitudinal study with intrapatient comparison of 83 very symptomatic cases without significant cardiopathy, submitted to cardioneuroablation, 49 (59%) male, 47.3±17 years old, having vagal paroxysmal atrial fibrillation 58 (70%) or neurocardiogenic syncope 25 (30%), New York Heart Association class<II and absence of significant comorbidities. Cardioneuroablation was performed in both atria by interatrial septum puncture, with irrigated conventional catheter and electroanatomic reconstruction. Ablation targeted the neuromiocardial interface by fragmentation mapping (AF-Nests) using the velocity fractionation software, conventional recording, and anatomic localization of the ganglionated plexi. Heart rate variability (time and frequency domain) and arrhythmias were compared by 24h-Holter, before, and 1 year and 2 years after cardioneuroablation. In a 40 month follow-up, 80% of patients were asymptomatic.
Results:
Time- and frequency-domain heart rate variability demonstrated significant decrease in all autonomic parameters, showing an important parasympathetic and sympathetic activity reduction at 2-year post-cardioneuroablation (
P
<0.001). There was no difference in heart rate variability between the 1-year and 2-year post-cardioneuroablation (
P
>0.05) suggesting that the reinnervation has halted. There was also an important reduction in all bradyarrhythmias and tachyarrhythmias pre-cardioneuroablation versus post-cardioneuroablation (
P
<0.01).
Conclusions:
There is an important and significant vagal and sympathetic denervation after 2 years of cardioneuroablation with a significant reduction in bradyarrhythmia and tachyarrhythmia in the whole group. There were no complications.
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Affiliation(s)
- Jose Carlos Pachon-M
- USP, Sao Paulo University, Brazil (Jose Carlos Pachon-M, E.I.P.-M., Juan Carlos Pachon-M, R.C.A., R.F.S.)
- HCor, Sao Paulo Heart Hospital (Jose Carlos Pachon-M, E.I.P.-M., C.T.C.P., T.G.S.-P., T.J.L., Juan Carlos Pachon-M, J.C.Z.-A., M.Z.C.P., C.H., F.A.O., R.C.A., R.F.S., T.G.O.)
- IDPC, Sao Paulo Dante Pazzanese Cardiology Institute, Brazil (Jose Carlos Pachon-M, E.I.P.-M., Jose Carlos Pachon-M, C.H., R.C.A., R.F.S., T.G.O.)
| | - Enrique I. Pachon-M
- USP, Sao Paulo University, Brazil (Jose Carlos Pachon-M, E.I.P.-M., Juan Carlos Pachon-M, R.C.A., R.F.S.)
- HCor, Sao Paulo Heart Hospital (Jose Carlos Pachon-M, E.I.P.-M., C.T.C.P., T.G.S.-P., T.J.L., Juan Carlos Pachon-M, J.C.Z.-A., M.Z.C.P., C.H., F.A.O., R.C.A., R.F.S., T.G.O.)
- IDPC, Sao Paulo Dante Pazzanese Cardiology Institute, Brazil (Jose Carlos Pachon-M, E.I.P.-M., Jose Carlos Pachon-M, C.H., R.C.A., R.F.S., T.G.O.)
| | - Carlos Thiene C. Pachon
- HCor, Sao Paulo Heart Hospital (Jose Carlos Pachon-M, E.I.P.-M., C.T.C.P., T.G.S.-P., T.J.L., Juan Carlos Pachon-M, J.C.Z.-A., M.Z.C.P., C.H., F.A.O., R.C.A., R.F.S., T.G.O.)
| | - Tomas G. Santillana-P
- HCor, Sao Paulo Heart Hospital (Jose Carlos Pachon-M, E.I.P.-M., C.T.C.P., T.G.S.-P., T.J.L., Juan Carlos Pachon-M, J.C.Z.-A., M.Z.C.P., C.H., F.A.O., R.C.A., R.F.S., T.G.O.)
| | - Tasso J. Lobo
- HCor, Sao Paulo Heart Hospital (Jose Carlos Pachon-M, E.I.P.-M., C.T.C.P., T.G.S.-P., T.J.L., Juan Carlos Pachon-M, J.C.Z.-A., M.Z.C.P., C.H., F.A.O., R.C.A., R.F.S., T.G.O.)
| | - Juan Carlos Pachon-M
- USP, Sao Paulo University, Brazil (Jose Carlos Pachon-M, E.I.P.-M., Juan Carlos Pachon-M, R.C.A., R.F.S.)
- HCor, Sao Paulo Heart Hospital (Jose Carlos Pachon-M, E.I.P.-M., C.T.C.P., T.G.S.-P., T.J.L., Juan Carlos Pachon-M, J.C.Z.-A., M.Z.C.P., C.H., F.A.O., R.C.A., R.F.S., T.G.O.)
- IDPC, Sao Paulo Dante Pazzanese Cardiology Institute, Brazil (Jose Carlos Pachon-M, E.I.P.-M., Jose Carlos Pachon-M, C.H., R.C.A., R.F.S., T.G.O.)
| | - Juan Carlos Zerpa-A
- HCor, Sao Paulo Heart Hospital (Jose Carlos Pachon-M, E.I.P.-M., C.T.C.P., T.G.S.-P., T.J.L., Juan Carlos Pachon-M, J.C.Z.-A., M.Z.C.P., C.H., F.A.O., R.C.A., R.F.S., T.G.O.)
| | - Maria Z. Cunha-P
- HCor, Sao Paulo Heart Hospital (Jose Carlos Pachon-M, E.I.P.-M., C.T.C.P., T.G.S.-P., T.J.L., Juan Carlos Pachon-M, J.C.Z.-A., M.Z.C.P., C.H., F.A.O., R.C.A., R.F.S., T.G.O.)
