The Role of Adenosine in Pulmonary Vein Isolation: A Critical Review

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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The impact of left atrium size on selection of the pulmonary vein isolation method for atrial fibrillation: Cryoballoon or radiofrequency catheter ablation

American Heart Journal ◽

10.1016/j.ahj.2020.10.061 ◽

2021 ◽

Vol 231 ◽

pp. 82-92

Author(s):

Takashi Ikenouchi ◽

Osamu Inaba ◽

Tomomasa Takamiya ◽

Yukihiro Inamura ◽

Akira Sato ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Left Atrium ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Radiofrequency Catheter Ablation ◽

Isolation Method ◽

The Impact ◽

Left Atrium Size ◽

Selection Of

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Changes of QT interval in the acute phase after pulmonary vein isolation for paroxysmal atrial fibrillation

European Heart Journal ◽

10.1093/ehjci/ehaa946.0414 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

A Chikata ◽

T Kato ◽

K Ududa ◽

S Fujita ◽

K Otowa ◽

...

Keyword(s):

Atrial Fibrillation ◽

Pulmonary Vein ◽

Female Patient ◽

Pulmonary Vein Isolation ◽

Acute Phase ◽

Paroxysmal Atrial Fibrillation ◽

Qt Interval ◽

Qt Prolongation ◽

Qtc Interval ◽

The Impact

Abstract Introduction Pulmonary vein isolation (PVI) affects ganglionated plexi (GP) around the atrium, leading to a modification of the intrinsic cardiac autonomic system (ANS). In animal models, GP ablation has a potential risk of QT prolongation and ventricular arrhythmias. However, the impact of PVI on QT intervals in humans remains unclear. Purpose This study aims to evaluate the Impact of PVI on QT interval in patients with paroxysmal atrial fibrillation. Methods We analyzed consecutive 117 PAF patients for their first PVI procedures. 12-lead ECG was evaluated at baseline, 4 hr, day 1, 1 month, and 3 months after ablation. Only patients with sinus rhythm on 12-lead ECG at each evaluation point without antiarrhythmic drugs were included. Results Heart rate significantly increased at 4 hr, day 1, and 1 month. Raw QT interval prolonged at 4 hr (417.1±41.6 ms, P<0.001) but shortened at day 1 (376.4±34.1 ms, P<0.001), 1 month (382.2±31.5 ms, P<0.001), and 3 months (385.1±32.8 ms, P<0.001) compared to baseline (391.6±31.4 ms). Bazett- and Fridericia- corrected QTc intervals significantly prolonged at 4hr (Bazett: 430.8±27.9 ms, P<0.001; Fridericia: 425.8±27.4 ms, P<0.001), day1 (Bazett: 434.8±22.3 ms, P<0.001; Fridericia: 414.1±23.7 ms, P<0.001), 1M (Bazett: 434.8±22.3 ms, P<0.001; Fridericia: 408.2±21.0 ms, P<0.05), and 3M (Bazett: 420.1±21.8 ms, P<0.001; Fridericia: 407.8±21.1 ms, P<0.05) compared to baseline (Bazett: 404.9±25.2 ms; Fridericia: 400.0±22.6 ms). On the other hand, Framingham- and Hodges- corrected QTc interval significantly prolonged only at 4hr (Framingham: 424.1±26.6 ms, P<0.001; Hodges: 426.8±28.4 ms, P<0.001) and at day1 (Framingham: 412.3±29.3 ms, P<0.01; Hodges: 410.6±40.2 ms, P<0.05) compared to baseline (Framingham: 399.2±22.7 ms; Hodges: 400.7±22.8 ms). At 4 hr after ablation, raw QT and QTc of all formulas significantly prolonged than baseline. Raw QT and QTc prolongation at 4hr after ablation were more frequently observed in female patients. Multiple regression analysis revealed that female patient is a significant predictor of raw QT and QTc interval prolongation of all formulas 4hr after PVI. Conclusions Raw QT and QTc prolonged after PVI, especially in the acute phase. Female patient is a risk factor for QT prolongation in the acute phase after PVI. Funding Acknowledgement Type of funding source: None

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Predictors of recurrence after durable pulmonary vein isolation for paroxysmal atrial fibrillation

EP Europace ◽

10.1093/europace/euaa383 ◽

2020 ◽

Author(s):

Michelle Lycke ◽

Maria Kyriakopoulou ◽

Milad El Haddad ◽

Jean-Yves Wielandts ◽

Gabriela Hilfiker ◽

...

