The role of autonomic denervation in the success of atrial fibrillation ablation: Can pulsed-field ablation provide the answer?

Although the role of cardiac autonomic nervous system (CANS) in triggering and maintenance of atrial fibrillation (AF) is established, the potential value of adjuvant autonomic denervation in AF ablation is debated. Autonomic denervation from collateral thermal injury of CANS during radiofrequency/cryo-based pulmonary vein (PV) isolation (PVI) is thought to confer additional clinical benefit. In contrast, follow-up studies with 24-hour Holter-based heart rate variability (HRV) assessment demonstrated recovery of HRV parameters to the preprocedure level within 3–6 months. However, HRV parameters mainly reflect the autonomic modulation of the sinus node. Hence, persistence of clinical benefit despite restoration of HRV parameters to the preprocedure level cannot be interpreted as restoration of left atrial autonomic innervation back to the preablation baseline. Unlike thermal energy–based radiofrequency ablation/cryoablation, irreversible electroporation during the emerging pulse field ablation (PFA) produces selective damage of cardiomyocytes without concurrent damage of surrounding structures. A recent study demonstrated a lesser degree of concurrent autonomic denervation after PVI with PFA compared to radiofrequency ablation. Minimal injury of epicardial autonomic ganglia during PFA may elucidate the role of autonomic denervation in AF ablation. With the understanding that radiofrequency ablation/cryoablation and PFA exert differential effects on CANS, one may expect different long-term (>2 year) ablation outcomes based on the 3 assumptions below.