Marked bradycardia elicited during pulmonary vein isolation: not a sign of success—Authors' reply

Marked bradycardia elicited during pulmonary vein isolation: not a sign of success—Authors' reply We would like to thank Dr. Aksu1 for his interesting comments on our paper.2 Some of them were actually a matter of thorough consideration for us upon planning this post hoc study analysis. Firstly, we would like to say that we completely disagree on the issue regarding a ‘relative’ definition of vagal response for the purposes of this study. A criterion of ‘progressive slowing of the sinus rate by 50%’, as suggested, would include patients who often enter the EP lab with sinus tachycardia (due to pre-procedural anxiety) and gradually calm down as the intervention proceeds and conscious sedation is administered. Once again, the objective of this analysis was to test the belief of some electrophysiologists (backed by some data published in the past) that marked vagal responses (VR) are a sign of success. No electrophysiologist believes that if a patient reduces his/her heart rate by 50% (especially when given sedation), this is a sign of success. Therefore, we would have no reason to use such a ‘soft’ definition for a VR. This also answers the second comment of Dr. Aksu on post-procedural changes of indices of vagal innervation: our objective was not to test whether ‘real’ autonomic modulation would result in better success rates. However, we should not fail to note that this is an insightful comment and we agree that such an undertaking (evaluating cardiac autonomic innervation after the procedure) would be interesting. However, it could not be done in the context of a post hoc analysis. In any case, we mention in the Limitations paragraph of our paper that ‘the study protocol did not involve any kind of post-procedural testing of vagal denervation, so that there is no direct way to assess the association of the observed VR to actual modification of cardiac vagal innervation.’ Finally, regarding the third point made by the author on the anatomic distribution of ganglionated complexes and the theoretical improbability that one could ablate ‘by sheer happenstance’ all or a significant proportion of them during a pulmonary vein isolation procedure, our response is quite straightforward: we completely agree and we have actually made this point in our Discussion, as it represents the backbone of our pathophysiological explanation of our findings. Conflict of interest: none declared. References 1 Aksu T. Can we say anything about ganglionated plexus modification during radiofrequency pulmonary vein isolation and post-ablation arrhythmia recurrence at this time? Europace  2018; 20:546. 2 Giannopoulos G, Kossyvakis C, Angelidis C, Panagopoulou V, Tsiachris D, Vrachatis DA et al.   Coincidental ganglionated plexus modification during radiofrequency pulmonary vein isolation and post-ablation arrhythmia recurrence. Europace  2017; 19:1967--72. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Europace Oxford University Press

Marked bradycardia elicited during pulmonary vein isolation: not a sign of success—Authors' reply

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Publisher
Oxford University Press
Copyright
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.
ISSN
1099-5129
eISSN
1532-2092
D.O.I.
10.1093/europace/euw427
Publisher site
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Abstract

We would like to thank Dr. Aksu1 for his interesting comments on our paper.2 Some of them were actually a matter of thorough consideration for us upon planning this post hoc study analysis. Firstly, we would like to say that we completely disagree on the issue regarding a ‘relative’ definition of vagal response for the purposes of this study. A criterion of ‘progressive slowing of the sinus rate by 50%’, as suggested, would include patients who often enter the EP lab with sinus tachycardia (due to pre-procedural anxiety) and gradually calm down as the intervention proceeds and conscious sedation is administered. Once again, the objective of this analysis was to test the belief of some electrophysiologists (backed by some data published in the past) that marked vagal responses (VR) are a sign of success. No electrophysiologist believes that if a patient reduces his/her heart rate by 50% (especially when given sedation), this is a sign of success. Therefore, we would have no reason to use such a ‘soft’ definition for a VR. This also answers the second comment of Dr. Aksu on post-procedural changes of indices of vagal innervation: our objective was not to test whether ‘real’ autonomic modulation would result in better success rates. However, we should not fail to note that this is an insightful comment and we agree that such an undertaking (evaluating cardiac autonomic innervation after the procedure) would be interesting. However, it could not be done in the context of a post hoc analysis. In any case, we mention in the Limitations paragraph of our paper that ‘the study protocol did not involve any kind of post-procedural testing of vagal denervation, so that there is no direct way to assess the association of the observed VR to actual modification of cardiac vagal innervation.’ Finally, regarding the third point made by the author on the anatomic distribution of ganglionated complexes and the theoretical improbability that one could ablate ‘by sheer happenstance’ all or a significant proportion of them during a pulmonary vein isolation procedure, our response is quite straightforward: we completely agree and we have actually made this point in our Discussion, as it represents the backbone of our pathophysiological explanation of our findings. Conflict of interest: none declared. References 1 Aksu T. Can we say anything about ganglionated plexus modification during radiofrequency pulmonary vein isolation and post-ablation arrhythmia recurrence at this time? Europace  2018; 20:546. 2 Giannopoulos G, Kossyvakis C, Angelidis C, Panagopoulou V, Tsiachris D, Vrachatis DA et al.   Coincidental ganglionated plexus modification during radiofrequency pulmonary vein isolation and post-ablation arrhythmia recurrence. Europace  2017; 19:1967--72. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.

Journal

EuropaceOxford University Press

Published: Mar 1, 2018

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