Adenosine testing in atrial flutter ablation: Unmasking of dormant conduction across the cavotricuspid isthmus and risk of recurrence

Gustavo X. Morales, Laurent Macle, Paul Khairy, Richard Charnigo, Evan Davidson, Sergio Thal, Ck Ching, Nicolas Lellouche, Matthew Whitbeck, Brian Delisle, Jenks Thompson, Luigi Di Biase, Andrea Natale, Stanley Nattel, Claude S. Elayi

Research output: Contribution to journalArticle

13 Citations (Scopus)

Abstract

Adenosine Unmasking Dormant Conduction Across the Cavotricuspid Isthmus Background Adenosine-induced hyperpolarization may identify pulmonary veins at risk of reconnection following electrical isolation for atrial fibrillation. The potential role of adenosine testing in other arrhythmic substrates, such as cavotricuspid isthmus (CTI)-dependent atrial flutter, remains unclear. We assessed whether dormant conduction across the CTI may be revealed by adenosine after ablation-induced bidirectional block, and its association with recurrent flutter. Methods and Results Patients undergoing catheter ablation for CTI-dependent flutter were prospectively studied. After confirming bidirectional block across the CTI by standard pacing maneuvers, adenosine (≥12 mg IV) was administered to assess resumption of conduction, followed by isoproterenol (ISP) bolus. Further CTI ablation was performed for persistent (but not transient) resumption of conduction. Bidirectional block across the CTI was achieved in all 81 patients (63 males), age 61.2 ± 11.0 years. The trans-CTI time increased from 71.9 ± 18.1 milliseconds preablation to 166.2 ± 26.4 milliseconds postablation. Adenosine elicited resumption of conduction across the CTI in 7 patients (8.6%), 2 of whom had transient recovery. No additional patient with dormant conduction was identified by ISP. Over a follow-up of 11.8 ± 8.0 months, atrial flutter recurred in 4 (4.9%) patients, 3/7(42.9%) with a positive adenosine challenge versus 1/74 (1.3%) with a negative response, P = 0.0016 (relative risk 31.7). Conclusion Adenosine challenge following atrial flutter ablation provoked transient or persistent resumption of conduction across the CTI in almost 9% of patients and identified a subgroup at higher risk of flutter recurrence. It remains to be determined whether additional ablation guided by adenosine testing during the index procedure may further improve procedural outcomes.

Original languageEnglish (US)
Pages (from-to)995-1001
Number of pages7
JournalJournal of Cardiovascular Electrophysiology
Volume24
Issue number9
DOIs
StatePublished - Sep 2013
Externally publishedYes

Fingerprint

Atrial Flutter
Adenosine
Recurrence
Isoproterenol
Catheter Ablation
Pulmonary Veins
Atrial Fibrillation

Keywords

  • adenosine
  • atrial flutter
  • catheter ablation
  • supraventricular tachycardia
  • transient conduction

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

Cite this

Adenosine testing in atrial flutter ablation : Unmasking of dormant conduction across the cavotricuspid isthmus and risk of recurrence. / Morales, Gustavo X.; Macle, Laurent; Khairy, Paul; Charnigo, Richard; Davidson, Evan; Thal, Sergio; Ching, Ck; Lellouche, Nicolas; Whitbeck, Matthew; Delisle, Brian; Thompson, Jenks; Di Biase, Luigi; Natale, Andrea; Nattel, Stanley; Elayi, Claude S.

In: Journal of Cardiovascular Electrophysiology, Vol. 24, No. 9, 09.2013, p. 995-1001.

Research output: Contribution to journalArticle

Morales, GX, Macle, L, Khairy, P, Charnigo, R, Davidson, E, Thal, S, Ching, C, Lellouche, N, Whitbeck, M, Delisle, B, Thompson, J, Di Biase, L, Natale, A, Nattel, S & Elayi, CS 2013, 'Adenosine testing in atrial flutter ablation: Unmasking of dormant conduction across the cavotricuspid isthmus and risk of recurrence', Journal of Cardiovascular Electrophysiology, vol. 24, no. 9, pp. 995-1001. https://doi.org/10.1111/jce.12174
Morales, Gustavo X. ; Macle, Laurent ; Khairy, Paul ; Charnigo, Richard ; Davidson, Evan ; Thal, Sergio ; Ching, Ck ; Lellouche, Nicolas ; Whitbeck, Matthew ; Delisle, Brian ; Thompson, Jenks ; Di Biase, Luigi ; Natale, Andrea ; Nattel, Stanley ; Elayi, Claude S. / Adenosine testing in atrial flutter ablation : Unmasking of dormant conduction across the cavotricuspid isthmus and risk of recurrence. In: Journal of Cardiovascular Electrophysiology. 2013 ; Vol. 24, No. 9. pp. 995-1001.
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abstract = "Adenosine Unmasking Dormant Conduction Across the Cavotricuspid Isthmus Background Adenosine-induced hyperpolarization may identify pulmonary veins at risk of reconnection following electrical isolation for atrial fibrillation. The potential role of adenosine testing in other arrhythmic substrates, such as cavotricuspid isthmus (CTI)-dependent atrial flutter, remains unclear. We assessed whether dormant conduction across the CTI may be revealed by adenosine after ablation-induced bidirectional block, and its association with recurrent flutter. Methods and Results Patients undergoing catheter ablation for CTI-dependent flutter were prospectively studied. After confirming bidirectional block across the CTI by standard pacing maneuvers, adenosine (≥12 mg IV) was administered to assess resumption of conduction, followed by isoproterenol (ISP) bolus. Further CTI ablation was performed for persistent (but not transient) resumption of conduction. Bidirectional block across the CTI was achieved in all 81 patients (63 males), age 61.2 ± 11.0 years. The trans-CTI time increased from 71.9 ± 18.1 milliseconds preablation to 166.2 ± 26.4 milliseconds postablation. Adenosine elicited resumption of conduction across the CTI in 7 patients (8.6{\%}), 2 of whom had transient recovery. No additional patient with dormant conduction was identified by ISP. Over a follow-up of 11.8 ± 8.0 months, atrial flutter recurred in 4 (4.9{\%}) patients, 3/7(42.9{\%}) with a positive adenosine challenge versus 1/74 (1.3{\%}) with a negative response, P = 0.0016 (relative risk 31.7). Conclusion Adenosine challenge following atrial flutter ablation provoked transient or persistent resumption of conduction across the CTI in almost 9{\%} of patients and identified a subgroup at higher risk of flutter recurrence. It remains to be determined whether additional ablation guided by adenosine testing during the index procedure may further improve procedural outcomes.",
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T2 - Unmasking of dormant conduction across the cavotricuspid isthmus and risk of recurrence

