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Kottmaier M, Bourier F, Wünscher S, Kornmayer M, Semmler V, Lengauer S, Telishevska M, Koch-Büttner K, Risse E, Brooks S, Hessling G, Deisenhofer I, Reents T. Repeat ablation for paroxysmal atrial fibrillation - Does adenosine play a role in predicting pulmonary vein reconnection patterns? Indian Pacing Electrophysiol J 2018; 18:203-207. [PMID: 30290206 PMCID: PMC6302775 DOI: 10.1016/j.ipej.2018.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 09/05/2018] [Accepted: 09/27/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Pulmonary vein (PV) reconduction after PV isolation (PVI) unmasked by adenosine is associated with a higher risk for paroxysmal atrial fibrillation (PAF) recurrence. It is unknown if the reconnected PVs after adenosine testing and immediate re-ablation can predict reconnection and reconnection patterns of PVs at repeat procedures. We assessed reconnection of PVs with and without dormant-conduction (DC) during the first and the repeat procedure. METHODS We included 67 patients undergoing PVI for PAF and a second procedure for PAF recurrence. DC during adenosine administration at first procedure was seen in 31 patients (46%). 264 PVs were tested with adenosine; DC was found in 48 PVs (18%) and re-ablated during first procedure. During the second procedure, all PVs where checked for reconnection. RESULTS Fifty-eight patients (87%) showed PV reconnection during the second procedure. Reconnection was found in 152/264 PVs (58%). Of 216 PVs without reconnection during adenosine testing at the first ablation, 116 PVs (53.7%) showed reconnection at the repeat procedure. Overall, 14.9% of patients showed the same PV reconnection pattern in the first and second procedure, expected statistical probability of encountering the same reconnection pattern was only 6.6%(p = 0.012). CONCLUSIONS In repeat procedures PVs showed significantly more often the same reconnection pattern as during first procedure than statistically expected. More than 50% of initial isolated PVs without reconnection during adenosine testing showed a reconnection during repeat ablation. Techniques to detect susceptibility for PV re-connection like prolonged waiting-period should be applied. Elimination of DC should be expanded from segmental to circumferential re-isolation or vaster RF application.
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Affiliation(s)
- M Kottmaier
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Germany.
| | - F Bourier
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Germany
| | - S Wünscher
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Germany
| | - M Kornmayer
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Germany
| | - V Semmler
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Germany
| | - S Lengauer
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Germany
| | - M Telishevska
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Germany
| | - K Koch-Büttner
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Germany
| | - E Risse
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Germany
| | - S Brooks
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Germany
| | - G Hessling
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Germany
| | - I Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Germany
| | - T Reents
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Germany
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Iqbal M, Jena A, Park HS, Baek YS, Lee KN, Roh SY, Shim JM, Choi JI, Kim YH. Value of adenosine test to reveal dormant conduction or adenosine-induced atrial fibrillation after pulmonary vein isolation. J Arrhythm 2017; 33:602-607. [PMID: 29255508 PMCID: PMC5728995 DOI: 10.1016/j.joa.2017.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 07/03/2017] [Accepted: 07/18/2017] [Indexed: 11/17/2022] Open
Abstract
Background Recent studies investigating the implications of additional ablation guided by dormant pulmonary vein (PV) conduction testing using adenosine showed conflicting results, and the data about atrial fibrillation (AF) recurrence after trigger site elimination in adenosine-induced AF are still lacking. Methods Of 846 patients with paroxysmal AF (PAF) who underwent PV isolation (PVI), adenosine test after PVI was performed in 148 patients. Results PVI was successfully achieved in 846 patients. We excluded 58 patients due to loss to the follow-up. A higher rate of AF recurrence was found in the group without adenosine test (136/644, 21%) compared to the group with adenosine test (20/144, 13%, log-rank P=0.047). In multivariate analysis model for AF freedom during the follow-up period, the only significant clinical predictor of AF freedom was adenosine test (hazard ratio [HR] 1.97; 95% confidence interval [CI]: 1.2-3.23; P=0.007).Among 148 patients with adenosine test, 114 (77%) patients showed neither dormant conductions nor AF-induced, 22 (15%) showed positive dormant conductions only, and 12 (8%) revealed adenosine-induced AF (6 of them also showed dormant conduction). After additional ablation in positive dormant conduction group and adenosine-induced AF group, AF recurrence was noted in 4/21 (19%) patients in positive dormant conduction group and 2/11 (18%) patients in adenosine-induced AF group, which was not different from that of patients in negative dormant conduction/ no AF-induced group (14/112, 12%, log-rank P=0.67). Conclusions Adenosine test after PVI to confirm the absence of dormant conduction and triggers initiating AF is beneficial to improve the outcomes after catheter ablation of PAF.
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Affiliation(s)
- Mohammad Iqbal
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, 73 Inchon-Ro, Seongbuk-Gu, Seoul 02841, Republic of Korea.,Department of Cardiology and Vascular Medicine, Universitas Padjadjaran, Jalan Eyckman 38, Bandung 40161, Indonesia
| | - Anupam Jena
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, 73 Inchon-Ro, Seongbuk-Gu, Seoul 02841, Republic of Korea
| | - Hee-Soon Park
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, 73 Inchon-Ro, Seongbuk-Gu, Seoul 02841, Republic of Korea
| | - Yong-Soo Baek
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, 73 Inchon-Ro, Seongbuk-Gu, Seoul 02841, Republic of Korea
| | - Kwang-No Lee
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, 73 Inchon-Ro, Seongbuk-Gu, Seoul 02841, Republic of Korea
| | - Seung-Young Roh
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, 73 Inchon-Ro, Seongbuk-Gu, Seoul 02841, Republic of Korea
| | - Jae-Min Shim
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, 73 Inchon-Ro, Seongbuk-Gu, Seoul 02841, Republic of Korea
| | - Jong-Il Choi
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, 73 Inchon-Ro, Seongbuk-Gu, Seoul 02841, Republic of Korea
| | - Young-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, 73 Inchon-Ro, Seongbuk-Gu, Seoul 02841, Republic of Korea
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Wang N, Phan S, Kanagaratnam A, Kumar N, Phan K. Adenosine Testing After Atrial Fibrillation Ablation: Systematic Review and Meta-Analysis. Heart Lung Circ 2017; 27:601-610. [PMID: 28655535 DOI: 10.1016/j.hlc.2017.04.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 04/20/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Adenosine can be used to reveal dormant pulmonary vein (PV) conduction after pulmonary vein isolation (PVI) for the treatment of atrial fibrillation (AF). We performed a systematic review and meta-analysis to assess the impact of adenosine administration in patients undergoing PVI for AF. METHODS Meta-analysis of 22 studies was performed to assess the rates of freedom from AF in 1) patients with dormant PV conduction versus patients without dormant PV conduction, and 2) patients given routine adenosine post PVI versus patients not given adenosine. Relative-risks (RR) were calculated using random effects modelling. RESULTS In 18 studies, 3038 patients received adenosine and freedom from AF in those patients with dormant PV reconnection was significantly lower (62.9%) compared to patients without PV reconnection (67.2%) (RR 0.87; 95% CI: 0.78-0.98). In seven studies with 3049 patients, the freedom from AF was significantly higher in patients who received adenosine (67%) versus those patients who did not receive adenosine (63%) (RR: 1.11; 95% CI: 1.01-1.22). CONCLUSIONS The present study showed clear benefits of adenosine testing for freedom from AF recurrence. Adenosine-guided dormant conduction is associated with higher AF recurrence despite further ablation. Future studies should investigate the optimal methodology, including dosage and waiting time between PVI and adenosine administration.
