Response by Rivarola and Scanavacca to Letter Regarding Article, “Targets and End Points in Cardiac Autonomic Denervation Procedures”

HomeCirculation: Arrhythmia and ElectrophysiologyVol. 10, No. 8Response by Rivarola and Scanavacca to Letter Regarding Article, "Targets and End Points in Cardiac Autonomic Denervation Procedures" Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBResponse by Rivarola and Scanavacca to Letter Regarding Article, "Targets and End Points in Cardiac Autonomic Denervation Procedures" Esteban Rivarola, MD, PhD and Mauricio Scanavacca, MD, PhD Esteban RivarolaEsteban Rivarola Heart Institute, University of São Paulo Medical School, Brazil and Mauricio ScanavaccaMauricio Scanavacca Heart Institute, University of São Paulo Medical School, Brazil Originally published9 Aug 2017https://doi.org/10.1161/CIRCEP.117.005650Circulation: Arrhythmia and Electrophysiology. 2017;10:e005650In Response:We would like to thank Dr Debruyne for his interest in our article Targets and End Points in Cardiac Autonomic Denervation Procedures1 and for bringing in some important topics on this technique. Based on his observations,2 Dr Debruyne proposes that:The procedure must be limited to the right side of the interatrial septum, and the anterior right ganglionated plexus should be considered the main target.The procedure must be tailored and the ablation lesion kept to a minimum.The P-P interval measurement should be considered a procedural end point.A solely anatomic approach is preferred.Whereas agreement among authors is often reached about some aspects of the denervation technique1–3 (such as the anatomic approach, the use of electrophysiological intervals shortening as end points, and the identification of the interatrial septum as a main target), other aspects are still controversial. The extent of radiofrequency ablation needed to produce clinical benefit and still avoid potential complications is one of the most important and controversial issues. The ability to tailor ablation to individuals is even more difficult when one considers the complexity of the morphology, distribution, and variability of the epicardial neural ganglionated plexi and their highly variable divisions and overlapping network of fibers. These topological characteristics prevent us from assuming that a focused targeted ablation will invariably solve the problem and that a final common pathway of vagal innervation can always be identified in every patient.Although Dr Debruyne2 was able to identify the anterior right ganglionated plexus as a sole critical spot in his case report, this might not be effective in a larger population. Furthermore, the choice of a multielectrode irrigated catheter for ablation makes clear that ablation over an area, rather than a focus, is desired. In our study, we report a success rate of 71% after a combined left and right septum approach. Whereas extensive ablation3 proposed by some authors aims at better results at the potential expense of higher risks, ablation restricted to only right-sided lesions2 might be less effective, particularly with long follow-up.What is the perfect combination of boldness and caution when it comes to denervation procedures? A randomized study might answer that question. Meanwhile, there are some clinical and experimental evidences that can guide us:Most epicardial ganglia are located on the posterior surfaces of both atria.4Both pulmonary vein ganglia and superior vena cava ganglia stimulation have been demonstrated to modulate sinoatrial node activation in experimental models, implying the presence of both left and right vagal pathways to that node.4During denervation, critical sites triggering significant shortening of the P-P and HV intervals could be located either in the left or right side of the interatrial septum.1In conclusion, we agree that ablation over extensive areas should be avoided. However, the complex neural anatomy raises concern as to the efficacy of targeting a single region for ablation. A multicenter randomized study is needed to determine the best technique.Esteban Rivarola, MD, PhDMauricio Scanavacca, MD, PhDHeart InstituteUniversity of São Paulo Medical SchoolBrazilDisclosuresNone.References1. Rivarola EW, Hachul D, Wu T, Pisani C, Hardy C, Raimundi F, Melo S, Darrieux F, Scanavacca M. Targets and end points in cardiac autonomic denervation procedures.Circ Arrhythm Electrophysiol. 2017; 1 0:e004638. doi: 10.1161/CIRCEP.116.004638.Google Scholar2. Debruyne P. "Cardio-neuromodulation" with a multielectrode irrigated catheter: a potential new approach for patients with cardio-inhibitory syncope.J Cardiovasc Electrophysiol. 