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Ahmed JJ, Walborn DL, Anghel TM, Chohan MR. Acute STEMI Due to Severe Triple-Vessel Spasm After IV Adenosine Injection During Cryo-Balloon Isolation. JACC Case Rep 2022; 4:617-620. [PMID: 35615221 PMCID: PMC9125512 DOI: 10.1016/j.jaccas.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 02/22/2022] [Accepted: 03/07/2022] [Indexed: 11/21/2022]
Abstract
Adenosine IV is commonly used after pulmonary vein isolation to check for dormant electrical conduction. Herein, we present the case of a 60-year-old patient who exhibited marked hypotension, conduction abnormalities, and ST-segment elevation after routine adenosine injection. Coronary angiography revealed diffuse coronary spasm that was successfully treated with intracoronary nitroglycerin. (Level of Difficulty: Intermediate.)
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Kobayashi S, Fukaya H, Oikawa J, Saito D, Sato T, Matsuura G, Arakawa Y, Shirakawa Y, Nishinarita R, Horiguchi A, Ishizue N, Kishihara J, Niwano S, Ako J. Optimal interlesion distance in ablation index-guided pulmonary vein isolation for atrial fibrillation. J Interv Card Electrophysiol 2020; 62:123-131. [PMID: 32975734 DOI: 10.1007/s10840-020-00881-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 09/16/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE Ablation index (AI) is a useful tool of the CARTO® system to make effective lesions during pulmonary vein isolation (PVI) for atrial fibrillation (AF). However, the optimal distance between neighboring ablation points (interlesion distance (ILD)) is still unclear. Here, we evaluated the optimal ILDs in the AI-guided PVI. METHODS Forty-nine AF patients who underwent AI-guided PVI in our institute from July 2018 to March 2019 were retrospectively enrolled in this study. Target AI was set at 500 and 400 for anterior and posterior walls, respectively, and we compared the ILDs with and without electrical gaps after a first encircling PVI. RESULTS In both PV, the ILDs with electrical gaps were longer than those without electrical gaps. The best cutoff values of ILD to detect the electrical gaps using the ROC curve were 5.4 mm for the RPV anterior wall (AUC, 0.67; sensitivity, 0.42; specificity, 0.84, P < 0.01) and 4.4 mm for the RPV posterior wall (AUC, 0.68; sensitivity, 0.91; specificity, 0.39, P < 0.01). Similarly, the best cutoff values of ILD were 5.5 mm for the LPV anterior wall (AUC, 0.74; sensitivity, 0.65; specificity, 0.82, P < 0.01) and 5.1 mm for the LPV posterior wall (AUC, 0.67; sensitivity, 0.79; specificity, 0.53, P =0.03). CONCLUSION The optimal interlesion distances for PVI were different in each PV segment. To achieve the first-pass isolation, less than 5.4/4.4 mm for the RPV anterior/posterior and 5.5/5.1 mm for the LPV anterior/posterior walls of interlesion distances were the best cutoff values in the patients with AF.
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Affiliation(s)
- Shuhei Kobayashi
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, 252-0374, Japan
| | - Hidehira Fukaya
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, 252-0374, Japan.
| | - Jun Oikawa
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, 252-0374, Japan
| | - Daiki Saito
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, 252-0374, Japan
| | - Tetsuro Sato
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, 252-0374, Japan
| | - Gen Matsuura
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, 252-0374, Japan
| | - Yuki Arakawa
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, 252-0374, Japan
| | - Yuki Shirakawa
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, 252-0374, Japan
| | - Ryo Nishinarita
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, 252-0374, Japan
| | - Ai Horiguchi
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, 252-0374, Japan
| | - Naruya Ishizue
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, 252-0374, Japan
| | - Jun Kishihara
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, 252-0374, Japan
| | - Shinichi Niwano
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, 252-0374, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, 252-0374, Japan
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Jiang R, Chen M, Yang B, Liu Q, Zhang Z, Zhang F, Ju W, Li M, Sheng X, Sun Y, Zhang P, Yu L, Chen S, Zhu J, Cheng H, Fu G, Tung R, Jiang C. Intraprocedural endpoints to predict durable pulmonary vein isolation: a randomized trial of four post-ablation techniques. Europace 2020; 22:567-575. [PMID: 32249915 DOI: 10.1093/europace/euz301] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 10/26/2019] [Indexed: 11/15/2022] Open
Abstract
AIMS The optimal procedural endpoint to achieve permanent pulmonary vein isolation (PVI) during ablation of atrial fibrillation (AF) remains unknown. We aimed to compare the impact of prolonged waiting periods and adenosine triphosphate (ATP) testing after PVI on long-term freedom from AF. METHODS AND RESULTS In total, 538 patients (median age 61 years, 62% male) undergoing first-time radiofrequency ablation for paroxysmal AF were randomized into four groups: Group 1 [PVI (no testing), n = 121], Group 2 (PVI + 30min waiting phase, n = 151), Group 3 (PVI+ATP, n = 131), and Group 4 (PVI + 30min+ATP, n = 135). The primary endpoint was freedom from AF. Repeat mapping to assess for late pulmonary vein (PV) reconnection was performed in patients who remained AF-free for >3 years (n = 46) and in those who had repeat ablation for AF recurrence (n = 82). During initial procedure, acute PV reconnection was observed in 33%, 26%, and 42% of patients in Groups 2, 3, and 4, respectively. At 36 months, no significant differences in freedom from AF recurrence were observed among all four groups (55%, 61%, 50%, and 62% for Groups 1, 2, 3, and 4, respectively; P = 0.258). Late PV reconnection was commonly observed, with a similar incidence between patients with and without AF recurrence (74% vs. 83%; P = 0.224). CONCLUSION Although PVI remains the cornerstone for AF ablation, intraprocedural techniques to assess for PV reconnection did not improve long-term success. Patients without AF recurrence after 3 years exhibited similarly high rates of PV reconnection as those that underwent repeat ablation for AF recurrence. The therapeutic mechanisms of AF ablation may not be solely predicated upon durable PVI.
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Affiliation(s)
- Ruhong Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Minglong Chen
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Bing Yang
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
- Division of Cardiology, Department of Cardiology, Shanghai East Hospital, Tongji University, Shanghai 200120, China
| | - Qiang Liu
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Zuwen Zhang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Fengxiang Zhang
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Weizhu Ju
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Mingfang Li
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Xia Sheng
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Yaxun Sun
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Pei Zhang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Lu Yu
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Shiquan Chen
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Jun Zhu
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Hui Cheng
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Guosheng Fu
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Roderick Tung
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
- Center for Arrhythmia Care, Heart and Vascular Center, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, IL 60637, USA
| | - Chenyang Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
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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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Yu HT, Jeong DS, Pak HN, Park HS, Kim JY, Kim J, Lee JM, Kim KH, Yoon NS, Roh SY, Oh YS, Cho YJ, Shim J. 2018 Korean Guidelines for Catheter Ablation of Atrial Fibrillation: Part II. INTERNATIONAL JOURNAL OF ARRHYTHMIA 2018. [DOI: 10.18501/arrhythmia.2018.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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No association between dormant conduction sites and pulmonary vein reconnection sites in late atrial fibrillation recurrence after catheter ablation. J Cardiol 2018; 72:488-493. [PMID: 30318077 DOI: 10.1016/j.jjcc.2018.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 04/20/2018] [Accepted: 05/07/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Despite use of provocation testing to unmask dormant left atrium (LA)-PV conduction after index pulmonary vein isolation (PVI) for atrial fibrillation (AF), AF recurrence still occurs, with PV reconnection as the main cause. In an effort to answer the question whether freedom from AF recurrence can be achieved by ablation that targets sites of dormant conduction, we compared sites of dormant conduction against sites of PV reconnection identified at the time of repeat ablation for AF recurrence. MATERIALS AND METHODS The study group comprised 46 patients (30 men/16 women, aged 58.7±10.3 years) with AF (paroxysmal: n=37, persistent: n=9) who underwent repeat ablation for AF recurrence 12.3 (7.4-29.7) months after the index ablation procedure. Ipsilateral PVs were divided into 8 segments each (736 total segments), and the relation between dormant conduction sites and PV reconnection sites was determined per segment. RESULTS Dormant LA-PV conduction was unmasked and ablated in 22 (47.8%) of the 46 patients at sites within 43 (5.8%) of the 736 PV segments. Late PV reconnection was found within 122 (17%) of the 736 PV segments at the time of re-ablation for AF recurrence. Only 22 (18%) of these 122 PV segments corresponded to dormant conduction sites identified during the index procedure. CONCLUSION Although additional ablation to eliminate dormant PV conduction unmasked during the index ablation procedure is performed, the majority of PVs that show reconduction at the time of treatment for clinical AF recurrence are PVs that have not shown dormant conduction.
