Incidence, timing, and characteristics of acute changes in heart rate during ongoing circumferential pulmonary vein isolation

Stefan Ketels, Richard Houben, Katarina Van Beeumen, Rene Tavernier, Mattias Duytschaever
Europace: European Pacing, Arrhythmias, and Cardiac Electrophysiology 2008, 10 (12): 1406-14

AIMS: Previous studies showed that catheter ablation of atrial fibrillation (AF) results in vagal denervation with an increase in average heart rate (HR) and a reduced overall HR variability (HRV) at follow-up. We analysed acute ablation-induced changes in HR and short-term HRV during percutaneous circumferential pulmonary vein isolation (CPVI). We also studied whether observed changes were predictors of successful outcome after first CPVI.

METHODS AND RESULTS: A total of 46 patients (35 men, 55 +/- 10 years) undergoing CARTO and computed tomography-guided CPVI for symptomatic AF were studied. Circumferential pulmonary vein isolation was performed under general anaesthesia by widely encircling the left and right pulmonary veins during sinus rhythm (SR). Radiofrequency (RF) current (35W, 48 degrees C) was applied with a 3.5 mm open irrigated tip catheter (Navistar Thermocool, Biosense Webster, Diamond Bar, CA, USA). Time- and frequency-domain analysis of short-term HRV was performed using 5 min electrocardiogram (ECG) recordings obtained at the beginning and the end of the CPVI procedure. Sinus rhythm cycle length was monitored continuously during CPVI. Circumferential pulmonary vein isolation was performed with 119 +/- 25 RF applications. Mean HR increased from 54 +/- 8 to 62 +/- 9 bpm (P < 0.001). Heart rate variability was significantly reduced (SDNN from 34 +/- 30 ms to 14 +/- 17 ms, P < 0.001, RMSSD from 27 +/- 22 ms to 13 +/- 14 ms, P < 0.001) with a marked change in sympathovagal balance towards less vagal activity (low frequency (LF)/high frequency (HF) ratio from 3.94 +/- 0.33 to 4.20 +/- 0.17, P < 0.001). Changes in RR interval, SDNN, and LF/HF ratio correlated significantly with RR interval (R = 0.56, P < 0.001), SDNN (R = 0.84, P < 0.001), and LF/HF ratio (R = -0.74, P < 0.001) at baseline. There were acute changes during ablation in HR and HRV, at the antero-superior junction between the left atrium (LA) and the right superior pulmonary vein (RSPV) in 36 patients (78%). Both HR and HRV at baseline and changes in HR/HRV were comparable between successful (n = 36) and failed (n = 10) patients.

CONCLUSION: (i) Percutaneous CPVI induces acute acceleration of HR and attenuation of short-term HRV (indicating vagal denervation during the procedure). (ii) Acute changes in HR and its variability invariably occur during RF energy delivery at the antero-superior junction between the LA and the RSPV. (iii) The degree of HR and short-term HRV changes depend on the vagal tone at the beginning of the procedure. (iv) In contrast to previously reported changes in overall HRV, acute changes in HR during the procedure are no predictors of long-term clinical outcome after CPVI.

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