title: Isolation of the posterior left atrium for patients with persistent atrial fibrillation: routine adenosine challenge for dormant posterior left atrial conduction improves long-term outcome.
abstract: OBJECTIVE
  Catheter ablation to achieve posterior left atrial wall (PW) isolation may be performed as an adjunct to pulmonary vein isolation (PVI) in patients with persistent atrial fibrillation (AF). We aimed to determine whether routine adenosine challenge for dormant posterior wall conduction improved long-term outcome.
  
  
  RESULTS
  A total of 161 patients with persistent AF (mean age 59 ± 9 years, AF duration 6 ± 5 years) underwent catheter ablation involving circumferential PVI followed by PW isolation. Posterior left atrial wall isolation was performed with a roof and inferior wall line with the endpoint of bidirectional block. In 54 patients, adenosine 15 mg was sequentially administered to assess reconnection of the pulmonary veins and PW. Sites of transient reconnection were ablated and adenosine was repeated until no further reconnection was present. Holter monitoring was performed at 6 and 12 months to assess for arrhythmia recurrence. Posterior left atrial wall isolation was successfully achieved in 91% of 161 patients (procedure duration 191 ± 49 min, mean RF time 40 ± 19 min). Adenosine-induced reconnection of the PW was demonstrated in 17%. The single procedure freedom from recurrent atrial arrhythmia was superior in the adenosine challenge group (65%) vs. no adenosine challenge (40%, P < 0.01) at a mean follow-up of 19 ± 8 months. After multiple procedures, there was significantly improved freedom from AF between patients with vs. without adenosine PW challenge (85 vs. 65%, P = 0.01).
  
  
  CONCLUSIONS
  Posterior left atrial wall isolation in addition to PVI is a readily achievable ablation strategy in patients with persistent AF. Routine adenosine challenge for dormant posterior wall conduction was associated with an improvement in the success of catheter ablation for persistent AF.
authors.affiliation: Department of Cardiovascular Medicine, Alfred Hospital and Baker IDI Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia.|Cardiology Department, Royal Melbourne Hospital, Parkville, VIC, Australia.|Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, VIC, Australia.
authors.forename: Alex J A
authors.initials: AJA
authors.lastname: McLellan
authors.affiliation: Department of Cardiovascular Medicine, Alfred Hospital and Baker IDI Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia.|Cardiology Department, Royal Melbourne Hospital, Parkville, VIC, Australia.|Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, VIC, Australia.
authors.forename: Sandeep
authors.initials: S
authors.lastname: Prabhu
authors.affiliation: Department of Cardiovascular Medicine, Alfred Hospital and Baker IDI Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia.|Cardiology Department, Royal Melbourne Hospital, Parkville, VIC, Australia.|Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, VIC, Australia.
authors.forename: Alex
authors.initials: A
authors.lastname: Voskoboinik
authors.affiliation: Department of Cardiovascular Medicine, Alfred Hospital and Baker IDI Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia.|Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, VIC, Australia.
authors.forename: Michael C G
authors.initials: MCG
authors.lastname: Wong
authors.affiliation: Department of Cardiovascular Medicine, Alfred Hospital and Baker IDI Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia.|Cardiology Department, Royal Melbourne Hospital, Parkville, VIC, Australia.|Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, VIC, Australia.
authors.forename: Tomos E
authors.initials: TE
authors.lastname: Walters
authors.affiliation: Department of Cardiovascular Medicine, Alfred Hospital and Baker IDI Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia.|Cardiology Department, Royal Melbourne Hospital, Parkville, VIC, Australia.|Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, VIC, Australia.
authors.forename: Bhupesh
authors.initials: B
authors.lastname: Pathik
authors.affiliation: Cardiology Department, Royal Melbourne Hospital, Parkville, VIC, Australia.
authors.forename: Gwilym M
authors.initials: GM
authors.lastname: Morris
authors.affiliation: Cardiology Department, Royal Melbourne Hospital, Parkville, VIC, Australia.
authors.forename: Ashley
authors.initials: A
authors.lastname: Nisbet
authors.affiliation: Department of Cardiovascular Medicine, Alfred Hospital and Baker IDI Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia.|Cardiology Department, Royal Melbourne Hospital, Parkville, VIC, Australia.
authors.forename: Geoffrey
authors.initials: G
authors.lastname: Lee
authors.affiliation: Cardiology Department, Royal Melbourne Hospital, Parkville, VIC, Australia.
authors.forename: Joseph B
authors.initials: JB
authors.lastname: Morton
authors.affiliation: Cardiology Department, Royal Melbourne Hospital, Parkville, VIC, Australia.|Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, VIC, Australia.
authors.forename: Jonathan M
authors.initials: JM
authors.lastname: Kalman
authors.affiliation: Department of Cardiovascular Medicine, Alfred Hospital and Baker IDI Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia.|Cardiology Department, Royal Melbourne Hospital, Parkville, VIC, Australia.|Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, VIC, Australia.
authors.forename: Peter M
authors.initials: PM
authors.lastname: Kistler
mesh_terms: D000200:Action Potentials; D000241:Adenosine / Q000008:administration & dosage*; D000368:Aged; D001281:Atrial Fibrillation / Q000175:diagnosis* / Q000503:physiopathology / Q000601:surgery*; D016279:Atrial Function, Left; D017115:Catheter Ablation / Q000009:adverse effects / Q000379:methods*; D018572:Disease-Free Survival; D015716:Electrocardiography, Ambulatory; D022062:Electrophysiologic Techniques, Cardiac; D005260:Female; D006325:Heart Atria / Q000503:physiopathology / Q000601:surgery*; D006339:Heart Rate; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011446:Prospective Studies; D011667:Pulmonary Veins / Q000503:physiopathology / Q000601:surgery*; D012008:Recurrence; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000241:Adenosine
keywords: Adenosine; Atrial fibrillation; Posterior left atrial wall isolation; Pulmonary vein isolation; Pulmonary vein reconnection