Keyword(s):

Atrial Fibrillation ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Paroxysmal Atrial Fibrillation ◽

Prospective Trial ◽

High Rate ◽

Binary Logistic Regression Analysis ◽

Ablation Time ◽

Increased Risk ◽

Af Recurrence

Abstract Aims Catheter ablation of paroxysmal atrial fibrillation (AF) reduces AF recurrence, AF burden, and improves quality of life. Data on clinical and procedural predictors of arrhythmia recurrence are scarce and are flawed by the high rate of pulmonary vein reconnection evidenced during repeat procedures after pulmonary vein isolation (PVI). In this study, we identified clinical and procedural predictors for AF recurrence 1 year after CLOSE-guided PVI, as this strategy has been associated with an increased PVI durability. Methods and results Patients with paroxysmal AF, who received CLOSE-guided PVI and who participated in a prospective trial in our centre, were included in this study. Uni- and multivariate models were plotted to find clinical and procedural predictors for AF recurrence within 1 year. Three hundred twenty-five patients with a mean age of 63 years (CHA2DS2VASc 1 [1–3], left atrium diameter 41 ± 6 mm) were included. About 60.9% were male individuals. After 1 year, AF recurrence occurred in 10.5% of patients. In a binary logistic regression analysis, the diagnosis-to-ablation time (DAT) was found to be the strongest predictor of AF recurrence (P = 0.011). Diagnosis-to-ablation time ≥1 year was associated with a nearly two-fold increased risk for developing AF recurrence. Conclusion The DAT is the most important predictor of arrhythmia recurrence in low-risk patients treated with durable pulmonary vein isolation for paroxysmal AF. Whether reducing the DAT could improve long-term outcomes should be investigated in another trial.

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Anatomic variants of pulmonary venous drainage and their relation to recurrences of atrial fibrillation after pulmonary vein isolation

Bulgarian Cardiology ◽

10.3897/bgcardio.27.e71311 ◽

2021 ◽

Vol 27 (3) ◽

pp. 55-68

Author(s):

Svetla Dineva ◽

Milko Stoyanov ◽

Aneliya Partenova ◽

Boyan Kunev ◽

Victoria Stoyanova ◽

...

Keyword(s):

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Local Population ◽

Venous Drainage ◽

Anatomical Variant ◽

Cox Regression Analysis ◽

Anatomical Variants ◽

The Impact ◽

Variant Anatomy ◽

Af Recurrence

Anatomical variants of pulmonary venous drainage in the left atrium are often found. Divergent results have been reported on the impact of variant anatomy on atrial ﬁ brillation (AF) recurrence after catheter ablation. We aimed to study the frequency of different anatomical variants of pulmonary venous drainage and their relationship with documented recurrences of AF after ablation. Material and methods: A retrospective study of patients with AF in whom radiofrequency pulmonary vein isolation was done after previously performed cardiac contrast-enhanced multidetector computed tomography. Clinical and procedural characteristics, type and frequency of anatomical variants of the veno-atrial junction and their association with AF recurrences were studied. Results: One hundred seventy-seven patients (112 men, 63.3%) with AF were studied, of which 148 (83.6%) with paroxysmal AF. Variant anatomy was found in 91 patients (51.4%). In 20.9% there was a common left trunk, in 23.2% – more or less than two right-sided veins, and in 7.3% – variations for both right and left veins. No differences in clinical and procedural characteristics were found between the groups with normal and variant anatomy. Recurrences of AF and their association with pulmonary venous anatomy were studied in 104 patients with follow-up ≥ 3 months. No signiﬁ cant relation was found between the presence of variant anatomy and AF recurrences within the blinding period after ablation, OR = 0.864, 95% CI = 0.397 – 1.88, p = 0.843, nor afterwards, OR = 1.12, 95% CI = 0.5 – 2.5, p = 0.839. Cox regression analysis showed no differences in AF recurrence-free survival regardless of the anatomical variant of pulmonary venous drainage, HR = 1.09, 95% CI = 0.58 – 2.05, p = 0.779. Conclusion: In this local population of patients with AF, the incidence of variant pulmonary venous drainage is just over 50%. No association was found between variant anatomy and the rate of AF recurrences after ﬁ rst pulmonary vein isolation.

