J Interv Card Electrophysiol (2014) 39:103–109 DOI 10.1007/s10840-013-9862-y
Adenosine triphosphate-induced atrial fibrillation: the clinical significance and relevance to spontaneous atrial fibrillation Susumu Tao & Yasuteru Yamauchi & Shingo Maeda & Hiroyuki Okada & Tetsuo Yamaguchi & Nobuhiro Hara & Yuji Konishi & Tomoyuki Umemoto & Takamichi Miyamoto & Tohru Obayashi & Kenzo Hirao & Mitsuaki Isobe
Received: 8 September 2013 / Accepted: 14 November 2013 / Published online: 10 December 2013 # Springer Science+Business Media New York 2013
Abstract Purpose Adenosine triphosphate (ATP) frequently triggers atrial fibrillation (AF), but the clinical significance of this phenomenon is unknown. The purpose of this study was to reveal the relevance between spontaneous AF and ATP-induced AF. Methods In 81 AF patients undergoing pulmonary vein isolation (PVI), we injected 20 mg of ATP before PVI, and recorded triggering sites of the AF induced. We also injected 20 mg of ATP in 44 patients receiving ablation for atrioventricular reciprocating tachycardia (AVRT). Results ATP provoked AF in 24 (29.6 %) of the 81 PVI patients and atrial ectopic beats in a further 48 (59.3 %). The trigger site of the AF was in the PV and the right atrium in 22 (91.7 %) and 2 patients, respectively. In 14 of those 24 patients, spontaneous AF arose from the same triggering site as the ATPinduced AF. In the 48 patients with ATP-provoked ectopic beats, spontaneous AF arose from the same site in 13. Conversely, among the 34 patients demonstrating spontaneous AF initiation, AF or ectopic beats were provoked by ATP from the same site in 14 (41.2 %) and 13 patients (38.2 %), respectively. ATP provoked AF in only 2 (4.5 %) of the AVRT patients. In summary, ATP provoked AF or atrial ectopic beats in 88.9 % of PVI patients, 36.1 % of whose triggering sites matched that of the spontaneous AF, while 79.4 % of spontaneous AF trigger sites matched ATP-provoked AF or ectopic beat sites. Conclusions ATP-induced AF was strongly associated with clinical AF, and ATP is useful for identifying arrhythmogenic sites. S. Tao (*) : Y. Yamauchi : S. Maeda : H. Okada : T. Yamaguchi : N. Hara : Y. Konishi : T. Umemoto : T. Miyamoto : T. Obayashi Department of Cardiology, Musashino Red Cross Hospital, Tokyo, Japan e-mail: [email protected] S. Tao : K. Hirao : M. Isobe Department of Cardiovascular Medicine, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
Keywords Atrial fibrillation . Adenosine triphosphate . Arrhythmogenicity . Pulmonary vein . Inducibility
1 Introduction The pulmonary veins (PV) are a key source of ectopic beats that initiate atrial fibrillation (AF) [1], and PV isolation is an established therapeutic option for patients with AF [1–4]. Adenosine triphosphate (ATP) is used to provoke dormant PV conduction after extensive encircling PV isolation [5], and radiofrequency applications for reconnections provoked in this manner between the left atrium and isolated PVs are helpful in reducing clinical AF recurrence [6, 7]. ATP sometimes also induces AF, but the clinical significance of this phenomenon is unknown [8–10]. In this study, we prospectively investigated the incidence of AF induced by ATP and that of spontaneous AF to test whether trigger sites of ATP-induced AF indicate trigger sites of AF that arises spontaneously during PV isolation procedure, and by inference, a patient’s clinical AF.