2016; 27:1110–1113. doi: 10.1111/jce.13031.CrossrefMedlineGoogle Scholar3. Pachon M JC, Pachon M EI, Santillana P TG, Lobo TJ, Pachon CTC, Pachon M JC, Albornoz V RN. Simplified method for vagal effect evaluation in cardiac ablation and electrophysiological procedures.JACC Clin Electrophysiol. 2015; 1:451–460. doi.org/10.1016/j.jacep.2015.06.008.CrossrefMedlineGoogle Scholar4. Ripplinger CM, Noujaim SF, Linz D. The nervous heart.Prog Biophys Mol Biol. 2016; 120:199–209. doi: 10.1016/j.pbiomolbio.2015.12.015.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Aksu T, Padmanabhan D, Shenthar J, Yalin K, Gautam S, Valappil S, Banavalikar B, Guler T, Bozyel S, Tanboga I, Lakkireddy D, Olshansky R and Gopinathannair R (2021) The benefit of cardioneuroablation to reduce syncope recurrence in vasovagal syncope patients: a case-control study, Journal of Interventional Cardiac Electrophysiology, 10.1007/s10840-020-00938-0, 63:1, (77-86), Online publication date: 1-Jan-2022. Aksu T, Guler T, Bozyel S, Golcuk S, Yalin K, Lakkireddy D and Gopinathannair R (2020) Medium-term results of cardioneuroablation for clinical bradyarrhythmias and vasovagal syncope: effects on QT interval and heart rate, Journal of Interventional Cardiac Electrophysiology, 10.1007/s10840-020-00704-2, 60:1, (57-68), Online publication date: 1-Jan-2021. Aksu T, Guler T, Bozyel S, Yalin K and Gopinathannair R (2020) Potential therapeutic effects of electrogram-guided cardioneuroablation in long QT syndrome: case series, Journal of Interventional Cardiac Electrophysiology, 10.1007/s10840-020-00831-w, 61:2, (385-393), Online publication date: 1-Aug-2021. Nantsupawat T, Krishnappa D and Benditt D (2020) Sinus arrest: A rare observation during radiofrequency ablation along the coronary sinus roof, Annals of Noninvasive Electrocardiology, 10.1111/anec.12772, 26:1, Online publication date: 1-Jan-2021. Aksu T, Guler T, Bozyel S and Yalin K (2020) Selective vagal innervation principles of ganglionated plexi: step-by-step cardioneuroablation in a patient with vasovagal syncope, Journal of Interventional Cardiac Electrophysiology, 10.1007/s10840-020-00757-3, 60:3, (453-458), Online publication date: 1-Apr-2021. Krishnappa D, Brignole M and Benditt D (2020) Cardioneuroablation for Cardioinhibitory Vasovagal Syncope Syncope, 10.1007/978-3-030-44507-2_26, (307-317), . Baysal E, Guler T, Gopinathannair R, Bozyel S, Yalin K and Aksu T (2020) Catheter Ablation of Atrioventricular Block, JACC: Case Reports, 10.1016/j.jaccas.2020.07.050, 2:11, (1793-1801), Online publication date: 1-Sep-2020. Lu Y, Wei W, Upadhyay G and Tung R (2020) Catheter-Based Cardio-Neural Ablation for Refractory Vasovagal Syncope, JACC: Case Reports, 10.1016/j.jaccas.2020.04.022, 2:8, (1161-1165), Online publication date: 1-Jul-2020. Scherschel K, Hedenus K, Jungen C, Lemoine M, Rübsamen N, Veldkamp M, Klatt N, Lindner D, Westermann D, Casini S, Kuklik P, Eickholt C, Klöcker N, Shivkumar K, Christ T, Zeller T, Willems S and Meyer C (2019) Cardiac glial cells release neurotrophic S100B upon catheter-based treatment of atrial fibrillation, Science Translational Medicine, 10.1126/scitranslmed.aav7770, 11:493, Online publication date: 22-May-2019. Issa Z, Miller J and Zipes D (2019) Atrial Fibrillation Clinical Arrhythmology and Electrophysiology, 10.1016/B978-0-323-52356-1.00015-3, (421-548), . Siliste C and Siliste R (2019) How to Induce Arrhythmias with Atropine Arrhythmia Induction in the EP Lab, 10.1007/978-3-319-92729-9_6, (49-61), . Aksu T, Guler T, Bozyel S and Yalin K (2019) Potential usage of cardioneuroablation in vagally mediated functional atrioventricular block, SAGE Open Medicine, 10.1177/2050312119836308, 7, (205031211983630), Online publication date: 1-Jan-2019. Antolic B and Zizek D (2018) Reply to the Editor— The proper usage of electroanatomic mapping–guided cardioneuroablation, HeartRhythm Case Reports, 10.1016/j.hrcr.2018.10.002, 4:12, (606-607), Online publication date: 1-Dec-2018. Aksu T, Guler T, Yalin K, Mutluer F, Ozcan K and Calò L (2018) Catheter Ablation of Bradyarrhythmia: From the Beginning to the Future, The American Journal of the Medical Sciences, 10.1016/j.amjms.2017.11.016, 355:3, (252-265), Online publication date: 1-Mar-2018. August 2017Vol 10, Issue 8 Advertisement Article InformationMetrics © 2017 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.117.005650PMID: 28794083 Originally publishedAugust 9, 2017 PDF download Advertisement SubjectsArrhythmiasCatheter Ablation and Implantable Cardioverter-DefibrillatorElectrophysiologyNeurostimulationPacemaker