Role of inducibility and its dynamic change in the outcome of catheter ablation of atrial fibrillation: a single center prospective study

Abstract

Background The role of atrial arrhythmia inducibility as an endpoint of catheter ablation of atrial fibrillation (AF) has been a controversial subject in many studies. Our goal is to evaluate the significance of inducibility, the impact of multiple sites or protocols of stimulation or the change in inducibility status in a prospective study including patients with AF undergoing first catheter ablation. Methods We studied 170 consecutive patients with AF (62.9% paroxysmal) undergoing catheter ablation. All patients underwent two separate stimulation protocols before and after the ablation from the coronary sinus ostium and the left atrial appendage: burst pacing at 300, 250, 200 milliseconds (or until refractoriness) for 10 seconds and ramp decrementing from 300 to 200 milliseconds in increments of 10 milliseconds every three beats for 10 seconds. Inducibility was defined as any sustained AF or organized atrial tachycardia (AT) lasting >30 seconds. Results We had AF/AT inducibility in 55 patients at baseline compared to 36 following ablation. After a mean of 41, 3 months follow‐up, 115 patients were free of AF. Inducibility before or after the ablation or change in inducibility status did not influence AF recurrence. There were no significant differences regarding paroxysmal or persistent patients with AF. Conclusions Non‐inducibility of atrial arrhythmia or change in inducibility status following pulmonary vein (PV) isolation and substrate modification are not associated with long‐term freedom from recurrent arrhythmia. Therefore, the use of induction of an endpoint in AF ablation is limited.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

“…7 Studies have evaluated the use of different endpoints immediately after catheter ablation for predicting durable PVI and the likelihood of future arrhythmias with mixed results. 19–28 In the largest randomized study to date, techniques such as waiting for 30 minutes, using adenosine triphosphate to facilitate PV reconnection, or the combination of waiting and using adenosine were not superior to no testing for predicting durable pulmonary vein isolation or reduction in future arrhythmias. Although noninducibility remains important in determining whether ablation for paroxysmal SVT has been successful, noninducibility after AF ablation or termination of AF with ablation have had mixed results for predicting the likelihood of future recurrence.…”

“…8–18 Although achieving durable pulmonary vein ablation in patients with AF has been associated with less recurrent arrhythmias, other endpoints, such as termination of F and noninducibility, have not been associated with improved outcomes. 19–28 Significant complications of AF ablation include stroke and TIAs, pericardial effusion, and vascular complications. 16 The most serious complication that occurs after the ablation procedure is development of an esophageal atrial fistula, although other complications, such as PV stenosis can occur.…”

“…Although noninducibility remains important in determining whether ablation for paroxysmal SVT has been successful, noninducibility after AF ablation or termination of AF with ablation have had mixed results for predicting the likelihood of future recurrence. 19–29 Multiple ablation targets beyond PVI have been evaluated in randomized controlled and observational trials, including the LAA, posterior wall, the ligament of Marshall, or atrial scar. 8–18 Results have been mixed, and no strategy has emerged that is broadly applicable in all patients, likely because the individual mechanisms for AF vary from patient to patient.…”

“…Although noninducibility remains important in determining whether ablation for paroxysmal SVT has been successful, noninducibility after AF ablation or termination of AF with ablation have had mixed results for predicting the likelihood of future recurrence. 19–29…”

Inducibility of atrial fibrillation after catheter ablation predicts recurrences of atrial fibrillation: a meta‐analysis

“…Fifteen studies seemed relevant according to title and abstract and were assessed for eligibility. One of the studies was excluded as no follow‐up was reported 22 and three because different additional ablation strategies were employed 23–25 . After exclusion of ineligible studies, eleven trials with 1544 patients were used for further analysis.…”