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Affiliation(s)
- Nelson Wang
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Collaborative Research (CORE) Group, Macquarie University, Sydney, NSW, Australia.
| | - Steven Phan
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Collaborative Research (CORE) Group, Macquarie University, Sydney, NSW, Australia
| | | | - Narendra Kumar
- Department of Cardiology, Paras HMRI Hospitals, Raja Bazar, Patna, India
| | - Kevin Phan
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Collaborative Research (CORE) Group, Macquarie University, Sydney, NSW, Australia
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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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Morales G, Darrat YH, Lellouche N, Kim SM, Butt M, Bidwell K, Lippert W, Ogunbayo G, Hamon D, Di Biase L, Natale A, Parrott K, Elayi CS. Use of adenosine to shorten the post ablation waiting period for cavotricuspid isthmus-dependent atrial flutter. J Cardiovasc Electrophysiol 2017; 28:876-881. [DOI: 10.1111/jce.13233] [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: 02/23/2017] [Revised: 03/31/2017] [Accepted: 04/12/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Gustavo Morales
- Gill Heart Institute; University of Kentucky; Lexington Kentucky USA
| | - Yousef H. Darrat
- Gill Heart Institute; University of Kentucky; Lexington Kentucky USA
| | | | - Sun Moon Kim
- Gill Heart Institute; University of Kentucky; Lexington Kentucky USA
| | - Muhammad Butt
- Gill Heart Institute; University of Kentucky; Lexington Kentucky USA
| | - Katrina Bidwell
- Gill Heart Institute; University of Kentucky; Lexington Kentucky USA
| | - William Lippert
- Gill Heart Institute; University of Kentucky; Lexington Kentucky USA
| | - Gbolahan Ogunbayo
- Gill Heart Institute; University of Kentucky; Lexington Kentucky USA
| | - David Hamon
- Service de Cardiologie; CHU Henri Mondor; Creteil France
| | - Luigi Di Biase
- Texas Cardiac Arrhythmia Institute; St. David's Medical Center; Austin TX USA
- Department of Cardiology; University of Foggia; Foggia Italy
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute; St. David's Medical Center; Austin TX USA
- Department of Biomedical Engineering; University of Texas; Austin TX USA
- Dell Medical School; University of Texas; Austin TX USA
| | - Kevin Parrott
- Gill Heart Institute; University of Kentucky; Lexington Kentucky USA
| | - Claude S Elayi
- Gill Heart Institute; University of Kentucky; Lexington Kentucky USA
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Pedrote A, Acosta J, Jáuregui-Garrido B, Frutos-López M, Arana-Rueda E. Paroxysmal atrial fibrillation ablation: Achieving permanent pulmonary vein isolation by point-by-point radiofrequency lesions. World J Cardiol 2017; 9:230-240. [PMID: 28400919 PMCID: PMC5368672 DOI: 10.4330/wjc.v9.i3.230] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 12/14/2016] [Accepted: 01/14/2017] [Indexed: 02/06/2023] Open
Abstract
Pulmonary vein isolation by point-by-point radiofrequency catheter ablation constitutes the cornerstone of catheter ablation strategies for the treatment of atrial fibrillation. However, despite advances in pulmonary vein isolation ablation strategies, long-term success rates after ablation remain suboptimal, which highlights the need to develop techniques to achieve more durable lesions. Strategies proposed to improve the durability of pulmonary vein isolation can be divided into two groups: Those addressed to improving the quality of the lesion and those that optimize the detection of acute PV reconnection during the ablation procedure. This manuscript reviews the role and potential benefits of these techniques according to current clinical evidence.
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Kocyigit D, Canpolat U, Aytemir K. Who Needs Catheter Ablation And Which Approach? J Atr Fibrillation 2016; 8:1335. [PMID: 27957233 DOI: 10.4022/jafib.1335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Revised: 09/29/2015] [Accepted: 09/29/2015] [Indexed: 12/29/2022]
Abstract
Catheter ablation therapy for atrial fibrillation (AF) has gained a significant role during maintenance of sinus rhythm compared to anti-arrhythmic medication. Catheter ablation techniques are also improved and progressed over years in parallel to better understanding of disease mechanisms and technological advancements. However, due to invasive nature of the therapy with its pertinent procedural risks, both appropriate patient selection and use of relevant approach should be considered by all electrophysiologists before decide to perform catheter ablation.
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Affiliation(s)
- Duygu Kocyigit
- Department of Cardiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ugur Canpolat
- Department of Cardiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Kudret Aytemir
- Department of Cardiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Kim JY, Kim SH, Song IG, Kim YR, Kim TS, Kim JH, Jang SW, Lee MY, Rho TH, Oh YS. Achievement of successful pulmonary vein isolation: methods of adenosine testing and incremental benefit of exit block. J Interv Card Electrophysiol 2016; 46:315-24. [DOI: 10.1007/s10840-016-0122-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 02/29/2016] [Indexed: 10/22/2022]
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DAS MOLOY, WYNN GARETHJ, MORGAN MAUREEN, RONAYNE CHRISTINA, WAKTARE JOHANE, TODD DERICKM, HALL MARKC, SNOWDON RICHARDL, MODI SIMON, GUPTA DHIRAJ. Reablated Sites of Acute Reconnection After Pulmonary Vein Isolation Do Not Predict Sites of Late Reconnection at Repeat Electrophysiology Study. J Cardiovasc Electrophysiol 2016; 27:381-9. [DOI: 10.1111/jce.12933] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 12/02/2015] [Accepted: 12/22/2015] [Indexed: 11/28/2022]
Affiliation(s)
- MOLOY DAS
- Institute of Cardiovascular Medicine and Science, Department of Cardiology; Liverpool Heart and Chest Hospital; Liverpool UK
| | - GARETH J. WYNN
- Institute of Cardiovascular Medicine and Science, Department of Cardiology; Liverpool Heart and Chest Hospital; Liverpool UK
| | - MAUREEN MORGAN
- Institute of Cardiovascular Medicine and Science, Department of Cardiology; Liverpool Heart and Chest Hospital; Liverpool UK
| | - CHRISTINA RONAYNE
- Institute of Cardiovascular Medicine and Science, Department of Cardiology; Liverpool Heart and Chest Hospital; Liverpool UK
| | - JOHAN E.P. WAKTARE
- Institute of Cardiovascular Medicine and Science, Department of Cardiology; Liverpool Heart and Chest Hospital; Liverpool UK
| | - DERICK M. TODD
- Institute of Cardiovascular Medicine and Science, Department of Cardiology; Liverpool Heart and Chest Hospital; Liverpool UK
| | - MARK C.S. HALL
- Institute of Cardiovascular Medicine and Science, Department of Cardiology; Liverpool Heart and Chest Hospital; Liverpool UK
| | - RICHARD L. SNOWDON
- Institute of Cardiovascular Medicine and Science, Department of Cardiology; Liverpool Heart and Chest Hospital; Liverpool UK
| | - SIMON MODI
- Institute of Cardiovascular Medicine and Science, Department of Cardiology; Liverpool Heart and Chest Hospital; Liverpool UK
| | - DHIRAJ GUPTA
- Institute of Cardiovascular Medicine and Science, Department of Cardiology; Liverpool Heart and Chest Hospital; Liverpool UK
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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: 14] [Impact Index Per Article: 1.8] [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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Sultan A, Lüker J, Hoffmann B, Servatius H, Schäffer B, Steven D, Willems S. Interventional management of recurrent paroxysmal atrial fibrillation despite isolated pulmonary veins: impact of an ablation strategy targeting inducible atrial tachyarrhythmias. Europace 2015; 18:994-9. [DOI: 10.1093/europace/euv332] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 09/03/2015] [Indexed: 11/14/2022] Open
