Prediction of low-voltage areas using modified APPLE score

Abstract

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 <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 < 50%) and (m)APPLE (last two variables changed by LAV ≥ 39 mL/m2, and LA-EF < 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.

The pre-ablation triglyceride-glucose index predicts late recurrence of atrial fibrillation after radiofrequency ablation in non-diabetic adults

“…Increased oxidative stress and inflammation can lead to IR and impaired insulin secretion [ 24 ]. Inflammation, IR, and oxidative stress injury are linked to one another and, consequently, result in atrial electrical remodeling [ 18 , 24 ], LA fibrosis [ 18 ], and LA low-voltage areas(LVAs) [ 25 ], which are likely the main constituents of AF pathophysiology [ 25 , 26 ]. Most components of IR, such as glucose tolerance abnormalities, obesity and abnormal lipid levels, were found to have an additive effect on the risk of AF progression, which has been reported to be related to late recurrence of AF after RFCA [ 15 , 17 ].…”

“…APPLE and DR-FLASH scores were recently verified as predictors of LA fibrosis and LVAs, which are closely associated with AF progression and reflect the severity of the AF stage [ 9 , 11 ]. A recent study reported that APPLE and DR‐FLASH scores were associated with LA remodeling or fibrosis [ 9 , 11 , 25 ]. In the present study, we found that the elevated TyG index significantly increased as the APPLE, DR-FLASH and CHA 2 DS 2 -VASc scores increased.…”

Pre-procedural predictors of left atrial low-voltage zones in patients undergoing catheter ablation of atrial fibrillation

“…Although late gadolinium-enhanced cardiac magnetic resonance imaging can detect LA fibrosis, and the extent of the late gadolinium enhancement area correlates with a high recurrence rate of AF after ablation [ 20 ], most hospitals would not be able to perform routine cardiac magnetic resonance imaging before the ablation. Age, sex, and LA volume are the components of assessment tools, such as APPLE, modified APPLE, and DR-FLASH scores, which reportedly predict LVZs [ 18 , 21 , 22 ]. Our findings also revealed that age, female sex, and a larger LA volume were independent pre-procedural predictors for LVZs in line with previous reports.…”

Predictors of left atrial fibrosis in patients with atrial fibrillation referred for catheter ablation

“…Recent studies have suggested an approximately 2-fold higher amount of LA fibrosis in women as compared to men, but it is unclear whether this finding is an independent gender-dependent effect or linked to other risk factors. Recently, the APPLE-score, which does not include female gender, has been suggested as a potential tool to predict LA fibrosis prior to catheter ablation of AF [ 3 ].…”