An E/e′ ratio on echocardiography predicts the existence of left atrial low-voltage areas and poor outcomes after catheter ablation for atrial fibrillation

Masuda, Masaharu; Fujita, Masashi; Iida, Osamu; Okamoto, Shin; Ishihara, Takayuki; Nanto, Kiyonori; Kanda, Takashi; Sunaga, Akihiro; Tsujimura, Takuya; Matsuda, Yasuhiro; Ohashi, Takuya; Uematsu, Masaaki

doi:10.1093/europace/eux119

Cited by 26 publications

(20 citation statements)

References 21 publications

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“…Diastolic early transmitral flow velocity/mitral annular velocity (E/E’; a noninvasive surrogate marker for LA end-diastolic pressure) has been found to correlate with low-voltage areas on mapping and recurrence after ablation. [ 126 ] Additional information that can be obtained from transoesophageal echocardiography include LAA velocity measured on Doppler and spontaneous echocardiographic contrast, which can be predictive of future LA thrombus formation. [ 127 , 128 ]…”

Section: Clinical Evaluation Of Myopathymentioning

confidence: 99%

Atrial Myopathy Underlying Atrial Fibrillation

Rivner

Mitrani

Goldberger

2020

Arrhythmia &Amp; Electrophysiology Review

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While AF most often occurs in the setting of atrial disease, current assessment and treatment of patients with AF does not focus on the extent of the atrial myopathy that serves as the substrate for this arrhythmia. Atrial myopathy, in particular atrial fibrosis, may initiate a vicious cycle in which atrial myopathy leads to AF, which in turn leads to a worsening myopathy. Various techniques, including ECG, plasma biomarkers, electroanatomical voltage mapping, echocardiography, and cardiac MRI, can help to identify and quantify aspects of the atrial myopathy. Current therapies, such as catheter ablation, do not directly address the underlying atrial myopathy. There is emerging research showing that by targeting this myopathy we can help decrease the occurrence and burden of AF.

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Section: Clinical Evaluation Of Myopathymentioning

confidence: 99%

Atrial Myopathy Underlying Atrial Fibrillation

Rivner

Mitrani

Goldberger

2020

Arrhythmia &Amp; Electrophysiology Review

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show abstract

“…Among patients with AF who undergo ablation, those who have increased LA dimensions, pressures or fibrosis, or LV fibrosis or abnormal diastolic filling parameters are at increased risk for AF recurrence and often require repeated ablation procedures; in patients without a prior myocardial infarction (i.e. HFpEF), the finding of ventricular fibrosis doubles the procedural failure rate .…”

Section: Therapeutic Challenges In Patients With a Metabolic Disordermentioning

confidence: 99%

“…34,39 Unfortunately, patients with AF who have myocardial fibrosis are unlikely to maintain sinus rhythm following an ablation procedure; 227,228 this is likely to explain the high rate of AF recurrence following catheter ablation in patients with obesity or type 2 diabetes. [229][230][231][232][233][234] Among patients with AF who undergo ablation, those who have increased LA dimensions, pressures or fibrosis, or LV fibrosis or abnormal diastolic filling parameters are at increased risk for AF recurrence and often require repeated ablation procedures; 227,228,[232][233][234][235][236][237][238][239][240] in patients without a prior myocardial infarction (i.e. HFpEF), the finding of ventricular fibrosis doubles the procedural failure rate.…”

Section: Pharmacological and Procedural Rhythm Controlmentioning

confidence: 99%

Do most patients with obesity or type 2 diabetes, and atrial fibrillation, also have undiagnosed heart failure? A critical conceptual framework for understanding mechanisms and improving diagnosis and treatment

