https://doi.org/10.1007/s00392-025-02625-4
1RHÖN-KLINIKUM AG Campus Bad Neustadt Kardiologie Bad Neustadt a. d. Saale, Deutschland; 2Krankenhaus Brilon Kardiologie Brilon, Deutschland; 3RHÖN-KLINIKUM AG Campus Bad Neustadt Klinik für Kardiologie II / Interventionelle Elektrophysiologie Bad Neustadt a. d. Saale, Deutschland; 4Zentralklinik Bad Berka GmbH Klinik für Kardiologie und Internistische Intensivmedizin Bad Berka, Deutschland; 5RHÖN-KLINIKUM AG Campus Bad Neustadt Klinik für Rhythmologie und Interventionelle Elektrophysiologie Bad Neustadt a. d. Saale, Deutschland
Background
There is a significant incidence of pulmonary vein (PV) conduction recovery after PV isolation (PVI) using conventional radiofrequency (RF) ablation and waiting time. With high-power short-duration (HPSD) ablation and use of ablation index (AI) PVI can be performed so fast that a waiting time of 20 min seems to be inappropriately long. Adenosin challenge was shown to unmask dormant PV conduction in up to 35% of PV after conventional RF ablation.
Objective:
The aim of this study was to evaluate the use of adenosine to uncover dormant conduction after HPSD ablation with ablation index (AI) guidance and the „CLOSE protocol“ but without a waiting period.
Methods
Atrial fibrillation (AF) patients (pt) undergoing their first PVI only procedure were consecutively included. The Thermocool SF ST catheter and CARTO3 were used for HPSD PVI performed at 50 W with a goal AI of at least 550 anteriorly and 400 posteriorly. Circumferential PVI lesions were applied starting with left-sided encircling and then right-sided encircling. First pass isolation was documented. After both encirclings were finished, the left PVs were first evaluated for bidirectional conduction block and then the right PVs were assessed with an adenosine challenge. In case of reconduction the gap was closed and adenosin challenge was repeated thereafter.
Results
Altogether, 33 pt were included (mean age 67 ±10 years, 70% men, 65% paroxysmal AF). First pass isolation was achieved in 76% of right PVs and 70% of left PVs. Additional cavotricuspid isthmus ablation was performed in 21% of patients. Mean procedure time for PVI only including adenosine challenge was 89 ±26 min. In 32/33 pt (97%), the right PVs were assessed by adenosine, and none of the 64 right PVs had conduction recovery. In one pt ablation started with right encircling, left PV were checked with adenosine without dormant conduction. In 22 (67%) pt, all PV were evaluated by adenosine. Two of the 44 left PVs reconnected. In both of those left PVs first pass isolation had not been achieved previously.
Conclusion
In this study, an adenosine challenge seems not to provide additional benefit in AI guided HPSD ablation when first pass isolation could be reached. Adenosine challenge might be more useful for detecting dormant conduction in those cases in which no first pass isolation was evident.