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Macle L, Khairy P, Weerasooriya R, Novak P, Verma A, Willems S, Arentz T, Deisenhofer I, Veenhuyzen G, Scavée C, Jaïs P, Puererfellner H, Levesque S, Andrade JG, Rivard L, Guerra PG, Dubuc M, Thibault B, Talajic M, Roy D, Nattel S. Adenosine-guided pulmonary vein isolation for the treatment of paroxysmal atrial fibrillation: an international, multicentre, randomised superiority trial. Lancet 2015. [PMID: 26211828 DOI: 10.1016/s0140-6736(15)60026-5] [Citation(s) in RCA: 166] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Catheter ablation is increasingly used to manage atrial fibrillation, but arrhythmia recurrences are common. Adenosine might identify pulmonary veins at risk of reconnection by unmasking dormant conduction, and thereby guide additional ablation to improve arrhythmia-free survival. We assessed whether adenosine-guided pulmonary vein isolation could prevent arrhythmia recurrence in patients undergoing radiofrequency catheter ablation for paroxysmal atrial fibrillation. METHODS We did this randomised trial at 18 hospitals in Australia, Europe, and North America. We enrolled patients aged older than 18 years who had had at least three symptomatic atrial fibrillation episodes in the past 6 months, and for whom treatment with an antiarrhythmic drug failed. After pulmonary vein isolation, intravenous adenosine was administered. If dormant conduction was present, patients were randomly assigned (1:1) to additional adenosine-guided ablation to abolish dormant conduction or to no further ablation. If no dormant conduction was revealed, randomly selected patients were included in a registry. Patients were masked to treatment allocation and outcomes were assessed by a masked adjudicating committee. Patients were followed up for 1 year. The primary outcome was time to symptomatic atrial tachyarrhythmia after a single procedure in the intention-to-treat population. The trial is registered with ClinicalTrials.gov, number NCT01058980. FINDINGS Adenosine unmasked dormant pulmonary vein conduction in 284 (53%) of 534 patients. 102 (69·4%) of 147 patients with additional adenosine-guided ablation were free from symptomatic atrial tachyarrhythmia compared with 58 (42·3%) of 137 patients with no further ablation, corresponding to an absolute risk reduction of 27·1% (95% CI 15·9-38·2; p<0·0001) and a hazard ratio of 0·44 (95% CI 0·31-0·64; p<0·0001). Of 115 patients without dormant pulmonary vein conduction, 64 (55·7%) remained free from symptomatic atrial tachyarrhythmia (p=0·0191 vs dormant conduction with no further ablation). Occurrences of serious adverse events were similar in each group. One death (massive stroke) was deemed probably related to ablation in a patient included in the registry. INTERPRETATION Adenosine testing to identify and target dormant pulmonary vein conduction during catheter ablation of atrial fibrillation is a safe and highly effective strategy to improve arrhythmia-free survival in patients with paroxysmal atrial fibrillation. This approach should be considered for incorporation into routine clinical practice. FUNDING Canadian Institutes of Health Research, St Jude Medical, Biosense-Webster, and M Lachapelle (Montreal Heart Institute Foundation).
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Affiliation(s)
- Laurent Macle
- Montreal Heart Institute and Montreal Health Innovations Coordinating Centre, Department of Medicine, Université de Montréal, Montreal, QC, Canada.
| | - Paul Khairy
- Montreal Heart Institute and Montreal Health Innovations Coordinating Centre, Department of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Rukshen Weerasooriya
- University of Western Australia and Hollywood Private Hospital, Perth, WA, Australia
| | - Paul Novak
- Royal Jubilee Hospital, Victoria, BC, Canada
| | - Atul Verma
- Southlake Regional Health Centre, Newmarket, ON, Canada
| | | | | | | | | | | | | | | | - Sylvie Levesque
- Montreal Heart Institute and Montreal Health Innovations Coordinating Centre, Department of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Jason G Andrade
- Montreal Heart Institute and Montreal Health Innovations Coordinating Centre, Department of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Lena Rivard
- Montreal Heart Institute and Montreal Health Innovations Coordinating Centre, Department of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Peter G Guerra
- Montreal Heart Institute and Montreal Health Innovations Coordinating Centre, Department of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Marc Dubuc
- Montreal Heart Institute and Montreal Health Innovations Coordinating Centre, Department of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Bernard Thibault
- Montreal Heart Institute and Montreal Health Innovations Coordinating Centre, Department of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Mario Talajic
- Montreal Heart Institute and Montreal Health Innovations Coordinating Centre, Department of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Denis Roy
- Montreal Heart Institute and Montreal Health Innovations Coordinating Centre, Department of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Stanley Nattel
- Montreal Heart Institute and Montreal Health Innovations Coordinating Centre, Department of Medicine, Université de Montréal, Montreal, QC, Canada
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Miyazaki S, Taniguchi H, Nakamura H, Hachiya H, Ichihara N, Araki M, Kuroi A, Takagi T, Iwasawa J, Hirao K, Iesaka Y. Adenosine Triphosphate Test After Cryothermal Pulmonary Vein Isolation: Creating Contiguous Lesions Is Essential for Eliminating Dormant Conduction. J Cardiovasc Electrophysiol 2015; 26:1069-74. [PMID: 26076357 DOI: 10.1111/jce.12726] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 05/17/2015] [Accepted: 06/03/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Adenosine triphosphate (ATP) testing reveals dormant pulmonary vein (PV) conduction after electrical PV isolation (PVI). This study aimed to evaluate the incidence of latent PV conduction after cryothermal PVI. METHODS Fifty-four consecutive paroxysmal atrial fibrillation patients undergoing cryothermal PVI were prospectively enrolled. PVI was performed with one 28-mm second-generation balloon using a 3-minute freeze technique, and touch-up lesions were created by focal cryothermal applications. ATP testing was performed following PVI with a 20-mm circular mapping catheter placed in each PV. RESULTS Of 217 PVs, 205 (94.5%) were isolated using a cryoballoon, and 12 required additional focal ablation. ATP testing was performed in 46 patients for 173 and 8 PVs, which were isolated by cryoballoons and focal ablation, respectively. No dormant PV conduction was provoked in any PVs, which were isolated by cryoballoons, whereas 4 (50.0%) out of 8 PVs requiring focal ablation had transient ATP-provoked reconnections (0 vs. 50.0%, P < 0.0001) with a median duration of 11.3 (10.7-17.1) seconds. The latent PV conduction site was identical to the residual conduction gap site after cryoballoon ablation in all. All latent conduction was successfully eliminated by 2 (2.0-9.5) additional focal applications. At a mean follow-up of 7.7 ± 1.6 months, 81.5% of the patients were arrhythmia free after a single procedure. CONCLUSIONS No dormant PV conduction was provoked in PVs, which were isolated by 28-mm second-generation cryoballoons, but was provoked in 50% of PVs, which were isolated by focal cryoablation. These findings suggest that creating contiguous lesions is essential for eliminating dormant conduction in cryothermal ablation.
