Application of kilohertz-frequency block to mitigate off-target motor effects of vagus nerve stimulation in swine

Selective activation of small versus large diameter nerve fibers represents a broad challenge in the electrical modulation of neural activity for clinical applications. For example, off-target activation of motor nerve fibers was implicated in several failed vagus nerve stimulation (VNS) clinical trials by effectively limiting maximum applicable current amplitudes, thereby preventing robust activation of smaller diameter fibers responsible for therapeutic effects. Kilohertz high-frequency (HF) block is one of several strategies proposed to overcome this gap, but has yet to be thoroughly investigated in large, multifascicular, mixed nerves comparable in scale to humans. Here, we evaluated effects of HF block on the neural, muscular, and cardiac responses evoked by traditional low-frequency (LF) VNS in a large animal (swine) model. We found that HF selectively blocks neural fibers, and their associated physiological responses, in a size dependent manner with a high degree of specificity and establish initial thresholds for achieving block in large multifascicular nerves. Critically, we demonstrate that appropriately titrating HF amplitude can eliminate off-target LF-evoked motor responses while preserving activation of smaller diameter fibers targeted by clinical VNS. Beyond VNS, these data establish HF as a potentially viable strategy in any neuromodulation therapies where off-target activation of large diameter fibers limits therapeutic efficacy.