CLINICAL VALUE OF ELIMINATION OF CONCEALED CONDUCTION REVEALED USING ADENOSINE TRIPHOSPHATE TEST AFTER PULMONARY VEIN RADIOFREQUENCY ISOLATION

To study the contribution of elimination of concealed conduction from pulmonary veins revealed with the aid of bolus administration of adenosine triphosphate to the effectiveness of radiofrequency catheter ablation (RFCA), 134 patients with paroxysmal and persistent atrial fibrillation (AF) and indications to RFCA were examined after the procedure. The patients were randomly distributed into two following groups: Group I (control group) where the concealed conduction was recorded but not subsequently eliminated (n=69) and Group II (n=65) where the concealed conduction was both registered and eliminated. No statistically significant difference in the clinical characteristics of the study group subjects was found. Most patients were men; three fourths of the study subjects had paroxysmal AF; in one fourth of the study subjects, typical atrial flutter was documented in addition to AF. The ablation catheter and circular 10 polar catheter were introduced into the left atrium via a transseptal access. Radiofrequency applications were made around the pulmonary vein antra in an irrigated regime until signs of the pulmonary vein isolation appear and the circular line closes. Later on, the patients were monitored for 30 minutes. In case of acute recurrence, additional radiofrequency applications were made in the “breach” area. After the period of monitoring, adenosine triphosphate tests were performed in all study subjects. If the concealed conduction in pulmonary veins was found, additional radiofrequency applications were made in transient “breach” areas in Group II until the negative test was reached, whereas in Group I the concealed conduction was left intact. The scheduled ECG Holter monitoring was performed in 3 and 6 months, as well as every 6 months thereafter. In all 134 cases, 268 ipsilateral pairs of pulmonary veins were isolated. The procedure duration was significantly longer in Group II (116±18 min and 130±16 min, respectively; p<0.0001). Nevertheless, the fluoroscopy time as well as the duration of radiofrequency applications did not significantly differ. The adenosine triphosphate test revealed concealed conduction in at least one ipsilateral pair of pulmonary veins in 31 of 134 subjects (23%). In total, the concealed conduction was found in 33 of 268 pairs (12%) of ipsilateral pulmonary veins. Within a three-year follow-up period, at least one sustained episode of AF or post-ablation tachycardia took place in 33 patients of Group I (48.8%) and 32 patients of Group II (49.2%), the difference was insignificant (log-rank test =0.084; p=0.77). Among 31 patients with the concealed treatment documented during the secondary adenosine triphosphate test, post-operation recurrence of arrhythmia occurred in 19 subjects (61%). At least one episode of AF or post-ablation tachycardia was found in 11 of 17 patients with concealed conduction in Group I (65%) and 8 of 14 patients with concealed conduction in Group II (57%). The difference in freedom of arrhythmia in patients with the concealed conduction in Group I and Group II did not reach the statistical significance (log-rank test =0.75; p=0.39). Thus, the elimination of concealed conduction revealed using the adenosine triphosphate test does not improve the late RFCA outcome.

atrial fibrillation, pulmonary veins, left duction, adenosine triphosphate

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