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Affiliation(s)
- Shinsuke Miyazaki
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Hiroshi Taniguchi
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Hiroaki Nakamura
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Hitoshi Hachiya
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Noboru Ichihara
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Makoto Araki
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Akio Kuroi
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Takamitsu Takagi
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Jin Iwasawa
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Kenzo Hirao
- Heart Rhythm Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoshito Iesaka
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
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14
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Reappraisal of the clinical implications of adenosine triphosphate in terms of the prediction of reconnection sites in cases with electrical isolation of the pulmonary veins. J Interv Card Electrophysiol 2015; 44:171-8. [PMID: 26115748 DOI: 10.1007/s10840-015-0019-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 05/25/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Dormant conduction (DC) induced by intravenous adenosine triphosphate (ATP) after pulmonary vein (PV) isolation (PVI) could predict subsequent PV reconnection (RC) sites. This study aimed to investigate the relationship between the DC and RC sites during the long-term follow-up. METHODS Ninety-one consecutive patients (62 males; mean age, 62 ± 11 years) with symptomatic persistent (n = 18) or paroxysmal (n = 73) atrial fibrillation (AF) who underwent PVI were included in this study. After a successful PVI, we administered ATP to reveal the DC sites. In total, DC sites were observed in 46 (51%) patients, and all were left un-ablated after marking or tagging all of them using fluoroscopic images and a three-dimensional (3D) mapping system. After the follow-up period (14.8 ± 3.6 months), AF recurred in 29 (32%) patients, all of whom had a DC in the initial ablation session, and underwent redo sessions. We divided the DC sites into three groups; in group A, the RC sites differed from the DC sites, in group B, the RC sites were identical to the DC sites, and in group C, the RC sites involved both DC and other sites. RESULTS As a result, 20 (69%), 3 (11.5%), and 6 (19.5%) patients belonged to groups A, B, and C, respectively. Statistical analyses comparing the agreement between DC and the RC sites yielded a weak relationship. CONCLUSIONS DC sites implying RC sites had a weak agreement, and other options to predict RC sites will be required to improve the clinical benefit of CA of AF.
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Üçer E, Fredersdorf S, Jungbauer CG, Seegers J, Debl K, Riegger G, Maier LS. Unmasking the dormant pulmonary vein conduction with adenosine administration after pulmonary vein isolation with laser energy. Europace 2015; 17:1376-82. [PMID: 25759410 DOI: 10.1093/europace/euu368] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 12/01/2014] [Indexed: 11/13/2022] Open
Abstract
AIMS The isolation of the pulmonary veins (PVs) is the mainstay of atrial fibrillation (AF) ablation, which with current ablation techniques can be achieved in almost all cases. Reconnection of PVs constitutes the most frequent cause of AF recurrence. Visually guided laser balloon ablation (VGLA) is a novel system with very high rate of persistence of pulmonary vein isolation (PVI) three months after the first procedure shown in preclinical and clinical studies. We aimed to determine the acute efficiency of the laser energy during PVI with the help of adenosine provocation. METHODS AND RESULTS Twenty-six patients (19 male; mean age 64 ± 9 years) with symptomatic paroxysmal AF were included in the study. Pulmonary vein isolation was performed using the VGLA system. After successful PVI, we studied the effects of intravenous adenosine (18 mg) on activation of each PV at least 20 min after PVI. A total of 104 PVs were targeted. The balloon catheter could not be placed in two PVs. Of the remaining 102 PVs 99 (97% of the ablated PVs) could be successfully isolated. Adenosine was administered for each isolated PV in 25 patients. Only six PVs (6.7%) in five patients (20%) showed a PV reconnection during adenosine provocation. CONCLUSION Pulmonary vein isolation with VGLA is a feasible technique for PVI with a very effective acute lesion formation. The clinical significance of this low reconnection rate has to be determined.
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Affiliation(s)
- Ekrem Üçer
- University Hospital Regensburg, Internal Medicine II - Cardiology, Franz Josef Strauss Allee 11-93053, Regenburg, Germany
| | - Sabine Fredersdorf
- University Hospital Regensburg, Internal Medicine II - Cardiology, Franz Josef Strauss Allee 11-93053, Regenburg, Germany
| | - Carsten Gerald Jungbauer
- University Hospital Regensburg, Internal Medicine II - Cardiology, Franz Josef Strauss Allee 11-93053, Regenburg, Germany
| | - Joachim Seegers
- University Hospital Regensburg, Internal Medicine II - Cardiology, Franz Josef Strauss Allee 11-93053, Regenburg, Germany
| | - Kurt Debl
- University Hospital Regensburg, Internal Medicine II - Cardiology, Franz Josef Strauss Allee 11-93053, Regenburg, Germany
| | - Günter Riegger
- University Hospital Regensburg, Internal Medicine II - Cardiology, Franz Josef Strauss Allee 11-93053, Regenburg, Germany
| | - Lars Siegfried Maier
- University Hospital Regensburg, Internal Medicine II - Cardiology, Franz Josef Strauss Allee 11-93053, Regenburg, Germany
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16
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Reichlin T, Lane C, Nagashima K, Nof E, Chopra N, Ng J, Barbhaiya C, Tadros T, John RM, Stevenson WG, Michaud GF. Feasibility, efficacy, and safety of radiofrequency ablation of atrial fibrillation guided by monitoring of the initial impedance decrease as a surrogate of catheter contact. J Cardiovasc Electrophysiol 2015; 26:390-396. [PMID: 25588901 DOI: 10.1111/jce.12621] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 12/26/2014] [Accepted: 12/30/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND The initial impedance decrease during radiofrequency (RF) ablation is an indirect marker of catheter contact and lesion formation. We aimed to assess feasibility, efficacy, and safety of an ablation approach guided by initial impedance decrease. METHODS A total of 25 patients with paroxysmal AF had point-by-point, wide antral pulmonary vein (PV) isolation. RF applications were aborted if a decrease of at least 5 Ω did not occur in the first 10 seconds; otherwise, ablation was continued for at least 20 seconds. Power was 30 Watts and reduced to 15-25 Watts on the posterior wall. RESULTS A total of 28% of RF applications were terminated because of inadequate impedance decrease. The remaining lesions showed a median decrease of 7.6 Ω (IQR 5.0-10.7) at 10 seconds and median duration of RF lesions was 38 seconds. Note that, 100 PVs were isolated with 49 rings. PVI occurred before anatomic completion of the ablation ring of adequate lesions in 39/49 (80%) and concurrent with ring completion in 7/49 (14%). Additional lesions were required in 3/49 (6%) rings. After PVI, additional lesions were required to eliminate dormant conduction in 2/47 (4%) and pace-capture on the ablation line in 24/49 vein pairs (49%). During short-term follow-up, 3 nonfatal esophageal injuries and 2 late pericardial effusions occurred. During a mean follow-up of 431 ± 87 days, 21/25 patients (84%) remained free of recurrent symptomatic atrial arrhythmias. CONCLUSIONS PVI guided by initial impedance decrease is feasible and results in PVI concurrent with or before completion of the ablation ring in 94% of patients. Single procedure efficacy after one year of follow-up was 84%. Near-term complications suggest that deeper lesions are created, indicating that further reduction of RF-power and duration is warranted.
