Came across this really interesting Mayo Clinic podcast about a relatively new technique for treating conditions exacerbated by the autonomic nervous system such as vasovagal syncope and afib.
Cardioneural ablation for atrial fibrillation: indications and rationale
"An overview of how a high vagal tone can contribute to atrial fibrillation. In addition, an understanding of cardioneural ablation, which is a promising new catheter ablation treatment option for these patients"
Topics Discussed
How does high vagal tone contribute to atrial fibrillation
What subset of patients with atrial fibrillation can benefit from cardioneural ablation
What studies have been performed in this field, and what does the future of Afib ablation look like?
Good to see someone mainstream discussing vagal tone. I will listen when I get a moment.
What I would say is that neural ablation sounds to me like a very risky and untested way of addressing AF (so I'm very interested to hear what subset of patients it might be suitable for).
The neural connections to the heart (in addition to the main SA and AV node connections) are extremely complex, many being in the form of ganglionic plexuses which ChatGPT explains as "networks of nerve fibers and ganglia that play key roles in the autonomic (involuntary) control of the heart, such as modulating heart rate and force of contraction." If you pop over to ChatGPT it has quite a good description and examples.
What I've noticed over the years of my AF education is that these ganglia have both vagal and adrenergic nerves in them, hence they have influences for both slowing down and speeding up the heart. They are all linked in an incredibly complex web of nerves, in 4 or more main ganglia on the outside of the heart, so both finding a "simple" target to ablate, and secondly being able to predict what the results will be, seem to me to be an impossibility.
I wait to listen to the podcast! But good on the doctors concerned for thinking about it amd expanding the knowledge.
Just listened. Interesting. Apparently some work has been done in Brazil, even back in the 90s (which of course is around the time Haïssaguerre started PVIs). Also he says there may be some collateral effects on the vagal tone when doing a PVI.
The tricky bit to my mind is as follows. I found early on that my PAF was vagally-mediated, and was able to help control it by recognising the triggers and, e.g. do little exercises to raise my heart rate to stop or ward off an episode. I eventually found out most of my gastric discomfort feeding in to this and setting off episodes was that I had a wheat intolerance, causing bloating, wind, and afib. When I stopped wheat I expected things to get a lot better due to the reduced vagal stimulation from the gut. They didn't, they got worse and I had to give up work as my AF was so bad, and I eventually went to Prof H for my ablation in 2002. So the neural influences are to do with the balance of the two autonomic branches, and I think the reason why our Prof Camm is cautious about seeing vagal influences as something easy to understand and fix. They aren't, and it's extremely complex. (See his chapter on neural influences in Falk and Podrid which at one edition replaced Coumel's original chapter on this)
"... these ganglia have both vagal and adrenergic nerves in them, hence they have influences for both slowing down and speeding up the heart. They are all linked in an incredibly complex web of nerves, in 4 or more main ganglia on the outside of the heart, so both finding a "simple" target to ablate, and secondly being able to predict what the results will be, seem to me to be an impossibility."
Isn't this what Dr Wolf does successfully in his minimaze procedure? as described in his videos.
Yes, Dr Wolf often refers to the vagal origin of all AF in his videos. Hard for me to give you a specific reference, but there was one ...
"Let's Review the Anatomy", with Efrain Miranda PhD (on the Houston Methodist DeBakey YouTube channel) where the ganglionated plexi were particularly mentioned.
It's not one of his clearer presentations, but I hope it helps ...
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