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Multicenter Study
. 2025 Aug;11(8):1757-1768.
doi: 10.1016/j.jacep.2025.04.015. Epub 2025 Apr 24.

Efficacy and Drug-Related Complications of Anticholinergic Drugs for Vagal Reaction Prevention During Pulsed Field Ablation

Giampaolo Vetta  1 , Domenico G Della Rocca  2 , Michele Magnocavallo  3 , Robin Richard-Vitton  4 , Alexandre Almorad  1 , Andres Betancur  4 , Antonio Sorgente  1 , Marco Polselli  3 , Lorenzo Marcon  1 , Sanghamitra Mohanty  5 , Alvise Del Monte  1 , Ilenia Lombardo  1 , Luigi Pannone  1 , Sahar Mouram  1 , Erwin Stroker  1 , Carola Gianni  5 , Vincenzo Mirco La Fazia  5 , Stefano Bianchi  3 , Ioannis Doundoulakis  1 , Ingrid Overeinder  1 , Charles Audiat  1 , Kazutaka Nakasone  1 , Gezim Bala  1 , Stephane Combes  4 , Andrea Sarkozy  1 , Juan Sieira  1 , Serge Boveda  4 , Pietro Rossi  3 , Andrea Natale  6 , Carlo de Asmundis  1 , Gian-Battista Chierchia  1 ; HRMC Investigators
Affiliations
Multicenter Study

Efficacy and Drug-Related Complications of Anticholinergic Drugs for Vagal Reaction Prevention During Pulsed Field Ablation

Giampaolo Vetta et al. JACC Clin Electrophysiol. 2025 Aug.

Abstract

Background: Vagal responses (VR) are frequently observed during pulmonary vein isolation (PVI) with pulsed field ablation (PFA).

Objectives: The aim of this study was to compare the effectiveness of 2 different anticholinergic (AC) medications, namely glycopyrrolate (GLY) or atropine (ATP), for VR prophylaxis in patients undergoing PVI via a pentaspline PFA catheter.

Methods: Consecutive patients with atrial fibrillation undergoing first-time PVI with PFA were prospectively enrolled at 4 centers between April 2023 and March 2024. Intravenous GLY 0.2 mg (Group GLY) or ATP 1 mg (Group ATP) were administered prophylactically before transseptal access. Clinically relevant VRs included sinus bradycardia (<40 beats/min), asystole (>6 seconds), atrioventricular block, and the need for temporary backup pacing. The incidence of periprocedural VRs was compared with that of patients without prophylactic AC drug administration (Group noAC). Drug-related adverse events were compared between the 2 AC drugs.

Results: We enrolled 240 patients (age 61 ± 12 years, 60.0% male) (GLY: n = 80; ATP: n = 80; noAC: n = 80). Intraprocedural VRs were observed in 65 patients (27.1%). GLY and ATP effectively reduced overall VRs (GLY: 7.5% vs ATP: 11.3% vs noAC: 62.5%; P < 0.001), asystole (GLY: 1.3% vs ATP: 2.5% vs noAC: 33.8%; P < 0.001), and need for temporary backup pacing (GLY: 1.3% vs ATP: 5.0% vs noAC: 23.8%; P < 0.001). The risk of overall drug-related adverse events (8.8% vs 0%; P = 0.007) and drug-induced atrial fibrillation (5% vs 0%; P = 0.043) was significantly higher with ATP.

Conclusions: Prophylactic AC drug administration effectively prevented clinically relevant VRs in patients undergoing PVI with PFA. Both AC drugs were equally highly effective, but ATP showed a significantly higher rate of drug-induced adverse events.

Keywords: atrial fibrillation; autonomic nervous system; ganglionated plexi; pulsed-field ablation; vagal response.

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Conflict of interest statement

Funding Support and Author Disclosures Dr Natale has received speaker honoraria from Boston Scientific, Biosense Webster, Abbott, Biotronik, and Medtronic; and is a consultant for Biosense Webster, Abbott, and Janssen. Dr de Asmundis receives research grants on behalf of the center from Biotronik, Medtronic, Abbott, LivaNova, Boston Scientific, AtriCure, Philips, and Acutus Medical. Dr Chierchia has received compensation for teaching purposes and for proctoring from Medtronic, Abbott, Biotronik, Boston Scientific, and Acutus Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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