Po-01-031 to check or not to check: lack of first pass isolation may identify patients who would benefit from provocative pharmacologic challenge during pulmonary vein isolation

Durable pulmonary vein isolation (PVI) is the cornerstone of successful ablation of atrial fibrillation. Adenosine and isoproterenol are two commonly used pharmacologic agents for assessing conduction recovery during PVI. However, the use of a provocative pharmacologic challenge (PPC) is highly operator dependent, and the effect on outcomes after PVI using contemporary methods is unclear. Additionally, first pass isolation (FPI) has recently gained recognition as a marker for durable PVI. We sought to explore the utility of a PPC depending on the achievement of FPI. To assess the utility of a PPC with either adenosine or isoproterenol in patients with or without FPI during PVI. The Real-world Experience of Catheter Ablation for the Treatment of Symptomatic Paroxysmal and PsAF Using Novel Contact Force Technologies registry (Real-AF) is a prospective, observational, multicenter registry of patients undergoing radiofrequency (RF) ablation. A total of 910 patients with paroxysmal atrial fibrillation undergoing de novo ablation were included in this study and were retrospectively analyzed. Patients were divided into four groups based on whether FPI was achieved in both pulmonary veins and whether a PPC was performed. Atrial arrhythmia recurrence at one year was reported. A total of 590 patients (65.5%) had FPI and 313 (34.5%) did not. A PPC was performed in 488 (82.7%) of the FPI group and 258 (82.2%) of the no FPI group. Baseline covariates were compared using an analysis of variance (ANOVA), shown in Table 1. Left atrial diameter, CHADS2VAsc score, left atrial volume, procedure time, and total RF ablation time were significantly different among the four groups. Adjusted Kaplan-Meier curves are shown in Figure 1. Using a Cox-proportional hazards adjustment for baseline covariates, PPC was not associated with atrial arrhythmia free survival in the FPI group (p=0.145) (Figure 1A) but was associated with atrial arrhythmia survival in the no FPI group (p=0.025) (Figure 1B). In patients without FPI, the use of PPC resulted in similar outcomes as the FPI group (Figure 1C). In patients undergoing PVI who have FPI, performing a PPC does not improve atrial arrhythmia free survival at one year. However, in patients without FPI, a PPC is associated with improved atrial arrhythmia free survival at one year, leading to similar outcomes to patients who achieved FPI. This may have important implications for intraprocedural decision-making and procedural efficiency during PVI.Tabled 1Table 1. Baseline Demographics and Procedural Characteristics (PO-01-031).FPI and PPC (n=488)FPI and No PPC (n=102)No FPI and PPC (n=258)No FPI and No PPC (n=55)p-value (ANOVA)Ejection Fraction (%)57.4 ±7.558.3±8.557.7±6.457.7±6.40.337Left atrial diameter (cm)3.9±0.74.0±0.63.9±0.54.2±0.60.042Age (years)64.9±11.666.6±10.163.6±10.965.5±8.80.117Hypertension336 (68%)65 (63%)179 (69%)30 (54%)0.101Diabetes Mellitus69 (14%)20 (19%)41 (16%)10 (18%)0.508Congestive Heart Failure29 (6%)9 (9%)18 (7%)8 (14%)0.114Sex (Female)245 (50%)42 (42%)108 (42%)21 (38%)0.076CHADS2Vasc Score2.6±1.52.5±1.42.3±1.42.0±1.60.025Left Atrial Volume (cm3)84.6±26.188.4±28.985.2±22.1103.2±30.6<0.001Left Atrial Low Voltage Area (% of surface area)2.6±7.74.7±9.02.5±7.74.3±6.70.062Procedure time (minutes)74±35102±4094±42117±44<0.001Total Radiofrequency Ablation time (minutes)18±826±1125±1128±11<0.001 Open table in a new tab