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Watanabe R, Okumura Y, Nagashima K, Iso K, Takahashi K, Arai M, Wakamatsu Y, Kurokawa S, Ohkubo K, Nakai T, Yoda S, Watanabe I, Hirayama A, Sonoda K, Tosaka T. Influence of balloon temperature and time to pulmonary vein isolation on acute pulmonary vein reconnection and clinical outcomes after cryoballoon ablation of atrial fibrillation. J Arrhythm 2018; 34:511-519. [PMID: 30327696 PMCID: PMC6174370 DOI: 10.1002/joa3.12108] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 06/30/2018] [Accepted: 07/20/2018] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Limited data exist on indicators of durable pulmonary vein isolation (PVI) undergoing cryoballoon ablation (CBA) for atrial fibrillation (AF). We investigated whether balloon temperature and time to PVI can be used to predict early PV reconduction (EPVR), including residual PV conduction and adenosine triphosphate-induced dormant conduction and the relation between touch-up ablation of EPVR sites and mid-term recurrence of AF. METHODS We obtained procedural and outcome data from the records of 130 consecutive patients who underwent CBA and followed up for 13.4 months. RESULTS EPVR was identified in 86 (17%) PVs of 61 (47%) patients. Balloon temperatures during 30 seconds (-27 ± 5.7°C vs -31 ± 5.5°C), 60 seconds (-36 ± 5.6°C vs -41 ± 5.4°C), and at the nadir point (-41 ± 7.4°C vs -49 ± 7.0°C) were significantly higher, and the time to PVI was longer (90 ± 50 seconds vs 52 ± 29 seconds) in PVs with EPVR than in those without (P < 0.0001 for all). Among PVs without EPVR, the time to PVI was longer and balloon temperature was lower for the left superior pulmonary vein/ right inferior pulmonary vein (LSPV/RIPV) than for the right superior pulmonary vein/left inferior pulmonary vein (RSPV/LIPV) (time: 60 ± 25/73 ± 37 seconds vs 41 ± 31/45 ± 20 seconds, P < 0.0001) (temp: -39.2 ± 11.3/-39.4 ± 8.3°C vs -33.8 ± 10.6/-33.6 ± 6.8°C, P = 0.0023). AF recurrence rates were equivalent between patients with and without EPVR (13% [8/69] vs 15% [9/61], P = 0.845). CONCLUSIONS Cryoballoon temperature and time to PVI appear to be useful in predicting durable PVI, that is, prevention of EPVR, but the balloon temperature and time required for PVI differ between PVs. Although EPVR does not predict AF recurrence, high success rates can be expected when touch-up ablation of EPVR sites is performed.
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Affiliation(s)
- Ryuta Watanabe
- Division of CardiologyDepartment of MedicineNihon University School of MedicineTokyoJapan
| | - Yasuo Okumura
- Division of CardiologyDepartment of MedicineNihon University School of MedicineTokyoJapan
| | - Koichi Nagashima
- Division of CardiologyDepartment of MedicineNihon University School of MedicineTokyoJapan
| | - Kazuki Iso
- Division of CardiologyDepartment of MedicineNihon University School of MedicineTokyoJapan
| | - Keiko Takahashi
- Division of CardiologyDepartment of MedicineNihon University School of MedicineTokyoJapan
| | - Masaru Arai
- Division of CardiologyDepartment of MedicineNihon University School of MedicineTokyoJapan
| | - Yuji Wakamatsu
- Division of CardiologyDepartment of MedicineNihon University School of MedicineTokyoJapan
| | - Sayaka Kurokawa
- Division of CardiologyDepartment of MedicineNihon University School of MedicineTokyoJapan
| | - Kimie Ohkubo
- Division of CardiologyDepartment of MedicineNihon University School of MedicineTokyoJapan
| | - Toshiko Nakai
- Division of CardiologyDepartment of MedicineNihon University School of MedicineTokyoJapan
| | - Shunichi Yoda
- Division of CardiologyDepartment of MedicineNihon University School of MedicineTokyoJapan
| | - Ichiro Watanabe
- Division of CardiologyDepartment of MedicineNihon University School of MedicineTokyoJapan
| | - Atsushi Hirayama
- Division of CardiologyDepartment of MedicineNihon University School of MedicineTokyoJapan
| | - Kazumasa Sonoda
- Division of CardiologyDepartment of MedicineTokyo Rinkai HospitalTokyoJapan
| | - Toshimasa Tosaka
- Division of CardiologyDepartment of MedicineTokyo Rinkai HospitalTokyoJapan
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Efficacy of adjunctive measures used to assist pulmonary vein isolation for atrial fibrillation: a systematic review. Curr Opin Cardiol 2018; 32:58-68. [PMID: 27755138 DOI: 10.1097/hco.0000000000000347] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE OF REVIEW Pulmonary vein reconnection leading to recurrence of atrial arrhythmias after pulmonary vein isolation (PVI) for atrial fibrillation remains a significant challenge. A number of adjunctive measures during PVI have been used to attempt to reduce pulmonary vein reconnection and recurrence of atrial arrhythmias. We performed a systematic review of the literature and meta-analysis of studies evaluating the efficacy of adjunctive measures used during PVI in reducing recurrent atrial arrhythmias. RECENT FINDINGS Our literature search found four interventions that met the prespecified definition of adjunctive measure: adenosine testing post-PVI, contact force-guided PVI, pacing inexcitability of the ablation line during PVI and additional ablation based on the computed tomography thickness of the pulmonary vein-left atrial appendage ridge. Sixteen studies enrolling 3507 patients met all inclusion and exclusion criteria. PVI performed with adjunctive measures was shown to reduce the 1-year recurrence rate of atrial arrhythmias. The point estimate for the combined relative risk of atrial arrhythmia recurrence was 0.56 [95% confidence interval (CI): 0.43-0.73; P value <0.001] in the PVI with adjunctive measures group. SUMMARY PVI for atrial fibrillation assisted by adjunctive measures results in clinically significant reduction of recurrent atrial arrhythmias. Additional research is required to assess the relative efficacy of individual or combined adjunctive strategies used during PVI for atrial fibrillation.
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Afzal MR, Kahaly O, Weiss R, Houmsse M, Daoud EG, Hummel JD. Adenosine triphosphate/adenosine guided pulmonary vein isolation does not improve the outcomes of ablation: a meta-analysis of randomized controlled trials. Expert Rev Cardiovasc Ther 2018; 16:313-318. [PMID: 29561176 DOI: 10.1080/14779072.2018.1455500] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Successful pulmonary vein isolation (PVI) is the most reliable predictor of success after ablation in patients with atrial fibrillation (AF). Adenosine triphosphate (ATP) unmasks the dormant conduction and can be used to improve the effectiveness of PVI. The impact of ATP guided PVI on clinical outcomes is discordant in various randomized controlled trials (RCTs). OBJECTIVES To delineate the incremental benefit of ATP during PVI in patients with AF through a meta-analysis. METHODS AND RESULTS Database searches through January 2017 identified 5 RCTs (enrolling 2839 patients) comparing ATP guided PVI versus standard PVI (non-ATP). Four trials exclusively studied paroxysmal AF while one trial included both paroxysmal and non-paroxysmal AF patients. Baseline characteristics, dose of adenosine and ablation strategies were clearly identified among all the trials. The risk ratio (RR) for AF episodes lasting >30 s after 3-month blanking period was calculated with random effects meta-analysis and showed no difference at a median follow up of 12 months [RR: 1.02, 95 % Confidence interval (CI): 0.85 to 1.25; p = 0.82]. Similarly, the number of repeat ablation was similar in both groups [RR: 1.02, 95 % CI: 0.63, 1.56; p = 0.98]. CONCLUSIONS ATP guided PVI does not decrease the recurrence of AF or the need for repeat ablation at 12 months.