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Affiliation(s)
- Tobias Reichlin
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Division of Cardiology, University Hospital, Basel, Switzerland
| | - Christopher Lane
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Koichi Nagashima
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Eyal Nof
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Nagesh Chopra
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Justin Ng
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Chirag Barbhaiya
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Tomas Tadros
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Roy M John
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - William G Stevenson
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Gregory F Michaud
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
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LIN FRANKS, IP JAMESE, MARKOWITZ STEVENM, LIU CHRISTOPHERF, THOMAS GEORGE, LERMAN BRUCEB, CHEUNG JIMW. Limitations of Dormant Conduction as a Predictor of Atrial Fibrillation Recurrence and Pulmonary Vein Reconnection after Catheter Ablation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 38:598-607. [DOI: 10.1111/pace.12596] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Revised: 01/06/2015] [Accepted: 01/14/2015] [Indexed: 01/10/2023]
Affiliation(s)
- FRANK S. LIN
- Division of Cardiology, Department of Medicine; Weill Cornell Medical College; New York New York
| | - JAMES E. IP
- Division of Cardiology, Department of Medicine; Weill Cornell Medical College; New York New York
| | - STEVEN M. MARKOWITZ
- Division of Cardiology, Department of Medicine; Weill Cornell Medical College; New York New York
| | - CHRISTOPHER F. LIU
- Division of Cardiology, Department of Medicine; Weill Cornell Medical College; New York New York
| | - GEORGE THOMAS
- Division of Cardiology, Department of Medicine; Weill Cornell Medical College; New York New York
| | - BRUCE B. LERMAN
- Division of Cardiology, Department of Medicine; Weill Cornell Medical College; New York New York
| | - JIM W. CHEUNG
- Division of Cardiology, Department of Medicine; Weill Cornell Medical College; New York New York
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18
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Andrade JG, Monir G, Pollak SJ, Khairy P, Dubuc M, Roy D, Talajic M, Deyell M, Rivard L, Thibault B, Guerra PG, Nattel S, Macle L. Pulmonary vein isolation using "contact force" ablation: the effect on dormant conduction and long-term freedom from recurrent atrial fibrillation--a prospective study. Heart Rhythm 2014; 11:1919-24. [PMID: 25068575 DOI: 10.1016/j.hrthm.2014.07.033] [Citation(s) in RCA: 130] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Indexed: 01/08/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI) is associated with PV to left atrium reconduction. Effective lesion creation necessitates adequate contact force between the ablation catheter and myocardium. OBJECTIVE The purpose of this study was to study the utility of contact force-guided ablation on immediate and long-term outcomes. METHODS Seventy-five patients with highly symptomatic paroxysmal AF underwent wide circumferential PVI using an irrigated-tip radiofrequency catheter. In 25 patients, ablation was guided by real-time contact force measurements (CF group; SmartTouch, Biosense Webster). A control group of 50 patients underwent PVI using a standard nonforce sensing catheter (standard group; ThermoCool, Biosense Webster). After PVI, all patients underwent adenosine testing to unmask dormant conduction. Patients were followed up at 3, 6, and 12 months and by transtelephonic monitoring as well. RESULTS Dormant conduction was unmasked and subsequently eliminated in 4 PV pairs (8%; 16% of patients) in the CF group and 35 PV pairs (35%; 52% of patients) in the standard group (P = .0004 per PV pair; P = .0029 per patient). The single-procedure, off-antiarrhythmic drug freedom from recurrent atrial arrhythmias at 1 year was 88% in the CF group vs 66% in the standard group (P = .047). Procedure duration and fluoroscopy time were significantly longer in the CF group (P = .0038 and P = .0001, respectively). CONCLUSION The use of real-time contact force guidance results in a significant reduction in the prevalence of dormant conduction with improved long-term freedom from recurrent arrhythmias. The utility of a contact force-guided approach requires evaluation in a long-term prospective randomized study.
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Affiliation(s)
- Jason G Andrade
- Electrophysiology Service at the Montreal Heart Institute and the Department of Medicine, Université de Montréal, Montreal, Canada; Department of Medicine, University of British Columbia, British Columbia, Canada.
| | - George Monir
- Florida Hospital Cardiovascular Institute, Orlando, Florida
| | - Scott J Pollak
- Florida Hospital Cardiovascular Institute, Orlando, Florida
| | - Paul Khairy
- Electrophysiology Service at the Montreal Heart Institute and the Department of Medicine, Université de Montréal, Montreal, Canada
| | - Marc Dubuc
- Electrophysiology Service at the Montreal Heart Institute and the Department of Medicine, Université de Montréal, Montreal, Canada
| | - Denis Roy
- Electrophysiology Service at the Montreal Heart Institute and the Department of Medicine, Université de Montréal, Montreal, Canada
| | - Mario Talajic
- Electrophysiology Service at the Montreal Heart Institute and the Department of Medicine, Université de Montréal, Montreal, Canada
| | - Marc Deyell
- Department of Medicine, University of British Columbia, British Columbia, Canada
| | - Léna Rivard
- Electrophysiology Service at the Montreal Heart Institute and the Department of Medicine, Université de Montréal, Montreal, Canada
| | - Bernard Thibault
- Electrophysiology Service at the Montreal Heart Institute and the Department of Medicine, Université de Montréal, Montreal, Canada
| | - Peter G Guerra
- Electrophysiology Service at the Montreal Heart Institute and the Department of Medicine, Université de Montréal, Montreal, Canada
| | - Stanley Nattel
- Electrophysiology Service at the Montreal Heart Institute and the Department of Medicine, Université de Montréal, Montreal, Canada
| | - Laurent Macle
- Electrophysiology Service at the Montreal Heart Institute and the Department of Medicine, Université de Montréal, Montreal, Canada
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Darrat Y, Morales G, Di BL, Natale A, Elayi CS. How To Achieve Durable Pulmonary Vein Antral Isolation? J Atr Fibrillation 2014; 6:1039. [PMID: 27957061 DOI: 10.4022/jafib.1039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 04/14/2014] [Accepted: 04/15/2014] [Indexed: 11/10/2022]
Abstract
The inability to achieve durable pulmonary vein isolation(PVI) remains a major limitation to a catheter ablation for thew treatment of atrial fibrillation(AF), potentially resulting in AF recurrence.In this review,we discuss the research performed investigating methods to improve lesion permanence for the goal of durable PVI.Investigations evaluted procedural techniques,various catheres utilized, adjunctive pharamacologic therapy and novel energy sources designed to improve ablation lesion permanence are discussed.
