A successful treatment of ganglionated plexus ablation for vagally mediated sleep-related advanced atrioventricular block

A successful treatment of ganglionated plexus ablation for vagally mediated sleep-related advanced atrioventricular block | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 14 October 2025 V1 Latest version Share on A successful treatment of ganglionated plexus ablation for vagally mediated sleep-related advanced atrioventricular block Authors : Guo caihong 0009-0002-9252-2609 , Weiping Huang , jinlin zhang 0000-0002-1601-1228 , and Yang wenjie [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.176041293.34793245/v1 139 views 112 downloads Contents Abstract Introduction Case presentation Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Background Sleep-related bradyarrhythmia is often overlooked due to the absence of symptoms and are now mostly believed to be related to excessive vagal nerve tension. The choice of treatment still remains controversial. Ganglionated plexus (GP) ablation, as an experimental therapeutic approach, could be effective for some cases. Case summary We report a case of 41-year-old male with recurrent nocturnal ventricular asystole up to 10.1 seconds related to advanced atrioventricular block, in whom sleep apnea syndrome was excluded. Echocardiography, thyroid function test levels, coronary angiography and transesophageal electrophysiological test were normal. Considering that this significant nocturnal bradyarrhythmia is associated with increased vagal tone and decreased sympathetic activity, and the patient refused pacemaker implantation, we proceeded with GP ablation in the left atrial for the patient. After ablation, the patient’s nocturnal advanced atrioventricular block completely disappeared. Holter monitoring revealed heart rate variability analysis data consistent with successful vagal plexus ablation. Conclusion It seems like GP ablation is a safe and effective treatment for functional sleep-related bradyarrhythmia. Currently, we found 2 cases on nocturnal bradyarrhythmia from all relevant literatures, among which vagal ganglion ablation was successfully performed with favorable therapeutic effects. The case we report now may be the third one. Interestingly, the three cases that opted for GP ablation also differed in the selection of ablation sites. All three cases achieved significant therapeutic effects after ablation, and the selection of ablation methods needs further investigation. Further research is needed to elucidate the pathophysiological mechanisms underlying this autonomic disorder, and long-term follow-up is required to evaluate its sustained therapeutic efficacy. A successful treatment of ganglionated plexus ablation for vagally mediated sleep-related advanced atrioventricular block Guo caihong 1 , Huang weiping 1 , Zhang jinlin 1 , Yang wenjie 1 Department of Cardiology, Wuhan Asia Heart Hospital, Wuhan 430030, China Corresponding Auther: Yang wenjie, BD Department of Cardiology, Wuhan Asia Heart Hospital, Wuhan 430030, China, E-mail: [email protected] Huang weiping, MD Department of Cardiology, Wuhan Asia Heart Hospital, Wuhan 430030, China, E-mail: [email protected] Background Sleep-related bradyarrhythmia is often overlooked due to the absence of symptoms and are now mostly believed to be related to excessive vagal nerve tension. The choice of treatment still remains controversial. Ganglionated plexus (GP) ablation, as an experimental therapeutic approach, could be effective for some cases. Case summary We report a case of 41-year-old male with recurrent nocturnal ventricular asystole up to 10.1 seconds related to advanced atrioventricular block, in whom sleep apnea syndrome was excluded. Echocardiography, thyroid function test levels, coronary angiography and transesophageal electrophysiological test were normal. Considering that this significant nocturnal bradyarrhythmia is associated with increased vagal tone and decreased sympathetic activity, and the patient refused pacemaker implantation, we proceeded with GP ablation in the left atrial for the patient. After ablation, the patient’s nocturnal advanced atrioventricular block completely disappeared. Holter monitoring revealed heart rate variability analysis data consistent with successful vagal plexus ablation. Conclusion It seems like GP ablation is a safe and effective treatment for functional sleep-related bradyarrhythmia. Currently, we found 2 cases on nocturnal bradyarrhythmia from all relevant literatures, among which vagal ganglion ablation was successfully performed with favorable therapeutic effects. The case we report now may be the third one. Interestingly, the three cases that opted for GP ablation also differed in the selection of ablation sites. All three cases achieved significant therapeutic effects after ablation, and the