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Affiliation(s)
- Muhammad R Afzal
- a Division of Cardiovascular Medicine, Department of Internal Medicine, Electrophysiology Section , Ross Heart Hospital, The Wexner Medical Center at the Ohio State University Medical Center , Columbus , OH , USA
| | - Omar Kahaly
- a Division of Cardiovascular Medicine, Department of Internal Medicine, Electrophysiology Section , Ross Heart Hospital, The Wexner Medical Center at the Ohio State University Medical Center , Columbus , OH , USA
| | - Raul Weiss
- a Division of Cardiovascular Medicine, Department of Internal Medicine, Electrophysiology Section , Ross Heart Hospital, The Wexner Medical Center at the Ohio State University Medical Center , Columbus , OH , USA
| | - Mahmoud Houmsse
- a Division of Cardiovascular Medicine, Department of Internal Medicine, Electrophysiology Section , Ross Heart Hospital, The Wexner Medical Center at the Ohio State University Medical Center , Columbus , OH , USA
| | - Emile G Daoud
- a Division of Cardiovascular Medicine, Department of Internal Medicine, Electrophysiology Section , Ross Heart Hospital, The Wexner Medical Center at the Ohio State University Medical Center , Columbus , OH , USA
| | - John D Hummel
- a Division of Cardiovascular Medicine, Department of Internal Medicine, Electrophysiology Section , Ross Heart Hospital, The Wexner Medical Center at the Ohio State University Medical Center , Columbus , OH , USA
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Yamaguchi T, Shimakawa Y, Mitsumizo S, Fukui A, Kawano Y, Otsubo T, Takahashi Y, Hirota K, Tsuchiya T, Eshima K. Feasibility of total intravenous anesthesia by cardiologists with the support of anesthesiologists during catheter ablation of atrial fibrillation. J Cardiol 2018; 72:19-25. [PMID: 29338895 DOI: 10.1016/j.jjcc.2017.12.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 12/08/2017] [Accepted: 12/13/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND The optimal methodology for sedation and anesthesia during atrial fibrillation (AF) ablation has not been well established. We assessed the feasibility of total intravenous anesthesia (TIVA) by cardiologists with support from anesthesiologists during AF ablation and quality of pulmonary vein isolation (PVI) and single procedure success rate at 12 months. METHODS TIVA was performed by cardiologists using IV propofol and fentanyl under controlled ventilation via i-gel™ without neuromuscular blocking drugs in 160 consecutive patients (80 nonparoxysmal) with no anticipated difficult airway or other severe diseases. Anesthesiologists were requested to be on standby during the procedure. The incidence of anesthesia-associated complications and ablation-associated complications were assessed. To evaluate the quality of PVI, the prevalence of acute adenosine triphosphate (ATP)-provoked PV reconnections and late PV reconnections among those requiring a redo procedure was analyzed. RESULTS TIVA was successfully completed in 152 patients (95%). In five (3%), we requested help from anesthesiologists, and in three (2%), TIVA was abandoned. No major anesthesia-associated complications were observed. Ablation-associated complications were observed in seven patients (4%). ATP provocation test was performed in 141 patients, and no acute PV reconnections were observed in 134 (95%). Success rates at 12 months were 85% of patients off antiarrhythmic drugs. Twenty-one of 24 patients with recurrence underwent a redo session, and 18 (86%) had no PV reconnections. CONCLUSIONS TIVA by cardiologists with support from anesthesiologists during AF ablation may be feasible. The success rate at 12 months was high, and prevalence of acute and late PV reconnection was very low.
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Affiliation(s)
- Takanori Yamaguchi
- Department of Cardiology, Saga-ken Medical Centre Koseikan, Saga, Japan.
| | - Yusuke Shimakawa
- Department of Anesthesiology, Saga-ken Medical Centre Koseikan, Saga, Japan
| | - Shinji Mitsumizo
- Department of Intensive Care Unit, Saga-ken Medical Centre Koseikan, Saga, Japan
| | - Akira Fukui
- EP Expert Doctors-Team Tsuchiya, Kumamoto, Japan
| | - Yuki Kawano
- Department of Cardiology, Saga-ken Medical Centre Koseikan, Saga, Japan
| | | | | | - Kei Hirota
- EP Expert Doctors-Team Tsuchiya, Kumamoto, Japan
| | | | - Kenichi Eshima
- Department of Cardiology, Saga-ken Medical Centre Koseikan, Saga, Japan
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Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, Akar JG, Badhwar V, Brugada J, Camm J, Chen PS, Chen SA, Chung MK, Cosedis Nielsen J, Curtis AB, Davies DW, Day JD, d’Avila A, (Natasja) de Groot NMS, Di Biase L, Duytschaever M, Edgerton JR, Ellenbogen KA, Ellinor PT, Ernst S, Fenelon G, Gerstenfeld EP, Haines DE, Haissaguerre M, Helm RH, Hylek E, Jackman WM, Jalife J, Kalman JM, Kautzner J, Kottkamp H, Kuck KH, Kumagai K, Lee R, Lewalter T, Lindsay BD, Macle L, Mansour M, Marchlinski FE, Michaud GF, Nakagawa H, Natale A, Nattel S, Okumura K, Packer D, Pokushalov E, Reynolds MR, Sanders P, Scanavacca M, Schilling R, Tondo C, Tsao HM, Verma A, Wilber DJ, Yamane T. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace 2018; 20:e1-e160. [PMID: 29016840 PMCID: PMC5834122 DOI: 10.1093/europace/eux274] [Citation(s) in RCA: 703] [Impact Index Per Article: 117.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Hugh Calkins
- From the Johns Hopkins Medical Institutions, Baltimore, MD
| | | | - Riccardo Cappato
- Humanitas Research Hospital, Arrhythmias and Electrophysiology Research Center, Milan, Italy (Dr. Cappato is now with the Department of Biomedical Sciences, Humanitas University, Milan, Italy, and IRCCS, Humanitas Clinical and Research Center, Milan, Italy)
| | | | - Eduardo B Saad
- Hospital Pro-Cardiaco and Hospital Samaritano, Botafogo, Rio de Janeiro, Brazil
| | | | | | - Vinay Badhwar
- West Virginia University School of Medicine, Morgantown, WV
| | - Josep Brugada
- Cardiovascular Institute, Hospital Clínic, University of Barcelona, Catalonia, Spain
| | - John Camm
- St. George's University of London, London, United Kingdom
| | | | | | | | | | | | - D Wyn Davies
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - John D Day
- Intermountain Medical Center Heart Institute, Salt Lake City, UT
| | | | | | - Luigi Di Biase
- Albert Einstein College of Medicine, Montefiore-Einstein Center for Heart & Vascular Care, Bronx, NY
| | | | | | | | | | - Sabine Ernst
- Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Guilherme Fenelon
- Albert Einstein Jewish Hospital, Federal University of São Paulo, São Paulo, Brazil
| | | | | | | | | | - Elaine Hylek
- Boston University School of Medicine, Boston, MA
| | - Warren M Jackman
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Jose Jalife
- University of Michigan, Ann Arbor, MI, the National Center for Cardiovascular Research Carlos III (CNIC) and CIBERCV, Madrid, Spain
| | - Jonathan M Kalman
- Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia
| | - Josef Kautzner
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Hans Kottkamp
- Hirslanden Hospital, Department of Electrophysiology, Zurich, Switzerland
| | | | | | - Richard Lee
- Saint Louis University Medical School, St. Louis, MO
| | - Thorsten Lewalter
- Department of Cardiology and Intensive Care, Hospital Munich-Thalkirchen, Munich, Germany
| | | | - Laurent Macle
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montréal, Canada
| | | | - Francis E Marchlinski
- Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, Philadelphia, PA
| | | | - Hiroshi Nakagawa
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX
| | - Stanley Nattel
- Montreal Heart Institute and Université de Montréal, Montreal, Canada, McGill University, Montreal, Canada, and University Duisburg-Essen, Essen, Germany
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | | | - Evgeny Pokushalov
- State Research Institute of Circulation Pathology, Novosibirsk, Russia
| | | | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | | | - Claudio Tondo
