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van Waaij K, Keçe F, de Riva M, Alizadeh Dehnavi R, Wijnmaalen AP, Piers SRD, Mertens BJ, Zeppenfeld K, Trines SA. Validation of a prediction model for early reconnection after cryoballoon ablation. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01811-0. [PMID: 38743141 DOI: 10.1007/s10840-024-01811-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 04/17/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND We previously developed an early reconnection/dormant conduction (ERC) prediction model for cryoballoon ablation to avoid a 30-min waiting period with adenosine infusion. We now aimed to validate this model based on time to isolation, number of unsuccessful cryo-applications, and nadir balloon temperature. METHODS Consecutive atrial fibrillation patients who underwent their first cryoballoon ablation in 2018-2019 at the Leiden University Medical Center were included. Model performance at the previous and at a new optimal cutoff value was determined. RESULTS A total of 201 patients were included (85.57% paroxysmal AF, 139 male, median age 61 years (IQR 53-69)). ERC was found in 35 of 201 included patients (17.41%) and in 41 of 774 veins (5.30%). In the present study population, the previous cutoff value of - 6.7 provided a sensitivity of 37.84% (previously 70%) and a specificity of 89.07% (previously 86%). Shifting the cutoff value to - 7.2 in both study populations resulted in a sensitivity of 72.50% and 72.97% and a specificity of 78.22% and 78.63% in data from the previous and present study respectively. Negative predictive values were 96.55% and 98.11%. Applying the model on the 101 patients of the present study with all necessary data for all veins resulted in 43 out of 101 patients (43%) not requiring a 30-min waiting period with adenosine testing. Two patients (2%) with ERC would have been missed when applying the model. CONCLUSIONS The previously established ERC prediction model performs well, recommending its use for centers routinely using adenosine testing following PVI.
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Affiliation(s)
- Kevin van Waaij
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Heart Lung Center, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Fehmi Keçe
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Heart Lung Center, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
- Department of Electrophysiology, Heart Center, University of Cologne, Cologne, Germany
| | - Marta de Riva
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Heart Lung Center, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Reza Alizadeh Dehnavi
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Heart Lung Center, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Adrianus P Wijnmaalen
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Heart Lung Center, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Sebastiaan R D Piers
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Heart Lung Center, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Bart J Mertens
- Bioinformatics Center of Expertise, Leiden University Medical Center, Leiden, The Netherlands
| | - Katja Zeppenfeld
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Heart Lung Center, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Serge A Trines
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Heart Lung Center, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands.
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Keçe F, de Riva M, Alizadeh Dehnavi R, Wijnmaalen AP, Mertens BJ, Schalij MJ, Zeppenfeld K, Trines SA. Predicting early reconnection after cryoballoon ablation with procedural and biophysical parameters. Heart Rhythm O2 2021; 2:290-297. [PMID: 34337580 PMCID: PMC8322820 DOI: 10.1016/j.hroo.2021.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Predicting early reconnection/dormant conduction (ERC) immediately after pulmonary vein isolation (PVI) can avoid a waiting period with adenosine testing. OBJECTIVE To identify procedural and biophysical parameters predicting ERC. METHODS Consecutive atrial fibrillation (AF) patients undergoing a first cryoballoon ablation (Arctic Front Advance) between 2014 and 2017 were included. ERC was defined as manifest or dormant pulmonary vein (PV) reconnection with adenosine 30 minutes after PVI. Time to isolation (TTI), balloon temperatures (BT), and thawing times were evaluated as potential predictors for ERC. Based on a multivariable model, cut-off-values were defined and a formula was constructed to be used in clinical practice. RESULTS A total of 136 patients (60 ± 10 years, 96 male, 95% paroxysmal AF) were included. ERC was found in 40 (29%) patients (ERC group) and in 53 of 575 (9%) veins. Procedural and total ablation time and the number of unsuccessful freezes were significantly longer/higher in the ERC group compared to the non-ERC group (150 ± 40 vs 125 ± 34 minutes; 24 ± 5 vs 17 ± 4 minutes, and 38% vs 24%, respectively (P = .028). Multivariable analysis showed that a higher nadir balloon temperature (hazard ratio [HR] 1.17 [1.09-1.23, P < .001), a higher number of unsuccessful freezes (HR 1.69 [1.15-2.49], P = .008) and a longer TTI (HR 1.02 [1.01-1.03], P < .001) were independently associated with ERC, leading to the following formula: 0.02 × TTI + 0.5 × number of unsuccessful freezes + 0.2 × nadir BT with a cut-off value of ≤-6.7 to refrain from a waiting period with adenosine testing. CONCLUSION Three easily available parameters were associated with ERC. Using these parameters during ablation can help to avoid a 30-minute waiting period and adenosine testing.
