Adenosine triphosphate/adenosine guided pulmonary vein isolation does not improve the outcomes of ablation: a meta-analysis of randomized controlled trials

ABSTRACT

Background: Successful pulmonary vein isolation (PVI) is the most reliable predictor of success after ablation in patients with atrial fibrillation (AF). Adenosine triphosphate (ATP) unmasks the dormant conduction and can be used to improve the effectiveness of PVI. The impact of ATP guided PVI on clinical outcomes is discordant in various randomized controlled trials (RCTs).

Objectives: To delineate the incremental benefit of ATP during PVI in patients with AF through a meta-analysis.

Methods and results: Database searches through January 2017 identified 5 RCTs (enrolling 2839 patients) comparing ATP guided PVI versus standard PVI (non-ATP). Four trials exclusively studied paroxysmal AF while one trial included both paroxysmal and non-paroxysmal AF patients. Baseline characteristics, dose of adenosine and ablation strategies were clearly identified among all the trials. The risk ratio (RR) for AF episodes lasting >30 s after 3-month blanking period was calculated with random effects meta-analysis and showed no difference at a median follow up of 12 months [RR: 1.02, 95 % Confidence interval (CI): 0.85 to 1.25; p = 0.82]. Similarly, the number of repeat ablation was similar in both groups [RR: 1.02, 95 % CI: 0.63, 1.56; p = 0.98].

Conclusions: ATP guided PVI does not decrease the recurrence of AF or the need for repeat ablation at 12 months.

KEYWORDS:

• Adenosine
• atrial fibrillation
• meta-analysis

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.

Notes on contributors

Muhammad R. Afzal

MR Afzal was primary author who hypothesized that a meta-analysis of randomized controlled trials pertaining to ATP-guided PVI would not improve arrhythmia free survival. Dr. Afzal worked on the statistical analysis, made the tables and figures and authored the introduction, methods and results section.

Omar Kahaly

O Kahaly helped write the discussion section of the paper. Also helped in responding to the reviewers and revising subsequent iterations of the meta-analysis.

Mahmoud Houmsse

R Weiss helped write the discussion section of the paper and edited critiques.

Emile G. Daoud

EG Daoud edited the manuscript and adjusted the text as deemed appropriate.

John D. Hummel

JD Hummel was senior author who guided the meta-analysis, edited the manuscript and continually appraised the text.