- Cardiac Arrhythmia Research Center, Centro Cardiologico Monzino, IRCCS, Department of Cardiovascular Sciences, University of Milan, Milan, Italy
| | | | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Toronto, Canada
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12
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Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, Akar JG, Badhwar V, Brugada J, Camm J, Chen PS, Chen SA, Chung MK, Nielsen JC, Curtis AB, Davies DW, Day JD, d’Avila A, de Groot N(N, Di Biase L, Duytschaever M, Edgerton JR, Ellenbogen KA, Ellinor PT, Ernst S, Fenelon G, Gerstenfeld EP, Haines DE, Haissaguerre M, Helm RH, Hylek E, Jackman WM, Jalife J, Kalman JM, Kautzner J, Kottkamp H, Kuck KH, Kumagai K, Lee R, Lewalter T, Lindsay BD, Macle L, Mansour M, Marchlinski FE, Michaud GF, Nakagawa H, Natale A, Nattel S, Okumura K, Packer D, Pokushalov E, Reynolds MR, Sanders P, Scanavacca M, Schilling R, Tondo C, Tsao HM, Verma A, Wilber DJ, Yamane T. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2017; 14:e275-e444. [PMID: 28506916 PMCID: PMC6019327 DOI: 10.1016/j.hrthm.2017.05.012] [Citation(s) in RCA: 1365] [Impact Index Per Article: 195.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Hugh Calkins
- Johns Hopkins Medical Institutions, Baltimore, MD
| | | | - Riccardo Cappato
- Humanitas Research Hospital, Arrhythmias and Electrophysiology Research Center, Milan, Italy (Dr. Cappato is now with the Department of Biomedical Sciences, Humanitas University, Milan, Italy, and IRCCS, Humanitas Clinical and Research Center, Milan, Italy)
| | | | - Eduardo B. Saad
- Hospital Pro-Cardiaco and Hospital Samaritano, Botafogo, Rio de Janeiro, Brazil
| | | | | | - Vinay Badhwar
- West Virginia University School of Medicine, Morgantown, WV
| | - Josep Brugada
- Cardiovascular Institute, Hospital Clínic, University of Barcelona, Catalonia, Spain
| | - John Camm
- St. George’s University of London, London, United Kingdom
| | | | | | | | | | | | - D. Wyn Davies
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - John D. Day
- Intermountain Medical Center Heart Institute, Salt Lake City, UT
| | | | | | - Luigi Di Biase
- Albert Einstein College of Medicine, Montefiore-Einstein Center for Heart & Vascular Care, Bronx, NY
| | | | | | | | | | - Sabine Ernst
- Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Guilherme Fenelon
- Albert Einstein Jewish Hospital, Federal University of São Paulo, São Paulo, Brazil
| | | | | | | | | | - Elaine Hylek
- Boston University School of Medicine, Boston, MA
| | - Warren M. Jackman
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Jose Jalife
- University of Michigan, Ann Arbor, MI, the National Center for Cardiovascular Research Carlos III (CNIC) and CIBERCV, Madrid, Spain
| | - Jonathan M. Kalman
- Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia
| | - Josef Kautzner
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Hans Kottkamp
- Hirslanden Hospital, Department of Electrophysiology, Zurich, Switzerland
| | | | | | - Richard Lee
- Saint Louis University Medical School, St. Louis, MO
| | - Thorsten Lewalter
- Department of Cardiology and Intensive Care, Hospital Munich-Thalkirchen, Munich, Germany
| | | | - Laurent Macle
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montréal, Canada
| | | | - Francis E. Marchlinski
- Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, Philadelphia, PA
| | | | - Hiroshi Nakagawa
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX
| | - Stanley Nattel
- Montreal Heart Institute and Université de Montréal, Montreal, Canada, McGill University, Montreal, Canada, and University Duisburg-Essen, Essen, Germany
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | | | - Evgeny Pokushalov
- State Research Institute of Circulation Pathology, Novosibirsk, Russia
| | | | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | | | - Claudio Tondo
- Cardiac Arrhythmia Research Center, Centro Cardiologico Monzino, IRCCS, Department of Cardiovascular Sciences, University of Milan, Milan, Italy
| | | | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Toronto, Canada
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13
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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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14
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WITHDRAWN: 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. J Arrhythm 2017. [DOI: 10.1016/j.joa.2017.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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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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Willems S, Khairy P, Andrade JG, Hoffmann BA, Levesque S, Verma A, Weerasooriya R, Novak P, Arentz T, Deisenhofer I, Rostock T, Steven D, Rivard L, Guerra PG, Dyrda K, Mondesert B, Dubuc M, Thibault B, Talajic M, Roy D, Nattel S, Macle L. Redefining the Blanking Period After Catheter Ablation for Paroxysmal Atrial Fibrillation: Insights From the ADVICE (Adenosine Following Pulmonary Vein Isolation to Target Dormant Conduction Elimination) Trial. Circ Arrhythm Electrophysiol 2017; 9:CIRCEP.115.003909. [PMID: 27516462 DOI: 10.1161/circep.115.003909] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 07/18/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND Early recurrences (ERs) of atrial tachyarrhythmia are common after catheter ablation of atrial fibrillation. A 3-month blanking period is recommended by current guidelines. This study sought to investigate the significance of ER during the first 3 months post ablation in predicting late recurrences and determine whether it varies according to timing. METHODS AND RESULTS A total of 401 patients with paroxysmal atrial fibrillation undergoing pulmonary vein isolation were followed for 12 months with transtelephonic monitoring in the ADVICE (Adenosine Following Pulmonary Vein Isolation to Target Dormant Conduction Elimination) trial. Patients with atrial tachyarrhythmia ≥30 s within the 3-month blanking period were stratified according to the timing of ER. A total of 179 patients (44.6%) experienced their last episode of ER during the first (n=53), second (n=44), or third (n=82) month of the 3-month blanking period. One-year freedom from symptomatic atrial tachyarrhythmia was 77.2% in patients without ER compared with 62.6%, 36.4%, and 7.8% in patients with ER 1, 2, and 3 months post ablation, respectively (P<0.0001). Receiver operating curve analyses revealed a strong correlation between the timing of ER and late recurrence (area under the curve 0.82, P<0.0001). Corresponding hazard ratios for ER during the first, second, and third months were 1.84, 4.45, and 9.64, respectively. CONCLUSIONS This study validates the use of a blanking period after catheter ablation for paroxysmal atrial fibrillation but calls into question the 90-day cut-off value. In particular, >90% of patients with ER during the third month post ablation experience late recurrence by 1 year. However, pending further study, repeat ablation before 90 days cannot be routinely advocated. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01058980.
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Affiliation(s)
| | - Paul Khairy
- For the author affiliations, please see the Appendix
| | | | | | | | - Atul Verma
- For the author affiliations, please see the Appendix
| | | | - Paul Novak
- For the author affiliations, please see the Appendix
| | - Thomas Arentz
- For the author affiliations, please see the Appendix
| | | | | | - Daniel Steven
- For the author affiliations, please see the Appendix
| | - Lena Rivard
- For the author affiliations, please see the Appendix
| | | | - Katia Dyrda
- For the author affiliations, please see the Appendix
| | | | - Marc Dubuc
- For the author affiliations, please see the Appendix
| | | | - Mario Talajic
- For the author affiliations, please see the Appendix
| | - Denis Roy
- For the author affiliations, please see the Appendix
| | | | - Laurent Macle
- For the author affiliations, please see the Appendix.
