Should adenosine test be performed systematically at the end of atrial fibrillation ablation procedure?

Pulmonary vein (PV) reconnection is a major limitation of atrial fibrillation (AF) ablation and is a significant contributor for arrhythmia recurrence, particularly in patients with paroxysmal AF. Recent technological advances, including the use of steerable sheaths and force sensing catheters resulted in reduced incidence of PV reconnection; however its incidence remains unacceptably high. Additional efforts to reduce pulmonary vein reconnection include the use adenosine to detect dormant PV to left atrial (LA) electrical conduction as well as identification of non-PV triggers. While this strategy is associated with an increased detection rate of reconnection that can be further targeted with ablation, its effect on long-term arrhythmia control is controversial. Still, adenosine-induced PV reconnection appears to be an independent predictor of arrhythmia recurrence despite additional ablation. We favor its use in patients with paroxysmal AF as an additional step for risk stratification and prediction of arrhythmia recurrence.