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Affiliation(s)
- Y Darrat
- University of Kentucky, Gill Heart Institute and VAMC, Cardiology, Lexington, KY
| | - G Morales
- University of Kentucky, Gill Heart Institute and VAMC, Cardiology, Lexington, KY
| | - Biase L Di
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX
| | - A Natale
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX
| | - C S Elayi
- University of Kentucky, Gill Heart Institute and VAMC, Cardiology, Lexington, KY
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20
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Anter E, Contreras-Valdes FM, Shvilkin A, Tschabrunn CM, Josephson ME. Acute pulmonary vein reconnection is a predictor of atrial fibrillation recurrence following pulmonary vein isolation. J Interv Card Electrophysiol 2014; 39:225-32. [PMID: 24532109 DOI: 10.1007/s10840-013-9864-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 11/20/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE Arrhythmia recurrence following pulmonary vein isolation (PVI) occurs predominantly due to the reconnection of previously isolated pulmonary veins (PVs). The prognostic implications of detection and treatment of acute PV reconnection are not well understood. We aim to examine the prognostic significance of acute PV reconnection on arrhythmia recurrence at 1 year following PVI. METHODS This prospective study included 44 patients (22 men, 60 ± 7 years) who underwent index PVI procedure for treatment of atrial fibrillation (AF). Acute PV reconnection and/or dormant PV conduction were assessed sequentially in response to a 30-min waiting period, intravenous isoproterenol infusion and/or adenosine. All cases of acute PV reconnection and/or dormant conduction were successfully targeted with additional ablation. RESULTS Freedom from AF at 1 year was 75 % (83.3 % in paroxysmal and 65 % in persistent AF, p = ns). Acute PV reconnection and/or dormant conduction were evident in 16 of 44 patients (36.3 %). AF recurrence was documented in eight of 16 patients with, but only in three of 28 patients without acute reconnection (p = 0.009). Three patients underwent a redo procedure, all from the group of patients with acute PV reconnection. In a multivariate model, acute PV reconnection was a strong independent predictor of arrhythmia recurrence (hazards ratio [HR], 6.36; 95 % confidence interval [CI], 1.12-31.6). CONCLUSION Identification of acute PV reconnection, even when successfully targeted, is a strong predictor of arrhythmia recurrence following PVI.
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Affiliation(s)
- Elad Anter
- Harvard-Thorndike Electrophysiology Institute, Division of Cardiovascular Disease, Beth Israel Deaconess Medical Center, Harvard Medical School, 85 Pilgrim Road, Baker 4, Boston, MA, 02215, USA,
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21
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Andrade JG, Macle L. Improving ablation strategies for the treatment of atrial fibrillation. Expert Rev Med Devices 2013; 11:77-88. [PMID: 24308741 DOI: 10.1586/17434440.2014.864232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice. The contemporary management of AF is centered on symptomatic improvement, as well as reduction in the AF associated morbidity and mortality. For many highly symptomatic patients catheter ablation offers an efficacious means to maintaining sinus rhythm when antiarrhythmic drugs have been ineffective, are contraindicated or cannot be tolerated. Over the past 15 years, catheter ablation has moved from an 'experimental therapy' to the standard of care for the maintenance of sinus rhythm. Unfortunately, while the results of ablation are unequivocally superior to medical therapy, recognized limitations of the contemporary AF ablation procedures have spurred several developments designed to improve the efficacy of the index ablation procedure, while limiting adverse events. The purpose of this review is to discuss the procedural refinements, and technological innovations proposed to outcomes of patients undergoing a percutaneous catheter ablation procedure for AF.
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Affiliation(s)
- Jason G Andrade
- Department of Medicine, Electrophysiology Service at the Montreal Heart Institute, Université de Montréal, Montreal, Canada
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Kaitani K, Kurotobi T, Kobori A, Okajima K, Yao T, Nakazawa Y, Nakagawa Y. Late re-conduction sites in the second session after pulmonary vein isolation using adenosine provocation for atrial fibrillation. Europace 2013; 16:521-7. [DOI: 10.1093/europace/eut258] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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23
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Andrade JG, Pollak SJ, Monir G, Khairy P, Dubuc M, Roy D, Talajic M, Deyell M, Rivard L, Thibault B, Guerra PG, Nattel S, Macle L. Pulmonary vein isolation using a pace-capture-guided versus an adenosine-guided approach: effect on dormant conduction and long-term freedom from recurrent atrial fibrillation--a prospective study. Circ Arrhythm Electrophysiol 2013; 6:1103-8. [PMID: 24097372 DOI: 10.1161/circep.113.000454] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Atrial fibrillation recurrence after pulmonary vein (PV) isolation is associated with PV to left atrium reconduction. We prospectively studied the use of 2 procedural techniques designed to facilitate identification of residual gaps within the index ablation line. METHODS AND RESULTS After wide circumferential PV isolation, 40 patients received additional ablation targeted at locations of left atrial capture during high-output pacing (pace-capture group), while 40 patients underwent adenosine testing with targeted ablation at sites of dormant conduction (adenosine group). Patients were followed up at 3, 6, and 12 months. After PV isolation, high-output pace-capture was documented in 39 PVs (25%; 50% of patients) in the pace-capture group. Dormant conduction was unmasked in 34 PVs (22%; 53% of patients) in the adenosine group. A subset of 25 patients in the pace-capture group underwent adenosine testing without targeted ablation of dormant conduction. In these patients, only 10 out of 86 PVs (11.6%; 24% of patients) demonstrated dormant conduction after the elimination of local pace-capture. At a follow-up of 329±124 days, the single procedure off antiarrhythmic drug freedom from recurrent atrial fibrillation was 67.5% in the adenosine group and 65.0% in the pace-capture group (P=0.814). Procedure duration and fluoroscopy time were significantly longer in the pace-capture group (P=0.002 and P<0.001), whereas radiofrequency ablation time was comparable (P=0.192). CONCLUSIONS The use of high-output pacing post-PV isolation results in a significant reduction in the incidence of dormant conduction with a comparable long-term freedom from recurrent atrial fibrillation (versus adenosine-guided ablation). The use of these approaches requires evaluation in a long-term prospective randomized study. [corrected].