Packer

2019

European J of Heart Fail

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Obesity and diabetes can lead to heart failure with preserved ejection fraction (HFpEF), potentially because they both cause expansion and inflammation of epicardial adipose tissue and thus lead to microvascular dysfunction and fibrosis of the underlying left ventricle. The same process also causes an atrial myopathy, which is clinically evident as atrial fibrillation (AF); thus, AF may be the first manifestation of HFpEF. Many patients with apparently isolated AF have latent HFpEF or subsequently develop HFpEF. Most patients with obesity or diabetes who have AF and exercise intolerance have increased left atrial pressures at rest or during exercise, even in the absence of diagnosed HFpEF. Among patients with AF, those who also have latent HFpEF have increased risk for systemic thromboembolism and death. The identification of HFpEF in patients with obesity or diabetes alters the risk‐to‐benefit relationship of commonly prescribed treatments. Bariatric surgery and statins can ameliorate AF and reduce the risk for HFpEF. Conversely, antihyperglycaemic drugs that promote adipogenesis or cause sodium retention (insulin and thiazolidinediones) may increase the risk for heart failure in patients with an underlying ventricular myopathy. Patients with obesity and diabetes who undergo catheter ablation for AF are at increased risk for AF recurrence and for post‐ablation increases in pulmonary venous pressures and worsening heart failure, especially if HFpEF coexists. Therefore, AF may be the earliest indicator of HFpEF in patients with obesity or type 2 diabetes, and recognition of HFpEF alters the management of these patients.

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“…Additionally, both obesity and diabetes are accompanied by a high rate of AF recurrence following catheter ablation . Procedural success following ablation is diminished by LA fibrosis, which is a common finding in both metabolic disorders, especially if the AF is long‐standing or is accompanied by latent HFpEF …”

Section: Heightened Risks Of Rate‐control Strategies For Af In Obesitmentioning

confidence: 99%

“…57,58 Procedural success following ablation is diminished by LA fibrosis, which is a common finding in both metabolic disorders, especially if the AF is long-standing or is accompanied by latent HFpEF. 59,60…”

Section: Heightened Risks Of Rate-control Strategies For Af In Obesmentioning

confidence: 99%

Heightened risk of intensive rate control in patients with atrial fibrillation who are obese or have type 2 diabetes: A critical review and re‐evaluation

Packer

2019

Cardiovasc electrophysiol

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Atrial fibrillation (AF) is common in patients with obesity and diabetes; the arrhythmia (if long‐standing) is typically managed by rate control and anticoagulation. However, the coexistence of these two metabolic disorders complicates therapeutic options for rate control. The likely pathogenesis of AF in these patients is an expansion of epicardial adipose tissue whose inflammation is transmitted to the left atrium causing electromechanical remodeling. However, this same process is also transmitted to the left ventricle (LV), impairing its distensibility and its ability to tolerate volume, leading to heart failure with preserved ejection fraction. Unfortunately, the latter diagnosis (although commonly present in patients with AF and a coexistent metabolic disorder) is often ignored. To achieve rate control, physicians prescribe intensive treatment with atrioventricular (AV) nodal–blocking drugs, often at doses that are titrated to blunt exercise as well as resting heart rate responses. However, strict rate control (target rate, <80/min) is associated with somewhat worse outcomes than lenient rate control (target rate, <110/min). Furthermore, any rate slowing that facilitates diastolic filling may aggravate filling pressures that are already disproportionately increased because the LV is stiff and overfilled as a result of cardiac inflammation. Rate slowing in AF with beta blockers may not achieve the benefit expected from the blockade of adrenergically mediated cardiotoxicity, and some AV nodal–blocking drugs (digoxin and dronedarone) can increase the risk of death in patients with AF. Finally, cardiac fibrosis in obesity and diabetes may affect the conduction system, which can predispose to serious bradyarrhythmias if patients are prescribed AV nodal–blocking drugs.

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An E/e′ ratio on echocardiography predicts the existence of left atrial low-voltage areas and poor outcomes after catheter ablation for atrial fibrillation

Abstract: A high E/e' obtained by pre-ablation echocardiography was associated with a left atrial arrhythmogenic substrate in patients undergoing AF ablation. Furthermore, a high E/e' predicted poor procedural outcomes after pulmonary vein isolation.

Cited by 26 publications

References 21 publications

Atrial Myopathy Underlying Atrial Fibrillation

Atrial Myopathy Underlying Atrial Fibrillation

Do most patients with obesity or type 2 diabetes, and atrial fibrillation, also have undiagnosed heart failure? A critical conceptual framework for understanding mechanisms and improving diagnosis and treatment

Heightened risk of intensive rate control in patients with atrial fibrillation who are obese or have type 2 diabetes: A critical review and re‐evaluation

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