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17
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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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18
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Development of Nonpulmonary Vein Foci Increases Risk of Atrial Fibrillation Recurrence After Pulmonary Vein Isolation. JACC Clin Electrophysiol 2017; 3:547-555. [DOI: 10.1016/j.jacep.2016.12.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 11/09/2016] [Accepted: 12/08/2016] [Indexed: 11/19/2022]
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19
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Letsas KP, Georgopoulos S, Efremidis M, Liu T, Bazoukis G, Vlachos K, Karamichalakis N, Lioni L, Sideris A, Ehrlich JR. Adenosine-guided radiofrequency catheter ablation of atrial fibrillation: A meta-analysis of randomized control trials. J Arrhythm 2017; 33:247-255. [PMID: 28765753 PMCID: PMC5529608 DOI: 10.1016/j.joa.2017.02.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 01/16/2017] [Accepted: 02/19/2017] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND The prognostic significance of adenosine-mediated dormant pulmonary vein conduction, and whether such dormant conduction should be eliminated, remains controversial. We sought to perform a meta-analysis of data from eligible studies to delineate the prognostic impact of adenosine-guided radiofrequency catheter ablation of atrial fibrillation. METHODS A systematic literature search was performed using online databases in order to identify relevant studies from January 2004 to September 2016. Ten studies [six observational and four randomized control trials (RCTs)] were included in the analysis. RESULTS Five studies (two observational and three RCTs) compared the efficacy of adenosine-mediated elimination of dormant conduction versus no adenosine test. Overall, the adenosine-guided ablation strategy displayed better long-term outcomes as compared with no adenosine testing (RR 1.08, 95% CI 1.01-1.14, p=0.02; Heterogeneity: I2=42%, p: 0.14). The meta-analysis of only RCTs failed to show any differences between the two strategies (RR 1.03, 95% CI 0.96-1.11, p=0.37; Heterogeneity: I2 0%, p: 0.41). Eight studies (five observational and three RCTs) addressed the efficacy of adenosine-induced dormant conduction and additional ablation versus no dormant conduction during adenosine challenge. Overall, a trend towards a better outcome in those without dormant conduction during drug challenge was noted (RR 0.89, 95% CI 0.77-1.03, p=0.11; Heterogeneity: I2 65% p: 0.006). The pooled analysis of RCTs failed to show any differences between the two arms (RR 0.90, 95% CI 0.62-1.30, p= 0.57; Heterogeneity: I2 88%, p: 0.0002). CONCLUSIONS Adenosine-guided radiofrequency catheter ablation of atrial fibrillation does not provide additional benefit in terms of freedom of arrhythmia recurrence.
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Affiliation(s)
- Konstantinos P Letsas
- Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Greece
| | - Stamatis Georgopoulos
- Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Greece
| | - Michael Efremidis
- Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Greece
| | - Tong Liu
- Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, People׳s Republic of China
| | - George Bazoukis
- Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Greece
| | - Konstantinos Vlachos
- Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Greece
| | | | - Louiza Lioni
- Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Greece
| | - Antonios Sideris
- Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Greece
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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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21
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Adenosine administration during hybrid atrial fibrillation ablation to test dormant pulmonary vein conduction. J Interv Card Electrophysiol 2017; 49:59-65. [PMID: 28285383 PMCID: PMC5403878 DOI: 10.1007/s10840-017-0239-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 03/01/2017] [Indexed: 11/22/2022]
Abstract
Background Adenosine administration after initial pulmonary vein isolation (PVI) reveals dormant conduction and predicts atrial fibrillation (AF) recurrence. Elimination of dormant conduction when present may increase a long-term success rate of AF ablation procedures. There are no studies till date using adenosine to reveal acute reconduction of pulmonary veins (PVs) after epicardial PVI during a hybrid AF ablation procedure. Methods We included 24 patients (21 male, 55 ± 9 years) undergoing hybrid ablation for symptomatic paroxysmal (n = 12) and persistent (n = 12) AF, using an epicardial bipolar radiofrequency clamp to perform PVI. All antiarrhythmic medications were discontinued 5 days prior to the procedure, except for patients on amiodarone. Thirty minutes after PVI and once sinus rhythm was obtained, a bolus of adenosine (12 to 36 mg) was administered intravenously. The subsequent response was assessed for each PV (n = 96) using an in situ circular mapping catheter. Results Dormant conduction (i.e., the reappearance of PV potentials during at least one beat) was seen in 1 out of 96 PVs (1%). If reconduction was seen, further endocardial ablation using a 3.5-mm irrigated tip catheter was performed until no more reconduction occurred after repeating the adenosine bolus. Conclusions Adenosine administration after PVI with the use of an epicardial bipolar radiofrequency clamp in the setting of hybrid AF ablation reveals acute reconduction in 1% of the PVs.
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22
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Narui R, Matsuo S, Isogai R, Tokutake K, Yokoyama K, Kato M, Ito K, Tanigawa SI, Yamashita S, Tokuda M, Inada K, Shibayama K, Miyanaga S, Sugimoto K, Yoshimura M, Yamane T. Impact of deep sedation on the electrophysiological behavior of pulmonary vein and non-PV firing during catheter ablation for atrial fibrillation. J Interv Card Electrophysiol 2017; 49:51-57. [PMID: 28285382 DOI: 10.1007/s10840-017-0238-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Accepted: 02/23/2017] [Indexed: 11/27/2022]
Abstract
PURPOSE Catheter ablation for atrial fibrillation is performed with and without deep sedation, which could affect the arrhythmogenic activity during the procedure. We investigated the impact of sedation on electrophysiological properties in patients with AF who underwent catheter ablation. METHODS This study consisted of 255 consecutive patients with atrial fibrillation (229 males, persistent: 105 patients) who underwent a single-catheter ablation procedure. The patients were divided into the following two groups according to the depth of sedation during the procedure: group M (mild sedation with flunitrazepam in 138 patients) and group D (deep sedation with propofol in 117 patients). Peripheral oxygen saturation was continuously monitored via pulse oximetry throughout the procedure. RESULTS A spontaneous dissociated pulmonary vein activity after pulmonary vein isolation occurred more frequently in group M than in group D (29.1 vs 15.7%, P < 0.01). Adenosine-induced dormant pulmonary vein conduction was more frequently observed in group M than in group D (19.2 vs 13.0% P = 0.01). There were no significant differences in the incidence of non-pulmonary vein triggers between groups M and D (15.2 vs 11.1%, P = 0.53). The atrial fibrillation recurrence rate following the single procedure did not differ between the two groups (29.0 vs 26.5%, in groups M and D, P = 0.85). CONCLUSIONS Although deep sedation reduced the incidence of a dissociated pulmonary vein activity and dormant pulmonary vein conduction following pulmonary vein isolation, it did not affect the recurrence rate for atrial fibrillation after the procedure.