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Affiliation(s)
- Fehmi Keçe
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Marta de Riva
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Reza Alizadeh Dehnavi
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Adrianus P. Wijnmaalen
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Bart J. Mertens
- Bioinformatics Center of Expertise, Leiden University Medical Center, Leiden, The Netherlands
| | - Martin J. Schalij
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Katja Zeppenfeld
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Serge A. Trines
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Leiden, The Netherlands
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3
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Scala O, Borio G, Paparella G, Varnavas V, Ströker E, Guimaraes Osorio T, Terasawa M, Sieira J, Maj R, Rizzo A, Al‐Hosari MM, Galli A, Brugada P, Asmundis C, Chierchia G. Predictors of durable electrical isolation in the setting of second‐generation cryoballoon ablation: A comparison between left superior, left inferior, right superior, and right inferior pulmonary veins. J Cardiovasc Electrophysiol 2019; 31:128-136. [DOI: 10.1111/jce.14286] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 10/12/2019] [Accepted: 11/14/2019] [Indexed: 01/29/2023]
Affiliation(s)
- Oriana Scala
- Heart Rhythm Management CenterUZ Brussel‐VUBBrussels Belgium
| | - Gianluca Borio
- Heart Rhythm Management CenterUZ Brussel‐VUBBrussels Belgium
| | | | | | - Erwin Ströker
- Heart Rhythm Management CenterUZ Brussel‐VUBBrussels Belgium
| | | | - Muryo Terasawa
- Heart Rhythm Management CenterUZ Brussel‐VUBBrussels Belgium
| | - Juan Sieira
- Heart Rhythm Management CenterUZ Brussel‐VUBBrussels Belgium
| | - Riccardo Maj
- Heart Rhythm Management CenterUZ Brussel‐VUBBrussels Belgium
| | | | | | - Alessio Galli
- Heart Rhythm Management CenterUZ Brussel‐VUBBrussels Belgium
| | - Pedro Brugada
- Heart Rhythm Management CenterUZ Brussel‐VUBBrussels Belgium
| | - Carlo Asmundis
- Heart Rhythm Management CenterUZ Brussel‐VUBBrussels Belgium
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4
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Keçe F, de Riva M, Naruse Y, Alizadeh Dehnavi R, Wijnmaalen AP, Schalij MJ, Zeppenfeld K, Trines SA. Optimizing ablation duration using dormant conduction to reveal incomplete isolation with the second generation cryoballoon: A randomized controlled trial. J Cardiovasc Electrophysiol 2019; 30:902-909. [PMID: 30884006 PMCID: PMC6850340 DOI: 10.1111/jce.13913] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/10/2019] [Accepted: 03/13/2019] [Indexed: 12/02/2022]
Abstract
Introduction Efficacy of cryoballoon ablation depends on balloon‐tissue contact and ablation duration. Prolonged duration may increase extracardiac complications. The aim of this study is to determine the optimal additional ablation duration after acute pulmonary vein isolation (PVI). Methods Consecutive patients with paroxysmal AF were randomized to three groups according to additional ablation duration (90, 120, or 150 seconds) after acute PVI (time‐to‐isolation). Primary outcome was reconnection/dormant conduction (DC) after a 30 minutes waiting period. If present, additional 240 seconds ablations were performed. Ablations without time‐to‐isolation <90 seconds, esophageal temperature <18°C or decreased phrenic nerve capture were aborted. Patients were followed with 24‐hour Holter monitoring at 3, 6, and 12 months. Results Seventy‐five study patients (60 ± 11 years, 48 male) were included. Reconnection/DC per vein significantly decreased (22%, 6% and 4%) while aborted ablations remained stable (respectively 4, 5, and 7%) among the 90, 120, and 150 seconds groups. A shorter cryo‐application time, longer time‐to‐isolation, higher balloon temperature and unsuccessful ablations predicted reconnection/DC. Freedom of atrial fibrillation was, respectively, 52, 56, and 72% in 90, 120, and 150 seconds groups (
P = 0.27), while repeated procedures significantly decreased from 36% to 4% (
P = 0.041) in the longer duration group compared to shorter duration group (150 seconds vs 90 seconds group). In multivariate Cox‐regression only reconnection/DC predicted recurrence. Conclusion Prolonging ablation duration after time‐to‐isolation significantly decreased reconnection/DC and repeated procedures, while recurrences and complications rates were similar. In a time‐to‐isolation approach, an additional ablation of 150 seconds ablation is the most appropriate.
