Can we say anything about ganglionated plexus modification during radiofrequency pulmonary vein isolation and post-ablation arrhythmia recurrence at this time?

Can we say anything about ganglionated plexus modification during radiofrequency pulmonary vein... LETTERS TO THE EDITOR of the left superior pulmonary vein), anterior right actually a matter of thorough consideration for us doi:10.1093/europace/euw420 2 GP (located anterior to the right superior pul- upon planning this post hoc study analysis. Published online 23 February 2017 monary vein), and inferior left and inferior right Firstly, we would like to say that we completely 3,4 GP (located at the inferior aspect of the poster- disagree on the issue regarding a ‘relative’ defin- Can we say anything about ior left atrial wall, just below the left and right ition of vagal response for the purposes of this ganglionated plexus inferior pulmonary vein). Furthermore, in our re- study. A criterion of ‘progressive slowing of the modification during search article and published case report, we sinus rate by 50%’, as suggested, would include pa- radiofrequency pulmonary vein showed that isolated right atrial ablation may be tients who often enter the EP lab with sinus tachy- isolation and post-ablation enough in the patients with atrioventricular cardia (due to pre-procedural anxiety) and block. So, isolated left atrial ablation during pul- gradually calm down as the intervention proceeds arrhythmia recurrence at this monary vein isolation probably cannot cause sig- and conscious sedation is administered. Once time? nificant vagal denervation and the results of the again, the objective of this analysis was to test the We read the article with a great interest by present study should not be interpreted as GP ab- belief of some electrophysiologists (backed by Giannopoulos et al. published recently in lation during RF antral pulmonary vein isolation some data published in the past) that marked vagal Europace Journal entitled ‘Coincidental ganglion- are not associated with longer freedom of ar- responses (VR) are a sign of success. No electro- ated plexus modification during radiofrequency rhythmia recurrence. physiologist believes that if a patient reduces his/ pulmonary vein isolation and post-ablation ar- her heart rate by 50% (especially when given sed- rhythmia recurrence’. In this study, the authors ation), this is a sign of success. Therefore, we References evaluated whether coincidentally elicited vagal re- 1. Giannopoulos G, Kossyvakis C, Angelidis C, would have no reason to use such a ‘soft’ defin- Panagopoulou V, Tsiachris D, Vrachatis DA et al. sponse (VR) during left atrial ablation are associ- ition for a VR. Coincidental ganglionated plexus modification during ated with lower atrial fibrillation recurrence rates. This also answers the second comment of Dr. radiofrequency pulmonary vein isolation and post- Heart rate <40 bpm or asystole lasting >5 s eli- Aksu on post-procedural changes of indices of ablation arrhythmia recurrence. Europace 2017;19: cited during or immediately after radiofrequency vagal innervation: our objective was not to test 1967–72. 2. Aksu T, Golcuk E, Yalin K, Guler TE, Erden I. Simplified (RF) energy application were defined as VR. We whether ‘real’ autonomic modulation would re- cardioneuroablation in the treatment of reflex syn- would like to take attention some issues related sult in better success rates. However, we should cope, functional AV Block, and sinus node dysfunction. to the article. Firstly, the authors might use a little not fail to note that this is an insightful comment Pacing Clin Electrophysiol 2016;39:42–53. bit more specific cut-off values for the definition and we agree that such an undertaking (evaluating 3. Chiou CW, Eble JN, Zipes DP. Efferent vagal innerv- of VR. It is well known that basal heart rate of the ation of the canine atria and sinus and atrioventricu- cardiac autonomic innervation after the proced- lar nodes. The third fat pad. Circulation 1997;95: patients may be very different at the beginning of ure) would be interesting. However, it could not 2573–84. the procedure. For example, heart rate of 70 bpm be done in the context of a post hoc analysis. In 4. Armour JA, Murphy DA, Yuan BX, Macdonald S, during RF application may be accepted as a VR if any case, we mention in the Limitations paragraph Hopkins DA. Gross and microscopic anatomy of the pre-procedural is greater than 120 bpm. So, a pro- human intrinsic cardiac nervous system. Anat Rec of our paper that ‘the study protocol did not in- 1997;247:289–98. gressive slowing of the sinus rate by 50% may be- volve any kind of post-procedural testing of vagal 5. Aksu T, Baysal E, Guler TE, Yalın K. Selective right come a more realistic indicator of VR. Secondly, denervation, so that there is no direct way to as- atrial cardioneuroablation in functional atrioventricular to discuss whether ganglionated plexus (GP) sess the association of the observed VR to actual block. Europace 2017;19:333. modification affects atrial fibrillation recurrence modification of cardiac vagal innervation.’ rates, the authors should discuss some data about Finally, regarding the third point made by post-procedural changes on basal electrophysio- the author on the anatomic distribution of Tolga Aksu* logical parameters. In our research article, we ganglionated complexes and the theoretical Department of Cardiology, Kocaeli Derince demonstrated a significant decrease on basal cycle improbability that one could ablate ‘by sheer Education and Research Hospital, Derince, lengths and atrioventricular Wenckebach points Kocaeli/Turkey happenstance’ all or a significant proportion of after the procedure in patients with reflex syn- them during a pulmonary vein isolation proced- *Corresponding author. Tel: þ90 531 990 32 78; cope. Also, it is well known that long-term dur- fax: þ90 262 317 80 00. E-mail address: ure, our response is quite straightforward: we aksutolga@gmail.com ability of vagal denervation might be investigated completely agree and we have actually made this by Holter recordings. It was demonstrated by our point in our Discussion, as it represents the back- group that vagal denervation may cause a signifi- bone of our pathophysiological explanation of cant increase in minimum and mean heart rates our findings. during 6-months follow-up. doi:10.1093/europace/euw427 Lastly, Chiou et al. demonstrated three differ- Published online 17 February 2017 Conflict of interest: none declared. ent vagal ganglia: Ganglion A is localized between Marked bradycardia elicited the aortic root and the medial superior vena cava., Ganglion B is localized between the right pul- References during pulmonary vein 1. Aksu T. Can we say anything about ganglionated monary veins and RA., and Ganglion C is local- isolation: not a sign of plexus modification during radiofrequency pulmonary ized in the inferoposterior interatrial septum. success—Authors’ reply vein isolation and post-ablation arrhythmia recur- Whereas, in a human study, main left atrial GP are rence at this time? Europace 2018;20:546. 1 1 categorized as follows: superior left GP (located We would like to thank Dr. Aksu for his interest- 2. Giannopoulos G, Kossyvakis C, Angelidis C, Panagopoulou V, Tsiachris D, Vrachatis DA et al. on the roof of the left atrium, near the medial side ing comments on our paper. Some of them were V C Published on behalf of the European Society of Cardiology. All rights reserved. The Author 2017. For permissions, please email: journals.permissions@oup.com. Downloaded from https://academic.oup.com/europace/article-abstract/20/3/560/3048653 by Ed 'DeepDyve' Gillespie user on 16 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Europace Oxford University Press

