Extent and spatial distribution of left atrial arrhythmogenic sites, late gadolinium enhancement at magnetic resonance imaging, and low-voltage areas in patients with persistent atrial fibrillation: comparison of imaging vs. electrical parameters of fibrosis and arrhythmogenesis

Chen, Juan; Arentz, Thomas; Cochet, Hubert; Müller‐Edenborn, Björn; Kim, Steven; Moreno-Weidmann, Zoraida; Minners, Jan; Kohl, Peter; Lehrmann, Heiko; Allgeier, Juergen; Trenk, Dietmar; Hocini, Mélèze; Jaı̈s, Pierre; Haı̈ssaguerre, Michel; Jadidi, Amir

doi:10.1093/europace/euz159

Cited by 58 publications

(48 citation statements)

References 25 publications

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“…[ 63 ] Chen et al studied the correlation between delayed enhancement on CMR imaging and LVAs on electroanatomic mapping in 16 patients with persistent AF. [ 64 ] There was a mismatch between delayed enhancement areas and LVAs; delayed enhancement was present in 61% of LVAs, whereas low voltage was present in 28% of delayed enhancement areas. In another recent multimodal examination of AF substrate, Zghaib et al demonstrated that LGE-MRI, high-density mapping and point-by-point mapping with the ablation catheter demonstrated good correlation in delineating electroanatomical AF substrate, providing some enthusiasm for the routine use of CMR imaging.…”

Section: How Best To Define Abnormal Atrial Substrate: Pitfallsmentioning

confidence: 99%

Atrial Fibrillation Structural Substrates: Aetiology, Identification and Implications

Al‐Kaisey

Lee

Kalman

2020

Arrhythm Electrophysiol Rev

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AF is the most common sustained cardiac rhythm disorder and is associated with increased morbidity and mortality. Since the first description of AF initiation by triggers from pulmonary veins sleeves, pulmonary vein isolation (PVI) has become the standard ablation strategy in patients with AF. 1 However, freedom from the arrhythmia, particularly in non-paroxysmal AF, remains suboptimal, and it is now clear that, in these patients, AF is maintained by an atrial substrate beyond the pulmonary veins. Although electrical remodelling may be reversible with termination of the arrhythmia, the development of atrial substrate due to fibrosis contributes to the progression of the AF phenotype from paroxysmal to persistent AF, leading to an arrhythmia that is more refractory to intervention. 2 It is clear from animal and human studies that prolonged AF can cause this structural change. Moreover, it is also apparent that a range of risk factors associated with AF, including age, obesity, heart failure (HF), valvular heart disease, hypertension (HT), sleep apnoea and alcohol intake, may also progress atrial remodelling. The rise in the prevalence of cardiovascular risk factors (particularly driven by ageing populations and the obesity epidemic) has been associated with an increase in the prevalence of AF and AF-related hospitalisations. 3 In this review, we focus on insights from electrophysiological mapping studies in cohorts with AF risk factors. We discuss substrate mapping and its implications for AF management and outcomes, and also focus on potential pitfalls. The Second Factor: Structural Remodelling is Required for AF Maintenance Early studies of animal models have demonstrated that AF promotes acute electrical remodelling, which in turn leads to further AF, thereby introducing the seminal concept that 'AF begets AF'. 4-6 In response to either induced AF or rapid atrial pacing, a reduction in the atrial effective refractory period (ERP) occurs with an increase in the spatial heterogeneity of ERP and loss of normal ERP rate adaptation, all resulting in progressively longer durations of AF. In this model, termination of the arrhythmia results in remodelling reversal, suggesting that sinus rhythm may beget sinus rhythm. However, human studies of early intervention to re-establish sinus rhythm do not fully support this concept; the re-establishment of sinus rhythm has not been found to prevent the progression of AF in the majority of patients. 7,8 Ongoing work has indicated that, beyond acute electrical remodelling, structural remodelling also occurs and is not necessarily fully reversible. This socalled second factor has been shown to occur as a result of longer durations of AF. However, the multiple conditions associated with AF also appear to promote significant structural remodelling.

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Section: How Best To Define Abnormal Atrial Substrate: Pitfallsmentioning

confidence: 99%

Atrial Fibrillation Structural Substrates: Aetiology, Identification and Implications

Al‐Kaisey

Lee

Kalman

2020

Arrhythm Electrophysiol Rev

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“…LVAs are found mainly on the LA septum, anterior LA, and posterior LA 16 . Chen et al 17 reported that LGE sites were present in 61% of LVAs, whereas LVAs were present at 28% of LGE sites. These findings indicated that the distribution of the LGE sites could not completely overlap with that of the LVAs.…”

Section: Discussionmentioning

confidence: 99%

Feasibility of catheter ablation in patients with persistent atrial fibrillation guided by fragmented late‐gadolinium enhancement areas

