Autonomic modulation after pulsed field vs. cryoballoon based pulmonary vein isolation and its effect on recurrence of atrial fibrillation

https://doi.org/10.1007/s00392-024-02526-y

Sandro Jäckle (Hamburg)1, M. Lemoine (Hamburg)1, J. Obergassel (Hamburg)2, J. Rieß (Hamburg)2, C. Mencke (Hamburg)1, I. My (Hamburg)1, F. Moser (Hamburg)2, L. Rottner (Hamburg)2, B. Reißmann (Hamburg)3, F. Ouyang (Hamburg)2, P. Kirchhof (Hamburg)2, A. Rillig (Hamburg)1, A. Metzner (Hamburg)1

1Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie mit Schwerpunkt Elektrophysiologie Hamburg, Deutschland; 2Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Hamburg, Deutschland; 3Universitäres Herz- und Gefäßzentrum Hamburg Allgemeine und Interventionelle Kardiologie Hamburg, Deutschland

 

Background:  Pulsed-field ablation (PFA) is a new energy source integrated into single- shot devices enabling pulmonary vein isolation (PVI) during atrial fibrillation (AF) ablation. Previous data has shown that PFA inflicts less neurocardiac damage than cryoballoon ablation (CBA) during PVI. Here we evaluated AF recurrence, PV reconnection rate and the impact of neurocardiac damage during PVI on autonomic functioning using heart rate (HR), heart rate variability (HRV) and premature ventricular beats (PVC) and their time- dependent changes during the first 6 months after PVI. 

Methods: We prospectively included consecutive patients with paroxysmal AF undergoing index pulmonary vein isolations (PVIs) applying PFA (n=65) or CBA (n=112). HRV was measured pre- and post-intervention, and in subgroups 3- and 6 months post PVI using Holter ECGs. HR was assessed continuously using wearables (PPG). Recurrent AF was detected using Holter ECGs, wearables and telephone interviews. The impact of PVI on premature ventricular contractions (PVC) burden was assessed by continuously measuring PVC burden in this post PVI setting. 

Results: Baseline characteristics did not differ between PFA and CBA. After CBA-based PVI, HR increased (pre 63 vs. post 70 bpm, p<0.001) and continuous monitoring of HR by PPG wearables confirmed the initial HR increase after CBA-PVI, followed by a decline in the 1st month and recovery of HR-increase in the following months. In contrast, HR did not substantially change over the observation period of 5 months for PFA. After CBA-based PVI, HRV decreased (SDNN pre 54 vs. post 26 ms, p=0.007) but not for PFA (SDNN pre 37 vs. post 36 ms, p=0.890). In a direct comparison, the HRV-decrease observed after CBA-based PVI was significant compared to PFA (SDNN -1 vs. 29 ms, p=0.003). After a follow-up of 3 and 6 months, the difference remained significantly different, whereas HRV in both groups seems to increase over time. PVC burden detected by PPG wearables (% of time of PVC >5%) increased on the post interventional day only after CBA-PVI, but not after PFA-PVI, while continuous follow-up revealed no difference anymore. PV reconnection rates in ReDo procedures were similar between PFA (37%) and CBA (36%). 1 year follow-up revealed freedom of AF in 79% after PFA and 73% after CBA (p=0.230).

Conclusion: These data suggest that neurocardiac damage near the pulmonary veins affects autonomic function. However, autonomic modulation did not contribute to freedom of AF recurrences after PVI.

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