Background Enlargement of left atrial ( LA ) size indicates advanced disease stage in patients with atrial fibrillation ( AF ) and is associated with poor success of different AF therapies. Two dimensional echocardiographic LA measurements do not reliably reflect the true size of LA anatomy. The aim of the current study was: 1) to analyze cardiovascular magnetic resonance ( CMR )‐derived LA dimensions and their association with low voltage areas ( LVA ); and 2) to investigate the association between these parameters and NT ‐pro ANP (N‐terminal proatrial natriuretic peptide) levels. Methods and Results Patients undergoing first AF catheter ablation were included. All patients underwent CMR imaging (Ingenia 1.5T Philips) before intervention. CMR data ( LA volume, superior–inferior, transversal and anterior–posterior LA diameters) were measured in all patients. LVA were determined using high‐density maps and a low voltage threshold <0.5 mV. Blood plasma samples from femoral vein were collected before catheter ablation. NT ‐pro ANP levels were studied using commercially available assays. There were 216 patients (65±11 years, 59% males, 56% persistent AF , 26% LVA ) included into analyses. NT ‐pro ANP levels in patients with LVA were significantly higher than in those without (median/interquartile range 22 [13–29] versus 15 [9–22] pg/mL, P =0.004). All CMR derived LA diameters correlated significantly with persistent AF ( r ²=0.291–0.468, all P <0.001), LVA ( r ²=0.187–0.306, all P <0.001), and NT ‐pro ANP levels ( r ²=0.258–0.352, P <0.01). On logistic regression multivariable analysis, age (odds ratio=1.090, 95% confidence interval: 1.030–1.153, P =0.003), females (odds ratio=2.686, 95% confidence interval: 1.047–6.891, P =0.040), and LA volume (odds ratio=1.022, 95% confidence interval: 1.009–1.035, P =0.001) remained significant predictors for LVA . Conclusions ...

Background In patients with atrial fibrillation (AF), left atrial (LA) enlargement, and the presence of low‐voltage areas (LVAs) indicate an advanced disease stage. NT‐proANP is a biomarker, which is significantly higher in both phenotypes. Prediction of LVAs before catheter ablation could impact the prognosis and therapeutical management in AF patients. Objective The aim of this study was to (a) analyze the predictive value of a novel biomarker‐based AF substrate prediction score, and (b) compare it with DR‐FLASH and APPLE scores. Methods Patients undergoing first AF catheter ablation were included. LA volume (LAV) was analyzed prior to ablation using cardiovascular magnetic resonance imaging (CMR). Blood plasma samples from the femoral vein were collected before AF ablation. NT‐proANP was analyzed using commercially available assays. LVAs were determined using high‐density maps during catheter ablation and defined as <0.5 mV. The novel ANP score (one point for A ge ≥ 65 years, N T‐proANP > 17 ng/mL, and P ersistent AF) was calculated at baseline. Results The study population included 156 AF patients (64 ± 10 years, 65% males, 61% persistent AF, 28% LVAs). The cut‐off ANP score ≥ 2 demonstrated 77% sensitivity and 70% specificity. On logistic regression (odds ratio [OR] 3.469) and receiver operating characteristic (ROC) analysis (area under the curve [AUC] 0.778, P < .001), the ANP score significantly predicted LVAs presence. There were no differences between novel ANP score – which is a new one ‐ is described in the Abstract; with APPLE (AUC 0.718, P = .378) and DR‐FLASH (AUC 0.766, P = .856) scores. Conclusions The novel biomarker‐based ANP score demonstrates good prediction of LVAs.

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Aims The presence of low-voltage areas (LVAs) in patients with atrial fibrillation (AF) reflects left atrial (LA) electroanatomical substrate, which is essential for individualized AF management. However, echocardiographic anteroposterior LA diameter included into previous LVAs prediction scores does not mirror LA size accurately and impaired left ventricular ejection fraction (LV-EF) is not directly associated with atrial myopathy. Therefore, we aimed to compare a modified (m)APPLE score, which included LA volume (LAV) and LA emptying fraction (LA-EF) with the regular APPLE score for the prediction of LVAs. Methods and results In patients undergoing first AF catheter ablation, LVAs were determined peri-interventionally using high-density maps and defined as signal amplitude &lt;0.5 mV. All patients underwent cardiovascular magnetic resonance imaging before intervention. The APPLE (one point for Age ≥ 65 years, Persistent AF, imPaired eGFR ≤ 60 mL/min/1.73 m2, LA diameter ≥ 43 mm, and LVEF &lt; 50%) and (m)APPLE (last two variables changed by LAV ≥ 39 mL/m2, and LA-EF &lt; 31%) scores were calculated at baseline. The study population included 219 patients [median age 65 (interquartile range 57–72) years, 41% females, 59% persistent AF, 25% LVAs]. Both scores were significantly associated with LVAs [OR 1.817, 95% CI 1.376–2.399 for APPLE and 2.288, 95% CI 1.650–3.172 for (m)APPLE]. Using receiver operating characteristic curves analysis, the (m)APPLE score [area under the curve (AUC) 0.779, 95% CI 0.702–0.855] showed better LVAs prediction than the APPLE score (AUC 0.704, 95% CI 0.623–0.784), however, without statistically significant difference (P = 0.233). Conclusion The modified (m)APPLE score demonstrated good prognostic value for LVAs prediction and was comparable with the regular APPLE score.

