Ectopy-triggering ganglionated plexuses ablation to prevent atrial fibrillation: GANGLIA-AF study

Figures

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  Figure 1. Study flowchart. GPA = ganglionated plexuses ablation; PVI = pulmonary vein isolation.

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  Figure 2. Example of HFS at a GP site. After the second HFS, PV ectopy is triggered (arrow) with the earliest signal in PV 3-4. This is repeated with further trains of synchronized HFS. Simultaneously, there is a progressive R-R prolongation until 2.8 seconds of AV block, followed by AF. This GP site demonstrates colocation of ectopy-triggering GP and AV dissociating GP. AF = atrial fibrillation; AV = atrioventricular; BP = blood pressure; CS = coronary sinus; GP = ganglionated plexuses; HFS = high frequency stimulation; Mapd = mapping catheter distal; Mapp = mapping catheter proximal; PV = pulmonary vein.

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  Figure 3. Primary end point. A: The primary end points at 12 months of follow-up in the PVI and the overall GPA group were not significantly different from each other. B: The GPA subgroup that had undergone ET-GP ablation only without incessant AF during GP mapping had greater freedom from >30 seconds of AF/AT than did the overall GPA group in panel A. AF = atrial fibrillation; AT = atrial tachycardia; ET-GP = ectopy-triggering ganglionated plexuses; GPA = ganglionated plexuses ablation; PVI = pulmonary vein isolation.

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  Figure 4. Example of successful ET-GP ablation without PVI. One hundred thirty-five sites were tested with synchronized HFS; 16.5 minutes of RF ablation was performed on 13 ET-GPs. PVs remained electrically connected. Pacemaker interrogation after 12 months showed no evidence of atrial arrhythmia since ET-GP ablation. The patient has remained symptom free and off all antiarrhythmic drugs. AP = anterior posterior; AF = atrial fibrillation; AT = atrial tachycardia; ET-GP = ectopy-triggering ganglionated plexuses; GP = ganglionated plexuses; HFS = high frequency stimulation; LAA = left atrial appendage; LIPV = left inferior pulmonary vein; LSPV = left superior pulmonary vein; PA = posterior anterior; PV = pulmonary vein; RAO = right anterior oblique; RF = radiofrequency; RIPV = right inferior pulmonary vein; RSPV = right superior pulmonary vein.

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  Figure 5. Acute AF modification with GPA and long-term outcomes. If >2 minutes of sustained AF was triggered during HFS mapping, GPA was attempted to try and restore SR. Acute AF modification included AF termination to SR, organization to AT, or prolongation of AF cycle length by ≥30 ms. There was a range of success in acute AF modification between patients, which was divided into 100% success in acute AF modification and <100% success in acute AF modification. These subgroups were also compared with patients who did not have sustained AF during HFS mapping. The differences in long-term freedom from ≥30 seconds of AF/AT after GPA in these subgroups was not statistically significant. SR = sinus rhythm; other abbreviations as in Figure 3.

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  Figure 6. Univariate and multivariate analyses in GPA and PVI groups. All variables with P values ≤0.05 from the univariate analysis and well-established risk factors for AF recurrence, such as age and hypertension, were entered into the multivariate regression analysis. AF = atrial fibrillation; AT = atrial tachycardia; AVD-GP = atrioventricular dissociating ganglionated plexuses; BMI = body mass index; CHA2DS2-VASc = congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, previous stroke, transient ischemic attack, or thromboembolism, vascular disease, age 65–74 years, sex category (female); CI = confidence interval; ET-GP = ectopy-triggering ganglionated plexuses; GP = ganglionated plexuses; GPA = ganglionated plexuses ablation; HFS = high frequency stimulation; HR = hazard ratio; HTN = hypertension; LA = left atrial; PVI = pulmonary vein isolation; SR = sinus rhythm; RF = radiofrequency.