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Affiliation(s)
- Fehmi Keçe
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Marta de Riva
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Yoshihisa Naruse
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Reza Alizadeh Dehnavi
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Adrianus P Wijnmaalen
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Martin J Schalij
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Katja Zeppenfeld
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Serge A Trines
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Leiden, The Netherlands
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5
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Skala T, Precek J, Hutyra M, Moravec O, Tudos Z, Skalova J, Klementova O, Antonicka A, Zapletalova J, Taborsky M. Long-term outcome of paroxysmal atrial fibrillation catheter ablation with and without pulmonary vein dormant conduction after adenosine challenge. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2019; 164:147-153. [PMID: 30829343 DOI: 10.5507/bp.2019.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 02/26/2019] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES The prognostic significance of adenosine-mediated pulmonary vein (PV) dormant conduction is unclear. We prospectively followed patients with adenosine-mediated PV reconduction with a subsequent repeated ablation until there was no reconduction inducible with patients without reconduction after PV isolation. METHOD AND RESULTS Consecutive patients (n=179) with paroxysmal atrial fibrillation (AF) without prior catheter ablation (CA) were enlisted in the study. We used a point-by-point CA and general anesthesia in all patients. Twenty minutes after PV isolation we administered adenosine in a dose sufficient to produce an atrioventricular block. If a dormant conduction was present (n=54) we performed additional ablation until there was no adenosine mediated reconduction inducible. During 36 months of follow-up, all patients were examined for eight 7-day ECG recordings. There was no difference in arrhythmia recurrence rate between patients with and without dormant conduction (29.6 vs. 24.8% at 12 months, P=0.500; 31.5 vs. 30.4% at 36 months, P=1.000), for any echocardiographic parameter or any parameter of the ablation procedure. CONCLUSION The patients with dormant conduction after adenosine during catheter ablation of paroxysmal atrial fibrillation with complete elimination of the dormant conduction by additional extensive ablation have the same outcome in the long term as patients without a dormant conduction.
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Affiliation(s)
- Tomas Skala
- Department of Internal Medicine I - Cardiology, University Hospital Olomouc, Czech Republic
| | - Jan Precek
- Department of Internal Medicine I - Cardiology, University Hospital Olomouc, Czech Republic
| | - Martin Hutyra
- Department of Internal Medicine I - Cardiology, University Hospital Olomouc, Czech Republic
| | - Ondrej Moravec
- Department of Internal Medicine I - Cardiology, University Hospital Olomouc, Czech Republic
| | - Zbynek Tudos
- Department of Radiology, University Hospital Olomouc, Czech Republic
| | - Jitka Skalova
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Olomouc, Czech Republic
| | - Olga Klementova
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Olomouc, Czech Republic
| | - Andrea Antonicka
- Cardiovascular Center, Tomas Bata County Hospital, Zlin, Czech Republic
| | - Jana Zapletalova
- Department of Biophysics, Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Milos Taborsky
- Department of Internal Medicine I - Cardiology, University Hospital Olomouc, Czech Republic
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6
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Chen C, Li D, Ho J, Liu T, Li X, Wang Z, Lin Y, Zou F, Tse G, Xia Y. Clinical Implications of Unmasking Dormant Conduction After Circumferential Pulmonary Vein Isolation in Atrial Fibrillation Using Adenosine: A Systematic Review and Meta-Analysis. Front Physiol 2019; 9:1861. [PMID: 30705634 PMCID: PMC6345194 DOI: 10.3389/fphys.2018.01861] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 12/11/2018] [Indexed: 12/04/2022] Open
Abstract
