Prevalence and clinical impact of spontaneous and adenosine-induced pulmonary vein reconduction in the Contact-Force vs. Cryoballoon Atrial Fibrillation Ablation (CIRCA-DOSE) study

Heart Rhythm. 2020 Jun;17(6):897-904. doi: 10.1016/j.hrthm.2020.01.017. Epub 2020 Jan 21.

Abstract

Background: Use of intraprocedural observation and pharmacologic challenges have been proposed as means to differentiate permanent pulmonary vein (PV)-left atrial conduction block from inadequate ablation lesions.

Objective: The purpose of this study was to determine the prevalence and clinical impact of spontaneous and adenosine-provoked reconnection using contemporary atrial fibrillation (AF) ablation technologies.

Methods: The CIRCA-DOSE (Cryoballoon vs. Irrigated Radiofrequency Catheter Ablation: Double Short vs. Standard Exposure Duration) study enrolled 346 patients with paroxysmal AF and randomized them to contact force-guided radiofrequency ablation (CF-RF) or cryoballoon ablation. Patients underwent provocative testing with adenosine after a 20-minute observation period. All patients received an implantable cardiac monitor for arrhythmia monitoring.

Results: Spontaneous reconnection was observed in 5.4% of PVs (71/1318) during the 20-minute postprocedure observation period, and dormant conduction was elicited in 5.7% of PVs (75/1318). Both spontaneous reconnection and dormant conduction were more common after CF-RF compared to cryoballoon ablation (P = .03 and P <.0001, respectively). Acute PV reconnection (spontaneous or adenosine-provoked) was associated with a significantly higher incidence of recurrent atrial tachyarrhythmia in the cryoballoon group (hazard ratio [HR] 2.39; 95% confidence interval [CI] 1.44-3.96; P = .0007) but not in the CF-RF group (HR 1.47; 95% CI 0.84-2.58; P = .16). In the absence of acute reconnection, the freedom from recurrent arrhythmia did not differ between groups (HR 0.95; 95% CI 0.6057-1.495; P = .83).

Conclusion: Patients without spontaneous or adenosine-provoked reconnection had better outcomes compared to those with acute PV reconnection, suggesting that efforts should be directed toward ensuring an ideal ablation lesion at the first attempt in order to achieve durable PV isolation.

Trial registration: ClinicalTrials.gov NCT01913522.

Keywords: Ablation; Adenosine; Atrial fibrillation; Contact force; Pulmonary vein electrophysiology; Pulmonary vein isolation.

Publication types

  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adenosine / pharmacology*
  • Atrial Fibrillation / diagnosis
  • Atrial Fibrillation / epidemiology
  • Atrial Fibrillation / surgery*
  • Cryosurgery / methods*
  • Female
  • Follow-Up Studies
  • Heart Conduction System / drug effects
  • Heart Conduction System / physiopathology*
  • Humans
  • Male
  • Middle Aged
  • Prevalence
  • Prospective Studies
  • Pulmonary Veins / drug effects
  • Pulmonary Veins / physiopathology
  • Pulmonary Veins / surgery*
  • Single-Blind Method
  • Vascular Remodeling / drug effects*
  • Vasodilator Agents / pharmacology

Substances

  • Vasodilator Agents
  • Adenosine

Associated data

  • ClinicalTrials.gov/NCT01913522