Clinical Significance of Induction of Atrial Fibrillation after Pulmonary Vein Isolation

Keywords: catheter ablation, arrhythmogenic substrate, recurrence, paroxysmal form, persistent form

Abstract

Pulmonary vein isolation is a standard for catheter treatment of atrial fibrillation (AF). As for the need for additional impact on the arrhythmogenic substrate in the atria, there is no consensus or unified technique.

The aim. To study the efficiency of AF induction by frequent atrial pacing as a prognostic criterium for arrhythmia recurrence in the long term after catheter treatment.

Materials and methods. We analyzed 55 catheter procedures of AF ablation in 55 patients (27 women, mean age 52 ± 6.8 years) without structural heart disease. There were 28 patients and 27 patients with paroxysmal and persistent arrhythmia, respectively. Concomitant diseases (coronary heart disease, hypertension, diabetes) were reported in 30 (54.5%) cases. The technique of the procedure was as follows. At first, the pulmonary veins were isolated. After that frequent stimulation was carried out from two sites with a cycle of 300 ms for 10 seconds, with a phased shortening by 20 ms, until atrial refractoriness was achieved. Arrhythmia was considered induced if its episode lasted more than 30 seconds. In case of induction of AF and absence of its spontaneous termination within the pre-specified time, the search and ablation of the areas with fragmented activity were performed. There were no additional effects on the substrate in the atria. Recurrence of AF was defined as the occurrence of AF within 3 months after ablation.

Results. Atrial fibrillation was induced in 9 (16.4%) of 55 patients. During the follow-up period lasting 12 to 26 months, recurrent arrhythmia occurred in 11 (20%) of 55 patients, including 3 (33.3%) of 9 with induced AF, and 8 (17.4 %) of 46 in whom it was not induced (relative risk 1.9; odds ratio 2.4; 95% confidence interval 16.5-23.5). Comparison of the recurrence rate depending on the form of arrhythmia did not reveal significant differences: the relative risk was 2.2 for persistent form and 1.5 for paroxysmal form (P > 0.05).

Conclusions. Our results indicate that in cases where AF was induced after pulmonary vein isolation, the likelihood of its subsequent recurrence was twice as high as in cases when it was not induced. This trend was observed both in paroxysmal and persistent forms of arrhythmia.