Purpose: Circumferential pulmonary vein isolation (CPVI) is a routine ablation strategy of atrial fibrillation (AF). The adenosine test can be used to unmask dormant conduction (DC) of pulmonary veins after CPVI, thereby demonstrating possible pulmonary vein re-connection and the need for further ablation. However, whether adenosine test could help improve the long term successful rate of CPVI is still controversial. This systemic review and meta-analysis was to determine the clinical utility of the adenosine test. Methods: PubMed, EMBASE, Web of Science and Cochrane Library database were searched through July 2016 to identify relevant studies using the keywords “dormant pulmonary vein conduction,” “adenosine test,” “circumferential pulmonary vein isolation,” and “atrial fibrillation.” A random-effects model was used to compare pooled outcomes and tested for heterogeneity. Results: A total of 17 studies including 5,169 participants were included in the final meta-analysis. Two groups of comparisons were classified: (1) Long-term successful rate in those AF patients underwent CPVI with and without adenosine test [Group A (+) and Group A (−)]; (2) Long-term successful rate in those patients who had adenosine test with and without dormant conduction [Group DC (+) and Group DC (−)]. The overall meta-analysis showed that no significant difference can be observed between Group A (+) and Group A (−) (RR 1.08; 95% CI 0.97–1.19; P = 0.16; I2 = 66%) and between Group DC (+) and Group DC (−) (RR 1.01; 95% CI 0.91–1.12; P = 0.88; I2 = 60%). Conclusion: Pooled meta-analysis suggested adenosine test may not improve long-term successful rate in AF patients underwent CPVI. Furthermore, AF recurrence may not be decreased by eliminating DC provoked by adenosine, even though adenosine test was applied after CPVI.
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Affiliation(s)
- Cheng Chen
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Daobo Li
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jeffery Ho
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Xintao Li
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Zhao Wang
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yajuan Lin
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Fuquan Zou
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Gary Tse
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China.,Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
| | - Yunlong Xia
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
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7
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Okishige K, Aoyagi H, Nishimura T, Shigeta T, Nakamura T, Yamauchi Y, Keida T, Sasano T, Hirao K. Characteristics of dormant pulmonary vein conduction induced by adenosine triphosphate in patients with atrial fibrillation undergoing cryoballoon ablation. J Cardiol 2018; 71:577-582. [PMID: 29496337 DOI: 10.1016/j.jjcc.2017.11.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 10/30/2017] [Accepted: 11/07/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Adenosine triphosphate (ATP) can provoke acute reconnections after pulmonary vein isolation (PVI). This study aimed to investigate dormant conduction (DC) after ablation with second-generation cryoballoon (CB). METHODS Two hundred sixteen patients (148 male; age 64±9 years) with atrial fibrillation (AF) were included. After a successful PVI with the CB, 20mg of ATP was administered. All patients were followed up for 425±56 days. RESULTS Seven hundred ninety-five out of 864 (92%) PVs were successfully isolated solely by the CB. DCs were revealed in 8 (3.7%) after ATP injections. AF recurrences occurred in 2 out of 8 patients, while no AF recurrences could be documented in 6 out of 8 patients with DCs after a blanking period of 3 months (25% vs. 75%). In contrast, 29 (13.9%) patients without DCs had AF recurrences, and there was no significant difference between those with and without DCs regarding the recurrence rate of AF (p=0.38). There were no reliable predictors of DCs after the PVI with the CB. CONCLUSION The present study demonstrated a low rate of transient PV reconnection after adenosine infusion following successful PVI with the CB. There was no reliable predictor of DCs. Further studies will be needed in order to appreciate the prognostic value of adenosine testing after successful PVI with the CB.
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Affiliation(s)
- Kaoru Okishige
- Heart Center, Japan Red Cross Yokohama City Bay Hospital, Yokohama, Japan.
