Changes in Autonomic Tone Resulting from Circumferential Pulmonary Vein Isolation
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In patients with normal hearts, increased vagal tone is associated with the onset of paroxysmal atrial fibrillation (AF). Vagal denervation of the atria renders AF less inducible. Circumferential pulmonary vein ablation (CPVA), with or without isolation (CPVI), is effective for treating paroxysmal AF, and has been shown to impact HRV indices, in turn reflecting vagal denervation. We examined the impact of CPVI on HRV indices over time, and evaluated the relationship between vagal modification and rate of recurrence of AF. High resolution ECG recordings were collected from 64 patients (49 male, 15 female, mean age 57.1±9.7) undergoing CPVI for paroxysmal (n=46) or persistent (n=18) AF. Recordings were made pre-procedure, and at intervals up to 12 months. Success was defined as no recurrence. After CPVI, 27 patients presented recurrence. Pre-procedure HRV variables did not differ from controls in patients with a subsequent successful procedure. However, patients with recurrence demonstrated significantly-reduced pre-procedure HRV compared both with controls, and with patients having successful procedures (39.6±23.4 & 33.7±19.2 vs 21.8±11.8, P =0.01 & P=0.04). Following the procedure, HRV was reduced vs pre-procedure in patients with successful procedures (33.7±19.2 vs 18.6±15.8, P=0.01), and did not differ from unsuccessful procedures over a 12 month FU. Both groups were reduced compared with a control value. There was no significant difference in HRV between patients who experienced recurring AF (n=9), and those who experienced AT or flutter (n=18). Our data suggests that patients experiencing recurrence after one procedure have reduced HRV that is not changed by CPVI; whereas patients with a successful single procedure experience a change in HRV variables that is sustained over a long period, but is no different post-procedure from patients experiencing recurrence. These data suggest that denervation associated with CPVI may benefit patients with normal vagal tone prior to the procedure, but that sustained denervation is not a critical factor in successful outcome after CPVI.