Piotr Kułakowski’s research while affiliated with Institute of Cardiology and other places

Inappropriate sinus tachycardia (IST) is a clinical syndrome that generally affects young patients and is associated with distressing symptoms. Cardioneuroablation (CNA) is a promising method for the treatment of asystolic reflex syncope, functional bradycardia or atrioventricular block. Because CNA involves parasympathetic denervation, one potential adverse effect may be IST. We present an educational case of a patient with mixed vasovagal syncope and symptomatic sinus bradycardia who underwent CNA, as a result of which bradycardia converted to IST and the patient required subsequent pacemaker implantation. We also review the incidence of IST after CNA and difficulties around the definition and treatment of post-CNA IST.

Introduction Pupil diameter (PD) assessment is an essential component of neurological evaluation and sometimes needs to be assessed during electrophysiological procedures. Cardioneuroablation (CNA) with radiofrequency energy is a promising treatment method for a spectrum of cardiac rhythm disorders associated with increased parasympathetic tone. A crucial part of pre-procedural evaluation is the diagnostic administration of atropine aimed at determining the future effect of parasympathetic denervation. However, atropine administration may affect pupil diameter in patients undergoing CNA. The impact of intravenously administered atropine on pupil diameter in the CNA population has not been determined yet. Methods Consecutive patients undergoing CNA were included in the study. A 2mg intravenous atropine test was performed in the setting of electrophysiology laboratory. Pupil diameter measurements of both eyes were conducted using a slit lamp directly before, immediately after, and at 3 and 16 hours post-atropine administration. Results Seventeen consecutive patients underwent pre-CNA evaluation (age 45±19, 10 females). Primary indications for the atropine test were: atrioventricular block (8), mixed-type vasovagal syncope (4), symptomatic sinus bradycardia (2), cardioinhibitory vasovagal syncope (1), vagally mediated atrial fibrillation (1), and long QT syndrome (1). Compared to baseline values, atropine administration caused statistically significant dilation of pupils immediately post-bolus (4.38±0.35 vs 4.84±0.47; p<0.0001); at 3 hours post-administration (4.38±0.35 vs 5.04±0.43; p<0.0001); and at 16 hours post-administration (4.38±0.35 vs 4.82±0.36; p<0.0001). Atropine administration significantly reduced deceleration capacity (DC) (7.7±4.4 vs 1.1±0.9ms; p<0.0001) and simultaneously increased heart rate (HR) (67±19bpm vs 112±27bpm, p<0.0001) in the study group. There were no statistically significant differences in DC (7.7±4.4ms vs 6.9±3.9ms; p=0.6) or HR (67±19 vs 68±18bpm; p=0.9) when baseline values were compared with measurements performed 16 hours post-administration. Conclusions Intravenous administration of atropine significantly affects pupil diameter in patients undergoing CNA, and this effect persists in a 16-hour observation. However, 16 hours post-atropine administration, atropine influence on HR and DC is minimal. These findings should impact timing of CNA following the atropine test.

Background The radiofrequency (RF) lesions obtained using very high-power short-duration (vHPSD) are shallower compared to high-power sort-duration (HPSD) or conventional ablation settings. Thus, there is a possibility that vHPSD RF applications may not achieve transmurality at thick parts of the anterior aspects of the pulmonary vein (PV)-left atrial (LA) wall junction. The aim of the study was to compare acute efficacy of pulmonary vein isolation (PVI) using vHPSD versus HPSD guided by AI ablation at the anterior aspects of PV in patients undergoing atrial fibrillation (AF) ablation. Methods The A-Q-RATE POWER Trial was a prospective, dual-center, randomized study. Patients were assigned to receive vHPSD versus HPSD ablation delivered at the anterior aspects of PV. In both arms, the posterior parts of PV were ablated with vHPSD. The primary outcome was the need for additional RF applications at the anterior aspect of PVs to achieve complete PVI. Results Seventy patients were randomly assigned to vHPSD (n = 35) or HPSD (n = 35). The vHPSD group required more touch-up RF applications at the anterior aspects of PV than the HPSD group (46% vs 19%, p < 0.001), especially at the right PVs (57% vs 20%, p = 0.001) compared to the left PVs (34% vs 17%, p = 0.1). The median duration of the procedure, LA dwell time, and fluoroscopy time were similar in both groups (112 [IQR 90–130] min vs 107 [90–125] min, p = 0.58; 95 [70–106] min vs 90 [71–100] min, p = 0.55; and 28 [IQR 14–69] s vs 46 [IQR 0–89] s, p = 0.97,respectively). Conclusion The proposed hybrid strategy is associated with a significantly lower need for additional touch-up RF applications than vHPSD only, without extending procedural and fluoroscopy duration. Graphical Abstract