| | - Hideshi Aoyagi
- Heart Center, Japan Red Cross Yokohama City Bay Hospital, Yokohama, Japan
| | - Takurou Nishimura
- Heart Center, Japan Red Cross Yokohama City Bay Hospital, Yokohama, Japan
| | - Takatoshi Shigeta
- Heart Center, Japan Red Cross Yokohama City Bay Hospital, Yokohama, Japan
| | - Tomofumi Nakamura
- Heart Center, Japan Red Cross Yokohama City Bay Hospital, Yokohama, Japan
| | - Yasuteru Yamauchi
- Heart Center, Japan Red Cross Yokohama City Bay Hospital, Yokohama, Japan
| | | | - Tetsuo Sasano
- Arrhythmia Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kenzo Hirao
- Arrhythmia Center, Tokyo Medical and Dental University, Tokyo, Japan
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8
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Kaplan RM, Dandamudi S, Bohn M, Verma N, Tomson TT, Arora R, Chicos AB, Goldberger JJ, Kim SS, Knight BP, Lin AC, Passman RS. Reconnection Rate and Long-Term Outcome with Adenosine Provocation During Cryoballoon Ablation for Pulmonary Vein Isolation. J Atr Fibrillation 2017; 9:1510. [PMID: 29250268 DOI: 10.4022/jafib.1510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 11/30/2016] [Accepted: 01/23/2017] [Indexed: 11/10/2022]
Abstract
Background Adenosine can unmask dormant conduction during pulmonary vein isolation (PVI) for atrial fibrillation (AF). Studies of adenosine use in radiofrequency PVI show high reconnection rates and conflicting results for long-term success, however there is limited data with cryoballoon ablation (CBA). Methods A prospectively maintained database of patients undergoing first CBA at a single institution was analyzed. Adenosine use was at the discretion of the primary operator. Additional freezes were delivered for reconnected veins until dormant conduction was eliminated. The primary endpoint, time to AF recurrence defined as any episode < 30 seconds after a 3-month blanking period, was assessed by Kaplan-Meier analysis. Results From 2011 to 2015, 406 patients underwent CBA, 361 of whom had > 3 months follow-up. The mean age was 61.7 years, 69% were male, and the prevalence of paroxysmal AF was 79% with no significant difference between those that did and did not receive adenosine (77% vs 86%, respectively, p = 0.23). Adenosine testing was performed in 78 patients (21.6%) with a mean dose of 10.6 mg/vein. Of the 306 veins evaluated, 17 (6%) demonstrated dormant conduction. Over a median 14.4 months follow-up, there was no significant difference in freedom from AF with adenosine use (p= 0.86). Conclusions Dormant conduction with adenosine is uncommon following CBA and its use does not improve long-term success rates.
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Affiliation(s)
- Rachel M Kaplan
- Division of Cardiology, Northwestern University, Feinberg School of Medicine
| | - Sanjay Dandamudi
- Division of Cardiology, Northwestern University, Feinberg School of Medicine
| | - Martha Bohn
- Division of Cardiology, Northwestern University, Feinberg School of Medicine
| | - Nishant Verma
- Division of Cardiology, Northwestern University, Feinberg School of Medicine
| | - Todd T Tomson
- Division of Cardiology, Northwestern University, Feinberg School of Medicine
| | - Rishi Arora
- Division of Cardiology, Northwestern University, Feinberg School of Medicine
| | - Alexandru B Chicos
- Division of Cardiology, Northwestern University, Feinberg School of Medicine
| | | | - Susan S Kim
- Division of Cardiology, Northwestern University, Feinberg School of Medicine
| | - Bradley P Knight
- Division of Cardiology, Northwestern University, Feinberg School of Medicine
| | - Albert C Lin
- Division of Cardiology, Northwestern University, Feinberg School of Medicine
| | - Rod S Passman
- Division of Cardiology, Northwestern University, Feinberg School of Medicine
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9
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Luni FK, Khan AR, Singh H, Riaz H, Malik SA, Khawaja O, Farid T, Cummings J, Taleb M. Identification and Ablation of Dormant Conduction in Atrial Fibrillation Using Adenosine. Am J Med Sci 2017; 355:27-36. [PMID: 29289258 DOI: 10.1016/j.amjms.2017.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 09/05/2017] [Accepted: 09/18/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Ablation is used for treatment of atrial fibrillation (AF) but recurrence is common. Dormant conduction is hypothesized to be responsible for these recurrences, and the role of adenosine in identification and ablation of these pathways is controversial with conflicting results on AF recurrence. MATERIALS AND METHODS We conducted a meta-analysis for studies evaluating AF ablation and adenosine use. Included in the meta-analysis were human studies that compared ablation using adenosine or adenosine triphosphate (ATP) and reported freedom from AF in patients beyond a minimum follow-up of 6 months. RESULTS Our analysis suggests that the use of adenosine leads to a decrease in recurrence of AF compared to the cohort which did not utilize adenosine. Subgroup analysis showed no difference in the recurrence of AF with the modality used for ablation (cryoablation vs. radiofrequency ablation) or with the preparation of adenosine used (ATP vs. adenosine). There was a significant benefit in delayed administration of ATP over early administration. Pooling results of only randomized control trials did not show any significant difference in AF recurrence. CONCLUSIONS Adenosine-guided identification and ablation of dormant pathways may lead to a decrease in recurrence of AF.
