Prediction of Left Atrial Fibrosis and Success of Catheter Ablation by Speckle Tracking Echocardiography in Patients Imaged in Persistent Atrial Fibrillation

Abstract

BackgroundNon-invasive evaluation of left atrial structural and functional remodeling should be considered in all patients with persistent atrial fibrillation (AF) to optimal management. Speckle tracking echocardiography (STE) has been shown to predict AF recurrence after catheter ablation; however in most studies, patients had paroxysmal AF, and STE was performed while patients were in sinus rhythm.AimThe aim of this study was to evaluate the ability of STE parameters acquired during persistent AF to assess atrial fibrosis measured by low voltage area, and to predict maintenance of sinus rhythm of catheter ablation.MethodsA total of 94 patients (69 men, 65 ± 9 years) with persistent AF prospectively underwent measurement of Global Peak Atrial Longitudinal Strain (GPALS), indexed LA Volume (LAVI), E/e′ ratio, and LA stiffness index (the ratio of E/e′ to GPALS) by STE prior to catheter ablation, while in AF. Low-voltage area (LVA) was assessed by electro-anatomical mapping and categorized into absent, moderate (>0 to <15%), and high (≥15%) atrial extent. AF recurrence was evaluated after 3 months of blanking.ResultsMultivariable regression showed that LAVI, GPALS, and LA stiffness independently predicted LVA extent after correcting for age, glomerular filtration rate, and CHA2DS2-VASc score. Of all the parameters, LA stiffness index had the highest diagnostic accuracy (AUC 0.85), allowing using a cut-off value ≥0.7 to predict moderate or high LVA with 88% sensitivity and 47% specificity, respectively. In multivariable Cox analysis, both GPALS and LA stiffness were able to significantly improve the c statistic to predict AF recurrence (n = 40 over 9 months FU) over CHARGE-AF (p < 0.001 for GPALS and p = 0.01 for LA stiffness) or CHA2DS2-VASc score (p < 0.001 for GPALS and p = 0.02 for LA stiffness). GPALS and LA stiffness also improved the net reclassification index (NRI) over the CHARGE-AF index (NRI 0.67, 95% CI [0.33–1.13] for GPALS and NRI 0.73, 95% CI [0.12–0.91] for LA stiffness, respectively), and over the CHA2DS2-VASc score (NRI 0.43, 95% CI [−0.14 to 0.69] for GPALS and NRI 0.52, 95% CI [0.10–0.84], respectively) for LA stiffness to predict AF recurrence at 9 months.ConclusionSTE parameters acquired during AF allow prediction of LVA extent and AF recurrence in patients with persistent AF undergoing catheter ablation. Therefore, STE could be a valuable approach to select candidates for catheter ablation.

Left atrial reservoir longitudinal strain and its incremental value to the left ventricular global longitudinal strain in predicting anthracycline‐induced cardiotoxicity

“…In the present study, we noticed a significantly increased PA‐TDI duration after the completion of chemotherapy, suggesting the atrial electrical and structural remodeling induced by anthracycline toxicity. The LASr has been reported to be associated with the extent of low‐voltage area in patients with AF 38 . Quantitative analysis further validated a solid inverse correlation between LASr and LA fibrosis confirmed with histopathology 39 and enhanced cardiac magnetic resonance (CMR) 40,41 .…”

“…The LASr has been reported to be associated with the extent of low-voltage area in patients with AF. 38 Quantitative analysis further validated a solid inverse correlation between LASr and LA fibrosis confirmed with histopathology 39 and enhanced cardiac magnetic resonance (CMR). 40,41 Therefore, LASr not only reflects LA function status but also the degree of pathological remodeling.…”

Left Atrial Glucose Metabolism Evaluation by 18F-FDG-PET in Persistent Atrial Fibrillation and in Sinus Rhythm

“…and all measurements were performed by averaging 3 cardiac cycles as described previously. 13 LV volumes and ejection fraction were calculated using Simpson’s biplane method. The E/e′ ratio was calculated from peak mitral flow E and the average of septal and lateral e′ tissue Doppler velocities.…”

“…Electroanatomic mapping of the LA was obtained using the ConfiDENSE CARTO3 system v6.0.70 using the 2515 Variable Loop Lasso Multi-Electrode Eco Nav (Biosense Webster) using ≥1,000 measurements as described previously. 13 Electrical cardioversion was attempted after an initial mapping, and mapping was repeated in SR. Low voltage area was defined as bipolar peak-to-peak voltage amplitude of <0.5 mV in SR and <0.31 mV in AF. All patients underwent radiofrequency PVI with additional lines or complex atrial fractionated electrogram ablations performed at the physician's discretion.…”

Efficacy of left atrial low-voltage area-guided catheter ablation of atrial fibrillation: An updated systematic review and meta-analysis

“…It is generally acknowledged that atrial structural remodeling involving atrial tissue fibrosis and scarring is an essential factor in the pathogenesis and progression of AF ( 7 , 8 ). Several trials have suggested that the existence of LVA was strongly associated with AF recurrence after catheter ablation for all AF types ( 9 – 12 ). In this context, in Rolf et al initially proposed LVA-guided ablation as an atrial substrate modification approach ( 9 ).…”