selection of ablation methods needs further investigation. Further research is needed to elucidate the pathophysiological mechanisms underlying this autonomic disorder, and long-term follow-up is required to evaluate its sustained therapeutic efficacy. Keywords Sleep-related bradyarrhythmia; Atrioventricular block; Ventricular asystole; Ganglionated plexus ablation Introduction Sleep-related bradyarrhythmia refers to an arrhythmia characterized by a significant decrease in heart rate or ventricular asystole that occurs solely during nocturnal sleep and is not associated with obstructive sleep apnea syndrome (OSAS). This includes sinus bradycardia, sinus arrest, advanced or third-degree atrioventricular block. This type of bradyarrhythmia was first reported by professor Guilleminault in 1984 [1] and is often underdiagnosed due to its asymptomatic occurrence during sleep. Although increased vagal tone and decreased sympathetic activity during the night are considered closely related to this condition, the exact underlying mechanism remains unclear. Currently, there is no established standard treatment regimen for sleep-related bradyarrhythmia. For nocturnal bradyarrhythmia carrying a risk of sudden death, implantation of a permanent pacemaker may be the conventional treatment approach [2, 3]. It is well-known that ganglion plexus (GP) ablation can effectively modulate the body’s autonomic nervous function and has shown good efficacy in treating cardioinhibitory vasovagal syncope [4]. However, there are few reports on whether GP ablation can improve nocturnal ventricular asystole by regulating autonomic nerve function in cases of sleep-related bradyarrhythmia without secondary causes. This article reports a case of successful treatment of a 10.1 seconds ventricular asystole caused by sleep-related advanced atrioventricular block through GP ablation. Case presentation We report the case of 41-year-old male presenting chest tightness and palpitations for over half a month with hypertension which was found just 2 months ago. A 10-day single-lead long-term Holter revealed a total of 555 ventricular pauses over 2 s, with the longest ventricular arrest lasting 10.1 seconds (Figure 1) due to advanced atrioventricular block. These ventricular asystoles occurred exclusively during nighttime sleep between 00:00 and 06:00, with the patient reporting no associated symptoms like startled awakenings, nightmares, dizziness, or other nocturnal events during this timeframe. There was no family history of specific genetic diseases, cardiovascular diseases or sudden death. After admission, all routine laboratory tests including thyroid function were within the normal range. Chest CT and echocardiography showed no abnormalities. Coronary CTA revealed coronary atherosclerosis and mild stenosis of the left anterior descending artery. Polysomnography showed mild obstructive sleep apnea syndrome (OSAS) with an AHI of 12.3 and lowest oxygen saturation of 87%. The timing of the nocturnal advanced atrioventricular block episodes did not correlate with the timing of the hypopnea and hypoxemia events. Electrophysiology study showed normal sinus node and atrioventricular node function. A head-up tilt test showed no abnormalities. Based on the results—specifically the timing of advanced atrioventricular block and ventricular asystole episodes—and a review of the relevant literature, we propose that the underlying mechanism in this case may be excessive nocturnal vagal nerve activity [5]. Since the patient did not experience any symptoms related to the ventricular asystole and refused permanent pacemaker implantation, we performed GP ablation for the patient. Prior to the intervention, written informed consent was secured from the patient, and the intervention was conducted under general anaesthesia. After a successful trans-septal puncture via the right femoral vein approach, a PENTARAY mapping catheter (Biosense Webster, USA) was introduced to construct a three-dimensional anatomical model of the left atrium using the CARTO 3 mapping system (Biosense Webster, USA). Considering that general anesthesia might suppress vagal plexus reflexes, we performed point-to-point anatomical ablation on the endocardial surface of the left atrium based on literature data [6] (Figure 2) by the 4 mm ablation catheter with steerable tip and cooled saline irrigation (Biosense Webster, USA). The ablation parameters for the left superior and right superior GP were 43°C / 45 W/30-60 s with an ablation index (AI) of 500-550. RF pulses were 43°C / 40 W/30-60 s with an AI of 450-500 for the left inferior and right inferior GP. The total RF application time was 45 min.The procedure time was 90 min and the radioscopy time was 32 min. To assess the efficacy of GP ablation, the patient was subjected to two Holter monitorings: a 48-hour