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Affiliation(s)
- Faraz Khan Luni
- Department of Cardiovascular Diseases and Department of Family Medicine, Mercy Saint Vincent Medical Center, Toledo, Ohio.
| | - Abdur Rahman Khan
- Department of Cardiovascular Diseases, University of Louisville, Louisville, Kentucky
| | - Hemindermeet Singh
- Department of Cardiovascular Diseases and Department of Family Medicine, Mercy Saint Vincent Medical Center, Toledo, Ohio
| | - Haris Riaz
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Sonia Ali Malik
- Department of Cardiovascular Diseases and Department of Family Medicine, Mercy Saint Vincent Medical Center, Toledo, Ohio
| | - Owais Khawaja
- Department of Cardiovascular Diseases and Department of Family Medicine, Mercy Saint Vincent Medical Center, Toledo, Ohio
| | - Talha Farid
- Department of Cardiovascular Diseases, University of Louisville, Louisville, Kentucky
| | - Jennifer Cummings
- Department of Cardiovascular Diseases, Northeastern Ohio Medical University, Canton, Ohio
| | - Mohammed Taleb
- Department of Cardiovascular Diseases and Department of Family Medicine, Mercy Saint Vincent Medical Center, Toledo, Ohio
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10
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McLellan AJ, Kumar S, Smith C, Ling LH, Prabhu S, Kalman JM, Kistler PM. The role of adenosine challenge in catheter ablation for atrial fibrillation: A systematic review and meta-analysis. Int J Cardiol 2017; 236:253-261. [DOI: 10.1016/j.ijcard.2017.01.070] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 01/06/2017] [Indexed: 10/20/2022]
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11
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Chen YH, Lin H, Xie CL, Hou JW, Li YG. Role of adenosine-guided pulmonary vein isolation in patients undergoing catheter ablation for atrial fibrillation: a meta-analysis. Europace 2017; 19:552-559. [PMID: 28431050 DOI: 10.1093/europace/euw201] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 06/08/2016] [Indexed: 10/13/2023] Open
Abstract
AIMS Adenosine had been reported to unmask dormant conduction and thus identify pulmonary vein at risk of reconnection. However, the role of adjunctive adenosine infusion after pulmonary vein isolation (PVI) on long-term arrhythmia-free survival was still contentious. The purpose of the present meta-analysis was to assess the association of adenosine testing with long-term ablation success in patients with atrial fibrillation (AF) (i.e. freedom from AF recurrence). METHODS AND RESULTS We systematically searched the electronic databases and finally included 10 studies, with 1771 patients undergoing adenosine-guided PVI and 1787 patients undergoing conventional PVI. In comparison to conventional PVI alone, adenosine-guided PVI improved the arrhythmia-free survival by 17% during a median follow-up of 12 months [relative risk (RR): 1.17; 95% confidence interval (CI): 1.07 to 1.27; P = 0.014]. Patients undergoing adenosine-guided PVI had similar fluoroscopy time to those who undergoing conventional PVI [weighted mean difference (WMD): 1.76; 95% CI: -5.66 to 9.17; P = 0.64], despite longer procedure time (WMD: 20.6; 95% CI: 0.70 to 40.50; P = 0.042). CONCLUSION From the available data of clinical studies, adenosine-guided PVI was associated with an increased arrhythmia-free survival when compared with conventional PVI in patients undergoing catheter ablation for AF.