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Affiliation(s)
- Jason G Andrade
- Electrophysiology Service at the Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Québec, Canada
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Brunelli M, Raffa S, Große A, Hanazawa K, Sammut M, Roos M, Frommhold M, Wauters K, Geller JC. Residual conduction after pulmonary vein isolation with a circular multielectrode radiofrequency ablation catheter: The role of adenosine and orciprenalin during a prolonged observation time. Int J Cardiol 2013; 168:4122-31. [DOI: 10.1016/j.ijcard.2013.07.071] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Revised: 04/07/2013] [Accepted: 07/07/2013] [Indexed: 11/26/2022]
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Yamaguchi T, Tsuchiya T, Nagamoto Y, Miyamoto K, Murotani K, Okishige K, Takahashi N. Long-term results of pulmonary vein antrum isolation in patients with atrial fibrillation: an analysis in regards to substrates and pulmonary vein reconnections. Europace 2013; 16:511-20. [PMID: 24078342 DOI: 10.1093/europace/eut265] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS To examine the impact of left atrial (LA) low-voltage zones (LVZs) on atrial fibrillation (AF) recurrence after pulmonary vein antrum isolation (PVAI) without LA substrate modification. METHODS AND RESULTS Seventy-six patients with AF (paroxysmal/persistent 65/11) were prospectively enroled. Left atrial voltage maps were constructed during sinus rhythm using NavX to identify LVZs (<0.5 mV), and PVAI without any LA substrate modification was performed using an open-irrigation catheter. After PVAI, 20 mg of adenosine triphosphate (ATP) was injected. Adenosine triphosphate-induced PV reconnections were eliminated by touch-up ablation when unmasked. Voltage maps revealed LVZs in 24 patients (32%) and no LVZs in 52 (68%). During 24 ± 7 months of follow-up, 15 patients (63%) with LVZs and 10 (19%) without had AF recurrences off antiarrhythmic drugs (log-rank P < 0.001). A multivariate logistic regression analysis revealed that LVZ areas [odds ratio (OR): 1.12 per 1 cm(2), 95% confidence interval (CI): 1.04-1.23, P = 0.001] and ATP-induced reconnection (OR: 2.08, 95% CI: 1.01-4.91, P = 0.046) were significant predictors of recurrence. In those with LVZs, the LVZ area was strongly correlated with the LA body volume (r = 0.81, P < 0.001) and a unique predictor of recurrence (OR: 1.17 per 1 cm(2), 95% CI: 1.01-1.55, P = 0.031), while in those without an LVZ, ATP-induced PV reconnection was a unique predictor (OR: 3.24, 95% CI: 1.15-15.39, P = 0.025). CONCLUSION The LVZ area was an independent predictor of recurrence after PVAI without any LA substrate modification. Adenosine triphosphate-induced PV reconnection was also an independent predictor, especially in those without LVZs.
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ELAYI CLAUDES, DI BIASE LUIGI, BAI RONG, BURKHARDT JDAVID, MOHANTY PRASANT, SANTANGELI PASQUALE, SANCHEZ JAVIER, HONGO RICHARD, GALLINGHOUSE GJOSEPH, HORTON RODNEY, BAILEY SHANE, BEHEIRY SALWA, NATALE ANDREA. Administration of Isoproterenol and Adenosine to Guide Supplemental Ablation After Pulmonary Vein Antrum Isolation. J Cardiovasc Electrophysiol 2013; 24:1199-206. [DOI: 10.1111/jce.12252] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Revised: 06/09/2013] [Accepted: 06/11/2013] [Indexed: 11/28/2022]
Affiliation(s)
- CLAUDE S. ELAYI
- Department of Cardiovascular Medicine, University of Kentucky; Lexington Kentucky USA
| | - LUIGI DI BIASE
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center; Austin Texas USA
- Department of Cardiology; University of Foggia; Foggia Italy
- Department of Biomedical Engineering, University of Texas; Austin Texas USA
| | - RONG BAI
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center; Austin Texas USA
| | - J. DAVID BURKHARDT
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center; Austin Texas USA
| | - PRASANT MOHANTY
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center; Austin Texas USA
| | - PASQUALE SANTANGELI
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center; Austin Texas USA
| | - JAVIER SANCHEZ
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center; Austin Texas USA
| | - RICHARD HONGO
- California Pacific Medical Center; California San Francisco USA
| | | | - RODNEY HORTON
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center; Austin Texas USA
| | - SHANE BAILEY
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center; Austin Texas USA
| | - SALWA BEHEIRY
- California Pacific Medical Center; California San Francisco USA
| | - ANDREA NATALE
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center; Austin Texas USA
- Department of Biomedical Engineering, University of Texas; Austin Texas USA
- California Pacific Medical Center; California San Francisco USA
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Roten L, Derval N, Pascale P, Scherr D, Komatsu Y, Shah A, Ramoul K, Denis A, Sacher F, Hocini M, Haïssaguerre M, Jaïs P. Current hot potatoes in atrial fibrillation ablation. Curr Cardiol Rev 2013; 8:327-46. [PMID: 22920482 PMCID: PMC3492816 DOI: 10.2174/157340312803760802] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Revised: 05/11/2012] [Accepted: 05/11/2012] [Indexed: 12/30/2022] Open
Abstract
Atrial fibrillation (AF) ablation has evolved to the treatment of choice for patients with drug-resistant and symptomatic AF. Pulmonary vein isolation at the ostial or antral level usually is sufficient for treatment of true paroxysmal AF. For persistent AF ablation, drivers and perpetuators outside of the pulmonary veins are responsible for AF maintenance and have to be targeted to achieve satisfying arrhythmia-free success rate. Both complex fractionated atrial electrogram (CFAE) ablation and linear ablation are added to pulmonary vein isolation for persistent AF ablation. Nevertheless, ablation failure and necessity of repeat ablations are still frequent, especially after persistent AF ablation. Pulmonary vein reconduction is the main reason for arrhythmia recurrence after paroxysmal and to a lesser extent after persistent AF ablation. Failure of persistent AF ablation mostly is a consequence of inadequate trigger ablation, substrate modification or incompletely ablated or reconducting linear lesions. In this review we will discuss these points responsible for AF recurrence after ablation and review current possibilities on how to overcome these limitations.
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Affiliation(s)
- Laurent Roten
- Hôpital Cardiologique du Haut-Lévêque and the Université Victor Segalen Bordeaux II, Bordeaux, France.
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Manlucu J, Brancato S, Lane C, Kazemian P, Michaud GF. Contemporary approaches to persistent atrial fibrillation. Expert Rev Cardiovasc Ther 2013; 10:1421-35. [PMID: 23244363 DOI: 10.1586/erc.12.136] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Atrial fibrillation (AF) is currently the most commonly treated cardiac arrhythmia. It is generally a progressive disease, often more difficult to control as electromechanical remodeling alters the underlying substrate. Patients typically evolve from infrequent, self-terminating episodes, to more frequent and sustained events. In addition, atrial remodeling may make sinus rhythm more challenging to achieve. Although an ablation strategy limited to pulmonary vein isolation may be curative in those with paroxysmal AF, a more extensive approach is often required in those with persistent AF. This article discusses the current approaches and most recent advances in the ablation of persistent and long-standing persistent AF.
