<div>Pulmonary Vein Isolation-induced Vagal Nerve Injury and Gastric Motility
Disorders</div><div>Bachir Lakkiss, MD; Marwan M. Refaat, MD</div><div>Division of Cardiology, Department of Internal Medicine, American
University of Beirut Medical Center, Beirut, Lebanon</div><div>Running Title: PVI-induced vagal nerve injury and gastric motility
disorders</div><div>Words: 665 (excluding the title page and references)</div><div>Keywords: Heart Diseases, Cardiovascular Diseases, Cardiac Arrhythmias,
Atrial Fibrillation, Catheter Ablation, Pulmonary Vein Isolation</div><div>Funding: None</div><div>Disclosures: None</div><div>Corresponding Author:</div><div>Marwan M. Refaat, MD, FACC, FAHA, FHRS, FRCP</div><div>Tenured Professor of Medicine</div><div>Tenured Professor of Biochemistry and Molecular Genetics</div><div>Van Dyck Medical Educator and Director of the Cardiovascular Fellowship
Program</div><div>Department of Internal Medicine, Cardiovascular Medicine/Cardiac
Electrophysiology</div><div>American University of Beirut Faculty of Medicine and Medical Center</div><div>PO Box 11-0236, Riad El-Solh 1107 2020- Beirut, Lebanon</div><div>US Address: 3 Dag Hammarskjold Plaza, 8th Floor, New York, NY 10017, USA</div><div>Office: +961-1-350000/+961-1-374374 Extension 5353 or Extension 5366
(Direct)</div><div>Email: mr48@aub.edu.lb</div><div>Atrial fibrillation (AF) is the most prevalent heart rhythm abnormality
worldwide. An estimated three to six million people in the United States
have AF. It is expected that this number is likely to double by 2050,
making AF a significant public health burden. (1) AF is a leading cause
of stroke and thromboembolism and is associated with a reduced quality
of life. (2) Furthermore, it is linked to an increased mortality in both
men and women, with an OR for death of 1.5 in men and 1.9 in women. (3)
Medical expenditures for AF are significant, ranging from an annual cost
of $1,632 to $21,099, with acute care accounting for the largest cost
component in addition to anticoagulation therapy, which accounted for
almost one-third of these costs. (4) The four pillars of AF management
include rhythm control, rate control, stroke prevention and risk factor
management. (5, 6) While antiarrhythmic drugs are used in some patients
for AF rhythm control, AF ablation using pulmonary vein isolation (PVI)
is regarded as the major modality for rhythm control. (6)</div><div>The vagal nerve provides most of the parasympathetic innervation to the
abdominal organs, including the stomach, esophagus, and a significant
portion of the intestines. It serves a major role in the regulation of
gastric and esophageal motility, in addition to maintaining lower
esophageal sphincter tone. (7-9) Due to the relatively close vicinity of
the vagal nerve plexus located on the anterior surface of the esophagus
and the left atrial posterior wall, the thermal energy utilized during
ablation can result in uncommon but potentially fatal complications such
as esophageal perforation and atrial-esophageal fistula formation.
(10-12) In addition, radiofrequency ablation for AF is associated with
non-fatal complications such as an increased risk of gastric motility
disorders and acid reflux. (13, 14)</div><div>In the current issue of the Journal of Cardiovascular Electrophysiology,
Meininghaus et al. recruited 85 patients to assess the incidence of
ablation-induced vagal nerve injury (VNI) using both cryoballoon and
radiofrequency ablation. Although many cases of VNI induced by PVI have
been documented previously, this is one of the first studies to utilize
electrophysiologic measurements of gastric motility (EGG) using
cutaneous electrodes to record the electrical activity of the stomach
two days prior to and two days after the procedure. (15-17) Moreover,
the authors have used endoscopy to detect lesions such as erosions,
ulcers, and perforations in the esophagus one week prior to and within
two days of the procedure.</div><div>The findings from this study add to our understanding of one of the
complications of PVI in patients with AF (13, 14). One of the key
outcomes the researchers observed was the perceived direct link between
VNI and preexisting esophageal vulnerability. The authors have found
that patients who had preexisting esophagitis had an elevated risk of
developing VNI. In addition, the authors identified that in patients in
whom EGG showed VNI, the elevated risk of ablation-induced endoscopic
pathology was present in the post-procedure endoscopy. Furthermore,
another significant finding was the detection of VNI on EGG in
approximately one-third of PVI patients, irrespective of energy source,
whether high power short duration, or moderate power moderate duration.
These findings did not corroborate other studies, which showed that
titration of the duration of the ablation energy could prevent VNI in
patients undergoing AF ablation. (18)</div><div>Overall, the authors should be commended for their tremendous efforts in
attempting to understand the intricate pathophysiology and the
association of esophageal lesions, atrial-esophageal fistula formation,
and vagal nerve injury following PVI using EGG. Certainly, the results
of this study have tremendous clinical implications. EGG could have a
very important role in the prevention of atrial-esophageal fistula
formation in the future. The article had a few limitations, mainly that
the results were from a single-center study. Further studies
incorporating additional patients from different medical centers should
be conducted to better understand the complex pathophysiology of vagal
nerve injury and gastric motility disorders following PVI. Advances in
esophageal protection technologies will help in decreasing esophageal
lesions during PVI. (19-20)</div><div>References</div><div>1. Miyasaka Y, Barnes ME, Gersh BJ, Cha SS, Bailey KR, Abhayaratna WP,
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