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Affiliation(s)
- Ryohsuke Narui
- Department of Cardiology, The Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Seiichiro Matsuo
- Department of Cardiology, The Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Ryota Isogai
- Department of Cardiology, The Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Kenichi Tokutake
- Department of Cardiology, The Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Kenichi Yokoyama
- Department of Cardiology, The Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Mika Kato
- Department of Cardiology, The Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Keiichi Ito
- Department of Cardiology, The Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Shin-Ichi Tanigawa
- Department of Cardiology, The Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Seigo Yamashita
- Department of Cardiology, The Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Michifumi Tokuda
- Department of Cardiology, The Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Keiichi Inada
- Department of Cardiology, The Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Kenri Shibayama
- Department of Cardiology, The Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Satoru Miyanaga
- Department of Cardiology, The Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Kenichi Sugimoto
- Department of Cardiology, The Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Michihiro Yoshimura
- Department of Cardiology, The Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Teiichi Yamane
- Department of Cardiology, The Jikei University School of Medicine, 3-25-8 Nishi-shinbashi, Minato-ku, Tokyo, 105-8461, Japan
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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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24
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PRABHU SANDEEP, MACKIN VINCENT, MCLELLAN ALEXJ, PHAN TUONG, MCGLADE DESMOND, LING LIANGHAN, PECK KAHY, VOSKOBOINIK ALEXANDR, PATHIK BUPESH, NALLIAH CHRISHANJ, WONG GEOFFR, AZZOPARDI SONIAM, LEE GEOFFREY, MARIANI JUSTIN, TAYLOR ANDREWJ, KALMAN JONATHANM, KISTLER PETERM. Determining the Optimal Dose of Adenosine for Unmasking Dormant Pulmonary Vein Conduction Following Atrial Fibrillation Ablation: Electrophysiological and Hemodynamic Assessment. DORMANT-AF Study. J Cardiovasc Electrophysiol 2016; 28:13-22. [DOI: 10.1111/jce.13107] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 09/05/2016] [Accepted: 09/07/2016] [Indexed: 11/28/2022]
Affiliation(s)
- SANDEEP PRABHU
- Department of Cardiology; Alfred Hospital; Melbourne Victoria Australia
- Baker IDI Heart and Diabetes Institute; Cabrini Health; Melbourne Victoria Australia
- Cardiology Department; Royal Melbourne Hospital; Melbourne Victoria Australia
- Faculty of Medicine, Dentistry, and Health Sciences; University of Melbourne; Melbourne Victoria Australia
- Cabrini Health; Melbourne Victoria Australia
| | | | - ALEX J.A. MCLELLAN
- Department of Cardiology; Alfred Hospital; Melbourne Victoria Australia
- Baker IDI Heart and Diabetes Institute; Cabrini Health; Melbourne Victoria Australia
- Cardiology Department; Royal Melbourne Hospital; Melbourne Victoria Australia
- Faculty of Medicine, Dentistry, and Health Sciences; University of Melbourne; Melbourne Victoria Australia
- Cabrini Health; Melbourne Victoria Australia
| | - TUONG PHAN
- Faculty of Medicine, Dentistry, and Health Sciences; University of Melbourne; Melbourne Victoria Australia
- Cabrini Health; Melbourne Victoria Australia
| | | | - LIANG-HAN LING
- Department of Cardiology; Alfred Hospital; Melbourne Victoria Australia
- Baker IDI Heart and Diabetes Institute; Cabrini Health; Melbourne Victoria Australia
- Cabrini Health; Melbourne Victoria Australia
| | - KAH Y. PECK
- Department of Cardiology; Alfred Hospital; Melbourne Victoria Australia
| | - ALEXANDR VOSKOBOINIK
- Department of Cardiology; Alfred Hospital; Melbourne Victoria Australia
- Baker IDI Heart and Diabetes Institute; Cabrini Health; Melbourne Victoria Australia
- Cardiology Department; Royal Melbourne Hospital; Melbourne Victoria Australia
- Faculty of Medicine, Dentistry, and Health Sciences; University of Melbourne; Melbourne Victoria Australia
- Cabrini Health; Melbourne Victoria Australia
| | - BUPESH PATHIK
- Cardiology Department; Royal Melbourne Hospital; Melbourne Victoria Australia
- Faculty of Medicine, Dentistry, and Health Sciences; University of Melbourne; Melbourne Victoria Australia
| | - CHRISHAN J. NALLIAH
- Cardiology Department; Royal Melbourne Hospital; Melbourne Victoria Australia
- Faculty of Medicine, Dentistry, and Health Sciences; University of Melbourne; Melbourne Victoria Australia
| | - GEOFF R. WONG
- Cardiology Department; Royal Melbourne Hospital; Melbourne Victoria Australia
- Faculty of Medicine, Dentistry, and Health Sciences; University of Melbourne; Melbourne Victoria Australia
| | - SONIA M. AZZOPARDI
- Department of Cardiology; Alfred Hospital; Melbourne Victoria Australia
- Baker IDI Heart and Diabetes Institute; Cabrini Health; Melbourne Victoria Australia
| | - GEOFFREY LEE
- Cardiology Department; Royal Melbourne Hospital; Melbourne Victoria Australia
| | - JUSTIN MARIANI
- Department of Cardiology; Alfred Hospital; Melbourne Victoria Australia
- Baker IDI Heart and Diabetes Institute; Cabrini Health; Melbourne Victoria Australia
| | - ANDREW J. TAYLOR
- Department of Cardiology; Alfred Hospital; Melbourne Victoria Australia
- Baker IDI Heart and Diabetes Institute; Cabrini Health; Melbourne Victoria Australia
- Cabrini Health; Melbourne Victoria Australia
| | - JONATHAN M. KALMAN
- Cardiology Department; Royal Melbourne Hospital; Melbourne Victoria Australia
- Faculty of Medicine, Dentistry, and Health Sciences; University of Melbourne; Melbourne Victoria Australia
| | - PETER M. KISTLER
- Department of Cardiology; Alfred Hospital; Melbourne Victoria Australia
- Baker IDI Heart and Diabetes Institute; Cabrini Health; Melbourne Victoria Australia
- Faculty of Medicine, Dentistry, and Health Sciences; University of Melbourne; Melbourne Victoria Australia
- Cabrini Health; Melbourne Victoria Australia
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25
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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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26
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Predictors of chronic pulmonary vein reconnections after contact force-guided ablation: importance of completing electrical isolation with circumferential lines and creating sufficient ablation lesion densities. J Interv Card Electrophysiol 2016; 47:321-331. [PMID: 27417148 DOI: 10.1007/s10840-016-0164-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 06/29/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE We aimed to identify the predictors of chronic pulmonary vein reconnections (CPVRs) after contact force (CF)-guided circumferential PV isolation (CPVI) of atrial fibrillation (AF). METHODS Forty-nine consecutive patients undergoing second ablation procedures for recurrent AF after CF-guided ablation were retrospectively studied. The CPVI was performed by point-by-point ablation with a target CF of 15-20 g. The incidence of CPVRs was evaluated along the right- and left-sided anterior and posterior CPVI regions (Ant-RPVs, Post-RPVs, Ant-LPVs, and Post-LPVs). RESULTS CPVRs were observed in 30.6, 22.4, 20.4, and 32.7 % of patients along the Ant-RPVs, Post-RPVs, Ant-LPVs, and Post-LPVs, respectively (P = 0.436). In the multivariate logistic analyses, completing a left atrium-PV conduction block with touch-up ablation inside the initially estimated CPVI lines (Ant-RPVs, Post-RPVs, Ant-LPVs, Post-LPVs; odds ratio [OR] 5.747, 15.000, 207.619, 7.940; P = 0.032, 0.004, 0.034, 0.021) and region length (Post-LPVs; OR 3.183, P = 0.027) were positive predictors of CPVRs, while the mean CF (Ant-RPVs; OR 0.861, P = 0.045) and number of radiofrequency applications per unit length (Ant-LPVs, Post-LPVs; OR 0.038, 0.122; P = 0.034, 0.029) were negative predictors. At optimal cutoffs of 5.8 cm for the region length, 14.2 g for the mean CF, and 1.97/cm (Ant-LPVs) and 2.01/cm (Post-LPVs) for the radiofrequency application density, the sensitivity and specificity were 93.8 and 63.6 %, 60.0 and 76.5 %, 90.0 and 64.1 %, and 75.0 and 63.6 %, respectively. CONCLUSIONS Completing PVI with circumferential lines without touch-up ablation and creating a sufficient density of radiofrequency ablation lesions on the lines with a sufficient CF may be necessary to prevent CPVRs after a CF-guided CPVI.
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27
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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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28
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Kogawa R, Okumura Y, Watanabe I, Sonoda K, Sasaki N, Takahashi K, Iso K, Nagashima K, Ohkubo K, Nakai T, Kunimoto S, Hirayama A. Difference Between Dormant Conduction Sites Revealed by Adenosine Triphosphate Provocation and Unipolar Pace-Capture Sites Along the Ablation Line After Pulmonary Vein Isolation. Int Heart J 2015; 57:25-9. [PMID: 26673441 DOI: 10.1536/ihj.15-231] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Dormant pulmonary vein (PV) conduction revealed by adenosine/adenosine triphosphate (ATP) provocation test and exit block to the left atrium by pacing from the PV side of the ablation line ("pace and ablate" method) are used to ensure durable pulmonary vein isolation (PVI). However, the mechanistic relation between ATP-provoked PV reconnection and the unexcitable gap along the ablation line is unclear.Forty-five patients with atrial fibrillation (AF) (paroxysmal: 31 patients, persistent: 14 patients; age: 61.1 ± 9.7 years) underwent extensive encircling PVI (EEPVI, 179 PVs). After completion of EEPVI, an ATP provocation test (30 mg, bolus injection) and unipolar pacing (output, 10 mA; pulse width, 2 ms) were performed along the previous EEPVI ablation line to identify excitable gaps. Dormant conduction was revealed in 29 (34 sites) of 179 PVs (16.2%) after EEP-VI (22/45 patients). Pace capture was revealed in 59 (89 sites) of 179 PVs (33.0%) after EEPVI (39/45 patients), and overlapping sites, ie, sites showing both dormant conduction and pace capture, were observed in 22 of 179 (12.3%) PVs (17/45 patients).Some of the ATP-provoked dormant PV reconnection sites were identical to the sites with excitable gaps revealed by pace capture, but most of the PV sites were differently distributed, suggesting that the main underling mechanism differs between these two forms of reconnection. These findings also suggest that performance of the ATP provocation test followed by the "pace and ablate" method can reduce the occurrence of chronic PV reconnections.
