Achievement of successful pulmonary vein isolation: methods of adenosine testing and incremental benefit of exit block
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Several approaches were tried to achieve complete pulmonary vein isolation (PVI). The aims of this study were to (1) compare adenosine-induced PV conduction and exit conduction, (2) determine the adequate adenosine dose, and (3) investigate the correlation of dormant conduction and recurrence of atrial fibrillation (AF).
A total of 378 consecutive patients who underwent PVI from June 2012 to April 2015 were prospectively included (the de novo procedure in 318 (84.1 %) and a redo procedure in 60 (15.9 %)). After the exit block was assessed, 20 mg adenosine was injected into the left atrium. If dormant conduction was observed, 12 and 6 mg of adenosine were injected sequentially.
Exit conduction during PV pacing was observed in 34 patients (9 %), and dormant conduction was observed in 92 patients (24.3 %). Among them, 74 (80.4 %, 74/92) demonstrated dormant conduction without exit conduction and 16 (47.1 %, 16/34) showed exit conduction without dormant conduction. The 20-mg dose of adenosine had an additive yield in patients with dormant conduction, compared to that of 12 mg (93 %, 86/92) or 6 mg (80 %, 74/92). There was no significant difference in the recurrence rate regarding dormant conduction. The pattern of prevalence of reconnected origin during the redo procedure was similar to that of dormant conduction during the index procedure.
There was a discrepancy between adenosine-induced PVI and exit block. Therefore, exit block test has additional value to verify latent incomplete PVI in conjunction with adenosine test. Furthermore, high-dose adenosine had an additive yield.
Clinical trial registration
KeywordsAdenosine Exit conduction Pulmonary vein isolation Atrial fibrillation Recurrence
We thank Jeong-Wook Park, Young-Woong Ha, Bo-Kyung Kim, and Inae Jung for their technical support and patient care and reporting.
Compliance with ethical standards
Conflict of interest
All procedures performed in the present study were in accordance with the ethical standards of the institutional review board of the Catholic Medical Center, South Korea.
- 3.Cappato, R., Negroni, S., Pecora, D., Bentivegna, S., Lupo, P. P., Carolei, A., et al. (2003). Prospective assessment of late conduction recurrence across radiofrequency lesions producing electrical disconnection at the pulmonary vein ostium in patients with atrial fibrillation. Circulation, 108(13), 1599–1604.CrossRefPubMedGoogle Scholar
- 5.Ouyang, F., Antz, M., Ernst, S., Hachiya, H., Mavrakis, H., Deger, F. T., et al. (2005). Recovered pulmonary vein conduction as a dominant factor for recurrent atrial tachyarrhythmias after complete circular isolation of the pulmonary veins: lessons from double Lasso technique. Circulation, 111(2), 127–135.CrossRefPubMedGoogle Scholar
- 12.Lin, F. S., Ip, J. E., Markowitz, S. M., Liu, C. F., Thomas, G., Lerman, B. B., et al. (2015). Limitations of dormant conduction as a predictor of atrial fibrillation recurrence and pulmonaryvein reconnection after catheter ablation. Pacing and Clinical Electrophysiology, 38(5), 598–607.CrossRefPubMedGoogle Scholar
- 13.Macle, L., Khairy, P., Weerasooriya, R., Novak, P., Verma, A., Willems, S., et al. (2015). Adenosine-guided pulmonary vein isolation for the treatment of paroxysmal atrial fibrillation: an international, multicentre, randomised superiority trial. The Lancet, 386(9994), 672–679.CrossRefGoogle Scholar
- 14.Kobori, A., Shizuta, S., Inoue, K., Kaitani, K., Morimoto, T., Nakazawa, Y., et al. (2015). Adenosine triphosphate-guided pulmonary vein isolation for atrial fibrillation: the UNmasking Dormant Electrical Reconduction by Adenosine TriPhosphate (UNDER-ATP) trial. European Heart Journal, 36(46), 3276–3287.PubMedGoogle Scholar
- 15.Kistler, P. M., Ho, S. Y., Rajappan, K., Morper, M., Harris, S., Abrams, D., et al. (2007). Electrophysiologic and anatomic characterization of sites resistant to electrical isolation during circumferential pulmonary vein ablation for atrial fibrillation: a prospective study. Journal of Cardiovascular Electrophysiology, 18(12), 1282–1288.CrossRefPubMedGoogle Scholar
- 16.Kaitani, K., Kurotobi, T., Kobori, A., Okajima, K., Yao, T., Nakazawa, Y., et al. (2014). Late re-conduction sites in the second session after pulmonary vein isolation using adenosine provocation for atrial fibrillation. Europace: European Pacing, Arrhythmias, and Cardiac Electrophysiology, 16(4), 521–527.CrossRefPubMedGoogle Scholar
- 17.Andrade, J. G., Pollak, S. J., Monir, G., Khairy, P., Dubuc, M., Roy, D., et al. (2013). 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. Circulation. Arrhythmia and Electrophysiology, 6(6), 1103–1108.CrossRefPubMedGoogle Scholar
- 18.Anter, E., Contreras-Valdes, F. M., Shvilkin, A., Tschabrunn, C. M., & Josephson, M. E. (2014). Acute pulmonary vein reconnection is a predictor of atrial fibrillation recurrence following pulmonary vein isolation. Journal of Interventional Cardiac Electrophysiology, 39(3), 225–232.CrossRefPubMedGoogle Scholar
- 22.Cheung, J. W., Lin, F. S., Ip, J. E., Bender, S. R., Siddiqi, F. K., Liu, C. F., et al. (2013). Adenosine-induced pulmonary vein ectopy as a predictor of recurrent atrial fibrillation after pulmonary vein isolation. Circulation. Arrhythmia and Electrophysiology, 6(6), 1066–1073.CrossRefPubMedGoogle Scholar