in-hospital monitoring conducted 2 days post-ablation, and a 10-day single-lead long-term monitoring performed on an outpatient basis 1 month after the procedure. Results showed both the minimum and average heart rates exhibited a significant elevation, and advanced atrioventricular block was completely resolved. Holter recordings obtained 10 days preoperatively and postoperatively revealed that the number of nocturnal ventricular pauses exceeding 2 seconds reduced from 555 to 0. Parameters reflecting heart rate variability, such as SDNN, SDANN, SDNN Index, rMSSD, and pNN50 were all significantly lower than pre-procedure data（Table 1）. Overall, these findings indicate an elevation in sympathetic nervous system activity concurrent with a reduction in vagal tone within the body. Discussion Vagus nerve mediated sleep-related bradyarrhythmia are typically characterized by a sudden, significant drop in heart rate (<40 bpm), long RR intervals (≥3 seconds), or transient cardiac arrest during the night. These may be accompanied by dizziness, syncope, or nocturnal awakening, although some patients may be asymptomatic [7]. The incidence of this condition and the rate of adverse events, such as nocturnal sudden cardiac death, are likely underestimated [8]. Diagnosing sleep-related bradyarrhythmias relies on capturing nocturnal arrhythmic events by Holter or loop recorders (ILRs) implantation, while excluding structural heart disease or other secondary causes such as drug-induced effects, hypothyroidism, or OSAS. After ruling out various secondary factors, we strongly suspected that the asymptomatic nocturnal bradyarrhythmia in this case was related to an imbalance in autonomic nervous regulation. Under normal physiological conditions, vagal nerve activity increases and sympathetic nerve activity decreases at night. The release of acetylcholine by the vagus nerve acting on the sinoatrial and atrioventricular nodes can lead to mild and benign physiological responses such as sinus bradycardia, sinus arrest, or first-degree or second-degree type I atrioventricular block. However, excessive vagal tone could trigger pathological and fatal responses such as sick sinus syndrome, high-degree or complete atrioventricular block [9-11]. It is currently believed that such nocturnal bradyarrhythmias often occur during rapid eye movement (REM) sleep stage [7]. The proposed mechanisms include: firstly, a sudden switch from sympathetic dominance to parasympathetic dominance during the phasic periods of REM sleep, which the body cannot compensate promptly; and secondly, an abrupt withdrawal of sympathetic activity during episodic REM sleep may lead to significant bradyarrhythmia. REM-related cardiac arrest may also be linked to the imbalance in the central nervous system’s regulation of the autonomic nervous system, but the specific mechanisms also remain unclear. Currently, there are no clear guideline recommendations for treating sleep-related bradyarrhythmias. Serafini A suggested that for nocturnal cardiac pauses >3 seconds (especially when associated with atrioventricular block), permanent pacemaker implantation should be considered to reduce the risk of fatal arrhythmias [12]. The 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients with Bradycardia and Cardiac Conduction Delay states [13]: Permanent pacing is not indicated for patients with nocturnal sinus bradycardia or transient sinus pauses during sleep in the absence of other secondary factors. The guideline specifically emphasizes: For acquired second-degree type II AV block, advanced AV block, or third-degree AV block (that is not due to reversible/physiological causes), permanent pacing is recommended regardless of symptoms. However, there remains no consensus on whether excessive vagal tone should be classified as a reversible cause currently. The 2021 ESC Guidelines on Cardiac Pacing and Cardiac Resynchronization Therapy [14] indicate regarding nocturnal sleep-related bradyarrhythmia, although most reported cases in the literature were treated with pacemakers, the evidence remains insufficient, and there is no consensus on the treatment strategy for such patients. The guidelines also emphasize nocturnal bradyarrhythmias are relatively common in the general population and are often physiological, vagally-mediated, asymptomatic events that usually require no intervention. Although the benefit of permanent pacemaker implantation in these patients is not established, cardiac pacing might reduce the risk of potential adverse events like sudden cardiac death [15-17]. Some literature also suggests that GP ablation could be attempted as an alternative treatment option. Although reports are currently limited, there have been two cases similar to ours that have achieved successful therapeutic effects through GP ablation [18-19]. The case we