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Affiliation(s)
- Yi-He Chen
- Department of Cardiology, Xinhua Hospital Affiliated to the Medical School of Shanghai Jiaotong University, 1665 Kongjiang Road, Shanghai 200092, China
| | - Hui Lin
- Department of Respiratory, The Second Af?liated Hospital of Wenzhou Medical University, Wenzhou 325027, China
| | - Cheng-Long Xie
- Department of Neurology, Xinhua Hospital Affiliated to the Medical School of Shanghai Jiaotong University, Shanghai 200092, China
| | - Jian-Wen Hou
- Department of Cardiology, Xinhua Hospital Affiliated to the Medical School of Shanghai Jiaotong University, 1665 Kongjiang Road, Shanghai 200092, China
| | - Yi-Gang Li
- Department of Cardiology, Xinhua Hospital Affiliated to the Medical School of Shanghai Jiaotong University, 1665 Kongjiang Road, Shanghai 200092, China
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Papageorgiou N, Providência R, Srinivasan N, Bronis K, Costa FM, Cavaco D, Adragão P, Tousoulis D, Hunter RJ, Schilling RJ, Segal OR, Chow A, Rowland E, Lowe M, Lambiase PD. Adenosine-guided pulmonary vein isolation versus conventional pulmonary vein isolation in patients undergoing atrial fibrillation ablation: An updated meta-analysis. Int J Cardiol 2017; 227:151-160. [DOI: 10.1016/j.ijcard.2016.11.152] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 11/06/2016] [Indexed: 01/11/2023]
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13
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Teunissen C, Clappers N, Kassenberg W, Hassink RJ, van der Heijden JF, Loh P. Time matters: adenosine testing immediately after pulmonary vein isolation does not substitute a waiting period. Europace 2016; 19:1140-1145. [DOI: 10.1093/europace/euw173] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 05/15/2016] [Indexed: 11/12/2022] Open
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14
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Tokuda M, Matsuo S, Isogai R, Uno G, Tokutake K, Yokoyama K, Kato M, Narui R, Tanigawa S, Yamashita S, Inada K, Yoshimura M, Yamane T. Adenosine testing during cryoballoon ablation and radiofrequency ablation of atrial fibrillation: A propensity score-matched analysis. Heart Rhythm 2016; 13:2128-2134. [PMID: 27520540 DOI: 10.1016/j.hrthm.2016.08.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND The infusion of adenosine triphosphate after radiofrequency (RF) pulmonary vein (PV) isolation (PVI), which may result in acute transient PV-atrium reconnection, can unmask dormant conduction. OBJECTIVE The purpose of this study was to compare the incidence and characteristics of dormant conduction after cryoballoon (CB) and RF ablation of atrial fibrillation (AF). METHODS Of 414 consecutive patients undergoing initial catheter ablation of paroxysmal AF, 246 (59%) propensity score-matched patients (123 CB-PVI and 123 RF-PVI) were included. RESULTS Dormant conduction was less frequently observed in patients who underwent CB-PVI than in those who underwent RF-PVI (4.5% vs 12.8% of all PVs; P < .0001). The incidence of dormant conduction in each PV was lower in patients who underwent CB-PVI than in those who underwent RF-PVI in the left superior PV (P < .0001) and right superior PV (P = .001). The site of dormant conduction was mainly located around the bottom of both inferior PVs after CB-PVI. Multivariable analysis revealed that a longer time to the elimination of the PV potential (odds ratio 1.018; 95% confidence interval 1.001-1.036; P = .04) and the necessity of touch-up ablation (odds ratio 3.242; 95% confidence interval 2.761-7.111; P < .0001) were independently associated with the presence of dormant conduction after CB-PVI. After the elimination of dormant conduction by additional ablation, the AF-free rate was similar in patients with and without dormant conduction after both CB-PVI and RF-PVI (P = .28 and P = .73, respectively). CONCLUSION The results of the propensity score-matched analysis showed that dormant PV conduction was less frequent after CB ablation than after RF ablation and was not associated with ablation outcomes.