AU - Morales, Gustavo X.

AU - Macle, Laurent

AU - Khairy, Paul

AU - Charnigo, Richard

AU - Davidson, Evan

AU - Thal, Sergio

AU - Ching, Ck

AU - Lellouche, Nicolas

AU - Whitbeck, Matthew

AU - Delisle, Brian

AU - Thompson, Jenks

AU - Di Biase, Luigi

AU - Natale, Andrea

AU - Nattel, Stanley

AU - Elayi, Claude S.

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N2 - Adenosine Unmasking Dormant Conduction Across the Cavotricuspid Isthmus Background Adenosine-induced hyperpolarization may identify pulmonary veins at risk of reconnection following electrical isolation for atrial fibrillation. The potential role of adenosine testing in other arrhythmic substrates, such as cavotricuspid isthmus (CTI)-dependent atrial flutter, remains unclear. We assessed whether dormant conduction across the CTI may be revealed by adenosine after ablation-induced bidirectional block, and its association with recurrent flutter. Methods and Results Patients undergoing catheter ablation for CTI-dependent flutter were prospectively studied. After confirming bidirectional block across the CTI by standard pacing maneuvers, adenosine (≥12 mg IV) was administered to assess resumption of conduction, followed by isoproterenol (ISP) bolus. Further CTI ablation was performed for persistent (but not transient) resumption of conduction. Bidirectional block across the CTI was achieved in all 81 patients (63 males), age 61.2 ± 11.0 years. The trans-CTI time increased from 71.9 ± 18.1 milliseconds preablation to 166.2 ± 26.4 milliseconds postablation. Adenosine elicited resumption of conduction across the CTI in 7 patients (8.6%), 2 of whom had transient recovery. No additional patient with dormant conduction was identified by ISP. Over a follow-up of 11.8 ± 8.0 months, atrial flutter recurred in 4 (4.9%) patients, 3/7(42.9%) with a positive adenosine challenge versus 1/74 (1.3%) with a negative response, P = 0.0016 (relative risk 31.7). Conclusion Adenosine challenge following atrial flutter ablation provoked transient or persistent resumption of conduction across the CTI in almost 9% of patients and identified a subgroup at higher risk of flutter recurrence. It remains to be determined whether additional ablation guided by adenosine testing during the index procedure may further improve procedural outcomes.

AB - Adenosine Unmasking Dormant Conduction Across the Cavotricuspid Isthmus Background Adenosine-induced hyperpolarization may identify pulmonary veins at risk of reconnection following electrical isolation for atrial fibrillation. The potential role of adenosine testing in other arrhythmic substrates, such as cavotricuspid isthmus (CTI)-dependent atrial flutter, remains unclear. We assessed whether dormant conduction across the CTI may be revealed by adenosine after ablation-induced bidirectional block, and its association with recurrent flutter. Methods and Results Patients undergoing catheter ablation for CTI-dependent flutter were prospectively studied. After confirming bidirectional block across the CTI by standard pacing maneuvers, adenosine (≥12 mg IV) was administered to assess resumption of conduction, followed by isoproterenol (ISP) bolus. Further CTI ablation was performed for persistent (but not transient) resumption of conduction. Bidirectional block across the CTI was achieved in all 81 patients (63 males), age 61.2 ± 11.0 years. The trans-CTI time increased from 71.9 ± 18.1 milliseconds preablation to 166.2 ± 26.4 milliseconds postablation. Adenosine elicited resumption of conduction across the CTI in 7 patients (8.6%), 2 of whom had transient recovery. No additional patient with dormant conduction was identified by ISP. Over a follow-up of 11.8 ± 8.0 months, atrial flutter recurred in 4 (4.9%) patients, 3/7(42.9%) with a positive adenosine challenge versus 1/74 (1.3%) with a negative response, P = 0.0016 (relative risk 31.7). Conclusion Adenosine challenge following atrial flutter ablation provoked transient or persistent resumption of conduction across the CTI in almost 9% of patients and identified a subgroup at higher risk of flutter recurrence. It remains to be determined whether additional ablation guided by adenosine testing during the index procedure may further improve procedural outcomes.

KW - adenosine

KW - atrial flutter

KW - catheter ablation

KW - supraventricular tachycardia

KW - transient conduction

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