Pre-existent left atrial scarring in patients undergoing pulmonary vein antrum isolation - An independent predictor of procedural failure

Section of Cardiovascular Electrophysiology, Department of Cardiology, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
Journal of the American College of Cardiology (Impact Factor: 16.5). 02/2005; 45(2):285-92. DOI: 10.1016/j.jacc.2004.10.035
Source: PubMed


The goal of this study was to assess the impact of left atrial scarring (LAS) on the outcome of patients undergoing pulmonary vein antrum isolation (PVAI) for atrial fibrillation (AF).
Left atrial scarring may be responsible for both the perpetuation and genesis of AF.
A total of 700 consecutive patients undergoing first-time PVAI were studied. Before ablation, extensive voltage mapping of the left atrium (LA) was performed using a multipolar Lasso catheter guided by intracardiac echocardiography (ICE). Patients with LAS were defined by a complete absence of electrographic recording by a circular mapping catheter in multiple LA locations, and this was validated by electroanatomic mapping. All four pulmonary vein antra and the superior vena cava were isolated using an ICE-guided technique. Patients were followed at least nine months for late AF recurrence. Univariate and multivariate analyses were performed to assess the predictive value of LAS and other variables on outcome.
Of 700 patients, 42 had LAS, which represented 21 +/- 11% of the LA surface area by electroanatomic mapping. Patients with LAS had a significantly higher AF recurrence (57%) compared with non-LAS patients (19%, p = 0.003). Also, LAS was associated with a significantly larger LA size, lower ejection fraction, and higher C-reactive protein levels. Univariate analysis revealed age, nonparoxysmal AF, and LAS as predictors of recurrence. Multivariate analysis showed LAS as the only independent predictor of recurrence (hazard ratio 3.4, 95% confidence interval 1.3 to 9.4; p = 0.01).
Pre-existent LAS in patients undergoing PVAI for AF is a powerful, independent predictor of procedural failure. Left atrial scarring is associated with a lower EF, larger LA size, and increased inflammatory markers.

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    • "Although this finding requires further study in larger populations, it is consistent with those of Akoum et al,23 who found that patients with increasing levels of preablation fibrosis, as denoted by Utah levels 1–4, had a higher chance of developing recurrent AF postablation. Similarly, patients with preprocedural atrial scarring found on endocardial voltage mapping had a significantly higher rate of procedural failure.24 LGE CMR may noninvasively identify patients with extensive atrial scarring, unlikely to benefit from PV isolation. "
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    ABSTRACT: BACKGROUND: For late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) assessment of atrial scar to guide management and targeting of ablation in AF, an objective, reproducible method of identifying atrial scar is required. Objective: We describe an automated method for operator-independent quantification of LGE that correlates with co-located endocardial voltage and clinical outcomes. METHODS: LGE CMR imaging was performed at 2 centres, before and 3 months after pulmonary vein isolation (PVI) for paroxysmal AF (PAF) (N=50). Left atrial (LA) surface scar map was constructed using automated software, expressing intensity as multiples of standard deviation (SD) above blood pool mean. 21 patients underwent endocardial voltage mapping at the time of PVI (11 were redo procedures). Scar maps and voltage maps were spatially registered to the same MRA segmentation. RESULTS: LGE levels of 3, 4 and 5 SD above blood pool intensity were associated with progressively lower bipolar voltages compared to the preceding enhancement level (0.85± 0.33mV, 0.50± 0.22mV and 0.38 ±0.28mV, p=0.002, p<0.001 and p=0.048 respectively).The proportion of atrial surface area classified as scar (i.e. >3 SD above blood pool mean) on pre-ablation scans was greater in patients with post-ablation AF recurrence than those without recurrence (6.6 ± 6.7% vs 3.5 ± 3.0%, p =0.032). LA volume >102ml was associated with a significantly greater proportion of LA scar (6.4± 5.9 vs 3.4± 2.2%, p=0.007). CONCLUSION: Left atrial scar quantified automatically by a simple objective method correlates with co-located endocardial voltage. Greater pre-ablation scar is associated with LA dilatation and AF recurrence.
    Full-text · Article · May 2013 · Heart rhythm: the official journal of the Heart Rhythm Society
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    • "Moreno-Reviriego et al. [109] demonstrated the presence of a dense scar (characterized by absence of capture at maximal paced impulse output) or low-voltage area in 10 of 16 patients with persistent/long lasting FA. Verma et al. [110] detected scar areas in 6% of AF patients and demonstrated the role of these areas as independent predictors of AF recurrences. Lo et al. [41] investigated the progressive decrease in the mean LA voltage and increase in the extension of low-voltage zones (subtracted the contribution of ablated areas) in patients with AF recurrences after PVI. "
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    ABSTRACT: The efficacy of catheter-based ablation techniques to treat atrial fibrillation is limited not only by recurrences of this arrhythmia but also, and not less importantly, by new-onset organized atrial tachycardias. The incidence of such tachycardias depends on the type and duration of the baseline atrial fibrillation and specially on the ablation technique which was used during the index procedure. It has been repeatedly reported that the more extensive the left atrial surface ablated, the higher the incidence of organized atrial tachycardias. The exact origin of the pathologic substrate of these trachycardias is not fully understood and may result from the interaction between preexistent regions with abnormal electrical properties and the new ones resultant from radiofrequency delivery. From a clinical point of view these atrial tachycardias tend to remit after a variable time but in some cases are responsible for significant symptoms. A precise knowledge of the most frequent types of these arrhythmias, of their mechanisms and components is necessary for a thorough electrophysiologic characterization if a new ablation procedure is required.
    Full-text · Article · Sep 2011 · Cardiology Research and Practice
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    ABSTRACT: Background The objective of this study was to investigate atrial myocardial properties through two-dimensional (2D) myocardial imaging in patients with atrial fibrillation (AF) and its predictive role for recurrence after catheter ablation. Methods and results Echocardiographic examinations were performed in 40 patients with paroxysmal AF before catheter ablation and 40 age- and gender-matched healthy control subjects. Using a software package, bidimensional acquisitions were analyzed to measure longitudinal strain and strain rate for the left atrium (LA). Systolic strain and strain rate in all eight segments, and its average values, were significantly reduced in AF patients compared to controls. During 9 months of follow-up after catheter ablation for AF, 11 of 40 AF patients had AF recurrence. AF recurrence was associated with gender, LA volume index, and average values of systolic strain and strain rate. By multivariate analysis, only average strain was an independent predictor of AF recurrence (OR = 0.88, 95% CI 0.79-0.98, p = 0.018). Conclusions Lower systolic strain of LA was strongly associated with recurrence after catheter ablation. Thus, diverse adjunctive ablation strategies should be considered to reduce recurrence in patients with lower systolic strain.
    No preview · Article · Nov 2009 · Journal of Interventional Cardiac Electrophysiology
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