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Affiliation(s)
- Michifumi Tokuda
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan.
| | - Seiichiro Matsuo
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Ryota Isogai
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Goki Uno
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Kenichi Tokutake
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Kenichi Yokoyama
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Mika Kato
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Ryohsuke Narui
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Shinichi Tanigawa
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Seigo Yamashita
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Keiichi Inada
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Michihiro Yoshimura
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Teiichi Yamane
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
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15
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Fürnkranz A, Bologna F, Bordignon S, Perrotta L, Dugo D, Schmidt B, Chun JKR. Procedural characteristics of pulmonary vein isolation using the novel third-generation cryoballoon. Europace 2016; 18:1795-1800. [PMID: 26935947 DOI: 10.1093/europace/euw012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 12/20/2015] [Indexed: 11/14/2022] Open
Abstract
AIM A novel third-generation cryoballoon (CB3) to perform pulmonary vein isolation (PVI) has recently been released, featuring a shortened distal balloon tip when compared with the second-generation (CB2), possibly allowing for enhanced intra-ablation pulmonary vein (PV) signal mapping. We aimed to investigate procedural efficacy and safety of the CB3 as compared to the CB2. METHODS AND RESULTS We studied 472 consecutive patients who underwent CB-PVI for paroxysmal or persistent atrial fibrillation (CB3: 49 patients; CB2: 423 patients). Detailed procedural data and in-hospital complications were registered in a prospective database. Complete PVI using the CB only was achieved in 98% of patients in each group. Single-freeze PVI was observed in 84/88% (CB2/CB3, P = n.s.) of the PVs. Time-to-PVI (TPVI) was 49 ± 32 (CB2) and 45 ± 27 s (CB3) (P = n.s.). Time-to-PVI determination rate was higher in the CB3 group (89.5 vs. 82.6%, P = 0.016). Signal noise due to ice formation on mapping electrodes occurred after 70 ± 46 s using CB3 and did not interfere with TPVI determination. Exchange of the spiral mapping catheter with a guide wire was more frequently required in the CB3 group (8.2 vs. 0.7% patients, P < 0.001). Balloon dislodgement during hockey stick manoeuvres occurred in 6.1% patients of the CB3 group only (P = 0.001). Complication rates were not different between the groups. CONCLUSION The CB3 offers a higher TPVI determination rate, facilitating dosing schemes based on TPVI, with equally high single-freeze efficacy compared with the CB2. The shortened distal tip of the CB3 requires adaptation of standard catheter manoeuvers to avoid balloon dislodgement.
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Affiliation(s)
- Alexander Fürnkranz
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Markus Krankenhaus, Wilhelm-Epstein-Street 4, D-60431 Frankfurt am Main, Germany
| | - Fabrizio Bologna
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Markus Krankenhaus, Wilhelm-Epstein-Street 4, D-60431 Frankfurt am Main, Germany
| | - Stefano Bordignon
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Markus Krankenhaus, Wilhelm-Epstein-Street 4, D-60431 Frankfurt am Main, Germany
| | - Laura Perrotta
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Markus Krankenhaus, Wilhelm-Epstein-Street 4, D-60431 Frankfurt am Main, Germany
| | - Daniela Dugo
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Markus Krankenhaus, Wilhelm-Epstein-Street 4, D-60431 Frankfurt am Main, Germany
| | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Markus Krankenhaus, Wilhelm-Epstein-Street 4, D-60431 Frankfurt am Main, Germany
| | - Julian K R Chun
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Markus Krankenhaus, Wilhelm-Epstein-Street 4, D-60431 Frankfurt am Main, Germany
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The Role of Adenosine in Pulmonary Vein Isolation: A Critical Review. Cardiol Res Pract 2016; 2016:8632509. [PMID: 26981309 PMCID: PMC4770126 DOI: 10.1155/2016/8632509] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 01/04/2016] [Indexed: 01/19/2023] Open
Abstract
The cornerstone of atrial fibrillation (AF) ablation is pulmonary vein isolation (PVI), which can be achieved in more than 95% of patients at the end of the procedure. However, AF recurrence rates remain high and are related to recovery of PV conduction. Adenosine testing is used to unmask dormant pulmonary vein conduction (DC). The aim of this study is to review the available literature addressing the role of adenosine testing and determine the impact of ablation at sites of PV reconnection on freedom from AF. Adenosine infusion, by restoring the excitability threshold, unmasks reversible injury that could lead to recovery of PV conduction. The studies included in this review suggest that adenosine is useful to unmask nontransmural lesions at risk of reconnection and that further ablation at sites of DC is associated with improvement in freedom from AF. Nevertheless it has been demonstrated that adenosine is not able to predict all veins at risk of later reconnection, which means that veins without DC are not necessarily at low risk. The role of the waiting period in the setting of adenosine testing has also been analyzed, suggesting that in the acute phase adenosine use should be accompanied by enough waiting time.
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