Can we say anything about ganglionated plexus modification during radiofrequency pulmonary vein isolation and post-ablation arrhythmia recurrence at this time?

Europace , Volume 20 (3) – Mar 1, 2018
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Abstract

LETTERS TO THE EDITOR of the left superior pulmonary vein), anterior right actually a matter of thorough consideration for us doi:10.1093/europace/euw420 2 GP (located anterior to the right superior pul- upon planning this post hoc study analysis. Published online 23 February 2017 monary vein), and inferior left and inferior right Firstly, we would like to say that we completely 3,4 GP (located at the inferior aspect of the poster- disagree on the issue regarding a ‘relative’ defin- Can we say anything about ior left atrial wall, just below the left and right ition of vagal response for the purposes of this ganglionated plexus inferior pulmonary vein). Furthermore, in our re- study. A criterion of ‘progressive slowing of the modification during search article and published case report, we sinus rate by 50%’, as suggested, would include pa- radiofrequency pulmonary vein showed that isolated right atrial ablation may be tients who often enter the EP lab with sinus tachy- isolation and post-ablation enough in the patients with atrioventricular cardia (due to pre-procedural anxiety) and block. So, isolated left atrial ablation during pul- gradually calm down as the intervention proceeds arrhythmia recurrence at this monary vein isolation probably cannot cause sig- and conscious sedation is administered. Once time? nificant vagal denervation and the results of the again, the objective of this analysis was to test the We read the article with a great interest by present study should not be interpreted as GP ab- belief of some electrophysiologists (backed by Giannopoulos et al. published recently in lation during RF antral pulmonary vein isolation some data published in the past) that marked vagal Europace Journal entitled ‘Coincidental ganglion- are not associated with longer freedom of ar- responses (VR) are a sign of success. No electro- ated plexus modification during radiofrequency rhythmia recurrence. physiologist believes that if a patient reduces his/ pulmonary vein isolation and post-ablation ar- her heart rate by 50% (especially when given sed- rhythmia recurrence’. In this study, the authors ation), this is a sign of success. Therefore, we References evaluated whether coincidentally elicited vagal re- 1. Giannopoulos G, Kossyvakis C, Angelidis C, would have no reason to use such a ‘soft’ defin- Panagopoulou V, Tsiachris D, Vrachatis DA et al. sponse (VR) during left atrial ablation are associ- ition for a VR. Coincidental ganglionated plexus modification during ated with lower atrial fibrillation recurrence rates. This also answers the second comment of Dr. radiofrequency pulmonary vein isolation and post- Heart rate <40 bpm or asystole lasting >5 s eli- Aksu on post-procedural changes of indices of ablation arrhythmia recurrence. Europace 2017;19: cited during or immediately after radiofrequency vagal innervation: our objective was not to test 1967–72. 2. Aksu T, Golcuk E, Yalin K, Guler TE, Erden I. Simplified (RF) energy application were defined as VR. We whether ‘real’ autonomic modulation would re- cardioneuroablation in the treatment of reflex syn- would like to take attention some issues related sult in better success rates. However, we should cope, functional AV Block, and sinus node dysfunction. to the article. Firstly, the authors might use a little not fail to note that this is an insightful comment Pacing Clin Electrophysiol 2016;39:42–53. bit more specific cut-off values for the definition and we agree that such an undertaking (evaluating 3. Chiou CW, Eble JN, Zipes DP. Efferent vagal innerv- of VR. It is well known that basal heart rate of the ation of the canine atria and sinus and atrioventricu- cardiac