Kiuchi

Fukuzawa

Takami

et al. 2021

Cardiovasc electrophysiol

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Background A computer simulation model has demonstrated that atrial fibrillation (AF) driver can be attached to heterogeneous fibrosis assessed by late gadolinium enhancement magnetic resonance imaging (LGE‐MRI). However, it has not been well elucidated in patients with persistent AF. The aim of this study was to investigate whether radiofrequency (RF) applications in the fragmented LGE area (FLA) could terminate AF or convert it to atrial tachycardia (AT) and improve the rhythm outcome. Methods A total of 31 consecutive persistent AF patients with FLAs were enrolled (FLA ablation group, mean age: 69 ± 8 years, mean left atrial diameter: 42 ± 6 mm). A favorable response was defined as direct AF termination or AT conversion during RF applications at the FLA. The rhythm outcome was compared between the FLA ablation group and FLA burden‐matched pulmonary vein isolation (PVI) group. Results Favorable responses were found in 15 (48%) of 31 patients in the FLA group (AF termination in seven, AT conversion in eight patients), but not in the PVI group. AF recurrence at 12 months follow‐up was significantly less in the FLA ablation group than in the PVI group (4 [13%] vs. 12 [39%] of 31 patients, log‐rank p = .023). In patients with a favorable response, AT recurred in 1 (7%) of 15 patients, but AF did not. Conclusions FLA ablation could terminate AF or convert it to AT in half of the patients. No AF recurrence was documented in patients with a favorable response.

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“…However, the main limitation of this imaging modality for fibrosis assessment is the suboptimal reproducibility of the results, mainly due to variable acquisition protocols and processing techniques that increase inter‐observer variability 35 . There are still discrepancies in the extent and distribution of late‐gadolinium enhancement‐MRI areas and EAM‐identified LVZs in patients with AF 36 …”

Section: Discussionmentioning

confidence: 99%

Evaluation of left atrial remodeling by 2D‐speckle‐tracking echocardiography versus by high‐density voltage mapping in patients with atrial fibrillation

Laish-Farkash

Brezinov

Valdman

et al. 2020

Cardiovasc electrophysiol

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Background Strain imaging during left atrial (LA) reservoir phase (LASr) is used as a surrogate for LA structural remodeling and fibrosis. Atrial fibrillation (AF) patients with >5% low‐voltage zones (LVZs) obtained by 3D‐electro‐anatomical‐mapping have higher recurrence rate post‐ablation. We investigated the relationship between LA remodeling using two‐dimensional‐speckle‐tracking echocardiography (2D‐STE) and high‐density voltage mapping in AF patients. Methods A prospective study of 42 consecutive patients undergoing AF ablation. 2D‐echo, 2D‐STE, and high‐density contact LA bipolar voltage maps were constructed before ablation. LVZs were determined with different bipolar amplitudes and their ratio per patient's LA area were investigated for correlation with LASr. We compared 2D‐LASr results in patients with LVZs ≥ 5% (LVZs group) versus those with LVZ < 5% (non‐LVZs group). Results Compared with non‐LVZs group (n = 15), LVZs group (n = 27) included significantly older patients, more women, more persistent AF, higher CHA2DS2‐VASc score, higher E/A ratio and higher LA volume index (p < .05). LVZs group had lower %LASr values (12.4 ± 5.9% vs. 21.1 ± 6.3, respectively; p<.001). LVZs% in different amplitudes (<0.1 mV, <0.2 mV, and <0.5 mV) were negatively correlated with %LASr (r = −.63, r = −.68, and r = −.72, respectively; p< .001). Atrial strain thresholds for LVZs ≥ 5% in amplitudes <0.1 mV, <0.2 mV, and <0.5 mV were associated with %LASr 12.98, 16.16 and 19.55, respectively; p< .05). In a multivariate analysis, %LASr was the only independent indicator of LVZs (OR, 0.8; 95% CI, 0.6–0.9; p= .04). Conclusions LVZs ≥ 5% has a negative association with atrial %LASr. Thus, a simple 2D‐STE measurement of %LASr can be used as a noninvasive method to evaluate significant LA remodeling and fibrosis in AF patients.

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Extent and spatial distribution of left atrial arrhythmogenic sites, late gadolinium enhancement at magnetic resonance imaging, and low-voltage areas in patients with persistent atrial fibrillation: comparison of imaging vs. electrical parameters of fibrosis and arrhythmogenesis

Cited by 58 publications

References 25 publications

Atrial Fibrillation Structural Substrates: Aetiology, Identification and Implications

Atrial Fibrillation Structural Substrates: Aetiology, Identification and Implications

Feasibility of catheter ablation in patients with persistent atrial fibrillation guided by fragmented late‐gadolinium enhancement areas

Evaluation of left atrial remodeling by 2D‐speckle‐tracking echocardiography versus by high‐density voltage mapping in patients with atrial fibrillation

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