Aims Cardiovascular magnetic resonance (CMR) imaging has long been a contraindication for patients with a cardiac implantable electronic device (CIED). Recent studies support the feasibility and safety for non-thoracic magnetic resonance imaging, but data for CMR are sparse. The aim of the current study was to determine the safety in patients with magnetic resonance (MR)-conditional or non-MR-conditional CIED and to develop a best practice approach. Methods and results All patients with a CIED undergoing CMR imaging (1.5 T) between April 2014 and April 2017 were included in the study. Devices were programmed according to the standardized protocol directly before and after the CMR examination. Follow-up interrogation was performed 6 months after CMR examination. Results were compared with a large, reference cohort of CIED patients not undergoing any MR examination. A total of 200 consecutive patients with a CIED (non-MR-conditional, n = 103) were included in the study. Directly after CMR imaging, one device failure (0.5%, battery status = end of service) was noted necessitating premature generator replacement. In three patients (2%) of pacemaker/implantable cardioverter-defibrillator (ICD) carriers a sustained ventricular tachycardia (VT) occurred during CMR imaging. Ten ICD showed a decrease in battery capacity immediately after CMR. Overall, the reference cohort showed comparable changes of CIED function during follow-up. Conclusion With adherence to a standardized protocol and established exclusion criteria CMR imaging could safely be performed in patients with a CIED. The potential risks of device malfunction necessitate the presence of a device trained individual during the entire CMR examination. If there is a history of VT storm the attendance of an experienced cardiologist, should be mandatory.

Background: Coronary artery disease (CAD) is a significant risk factor for atrial fibrillation (AF). Experimental studies demonstrated that atrial ischemia induced by right coronary artery (RCA) stenosis promote AF triggers and development of electro-anatomical substrate for AF. Aim: To analyze the association between AF prevalence and coronary arteries status in the LIFE-Heart Study. Methods: This analysis included patients with available coronary catheterization data recruited between 2006 and 2014. Patients with acute myocardial infarction were excluded. CAD was defined as stenosis ≥75%, while coronary artery sclerosis (CAS) was defined as non-critical plaque(s) <75%. Results: In total, 3.458 patients (median age 63 years, 34% women) were included into analysis. AF was diagnosed in 238 (6.7%) patients. There were 681 (19.7%) patients with CAS and 1.411 (40.8%) with CAD (27.5% with single, 32.4% with double, and 40.1% with triple vessel CAD). In multivariable analysis, there was a significant association between prevalent AF and coronary artery status (OR 0.64, 95% CI 0.53-0.78, P trend < .001). Similarly, AF risk was lower in patients with higher CAD extent (OR 0.54, 95%CI 0.35-0.83, P trend = .005). Compared to single vessel CAD, the risk of AF was lower in double (OR 0.42, 95%CI 0.19-0.95, P = .037) and triple CAD (OR 0.31, 95%CI 0.13-0.71, P = .006). Finally, no association was found between AF prevalence and CAD origin among patients with single vessel CAD. Conclusion: In the LIFE-Heart Study, CAS but not CAD was associated with increased risk of AF.

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BackgroundIdentifying patients with advanced left atrial (LA) remodeling before catheter ablation (CA) of atrial fibrillation (AF) is crucial.HypothesisThis study aimed to identify echocardiographic parameters associated with changes in anatomy and conduction properties of the left atrium (LA).MethodsWe examined 75 AF patients prior to CA and measured the intervals from the P‐wave‐onset to four mitral annulus sites by pulsed‐wave tissue Doppler imaging (PW‐TDI). Patients were grouped to an upward U‐pattern (delayed anterior activation) and a downward D‐pattern (earliest LA activation anterior). CT‐data were used to measure the LA volume (LAV). LAV was divided into anterior‐ (LA‐A) and posterior‐parts by a plane, parallel to the posterior wall and between the veins and the appendage, to calculate the asymmetry index (ASI = LA‐A/LAV).ResultsPatients with U‐pattern (n = 66) had a higher ASI (65 ± 6 vs. 61 ± 3%, p = .014), older age (61 ± 11 vs. 51 ± 11 years, p = .03) and more diastolic dysfunction (71 vs. 22%, p = .008) Multivariate regression showed that age (OR 1.1 per year, CI 1.007–1.199) and diastolic dysfunction (OR 6.36, CI 1.132–35.7, p = .036) were independent predictors of the U‐pattern. Diastolic dysfunction (B 4.49, CI 1.61–7.37, p = .003) was the only independent predictor of ASI in linear regression analysis.ConclusionAF patients with a U‐pattern have an increased LA asymmetry. Diastolic dysfunction is a common cause of this LA activation and remodeling. Therefore, detection of a U‐pattern signifies patients with advanced AF and may facilitate selection for an appropriate ablation strategy.