References

  1. Oral H, Chugh A, Lemola K, Cheung P, Hall B, Good E, Han J, Tamirisa K, Bogun F, Pelosi F Jr, Morady F. Noninducibility of atrial fibrillation as an end point of left atrial circumferential ablation for paroxysmal atrial fibrillation: a randomized study. Circulation. 2004;110(18):2797-801. https://doi.org/10.1161/01.CIR.0000146786.87037.26
  2. Essebag V, Baldessin F, Reynolds MR, McClennen S, Shah J, Kwaku KF, Zimetbaum P, Josephson ME. Non-inducibility post-pulmonary vein isolation achieving exit block predicts freedom from atrial fibrillation. Eur Heart J. 2005;26(23):2550-5. https://doi.org/10.1093/eurheartj/ehi507
  3. Jaïs P, Hocini M, Sanders P, Hsu LF, Takahashi Y, Rotter M, Rostock T, Sacher F, Clementy J, Haissaguerre M. Long-term evaluation of atrial fibrillation ablation guided by noninducibility. Heart Rhythm. 2006;3(2):140-5. https://doi.org/10.1016/j.hrthm.2005.11.012
  4. Richter B, Gwechenberger M, Filzmoser P, Marx M, Lercher P, Gossinger HD. Is inducibility of atrial fibrillation after radio frequency ablation really a relevant prognostic factor? Eur Heart J. 2006;27(21):2553-9. https://doi.org/10.1093/eurheartj/ehl307
  5. Chang SL, Tai CT, Lin YJ, Wongcharoen W, Lo LW, Tuan TC, Udyavar AR, Chang SH, Tsao HM, Hsieh MH, Hu YF, Chen YJ, Chen SA. The efficacy of inducibility and circumferential ablation with pulmonary vein isolation in patients with paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol. 2007;18(6):607–11 https://doi.org/10.1111/j.1540-8167.2007.00823.x
  6. Satomi K, Tilz R, Takatsuki S, Chun J, Schmidt B, Bänsch D, Antz M, Zerm T, Metzner A, Köktürk B, Ernst S, Greten H, Kuck KH, Ouyang F. Inducibility of atrial tachyarrhythmias after circumferential pulmonary vein isolation in patients with paroxysmal atrial fibrillation: clinical predictor and outcome during follow-up. Europace. 2008;10(8):949-54. https://doi.org/10.1093/europace/eun131
  7. Crawford T, Chugh A, Good E, Yoshida K, Jongnarangsin K, Ebinger M, Pelosi F Jr, Bogun F, Morady F, Oral H. Clinical value of noninducibility by high-dose isoproterenol versus rapid atrial pacing after catheter ablation of paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol. 2010;21(1):13-20. https://doi.org/10.1111/j.1540-8167.2009.01571.x
  8. Nagamoto Y, Park JS, Tanubudi D, Ko YK, Ban JE, Kwak JJ, Choi JI, Lim HE, Park SW, Kim YH. Clinical significance of induced atrial tachycardia after termination of longstanding persistent atrial fibrillation using a stepwise approach. J Cardiovasc Electrophysiol. 2012;23(11):1171-8. https://doi.org/10.1111/j.1540-8167.2012.02382.x
  9. Calvo D, Atienza F, Jalife J, Martínez-Alzamora N, Bravo L, Almendral J, González-Torrecilla E, Arenal Á, Bermejo J, Fernández-Avilés F, Berenfeld O. High-rate pacing-induced atrial fibrillation effectively reveals properties of spontaneously occurring paroxysmal atrial fibrillation in humans. Europace. 2012;14(11):1560-6. https://doi.org/10.1093/europace/eus180
  10. Leong-Sit P, Robinson M, Zado ES, Callans DJ, Garcia F, Lin D, Dixit S, Bala R, Riley MP, Hutchinson MD, Cooper J, Gerstenfeld EP, Marchlinski FE. Inducibility of atrial fibrillation and flutter following pulmonary vein ablation. J Cardiovasc Electrophysiol. 2013;24(6):617-23. https://doi.org/10.1111/jce.12088
  11. Adlbrecht C, Gwechenberger M, Richter B, Sipötz J, Kaider A, Gössinger H. Prognostic value of induction of atrial fibrillation before and after pulmonary vein isolation. Int J Cardiol. 2013;164(2):212-6. https://doi.org/10.1016/j.ijcard.2011.07.023
  12. Santangeli P, Zado ES, Garcia FC, Riley MP, Lin D, Frankel DS, Supple GE, Schaller RD, Dixit S, Callans DJ, Marchlinski FE. Lack of prognostic value of atrial arrhythmia inducibility and change in inducibility status after catheter ablation of atrial fibrillation. Heart Rhythm. 2018;15(5):660-5. https://doi.org/10.1016/j.hrthm.2017.10.023
  13. Otsuka T, Sagara K, Arita T, Yagi N, Suzuki S, Ikeda T, Yamashita T. Impact of electrophysiological and pharmacological noninducibility following pulmonary vein isolation in patients with paroxysmal and persistent atrial fibrillation. J Arrhythm. 2018;34(5):501-10. https://doi.org/10.1002/joa3.12085
  14. Kawai S, Mukai Y, Inoue S, Yakabe D, Nagaoka K, Sakamoto K, Takase S, Chishaki A, Tsutsui H. Predictive value of the induction test with atrial burst pacing with regard to long-term recurrence after ablation in persistent atrial fibrillation. J Arrhythm. 2019;35(2):223-9. https://doi.org/10.1002/joa3.12150
  15. Skala T, Tudos Z, Moravec O, Hutyra M, Precek J, Skalova J, Klementova O, Zapletalova J, Taborsky M. Atrial fibrillation inducibility after pulmonary vein isolation under general anaesthesia. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2020;164(3):261-6. https://doi.org/10.5507/bp.2019.004
  16. Liu H, Yuan P, Zhu X, Fu L, Hong K, Hu J. Is atrial fibrillation noninducibility by burst pacing after catheter ablation associated with reduced clinical recurrence? A Systematic Review and Meta-Analysis. J Am Heart Assoc. 2020;9(14):e015260. https://doi.org/10.1161/JAHA.119.015260
  17. Steinberg JS, O’Connell H, Li S, Ziegler PD. Thirty-second gold standard definition of atrial fibrillation and its relationship with subsequent arrhythmia patterns: analysis of a large prospective device database. Circ Arrhythm Electrophysiol. 2018;11(7):e006274. https://doi.org/10.1161/CIRCEP.118.006274
  18. Millenaar D, Becker N, Pavlicek V, Wintrich J, Böhm M, Mahfoud F, Ukena C. Inducibility of atrial fibrillation after catheter ablation predicts recurrences of atrial fibrillation: a meta-analysis. Pacing Clin Electrophysiol. 2021;44(4):667-76. https://doi.org/10.1111/pace.14216
  19. Huang W, Liu T, Shehata M, Zhang K, Yao Y, Niu G, Amorn A, Liu X, Chugh SS, Wang X. Inducibility of atrial fibrillation in the absence of atrial fibrillation: what does it mean to be normal? Heart Rhythm. 2011;8(4):489-92. https://doi.org/10.1016/j.hrthm.2010.11.036
Published
2022-03-23
How to Cite
Stychynskyi, O. S., Almiz, P. O., & Topchii, A. V. (2022). Clinical Significance of Induction of Atrial Fibrillation after Pulmonary Vein Isolation. Ukrainian Journal of Cardiovascular Surgery, 30(1), 59-63. https://doi.org/10.30702/ujcvs/22.30(01)/SA001-5963