Time matters: adenosine testing immediately after pulmonary vein isolation does not substitute a waiting period

Teunissen, Cas; Clappers, Nick; Kassenberg, Wil; Hassink, Rutger J.; Heijden, Jeroen F. van der; Loh, Peter

doi:10.1093/europace/euw173

Cited by 9 publications

(4 citation statements)

References 10 publications

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“…[9] Many studies have shown that most reconnections occur during the first 30 min after the initial PVI, with a significant proportion of patients having further reconnections at 60 min and very few between 60 and 90 min. [10,11,12,13] Consequently, in the "2017 HRS/EHRA/ECAS/APHRS/SOLAECE Expert Consensus statement on catheter and surgical ablation of AF", experts recommend a 20 min waiting period as a reasonable option during AF ablation using RF energy (Class IIa recommendation). [2] Adenosine induces a transient hyperpolarization of the resting membrane potential of cardiomyocytes, restoring excitability in damaged but viable cells and, consequently, the conduction between PVs and the left atrium.…”

Section: Avoiding Gaps During the Initial Ablationmentioning

confidence: 99%

Localization of Residual Conduction Gaps After Wide Antral Circumferential Ablation of Pulmonary Veins

Martins

Galand

Béhar

et al. 2019

JACC: Clinical Electrophysiology

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Section: Avoiding Gaps During the Initial Ablationmentioning

confidence: 99%

Localization of Residual Conduction Gaps After Wide Antral Circumferential Ablation of Pulmonary Veins

Martins

Galand

Béhar

et al. 2019

JACC: Clinical Electrophysiology

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“…This was confirmed in a recent meta-analysis indicating a potential benefit of adenosine administration for detection of dormant conduction [47]. Nevertheless, adenosine testing cannot be used as a substitute for the waiting period following successful PVI [48] but rather as an adjunct.…”

Section: Choice Of the Appropriate Techniquementioning

confidence: 72%

Catheter ablation of atrial fibrillation: current status, techniques, outcomes and challengesCatheter ablation of atrial fibrillation: current status, techniques, outcomes, and challenges

Hindricks¹,

Shamloo²,

Lenarczyk³

et al. 2018

Kardiol Pol

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Atrial fibrillation (AF) is the most common human arrhythmia. Interventional treatment with catheter ablation is an established technique that is increasingly applied and has become one of the main treatment modalities in patients with AF. Ablation results in significant improvement of symptoms and the quality of life. There is as yet no clear evidence of any impact of the procedure on hard clinical endpoints, except in patients with heart failure, who seem to benefit significantly from ablation. The cornerstone of the procedure is the achievement of pulmonary vein isolation. Radiofrequency energy is the main applied energy source, but cryoballoon ablation has emerged as a safe and effective alternative to radiofrequency ablation. Additional ablation strategies and novel technical features have been proposed but without unequivocal proof of clinical benefit. The most promising of these seems to be substrate mapping of the left atrium with substrate modification in areas with low voltage as an adjunct to pulmonary vein isolation. Complication rates remain considerable despite accumulated experience and can be partly reduced by application of preventive measures.

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“…A possible explanation for the discrepancy is the timing of the adenosine/ATP testing after PVI. Teunissen [ 1 5 _ T D $ D I F F ] et al [21] reported that adenosine testing immediately after PVI did not reliably exclude later spontaneous or adenosine-induced PV reconnection and that adenosine testing should thus be performed after an appropriate observation period (!30 min[ 1 6 _ T D $ D I F F ] ) to reduce the risk of PV reconnection.…”

Section: Dormant La-pv Reconduction By Atpmentioning

confidence: 99%

“…Teunissen [ 1 5 _ T D $ D I F F ] et al [21] reported that in patients who showed no reconnection during immediate adenosine testing, 12.5% of the left PVs and 30.6% of the right PVs showed either spontaneous or restored PV conduction during late adenosine testing. We reported that some sites of ATP-provoked dormant conduction were identical to unipolar pace-capture sites with excitable gaps along the ablation line, but this was not true of most PV sites, suggesting that the main underlying mechanism differs between the [ 2 2 _ T D $ D I F F ] two forms of reconnection [28].…”

Section: Comparison Of Dormant La-pv Conduction and Late Pv Reconnection Sitesmentioning

confidence: 99%

No association between dormant conduction sites and pulmonary vein reconnection sites in late atrial fibrillation recurrence after catheter ablation

Iso

Watanabe

Okumura

et al. 2018

Journal of Cardiology

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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 AE 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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Time matters: adenosine testing immediately after pulmonary vein isolation does not substitute a waiting period

Abstract: Adenosine testing immediately after PVAI does not reliably exclude later spontaneous or adenosine-induced PV reconnection. Adenosine testing should be performed after an appropriate observation period to reduce risk of PV reconnection.

Cited by 9 publications

References 10 publications

Localization of Residual Conduction Gaps After Wide Antral Circumferential Ablation of Pulmonary Veins

Localization of Residual Conduction Gaps After Wide Antral Circumferential Ablation of Pulmonary Veins

Catheter ablation of atrial fibrillation: current status, techniques, outcomes and challengesCatheter ablation of atrial fibrillation: current status, techniques, outcomes, and challenges

No association between dormant conduction sites and pulmonary vein reconnection sites in late atrial fibrillation recurrence after catheter ablation

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