Low contact force and force-time integral predict early recovery and dormant conduction revealed by adenosine after pulmonary vein isolation

Abstract

Aim: After pulmonary vein isolation (PVI), dormant conduction (DC) is present in at least one vein in a substantial number of patients. The present study seeks to determine whether there is a relationship between poor contact forces (CF) and the presence of DC after PVI.

Methods and results: This prospective, operator-blinded, non-randomized dual-centre trial enrolled 34 consecutive patients with paroxysmal atrial fibrillation who were candidates for PVI. Radiofrequency (RF) energy was delivered by using an irrigated-tip force-sensing ablation catheter (Tacticath, St Jude Medical) at pre-defined target power. The operators were blinded to the CF data at all times. A total of 1476 RF applications were delivered in 743 pre-defined PV segments. For each application, the precise location of the catheter was registered and the following data were extracted from the Tacisys unit: application duration, minimum contact force, maximum contact force, average contact force (CF), and force-time integral (FTI). Sixty minutes after PVI, spontaneous early recovery (ER) of the left atrium (LA) to PV conduction was evaluated. In the absence of ER, the presence of a DC was evaluated by using intravenous adenosine (ATP). In the 34 patients recruited (23 males; mean age: 62 ± 9 years), all PVs were successfully isolated. At the end of the 60 min waiting period, 22 patients demonstrated at least one spontaneous ER or DC under ATP. The mean CF and FTI per PV segment differed significantly among the different veins but the sites of ER and DC were evenly distributed. However, both the minimum, the first and the mean CF and FTI per PV segment were significantly lower in the PV segments presenting either ER or DC as compared with those without ER or DC (mean CF: 4.9 ± 4.8 vs. 12.2 ± 1.65 g and mean FTI: 297 ± 291 vs. 860 ± 81 g s, P < 0.001 for both). Using multivariate analysis, both the mean CF and the FTI per lesion remained significantly associated with the risk of ER or DC. Moreover, a CF < 5 g per PV segment predicted ER+ and DC+ with a sensitivity of 71% and specificity of 82%. In contrast, ER and DC were very unlikely if RF application was performed with a mean CF > 10 g (negative predictive value: 98.7%).

Conclusion: Both a low CF and a low FTI are associated with the ER of the PVI and DC after PVI.

Keywords: Adenosine; Atrial fibrillation; Contact force; Dormant conduction; Pulmonary vein isolation; Radiofrequency ablation; Tacticath.

© The Author 2015. Published by Oxford University Press on behalf of the European Society of Cardiology.

Figures

Figure 1

Average CF (g) per PV segment according to the presence or absence of ER or DC at 60 min after PVI. ER+: red stars and values; DC+: green stars and values; ER−/DC−: values in blue. LSPV, left superior pulmonary vein; RSPV, right superior pulmonary vein; LIPV, left inferior pulmonary vein; RIPV, right inferior pulmonary vein.

Figure 2

Average FTI (g s) per PV segment according to the presence or the absence of ER or DC at 60 min after PVI. ER+: red stars and values; DC+: green stars and values; ER−/DC−: values in blue (legend as in Figure 1).

Figure 3

Receiving operator curve for ER/DC predictability. The mean CF had the best predictive value with an area under the curve of 0.80. The best compromise between the sensitivity and specificity was found at 5 g (Se: 71%; Sp: 81%; PPV: 14%).

Figure 4

Rate of ER and DC revealed by adenosine infusion 60 min after validation of pulmonary vein isolation according to the mean contact force per pulmonary vein segment.