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Affiliation(s)
- Rikitake Kogawa
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
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29
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Huemer M, Attanasio P, Wutzler A, Parwani AS, Boldt LH, Haverkamp W. [Mapping and ablation of a mechanically blocked concealed accessory pathway under repeated adenosine bolus infusions]. Herzschrittmacherther Elektrophysiol 2015; 26:371-373. [PMID: 26264483 DOI: 10.1007/s00399-015-0395-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 07/27/2015] [Indexed: 06/04/2023]
Abstract
During mapping and catheter ablation of an accessory pathway, a mechanically induced conduction block can occur. Adenosine is used to detect dormant conduction of incomplete ablation lesions. Presented in this article is the case of a patient with a left-sided accessory pathway, which was mechanically blocked during the mapping procedure and could only be successfully ablated after repeated adenosine bolus infusions, which resulted in intermittent restitution of conduction via the accessory pathway.
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Affiliation(s)
- Martin Huemer
- Medizinische Klinik mit Schwerpunkt Kardiologie, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13553, Berlin, Deutschland.
| | - Philipp Attanasio
- Medizinische Klinik mit Schwerpunkt Kardiologie, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13553, Berlin, Deutschland
| | - Alexander Wutzler
- Medizinische Klinik mit Schwerpunkt Kardiologie, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13553, Berlin, Deutschland
| | - Abdul Shokor Parwani
- Medizinische Klinik mit Schwerpunkt Kardiologie, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13553, Berlin, Deutschland
| | - Leif-Hendrik Boldt
- Medizinische Klinik mit Schwerpunkt Kardiologie, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13553, Berlin, Deutschland
| | - Wilhelm Haverkamp
- Medizinische Klinik mit Schwerpunkt Kardiologie, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13553, Berlin, Deutschland
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30
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Nakamura K, Naito S, Sasaki T, Nakano M, Minami K, Nakatani Y, Ikeda K, Yamashita E, Kumagai K, Funabashi N, Oshima S. Randomized comparison of contact force-guided versus conventional circumferential pulmonary vein isolation of atrial fibrillation: prevalence, characteristics, and predictors of electrical reconnections and clinical outcomes. J Interv Card Electrophysiol 2015; 44:235-45. [PMID: 26387117 DOI: 10.1007/s10840-015-0056-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 09/10/2015] [Indexed: 01/29/2023]
Abstract
PURPOSE We prospectively investigated the differences in pulmonary vein reconnections (PVRs) and clinical outcomes between contact force (CF)-guided and conventional circumferential PV isolation (CPVI) of atrial fibrillation (AF). METHODS One hundred twenty consecutive AF patients (63 ± 10 years; 88 males) undergoing an initial CPVI were randomized to ablation with a target CF of 20 g (CF group; n = 60) or that with operators blinded to the CF information (blind group; n = 60). RESULTS The CF group had fewer PVRs (0.67 ± 0.91/patient vs. 1.16 ± 1.16/patient; P = 0.007), a lower incidence of persistent PVRs (13.2 vs. 41.2%; P < 0.001), and a shorter procedural time for the CPVI (50 vs. 56 min; P = 0.019) than the blind group. The mean CF was higher in the CF group than the blind group (18.0 vs. 16.1 g; P < 0.001), with the most significant difference observed along the posterior right-sided PVs (P-RPVs) and anterior left-sided PVs (A-LPVs). In logistic regression models, the mean CF was a negative predictor of PVRs along the P-RPVs and A-LPVs in the blind group (odds ratios, 0.728 and 0.786; P < 0.001 and 0.007), while no significant predictor was identified in the CF group or elsewhere in the blind group. In the Kaplan-Meier analysis, the arrhythmia-free survival rate at 12 months was 89.9% in the CF group and 88.2% in the blind group, respectively (P = 0.624). CONCLUSIONS CF-guided CPVI can reduce PVRs and the procedural time and be particularly beneficial along regions where a relatively low CF tends to be applied: the P-RPVs and A-LPVs. The comparable clinical outcomes may be due to the learning curve effect obtained by the CF-guided technique and repeated provocation of dormant PV conduction.
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Affiliation(s)
- Kohki Nakamura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan.
| | - Shigeto Naito
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan
| | - Takehito Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan
| | - Masahiro Nakano
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan
| | - Kentaro Minami
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan
| | - Yosuke Nakatani
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan
| | - Kentaro Ikeda
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan
| | - Eiji Yamashita
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan
| | - Koji Kumagai
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan
| | - Nobusada Funabashi
- Department of Cardiovascular Science and Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba City, Chiba, 260-8670, Japan
| | - Shigeru Oshima
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan
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31
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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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Datino T. ADVICE on adenosine to improve atrial fibrillation ablation. Lancet 2015. [PMID: 26211829 DOI: 10.1016/s0140-6736(15)60241-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Tomás Datino
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Madrid 28007, Spain.
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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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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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Andrade JG, Rivard L, Macle L. The Past, the Present, and the Future of Cardiac Arrhythmia Ablation. Can J Cardiol 2014; 30:S431-41. [DOI: 10.1016/j.cjca.2014.07.731] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 07/20/2014] [Accepted: 07/21/2014] [Indexed: 10/25/2022] Open
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Spotnitz MD, Markowitz SM, Liu CF, Thomas G, Ip JE, Liez J, Lerman BB, Cheung JW. Mechanisms and clinical significance of adenosine-induced dormant accessory pathway conduction after catheter ablation. Circ Arrhythm Electrophysiol 2014; 7:1136-43. [PMID: 25378468 DOI: 10.1161/circep.114.002140] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Adenosine can unmask dormant pulmonary vein conduction after isolation. The role of adenosine in uncovering dormant accessory pathway (AP) conduction after AP ablation is unknown. METHODS AND RESULTS We evaluated 109 consecutive patients (age, 41 ± 28 years; 62 [57%] men) who were administered adenosine after successful AP ablation. Dormant AP conduction was defined as adenosine-induced recurrent AP conduction, as demonstrated by recurrent preexcitation or change in retrograde ventriculoatrial activation patterns. Dormant AP conduction was identified in 13 (12%) patients. Adenosine led to transient retrograde AP conduction in 6 patients and transient anterograde AP conduction in 8 patients. In all these cases, adenosine-induced AP conduction occurred during the bradycardia phase of adenosine effect and resulted in dormant AP conduction times shorter than atrioventricular nodal conduction times before adenosine administration. On the basis of analysis of timing of occurrence of dormant AP conduction, the mechanism of adenosine-induced AP conduction was determined to be caused by AP excitability recovery in ≥ 12 (92%) cases. The presence of dormant AP conduction was a significant predictor of chronic recurrent AP conduction requiring repeat ablation (odds ratio, 8.54; 95% confidence interval, 1.09-66.9; P=0.041). CONCLUSIONS Adenosine can unmask dormant AP conduction after catheter ablation. Direct effects of adenosine on the AP, possibly via AP membrane potential hyperpolarization, are the dominant mechanism of adenosine-induced AP conduction after ablation. Dormant AP conduction is associated with higher rates of recurrent AP conduction requiring repeat ablation.
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Affiliation(s)
- Michelle D Spotnitz
- From the Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Steven M Markowitz
- From the Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Christopher F Liu
- From the Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York, NY
| | - George Thomas
- From the Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York, NY
| | - James E Ip
- From the Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Joshua Liez
- From the Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Bruce B Lerman
- From the Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Jim W Cheung
- From the Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York, NY.