2 Methods 2.1 Study subjects The present study prospectively investigated 81 patients with AF who underwent extensive encircling PV isolation and 44 patients with atrioventricular reciprocating tachycardia (AVRT) who underwent an accessory pathway ablation as the control group, from October 2009 to August 2010 at Musashino Red Cross Hospital. The hospital’s ethics committee approved the study protocol, and written informed consent was obtained from all patients before enrollment. Prior to radiofrequency catheter ablation, all antiarrhythmic drugs were discontinued for at least 1 week, and all patients with AF underwent a transesophageal
104
echocardiography to rule out any left atrial thrombi as well as transthoracic echocardiography. Paroxysmal AF was defined as AF that spontaneously terminated within 7 days and persistent AF was defined as AF that lasted for more than 7 days. 2.2 Electrophysiological study In the AF group, one diagnostic catheter was positioned in the right ventricle (RV). Another catheter was introduced from the right jugular vein into the coronary sinus (CS), the proximal electrodes of which could record right atrial (RA) and superior vena cava (SVC) potentials (CS-SVC catheter). In the left atrium, decapolar Lasso catheters were placed in both the right and left superior PVs, and one ablation catheter in the left inferior PV. Prior to any PV isolation, we identified the sites where spontaneous AF and repetitive atrial premature complexes (APCs) originated. Repetitive APCs were defined as two or more consecutive APCs with coupling interval
Adenosine triphosphate-induced atrial fibrillation: the clinical significance and relevance to spontaneous atrial fibrillation Susumu Tao & Yasuteru Yamauchi & Shingo Maeda & Hiroyuki Okada & Tetsuo Yamaguchi & Nobuhiro Hara & Yuji Konishi & Tomoyuki Umemoto & Takamichi Miyamoto & Tohru Obayashi & Kenzo Hirao & Mitsuaki Isobe
Received: 8 September 2013 / Accepted: 14 November 2013 / Published online: 10 December 2013 # Springer Science+Business Media New York 2013
Abstract Purpose Adenosine triphosphate (ATP) frequently triggers atrial fibrillation (AF), but the clinical significance of this phenomenon is unknown. The purpose of this study was to reveal the relevance between spontaneous AF and ATP-induced AF. Methods In 81 AF patients undergoing pulmonary vein isolation (PVI), we injected 20 mg of ATP before PVI, and recorded triggering sites of the AF induced. We also injected 20 mg of ATP in 44 patients receiving ablation for atrioventricular reciprocating tachycardia (AVRT). Results ATP provoked AF in 24 (29.6 %) of the 81 PVI patients and atrial ectopic beats in a further 48 (59.3 %). The trigger site of the AF was in the PV and the right atrium in 22 (91.7 %) and 2 patients, respectively. In 14 of those 24 patients, spontaneous AF arose from the same triggering site as the ATPinduced AF. In the 48 patients with ATP-provoked ectopic beats, spontaneous AF arose from the same site in 13. Conversely, among the 34 patients demonstrating spontaneous AF initiation, AF or ectopic beats were provoked by ATP from the same site in 14 (41.2 %) and 13 patients (38.2 %), respectively. ATP provoked AF in only 2 (4.5 %) of the AVRT patients. In summary, ATP provoked AF or atrial ectopic beats in 88.9 % of PVI patients, 36.1 % of whose triggering sites matched that of the spontaneous AF, while 79.4 % of spontaneous AF trigger sites matched ATP-provoked AF or ectopic beat sites. Conclusions ATP-induced AF was strongly associated with clinical AF, and ATP is useful for identifying arrhythmogenic sites. S. Tao (*) : Y. Yamauchi : S. Maeda : H. Okada : T. Yamaguchi : N. Hara : Y. Konishi : T. Umemoto : T. Miyamoto : T. Obayashi Department of Cardiology, Musashino Red Cross Hospital, Tokyo, Japan e-mail: [email protected] S. Tao : K. Hirao : M. Isobe Department of Cardiovascular Medicine, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
Keywords Atrial fibrillation . Adenosine triphosphate . Arrhythmogenicity . Pulmonary vein . Inducibility
1 Introduction The pulmonary veins (PV) are a key source of ectopic beats that initiate atrial fibrillation (AF) [1], and PV isolation is an established therapeutic option for patients with AF [1–4]. Adenosine triphosphate (ATP) is used to provoke dormant PV conduction after extensive encircling PV isolation [5], and radiofrequency applications for reconnections provoked in this manner between the left atrium and isolated PVs are helpful in reducing clinical AF recurrence [6, 7]. ATP sometimes also induces AF, but the clinical significance of this phenomenon is unknown [8–10]. In this study, we prospectively investigated the incidence of AF induced by ATP and that of spontaneous AF to test whether trigger sites of ATP-induced AF indicate trigger sites of AF that arises spontaneously during PV isolation procedure, and by inference, a patient’s clinical AF.
2 Methods 2.1 Study subjects The present study prospectively investigated 81 patients with AF who underwent extensive encircling PV isolation and 44 patients with atrioventricular reciprocating tachycardia (AVRT) who underwent an accessory pathway ablation as the control group, from October 2009 to August 2010 at Musashino Red Cross Hospital. The hospital’s ethics committee approved the study protocol, and written informed consent was obtained from all patients before enrollment. Prior to radiofrequency catheter ablation, all antiarrhythmic drugs were discontinued for at least 1 week, and all patients with AF underwent a transesophageal
104
echocardiography to rule out any left atrial thrombi as well as transthoracic echocardiography. Paroxysmal AF was defined as AF that spontaneously terminated within 7 days and persistent AF was defined as AF that lasted for more than 7 days. 2.2 Electrophysiological study In the AF group, one diagnostic catheter was positioned in the right ventricle (RV). Another catheter was introduced from the right jugular vein into the coronary sinus (CS), the proximal electrodes of which could record right atrial (RA) and superior vena cava (SVC) potentials (CS-SVC catheter). In the left atrium, decapolar Lasso catheters were placed in both the right and left superior PVs, and one ablation catheter in the left inferior PV. Prior to any PV isolation, we identified the sites where spontaneous AF and repetitive atrial premature complexes (APCs) originated. Repetitive APCs were defined as two or more consecutive APCs with coupling interval
