Role of adenosine after antral pulmonary vein isolation of paroxysmal atrial fibrillation: A randomized controlled trial

Abstract

Background: Adenosine can reveal dormant pulmonary vein (PV) conduction after PV isolation (PVI) in patients with paroxysmal atrial fibrillation (AF). However, the impact of elimination of adenosine-provoked dormant PV conduction after PVI has not been formally evaluated.

Objective: The purpose of this study was to determine whether ablation of PV reconnections unmasked by adenosine improves outcomes.

Methods: Patients with paroxysmal AF (n = 129) were randomized to receive either adenosine (n = 61) or no adenosine (n = 68) after PVI. Dormant conduction revealed by adenosine after PVI was ablated until all adenosine-mediated reconnections were eliminated. Thereafter, both groups received isoproterenol.

Results: Acute reconnection was seen in 23 patients (37%) in the adenosine group. There was a significant difference between the number of PVs reconnected if patients were given adenosine >60 minutes after initial PVI compared to those who received adenosine <60 minutes after initial PVI (3/32 [9.4%] vs 24/32 [75%], P <.0001). Patients who did not receive adenosine had more PV reconnections after isoproterenol infusion compared to patients in the adenosine group (17/68 [25.0%] vs 5/61 [8.2%], P = .018). There was no difference in the rate of AF recurrence in patients who received adenosine (24/61 [39%]) compared to control patients (23/68 [34%], log-rank P = .83).

Conclusion: Adenosine can reveal dormant conduction in more than one-third of patients with paroxysmal AF undergoing PVI. However, adenosine administration, and additional ablation of the resultant connections, does not improve long-term outcomes compared to a protocol that includes isoproterenol infusion.

Keywords: Adenosine; Atrial fibrillation; Catheter ablation; Dormant conduction; Pulmonary vein.