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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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Kriatselis C, Kaufmann J, Nedios S, Tang M, Gerds-Li JH, Fleck E. Prolonged ablation on critical segments of pulmonary vein ostia in paroxysmal atrial fibrillation: a prospective randomized controlled study. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2014; 37:603-9. [PMID: 24883449 DOI: 10.1111/pace.12304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Electrical reconnection of the pulmonary veins (PVs) plays a key role in the recurrence of atrial fibrillation (AF) after ablative treatment. This randomized controlled study tested the hypothesis that prolonged ablations, on areas that may be critical for left atrial (LA)-PV conduction, can significantly reduce the rate of acute PV reconnection and AF recurrence. METHODS Patients with paroxysmal AF were randomly assigned to either a control or an add-on group.Ostial PV isolation (PVI) was performed by point-to-point RF ablation (irrigated tip, 30 Watts, 30 seconds).An ostial segment was assumed to be critical for LA-PV connection if any of the following reactions occurred during RF application: (1) sudden delay of LA-PV conduction, (2) change of activation sequence,and (3) PVI. In this case, RF application was prolonged from 30 seconds to 90 seconds in the add-on group only. RESULTS A total of 131 patients (58 ± 11 years, 47 female) were assigned to a control (n = 64) and an add-on (n = 67) group. Ablation time was longer in the add-on (48 ± 16 minutes vs 37 ± 15 minutes, P = 0.03). Acute PV reconnection was observed in 20 of 64 controls and in eight of 66 add-on patients (31% vs 12%, P < 0.001). During a follow-up of 26 months, AF recurred in 33 of 64 controls and in 16 of 66 add-on patients (52% vs 24%, P = 0.001) after a single ablation procedure. CONCLUSIONS Prolonged radiofrequency application on critical segments of LA-PV connection is a safe and effective ablative strategy that significantly reduces acute PV reconnection and AF recurrence rates after a single ablation procedure for paroxysmal AF.
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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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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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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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Cheung JW, Lin FS, Ip JE, Bender SR, Siddiqi FK, Liu CF, Thomas G, Markowitz SM, Lerman BB. Adenosine-induced pulmonary vein ectopy as a predictor of recurrent atrial fibrillation after pulmonary vein isolation. Circ Arrhythm Electrophysiol 2013; 6:1066-73. [PMID: 24243786 DOI: 10.1161/circep.113.000796] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Adenosine can unmask dormant pulmonary vein (PV) conduction after PV isolation. Adenosine can also induce ectopy in electrically silent PVs after isolation, possibly via activation of autonomic triggers. We sought to identify the implications of adenosine-induced PV ectopy for atrial fibrillation (AF) recurrence after PV isolation. METHODS AND RESULTS A total of 152 patients (age, 60±11 years; 63% paroxysmal AF) undergoing PV isolation for AF were studied. After each PV was isolated, adenosine was administered and the presence of adenosine-induced PV reconnection and PV ectopy were recorded. Dormant conduction was targeted with additional ablation. Adenosine-induced PV ectopy was seen in 45 (30%) patients, and dormant conduction was seen in 44 (29%) patients. After a median follow-up of 374 days, 48 (32%) patients had recurrent AF after a single ablation procedure. Rates of freedom from AF among patients with adenosine-induced PV ectopy were significantly lower than patients without adenosine-induced PV ectopy (63% versus 76% at 1 year; log rank, 0.014). Rates of freedom from AF among patients with dormant conduction were also lower than patients without dormant conduction (64% versus 76% at 1 year; log rank, 0.062). With multivariate analysis, adenosine-induced PV ectopy was found to be the only independent predictor of AF after PV isolation (hazard ratio, 1.90; 95% confidence interval, 1.06-3.40; P=0.032). CONCLUSIONS Adenosine-induced PV ectopy is a predictor of recurrent AF after PV isolation and may be a marker of increased susceptibility to autonomic triggers of AF.
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Affiliation(s)
- Jim W Cheung
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York, NY
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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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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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Nakamura K, Naito S, Kaseno K, Tsukada N, Sasaki T, Hayano M, Nishiuchi S, Fuke E, Miki Y, Sakamoto T, Nakamura K, Kumagai K, Kataoka A, Takaoka H, Kobayashi Y, Funabashi N, Oshima S. Optimal observation time after completion of circumferential pulmonary vein isolation for atrial fibrillation to prevent chronic pulmonary vein reconnections. Int J Cardiol 2013; 168:5300-10. [DOI: 10.1016/j.ijcard.2013.08.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 08/03/2013] [Indexed: 11/29/2022]
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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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Andrade JG, Khairy P, Nattel S, Vanella A, Rivard L, Guerra PG, Dubuc M, Dyrda K, Thibault B, Talajic M, Mondesert B, Roy D, Macle L. Corticosteroid use during pulmonary vein isolation is associated with a higher prevalence of dormant pulmonary vein conduction. Heart Rhythm 2013; 10:1569-75. [PMID: 23892341 DOI: 10.1016/j.hrthm.2013.07.037] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI) is associated with PV to left atrium reconduction. OBJECTIVE The purpose of this study was to prospectively determine if the use of intraprocedural corticosteroids to limit the extent of tissue edema and/or inflammation alters the prevalence of spontaneous and adenosine-induced acute PV reconnection after PVI. METHODS Prior to wide circumferential PVI, 45 patients received a single intravenous (IV) bolus of hydrocortisone 250 mg immediately after transseptal access (steroid group). Another 45 consecutive patients underwent standard PVI without IV hydrocortisone (nonsteroid group). After PVI, all patients underwent adenosine testing to unmask dormant conduction. Patients were followed at 3, 6, and 12 months. RESULTS Dormant conduction was unmasked in a significantly higher proportion of PVs in the steroid group compared with the nonsteroid group (32.8% of PVs [60/183] vs 21.1% of PVs [37/175], P = .03). On multivariate generalized estimating equation analysis, steroid use remained independently associated with dormant PV conduction (P = .03). There was no difference in the segmental distribution of reconnection between the 2 groups. The 1-year freedom from recurrent AF did not differ between groups (P = .37). Radiofrequency time was significantly longer in the steroid group (58 ± 21 minutes vs 48 ± 18 minutes, P <.01), whereas procedure duration and fluoroscopy time were comparable (P = .55 and P = .44, respectively). CONCLUSION A single bolus of hydrocortisone 250 mg IV prior to PVI results in greater radiofrequency requirements for PVI and a higher prevalence of dormant PV conduction unmasked by adenosine. The utility of these approaches 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 Department of Medicine, Université de Montréal, Montreal, Canada,; Department of Medicine, The University of British Columbia, Vancouver, Canada.
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Morales GX, Macle L, Khairy P, Charnigo R, Davidson E, Thal S, Ching CK, Lellouche N, Whitbeck M, Delisle B, Thompson J, Di Biase L, Natale A, Nattel S, Elayi CS. Adenosine testing in atrial flutter ablation: unmasking of dormant conduction across the cavotricuspid isthmus and risk of recurrence. J Cardiovasc Electrophysiol 2013; 24:995-1001. [PMID: 23701241 DOI: 10.1111/jce.12174] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Revised: 03/26/2013] [Accepted: 04/05/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND Adenosine-induced hyperpolarization may identify pulmonary veins at risk of reconnection following electrical isolation for atrial fibrillation. The potential role of adenosine testing in other arrhythmic substrates, such as cavotricuspid isthmus (CTI)-dependent atrial flutter, remains unclear. We assessed whether dormant conduction across the CTI may be revealed by adenosine after ablation-induced bidirectional block, and its association with recurrent flutter. METHODS AND RESULTS Patients undergoing catheter ablation for CTI-dependent flutter were prospectively studied. After confirming bidirectional block across the CTI by standard pacing maneuvers, adenosine (≥ 12 mg IV) was administered to assess resumption of conduction, followed by isoproterenol (ISP) bolus. Further CTI ablation was performed for persistent (but not transient) resumption of conduction. Bidirectional block across the CTI was achieved in all 81 patients (63 males), age 61.2 ± 11.0 years. The trans-CTI time increased from 71.9 ± 18.1 milliseconds preablation to 166.2 ± 26.4 milliseconds postablation. Adenosine elicited resumption of conduction across the CTI in 7 patients (8.6%), 2 of whom had transient recovery. No additional patient with dormant conduction was identified by ISP. Over a follow-up of 11.8 ± 8.0 months, atrial flutter recurred in 4 (4.9%) patients, 3/7(42.9%) with a positive adenosine challenge versus 1/74 (1.3%) with a negative response, P = 0.0016 (relative risk 31.7). CONCLUSION Adenosine challenge following atrial flutter ablation provoked transient or persistent resumption of conduction across the CTI in almost 9% of patients and identified a subgroup at higher risk of flutter recurrence. It remains to be determined whether additional ablation guided by adenosine testing during the index procedure may further improve procedural outcomes.
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Affiliation(s)
- Gustavo X Morales
- University of Kentucky, Lexington, Kentucky; Lexington VA Medical Center, Lexington, Kentucky
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