Background The autonomic nervous system (ANS) plays a significant role in atrial fibrillation (AF). Catheter ablation (CA) is a well-established treatment method for AF and significantly affects the ANS, including baroreceptor (BR) function. However, little is known about the changes in BR function caused by radiofrequency (RF) or cryoballoon energy (CB) and its impact on future AF recurrences. Purpose To assess 1-year efficacy of CA of AF in relation to BR function modification and type of ablation energy used. Methods The study group consisted of 78 patients (25 females, mean age 58 ± 9 years) with paroxysmal AF and first CA (39 patients in the RF group and 39 in the CB group). The BR function was assessed non-invasively, using tilt testing before and after CA, and three BR parameters were calculated: event count (BREC) depicting overall BR activity, slope mean depicting BR sensitivity (BRS), and BR effectiveness index (BEI). The efficacy of CA was assessed during 1-year follow-up, which consisted of ambulatory visits and 24-h Holter ECG recordings at 3, 6, and 12 months after CA. The quality of life was assessed by using a dedicated scale [University of Toronto Atrial Fibrillation Severity Scale (AFSS)]. Results The two groups did not show differences in terms of clinical or demographic data. One-year follow-up was completed for 35 (89.7%) patients from the CB group and for 34 (87.2%) from the RF group. The rates of efficacy of CB and RF were similar [31/35 (88.6%) vs. 26/34 (76.5%), respectively]. After CA, the BR function decreased in both groups, with a significantly greater decrease in the CB group. The changes in BR parameters were similar in both responders and non-responders after CA in the whole group [BREC 10.0 (2.0–24.0) vs. 12.0 (4.0–21.5), p = 0.939; BRS 5.4 (3.7–6.5) vs. 4.8 (3.6–7.2), p = 0.809; BEI 24.8 (15.9–27.4) vs. 17.5 (8.9–27.5), p = 0.508, respectively]. According to the AFSS, the AF symptoms were significantly reduced in both groups to a similar extent. Conclusions CA for AF significantly decreased the BR function, especially in patients undergoing CB. There was no correlation between CA-induced changes in BR parameters and ablation outcome.

Cardioneuroablation has emerged as a potential alternative to cardiac pacing in selected cases with vasovagal reflex syncope, extrinsic vagally induced sinus bradycardia-arrest or atrioventricular block. The technique was first introduced decades ago, and its use has risen over the past decade. However, as with any intervention, proper patient selection and technique are a prerequisite for a safe and effective use of cardioneuroablation therapy. This document aims to review and interpret available scientific evidence and provide a summary position on the topic.

Cardioneuroablation has emerged as a potential alternative to cardiac pacing in selected cases with vasovagal reflex syncope, extrinsic vagally induced sinus bradycardia-arrest or atrioventricular block. The technique was first introduced decades ago, and its use has risen over the past decade. However, as with any intervention, proper patient selection and technique are a prerequisite for a safe and effective use of cardioneuroablation therapy. This document aims to review and interpret available scientific evidence and provide a summary position on the topic.