What does this research mean for the field?

Adenosine administration after epicardial pulmonary vein isolation using a bipolar radiofrequency clamp during hybrid atrial fibrillation ablation reveals acute reconduction in only 1% of pulmonary veins. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

March 11, 2017Journal of Interventional Cardiac ElectrophysiologyOpen Access

Adenosine administration during hybrid atrial fibrillation ablation to test dormant pulmonary vein conduction

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Why the study?

Does adenosine administration unmask dormant pulmonary vein conduction in patients undergoing hybrid atrial fibrillation ablation?

Structured PICO

Does adenosine administration unmask dormant pulmonary vein conduction in patients undergoing hybrid atrial fibrillation ablation?

Population

24 patients (21 male, 55 ± 9 years) undergoing hybrid ablation for symptomatic paroxysmal (n = 12) and persistent (n = 12) atrial fibrillation.

Intervention

Adenosine (12 to 36 mg) administered intravenously as a bolus 30 minutes after epicardial pulmonary vein isolation (PVI) using a bipolar radiofrequency clamp.

Outcome

Dormant conduction (reappearance of pulmonary vein potentials during at least one beat) assessed for each pulmonary vein using an in situ circular mapping catheter.surrogate

Adenosine administration after epicardial PVI during hybrid AF ablation reveals a very low rate (1%) of acute pulmonary vein reconduction, suggesting epicardial clamping creates highly durable transmural lesions.

Limitations

Small number of patients in this single-center study prevents definitive conclusions.
It remains unclear whether additional endocardial application of RF at sites showing acute reconnection improves long-term results.
Previous catheter ablation may have favorably influenced the results.
The creation of additional linear lesions (roof and inferior line) connecting with antral PVI may have reduced finding dormant conduction.
The role of general anesthesia may have played a role in the low prevalence of PV reconnection.

Implication

Supports durable epicardial lesions in hybrid AF ablation; leaves open need for randomized trials on adenosine testing.

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.