report may be the third one. Interestingly, the three cases that opted for vagal ganglion ablation also differed in the selection of ablation sites: the first case chose vagal innervation in the right and left aspects of the inter-atrial septum responsible for the sinus node and AV node modulation; the second one underwent GP ablation in both the left and right atrium; while in our case, ablation was performed solely in the left atrium-related area. The selection of ablation methods needs further investigation. As this patient was asymptomatic and refused permanent pacemaker implantation, and after excluding other secondary causes, we strongly suspected that the nocturnal ventricular asystole caused by advanced AV block was mediated by excessively high vagal tone. We recommended GP ablation for the patient. Pre-operatively, frequent ventricle pauses up to 10.1 seconds were observed during sleep. Post-operative Holter monitoring showed 0 episodes of ventricle pauses and atrioventricular block completely disappeared. Furthermore, post-operative heart rate variability parameters (SDNN, SDANN, SDNN Index, rMSSD, pNN50) decreased compared to pre-operative values, indicating that GP ablation effectively reduced vagal nerve activity. Therefore, GP ablation successfully treated the patient’s severe nocturnal ventricular asystole while avoiding permanent pacemaker implantation, demonstrating that GP ablation is an effective treatment strategy for such patients. Conclusion Currently, there is no standardized treatment for REM sleep-related bradyarrhythmia. Patients with recurrent advanced atrioventricular block or severe ventricular asystole may face a certain risk of sudden death. Apart from conventional pacemaker therapy, vagal GP ablation could be considered for young patients or those unwilling to undergo pacemaker implantation. This case confirms the effectiveness of such treatment. However, it is a single-center case report lacking long-term follow-up. The long-term efficacy of GP ablation for this condition requires further follow-up to be confirmed, and its feasibility and applicability as a treatment option need validation through multicenter, large-sample studies. Acknowledgments GCH analyzed the data and wrote this manuscript. Hwp and YWJ helped to collect the data and treated this patient. ZJL guided the treatment and checked this manuscript. All the authors have read and approved the manuscript for publication. 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Pacing Clin Electrophysiol. 2012 Jul;35(7):e210-3 [16] Yasar S, Gökoğlan Y, Görmel S, et al. A rare case of REM sleep-related bradyarrhythmıa syndrome: 19.5-s asystole during REM sleep. J Interv Card Electrophysiol. 2022 Mar;63(2):227-228. [17] PachonJ, PachonE, PachonJ, et al. Cardioneuroablation – new treatment for neurocardiogenic syncope, functional AV block and sinus dysfunction using catheter RF ablation. Europace 2005;7:1-13. [18] Rivarola E, Hardy C, Sosa E, et al. Selective atrial vagal denervation guided by spectral mapping to treat advanced atrioventricular block. Europace. 2016 Mar;18(3):445-9. [19] Kobayashi M, Ichikawa T, Wakabayashi Y, et al. A successful treatment of ganglionated plexi ablation for vagally mediated nocturnal atrioventricular block. J Cardiol Cases. 2022 Jun 10;26(3):232-235. Figure legends: Fig.1. Electrocardiogram displaying a ventricular pause of 10.1 seconds length in an asymptomatic patient with nocturnal advanced AV block Fig.2. Anatomical ablation sites of the vagus ganglion based on literature. The red dots indicate the ablation sites Table 1. Holter recording demonstrating the data pre-ablation and post-ablation Holter Minimum/ average/ maximum HR Pause＞2s Maximum pause length SDNN SDANN SDNN Index rMSSD pNN pre 24/71/127 55.5 10.1 208 198 72 60 13.03 2 days 65/80/117 0 0 65 60 20 10 0.01 1 month 57/80/121 0 0 113 109 26 10 0.04 Information & Authors Information Version history V1 Version 1 14 October 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Authors Affiliations Guo caihong 0009-0002-9252-2609 Wuhan Asia Heart Hospital View all articles by this author Weiping Huang Wuhan Asia Heart Hospital View all articles by this author jinlin zhang 0000-0002-1601-1228 Wuhan Asia Heart Hospital View all articles by this author Yang wenjie [email protected] Wuhan Asia Heart Hospital View all articles by this author Metrics & Citations Metrics Article Usage 139 views 112 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Guo caihong, Weiping Huang, jinlin zhang, et al. A successful treatment of ganglionated plexus ablation for vagally mediated sleep-related advanced atrioventricular block. Authorea . 14 October 2025. DOI: https://doi.org/10.22541/au.176041293.34793245/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. 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