autonomic innervation after the proced- lar nodes. The third fat pad. Circulation 1997;95: patients may be very different at the beginning of ure) would be interesting. However, it could not 2573–84. the procedure. For example, heart rate of 70 bpm be done in the context of a post hoc analysis. In 4. Armour JA, Murphy DA, Yuan BX, Macdonald S, during RF application may be accepted as a VR if any case, we mention in the Limitations paragraph Hopkins DA. Gross and microscopic anatomy of the pre-procedural is greater than 120 bpm. So, a pro- human intrinsic cardiac nervous system. Anat Rec of our paper that ‘the study protocol did not in- 1997;247:289–98. gressive slowing of the sinus rate by 50% may be- volve any kind of post-procedural testing of vagal 5. Aksu T, Baysal E, Guler TE, Yalın K. Selective right come a more realistic indicator of VR. Secondly, denervation, so that there is no direct way to as- atrial cardioneuroablation in functional atrioventricular to discuss whether ganglionated plexus (GP) sess the association of the observed VR to actual block. Europace 2017;19:333. modification affects atrial fibrillation recurrence modification of cardiac vagal innervation.’ rates, the authors should discuss some data about Finally, regarding the third point made by post-procedural changes on basal electrophysio- the author on the anatomic distribution of Tolga Aksu* logical parameters. In our research article, we ganglionated complexes and the theoretical Department of Cardiology, Kocaeli Derince demonstrated a significant decrease on basal cycle improbability that one could ablate ‘by sheer Education and Research Hospital, Derince, lengths and atrioventricular Wenckebach points Kocaeli/Turkey happenstance’ all or a significant proportion of after the procedure in patients with reflex syn- them during a pulmonary vein isolation proced- *Corresponding author. Tel: þ90 531 990 32 78; cope. Also, it is well known that long-term dur- fax: þ90 262 317 80 00. E-mail address: ure, our response is quite straightforward: we aksutolga@gmail.com ability of vagal denervation might be investigated completely agree and we have actually made this by Holter recordings. It was demonstrated by our point in our Discussion, as it represents the back- group that vagal denervation may cause a signifi- bone of our pathophysiological explanation of cant increase in minimum and mean heart rates our findings. during 6-months follow-up. doi:10.1093/europace/euw427 Lastly, Chiou et al. demonstrated three differ- Published online 17 February 2017 Conflict of interest: none declared. ent vagal ganglia: Ganglion A is localized between Marked bradycardia elicited the aortic root and the medial superior vena cava., Ganglion B is localized between the right pul- References during pulmonary vein 1. Aksu T. Can we say anything about ganglionated monary veins and RA., and Ganglion C is local- isolation: not a sign of plexus modification during radiofrequency pulmonary ized in the inferoposterior interatrial septum. success—Authors’ reply vein isolation and post-ablation arrhythmia recur- Whereas, in a human study, main left atrial GP are rence at this time? Europace 2018;20:546. 1 1 categorized as follows: superior left GP (located We would like to thank Dr. Aksu for his interest- 2. Giannopoulos G, Kossyvakis C, Angelidis C, Panagopoulou V, Tsiachris D, Vrachatis DA et al. on the roof of the left atrium, near the medial side ing comments on our paper. Some of them were V C Published on behalf of the European Society of Cardiology. All rights reserved. The Author 2017. For permissions, please email: journals.permissions@oup.com. Downloaded from https://academic.oup.com/europace/article-abstract/20/3/560/3048653 by Ed 'DeepDyve' Gillespie user on 16 March 2018

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EuropaceOxford University Press

Published: Mar 1, 2018

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