Incremental Benefit of Stepwise Nonpulmonary Vein Trigger Provocation During Catheter Ablation of Atrial Fibrillation

• DOI: 10.1016/j.jacep.2024.06.005
• Publication Date: 2024-07-29T19:05:27Z
• Authors: Alireza Oraii; Corentin Chaumont; Oriol Rodriguez-Q...; Adrian Petzl; Erica Zado; Timothy M. Markman; Matthew C. Hyman; Cory M. Tschabrunn; Andres Enriquez; Poojita Shivamurthy; Ramanan Kumareswaran; Michael P. Riley; David Lin; Gregory E. Supple; Fermin C. Garcia; Robert D. Schaller; Saman Nazarian; David S. Frankel; Sanjay Dixit; David J. Callans; Francis E. Marchl...
• Keywords: Male; Pulmonary Veins; Atrial Fibrillation; Catheter Ablation; Isoproterenol; Electric Countershock; Humans; Female; Middle Aged; Aged; Retrospective Studies

The importance of nonpulmonary vein (PV) triggers for the initiation/recurrence of atrial fibrillation (AF) is well established.This study sought to assess the incremental benefit of provocative maneuvers for identifying non-PV triggers.We included consecutive patients undergoing first-time AF ablation between 2020 and 2022. The provocation protocol included step 1, identification of spontaneous non-PV triggers after cardioversion of AF and/or during sinus rhythm; step 2, isoproterenol infusion (3, 6, 12, and 20-30 μg/min); and step 3, atrial burst pacing to induce AF followed by cardioversion during residual or low-dose isoproterenol infusion or induce focal atrial tachycardia. Non-PV triggers were defined as non-PV ectopic beats triggering AF or sustained focal atrial tachycardia.Of 1,372 patients included, 883 (64.4%) underwent the complete stepwise provocation protocol with isoproterenol infusion and burst pacing, 334 (24.3%) isoproterenol infusion only, 77 (5.6%) burst pacing only, and 78 (5.7%) no provocative maneuvers (only step 1). Overall, 161 non-PV triggers were found in 135 (9.8%) patients. Of these, 51 (31.7%) non-PV triggers occurred spontaneously, and the remaining 110 (68.3%) required provocative maneuvers for induction. Among those receiving the complete stepwise provocation protocol, there was a 2.2-fold increase in the number of patients with non-PV triggers after isoproterenol infusion, and the addition of burst pacing after isoproterenol infusion led to a total increase of 3.6-fold with the complete stepwise provocation protocol.The majority of non-PV triggers require provocative maneuvers for induction. A stepwise provocation protocol consisting of isoproterenol infusion followed by burst pacing identifies a 3.6-fold higher number of patients with non-PV triggers.