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Review
. 2016:2016:8632509.
doi: 10.1155/2016/8632509. Epub 2016 Feb 15.

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

Paolo D Dallaglio  1 , Timothy R Betts  2 , Matthew Ginks  2 , Yaver Bashir  2 , Ignasi Anguera  1 , Kim Rajappan  2
Affiliations
Review

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

Paolo D Dallaglio et al. Cardiol Res Pract. 2016.

Abstract

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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Figures

Figure 1
Figure 1
Microelectrode recordings before and after pulmonary vein isolation in a PV without dormant conduction (upper panel) and in a PV with dormant conduction (lower panel). S: stimulus artifacts with no response. Dotted line: excitability threshold at −50 mV (adapted from Datino et al. [7]).
Figure 2
Figure 2
Freedom from AF in three nonrandomized retrospective studies comparing adenosine given versus adenosine not given [–14]. PVI: pulmonary vein isolation.
Figure 3
Figure 3
Freedom from AF in three nonrandomized studies comparing patients with adenosine induced reconnection and reablation (dormant PV) versus no reconnection [15, 17, 18]. PV: pulmonary vein.
Figure 4
Figure 4
Freedom from symptomatic atrial tachyarrhythmia after a single ablation procedure in the ADVICE trial [9, 10].
Figure 5
Figure 5
(a) Study algorithm and results from Yamane et al. [32]; PVAI: pulmonary vein isolation, ATP: Adenosine Triphosphate. (b) Incidence of reconnection in individual pulmonary veins mediated by adenosine and/or time, adapted from Jiang et al. [33] (see text for details).
Figure 6
Figure 6
(a) Adenosine testing results and PV reconnection rate at redo procedure in Lin et al. [34]. (b) Example of redo procedure reconnection sites that totally differed from DC sites at first procedure [35]. DC: dormant conduction. PVI: pulmonary vein isolation (see text for details).
See this image and copyright information in PMC

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