Catheter Ablation of Ganglionated Plexi in Patients with Adenosine
Triphosphate Induced Atrial Fibrillation After Pulmonary Vein Isolation
Aims: Intravenous ATP may induce atrial fibrillation (AF). ATP
shares similar receptor-effector coupling systems with acetylcholine.
However, the association between an ATP injection and the hyperactivity
of the intrinsic cardiac autonomic nervous system, known as ganglionated
plexi (GPs), are not well-understood. We described a series of patients
with non-pulmonary vein (PV) trigger sites provoked by an ATP injection,
and assessed the feasibility of a ganglionated plexus (GP) ablation.
Methods: Five hundred and ninety-nine consecutive patients
(69% men; mean age, 68 ± years, 60% paroxysmal AF) were
retrospectively examined. A total of 7 patients (1.2%) that had
ATP-induced AF following a PV isolation were enrolled in this analysis.
Results: The distribution of the foci overlapped the GP
location; the coronary sinus (CS) in six patients, right atrial
posterior wall (RAPW) adjacent to the interatrial groove in 2, mitral
annulus in 2, ligament of Marshall in 1, right septum below the foramen
ovale in 1 and left atrial posterior wall in 1, respectively. Among
those trigger foci, we confirmed a vagal response by high frequency
stimulation in the CS and RAPW in six and two patients, respectively.
After a median RF time of 2.9 minutes (range 2.5 to 11.3) targeting
those foci, six patients who received a repeat ATP injection became
non-inducible. Conclusion: ATP-induced AF after a PV/Box
isolation was associated with hyperactivity of atrial GP. The GP
ablation was effective in this rare, but challenging situation.