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Chan KH, Sy RW. Toward permanent pulmonary vein isolation: The use of adenosine to unmask dormant conduction. Heart Rhythm 2013; 10:636-7. [DOI: 10.1016/j.hrthm.2013.01.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Indexed: 10/27/2022]
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MCLELLAN ALEXJ, KUMAR SAURABH, SMITH CATHERINE, MORTON JOSEPHB, KALMAN JONATHANM, KISTLER PETERM. The Role of Adenosine Following Pulmonary Vein Isolation in Patients Undergoing Catheter Ablation for Atrial Fibrillation: A Systematic Review. J Cardiovasc Electrophysiol 2013; 24:742-51. [DOI: 10.1111/jce.12121] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2012] [Revised: 01/16/2013] [Accepted: 02/12/2013] [Indexed: 11/27/2022]
Affiliation(s)
- ALEX J.A. MCLELLAN
- Alfred Heart Centre; Alfred Hospital; Melbourne Victoria Australia
- Department of Cardiology; Royal Melbourne Hospital; Parkville Victoria Australia
- Baker IDI Heart and Diabetes Institute; Melbourne Victoria Australia
| | - SAURABH KUMAR
- Alfred Heart Centre; Alfred Hospital; Melbourne Victoria Australia
- Department of Cardiology; Royal Melbourne Hospital; Parkville Victoria Australia
| | - CATHERINE SMITH
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - JOSEPH B. MORTON
- Department of Cardiology; Royal Melbourne Hospital; Parkville Victoria Australia
- Melbourne Private Hospital; Parkville Victoria Australia
| | - JONATHAN M. KALMAN
- Department of Cardiology; Royal Melbourne Hospital; Parkville Victoria Australia
- Melbourne Private Hospital; Parkville Victoria Australia
| | - PETER M. KISTLER
- Alfred Heart Centre; Alfred Hospital; Melbourne Victoria Australia
- Melbourne Private Hospital; Parkville Victoria Australia
- Baker IDI Heart and Diabetes Institute; Melbourne Victoria Australia
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De Greef Y, Tavernier R, Schwagten B, De Keulenaer G, Stockman D, Duytschaever M. Impact of Radiofrequency Characteristics on Acute Pulmonary Vein Reconnection and Clinical Outcome After PVAC Ablation. J Cardiovasc Electrophysiol 2012; 24:290-6. [PMID: 23110335 DOI: 10.1111/jce.12021] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Yves De Greef
- Department of Cardiology, Antwerp Cardiovascular Institute Middelheim, Antwerpen, Belgium.
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REICHLIN TOBIAS, MICHAUD GREGORYF. Our Approach to Maximizing the Durability of Pulmonary Vein Isolation During a Paroxysmal Atrial Fibrillation Ablation Procedure. J Cardiovasc Electrophysiol 2012; 23:1272-6. [DOI: 10.1111/j.1540-8167.2012.02414.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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De Potter TJR, Eisenberger M, McCann C, Peytchev P, Geelen P. Adenosine plus dipyridamole: a novel strategy to enhance adenosine-induced conduction recovery after pulmonary vein isolation. Europace 2012; 14:1567-71. [PMID: 22622141 DOI: 10.1093/europace/eus159] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Intravenous administration of adenosine after a pulmonary vein (PV) isolation procedure can unmask residual, so-called 'dormant', conduction that would otherwise remain unnoticed. Elimination of these dormant potentials is challenging because of the transient effect of adenosine, often requiring repeated injections. We tested the hypothesis that dipyridamole, a drug which inhibits adenosine deamination, can provoke longer-lasting unmasking of dormant conduction. METHODS AND RESULTS In 191 patients with drug refractory paroxysmal atrial fibrillation, a bolus of 12-24 mg of adenosine was administered after all 764 PVs were isolated. In the case of transient dormant conduction, a short infusion of dipyridamole 50 mg was given and a bolus of adenosine was repeated. In all cases, re-isolation was attempted guided by the activation pattern in the PV on a circular mapping catheter. Duration of adenosine-induced dormant conduction before and after dipyridamole was recorded as the time between administration of adenosine and cessation of dormant conduction either spontaneously or by catheter ablation. Transient dormant conduction was re-established by a single bolus of adenosine in 24 of 191 patients (12.6%). Mean duration of adenosine-induced dormant conduction before dipyridamole was 13.1 ± 6.4 s, whereas it was significantly longer at 218.9 ± 165.6 s after dipyridamole (P < 0.0001). Eighteen of the 24 PVs were re-isolated by catheter ablation before spontaneous cessation of dormant conduction, and in 6 cases dormant conduction disappeared spontaneously before PV re-isolation was achieved. CONCLUSION Dipyridamole significantly prolongs the effect of adenosine to unmask dormant conduction after PV isolation and may thus facilitate its elimination by catheter ablation.
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Affiliation(s)
- Tom J R De Potter
- Arrhythmia Unit, Cardiovascular Centre, OLV Hospital, Moorselbaan 164, B9300 Aalst, Belgium.
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The anatomical basis of pulmonary vein reconnection after ablation for atrial fibrillation: wounds that never felt a scar? J Am Coll Cardiol 2012; 59:939-41. [PMID: 22381430 DOI: 10.1016/j.jacc.2011.11.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Revised: 11/21/2011] [Accepted: 11/29/2011] [Indexed: 01/20/2023]
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Macle L, Khairy P, Verma A, Weerasooriya R, Willems S, Arentz T, Novak P, Veenhuyzen G, Scavée C, Skanes A, Puererfellner H, Jaïs P, Khaykin Y, Rivard L, Guerra PG, Dubuc M, Thibault B, Talajic M, Roy D, Nattel S. Adenosine Following Pulmonary Vein Isolation to Target Dormant Conduction Elimination (ADVICE): Methods and Rationale. Can J Cardiol 2012; 28:184-90. [DOI: 10.1016/j.cjca.2011.10.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Revised: 09/21/2011] [Accepted: 10/06/2011] [Indexed: 10/14/2022] Open
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Miyazaki S, Kuwahara T, Kobori A, Takahashi Y, Takei A, Sato A, Isobe M, Takahashi A. Impact of adenosine-provoked acute dormant pulmonary vein conduction on recurrence of atrial fibrillation. J Cardiovasc Electrophysiol 2011; 23:256-60. [PMID: 22034876 DOI: 10.1111/j.1540-8167.2011.02195.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Adenosine can be associated with acute recovery of conduction to the pulmonary veins (PVs) immediately after isolation. The objective of this study was to evaluate whether the response to adenosine predicts atrial fibrillation (AF) recurrence after a single ablation procedure in patients with paroxysmal AF. METHODS AND RESULTS A total of 109 consecutive patients (61 ± 10 years; 91 males) with drug-refractory paroxysmal AF who underwent AF ablation were analyzed. After PV antrum isolation (PVAI), dormant PV conduction was evaluated by an administration of adenosine in all patients. No acute reconnections were provoked by the adenosine in 70 (64.2%) patients (Group-1), but they were provoked in at least one side of the ipsilateral PVs in 39 (35.8%) patients (Group-2). All adenosine-provoked dormant conductions were successfully eliminated by additional ablation applications. By 12 months after the initial procedure, 72 (66.1%) patients were free of AF recurrences without any antiarrhythmic drugs. A Cox regression multivariate analysis of the variables including the adenosine-provoked reconductions, age, gender, duration of AF, presence of hypertension or structural heart disease, left atrial size, left ventricular ejection fraction, and body mass index demonstrated that adenosine-provoked reconductions were an independent predictor of AF recurrence after a single ablation procedure (hazard ratio: 1.387; 95% confidence interval: 1.018-1.889, P = 0.038). At the repeat session for recurrent AF, conduction recovery was observed similarly in both groups (P = 0.27). CONCLUSION Even after the elimination of any adenosine-provoked dormant PV conduction, the appearance of acute adenosine-provoked reconduction after the PVAI was an independent predictor of AF recurrence after a single AF ablation procedure.
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Affiliation(s)
- Shinsuke Miyazaki
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yonegahamadori, Yokosuka-shi, Kanagawa-ken, Japan.
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