| | - Christian Higuti
- HCor, Sao Paulo Heart Hospital (Jose Carlos Pachon-M, E.I.P.-M., C.T.C.P., T.G.S.-P., T.J.L., Juan Carlos Pachon-M, J.C.Z.-A., M.Z.C.P., C.H., F.A.O., R.C.A., R.F.S., T.G.O.)
| | - Felipe Augusto Ortencio
- HCor, Sao Paulo Heart Hospital (Jose Carlos Pachon-M, E.I.P.-M., C.T.C.P., T.G.S.-P., T.J.L., Juan Carlos Pachon-M, J.C.Z.-A., M.Z.C.P., C.H., F.A.O., R.C.A., R.F.S., T.G.O.)
| | - Ricardo C. Amarante
- USP, Sao Paulo University, Brazil (Jose Carlos Pachon-M, E.I.P.-M., Juan Carlos Pachon-M, R.C.A., R.F.S.)
- HCor, Sao Paulo Heart Hospital (Jose Carlos Pachon-M, E.I.P.-M., C.T.C.P., T.G.S.-P., T.J.L., Juan Carlos Pachon-M, J.C.Z.-A., M.Z.C.P., C.H., F.A.O., R.C.A., R.F.S., T.G.O.)
- IDPC, Sao Paulo Dante Pazzanese Cardiology Institute, Brazil (Jose Carlos Pachon-M, E.I.P.-M., Jose Carlos Pachon-M, C.H., R.C.A., R.F.S., T.G.O.)
| | - Ricardo F. Silva
- USP, Sao Paulo University, Brazil (Jose Carlos Pachon-M, E.I.P.-M., Juan Carlos Pachon-M, R.C.A., R.F.S.)
- HCor, Sao Paulo Heart Hospital (Jose Carlos Pachon-M, E.I.P.-M., C.T.C.P., T.G.S.-P., T.J.L., Juan Carlos Pachon-M, J.C.Z.-A., M.Z.C.P., C.H., F.A.O., R.C.A., R.F.S., T.G.O.)
- IDPC, Sao Paulo Dante Pazzanese Cardiology Institute, Brazil (Jose Carlos Pachon-M, E.I.P.-M., Jose Carlos Pachon-M, C.H., R.C.A., R.F.S., T.G.O.)
| | - Thiago G. Osorio
- HCor, Sao Paulo Heart Hospital (Jose Carlos Pachon-M, E.I.P.-M., C.T.C.P., T.G.S.-P., T.J.L., Juan Carlos Pachon-M, J.C.Z.-A., M.Z.C.P., C.H., F.A.O., R.C.A., R.F.S., T.G.O.)
- IDPC, Sao Paulo Dante Pazzanese Cardiology Institute, Brazil (Jose Carlos Pachon-M, E.I.P.-M., Jose Carlos Pachon-M, C.H., R.C.A., R.F.S., T.G.O.)
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Vrije Universiteit Brussel, Belgium (T.G.O.)
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Aksu T, Erdem Guler T, Gopinathannair R. Letter by Aksu et al Regarding Article, "Relation of Fractionated Atrial Potentials With the Vagal Innervation Evaluated by Extracardiac Vagal Stimulation During Cardioneuroablation". Circ Arrhythm Electrophysiol 2020; 13:e008595. [PMID: 32809879 DOI: 10.1161/circep.120.008595] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Tolga Aksu
- Department of Cardiology, University of Health Sciences, Kocaeli Derince Training and Research Hospital, Turkey (T.A., T.E.G.)
| | - Tumer Erdem Guler
- Department of Cardiology, University of Health Sciences, Kocaeli Derince Training and Research Hospital, Turkey (T.A., T.E.G.)
| | - Rakesh Gopinathannair
- Department of Electrophysiology, Kansas City Heart Rhythm Institute and Research Foundation, Overland Park (R.G.)
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24
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Pachón-M JC, Pachón-M EI. Response by J.C. Pachón-M and E.I. Pachón-M to Letter Regarding Article, "Relation of Fractionated Atrial Potentials With the Vagal Innervation Evaluated by Extracardiac Vagal Stimulation During Cardioneuroablation". Circ Arrhythm Electrophysiol 2020; 13:e008948. [PMID: 32809883 DOI: 10.1161/circep.120.008948] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- José C Pachón-M
- Sao Paulo University-USP, Heart Hospital-HCor and Dante Pazzanese Cardiology Institute, Brazil
| | - Enrique I Pachón-M
- Sao Paulo University-USP, Heart Hospital-HCor and Dante Pazzanese Cardiology Institute, Brazil
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25
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Stec S, Dobaj Ł, Śledź A, Stępień-Wałek AM, Ton V, Śledź J. Cardioneuroablation for management of cardioinhibitory vasovagal syncope and pacemaker complications. HeartRhythm Case Rep 2020; 6:531-534. [PMID: 32817835 PMCID: PMC7424299 DOI: 10.1016/j.hrcr.2020.04.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Sebastian Stec
- Research and Development Centre, MediNice, Rzeszów, Poland
- ELMedica, EP-Network, Skarżysko-Kamienna, Poland
| | - Łukasz Dobaj
- Research and Development Centre, MediNice, Rzeszów, Poland
- Department of Cardiovascular Rehabilitation, Busko-Zdrój, Poland
| | | | | | - Victor Ton
- EPMap-System, Pulmokard, Herdecke, Germany
| | - Janusz Śledź
- ELMedica, EP-Network, Skarżysko-Kamienna, Poland
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