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Abstract 15934: Comparison of Atrial Fibrillation Burden Reduction in Patients With Paroxysmal and Persistent Atrial Fibrillation Undergoing Cryoballoon Pulmonary Vein Isolation

Circulation ◽

10.1161/circ.142.suppl_3.15934 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Dan L Musat ◽

Nicolle S Milstein ◽

Jacqueline Pimienta ◽

Advay Bhatt ◽

Tina C Sichrovsky ◽

...

Keyword(s):

Atrial Fibrillation ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Persistent Atrial Fibrillation ◽

Loop Recorder ◽

Similar Reduction ◽

Af Ablation ◽

Ablation Success ◽

One Year ◽

Af Recurrence

Background: Pulmonary vein isolation (PVI) is a cornerstone of atrial fibrillation (AF) ablation procedures to treat symptomatic AF. Ablation success is defined by absence of AF recurrence >30 seconds. However, reduction in AF burden (AFB) is also an important endpoint. Whether patients with paroxysmal (PAF) and persistent AF (PeAF) have similar reduction in AFB post-ablation is unknown. Objective: To compare the decrease in AFB following cryoballoon (CB) PVI in patients with PAF and PeAF. Methods: We enrolled consecutive pts with an implantable loop recorder (ILR) who subsequently underwent CB PVI. All patients were followed prospectively for at least one year, or until repeat ablation; we compared AFB pre and post-ablation. Results: The cohort included had 47 patients (66 ± 10 years; 32 [68%] male; PAF [n=23, 49%]; CHA 2 DS 2 -VASc 2.7 ± 1.7, 34 [72%] on AAD at the time of ablation). A median of 136 days [IQR 280, 73; minimum of 30 days] of ILR data pre-ablation were available. The median AFB for PAF was 4.7% [IQR 0.9, 14.8] and PeAF was 6.8% [IQR 1.1, 40.4]. After excluding a 3-month post-ablation blanking period, recurrent AF occurred in 12 (52%) PAF and 11 (46%) PeAF patients. The median AFB post-ablation for PAF and PeAF cohorts was 0.03%, [IQR 0, 0.3] and 0.04%, [IQR 0, 1.1], respectively. This represents a >99% reduction in AFB. Conclusion: Although 50% of patients undergoing CB PVI for PAF or PeAF had a recurrence of AF, there was >99% reduction in AFB in both groups. These data highlight the importance of using AFB burden as a marker of therapeutic efficacy post-AF ablation.

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Addition of B-Type Natriuretic Peptide to Existing Clinical Risk Scores Enhances Identification of Patients at Risk for Atrial Fibrillation Recurrence After Pulmonary Vein Isolation

Critical Pathways in Cardiology ◽

10.1097/hpc.0000000000000060 ◽

2015 ◽

Vol 14 (4) ◽

pp. 157-165 ◽

Cited By ~ 5

Author(s):

Amir Y. Shaikh ◽

Nada Esa ◽

William Martin-Doyle ◽

Menhel Kinno ◽

Iryna Nieto ◽

...

Keyword(s):

Atrial Fibrillation ◽

At Risk ◽

Pulmonary Vein ◽

Natriuretic Peptide ◽

Pulmonary Vein Isolation ◽

Risk Scores ◽

Atrial Fibrillation Recurrence ◽

Clinical Risk ◽

Patients At Risk

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Intraprocedural endpoints to predict durable pulmonary vein isolation: a randomized trial of four post-ablation techniques

EP Europace ◽

10.1093/europace/euz301 ◽

2019 ◽

Vol 22 (4) ◽

pp. 567-575 ◽

Cited By ~ 4

Author(s):

Ruhong Jiang ◽

Minglong Chen ◽

Bing Yang ◽

Qiang Liu ◽

Zuwen Zhang ◽

...

Keyword(s):

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Af Ablation ◽

Group 4 ◽

Initial Procedure ◽

Group 2 ◽

Waiting Periods ◽

The Impact ◽

Af Recurrence

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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