Conventional versus 3-D Echocardiography to Predict Arrhythmia Recurrence After Atrial Fibrillation Ablation.

Arrhythmia recurrence after atrial fibrillation (AF) ablation remains high and requires repeat interventions in a substantial number of patients. We assessed the value of conventional and 3-D echocardiography to predict AF recurrence. Consecutive patients undergoing AF ablation by means of pulmonary vein isolation were included in a prospective registry. Echocardiograms were obtained prior to the ablation procedure, and analyzed offline in a standardized manner, including 3-D left atrial (LA) volumetry and determination of LA function and sphericity. The primary endpoint, AF recurrence (>30 seconds) between 3 to 12 months after AF ablation, was independently adjudicated. We included 276 patients (73% male, mean age 59.9 ± 9.9 years). Paroxysmal and persistent AF were present in 178 (64%) and 98 (36%) patients, respectively. Mean left ventricular ejection fraction and indexed LA volume in 3-D (LAVI) were 52 ± 12% and 42 ± 13 mL/m2 , respectively. AF recurrence was observed in 110 (40%) patients after a single procedure. Median (interquartile range) time to AF recurrence was 123 (92; 236) days. In multivariable Cox regression models, the only predictors for AF recurrence were the minimal, maximal, and indexed 3-D LA volumes, P = 0.024, P = 0.016, and P = 0.014, respectively. Quartile specific analysis of 3-D LAVI showed an HR of 1.885 (95%CI 1.066-3.334; P for trend = 0.015) for the highest compared to the lowest quartile. Our results show the important role of LA volume for the long-term freedom from arrhythmia after AF ablation. These data also highlight the potential of 3-D echocardiography in this context and may facilitate patient selection for AF ablation.

Bossard M ，Knecht S ，Aeschbacher S ，Buechel RR ，Hochgruber T ，Zimmermann AJ ，Kessel-Schaefer A ，Stephan FP ，Völlmin G ，Pradella M ，Sticherling C ，Osswald S ，Kaufmann BA ，Conen D ，Kühne M ... -  《-》

Left atrial volume computed by 3D rotational angiography best predicts atrial fibrillation recurrence after circumferential pulmonary vein isolation.

Strisciuglio T ，Di Gioia G ，Chatzikyriakou S ，Silva Garcia E ，Barbato E ，Geelen P ，De Potter T ... -  《-》

Left atrial anatomy, atrial fibrillation burden, and P-wave duration-relationships and predictors for single-procedure success after pulmonary vein isolation.

Atrial fibrillation (AF) is associated with changes in left atrial (LA) volume, but the relationship between LA size, AF burden, and electrical conduction behaviour is still uncertain. The aim of this study was to quantify the association and impact of these parameters on the single-procedure outcome after circumferential antral ablation for pulmonary vein isolation. Left atrial assessment was performed in 129 consecutive patients using pre-procedural imaging in three dimensions (sphericity, indexed volume), two dimensions (diameters), and from echocardiography in one dimension (long axis). Atrial fibrillation burden was classified based on the clinical assessment as paroxysmal and persistent and based on a validated scoring system including frequency, duration of AF episodes, and number of cardioversions into four grades (minimal, mild, moderate, and severe). P-wave duration and PR interval was measured on the 12-lead electrocardiogram at the end of the procedure. Atrial fibrillation burden score (AFB) was minimal (2%), mild (75%), moderate (9%), and severe (14%) and 65% had paroxysmal and 35% had persistent AF. The recurrence rate was significantly higher in patients with persistent AF, with higher AFB, with prolonged P-wave, and with an indexed LA volume  > 55 mL/m2. In multivariable analysis, AFB (hazard ratio: 2.018(1.383-2.945), P > 0.001) and a prolonged P-wave (hazard ratio: 2.612(1.248-5.466), P = 0.011) were identified as significant predictors for AF recurrence. In our cohort of patients with symptomatic AF, the AFB and the P-wave duration but none of the anatomical parameter revealed to be independent predictors for AF/AT recurrence after circumferential antral pulmonary vein isolation.

Knecht S ，Pradella M ，Reichlin T ，Mühl A ，Bossard M ，Stieltjes B ，Conen D ，Bremerich J ，Osswald S ，Kühne M ，Sticherling C ... -  《-》

Restoration of sinus rhythm and atrial transport function after the maze procedure: U lesion set versus box lesion set.

In a U lesion set, the left atrium (LA) roof between the right and left superior pulmonary veins is not ablated, to allow activation to propagate across the posterior LA and to recruit this segment as a contractile atrial component. In contrast, the box lesion set isolates the entire posterior LA. To compare the two lesion sets, postoperative freedom from atrial fibrillation (AF) and LA transport function were examined in 402 patients who underwent surgery for AF with a U lesion (n = 329) or box lesion (n = 73) set. Patients who underwent pulmonary vein isolation alone or other simplified procedures were excluded from the study. LA transport function was quantified at 20 ± 33 months postoperatively by the ratio of peak velocity of the A wave to the E wave (peak A/E) of the transmitral Doppler flow. In patients with long-standing persistent AF, freedom from AF was 85% with the U lesion set and 77% with the box lesion set at 5 years after the maze procedure, and 82% and 77%, respectively, at 10 years after the procedure. There was no significant difference between the U lesion set and box lesion set in patients with long-standing persistent AF (P = .30) and those with paroxysmal or persistent AF (P = .90). Proportional hazards analysis identified increased LA diameter (P = .003) and long-standing persistent AF (P = .03), but not the type of lesion set (P = .51), as predictive of postoperative AF recurrence. The postoperative peak A/E was significantly greater after the U lesion set than after the box lesion set (0.42 ± 0.22 vs 0.23 ± 0.17), and multiple regression analysis demonstrated that the type of lesion set and preoperative LA diameter significantly affected postoperative A/E. The U lesion set restores sinus rhythm frequently as the box lesion set and provides better LA transport function. A dilated LA is a risk factor for postoperative recurrence of AF and poor postoperative LA transport function.

Nitta T ，Ishii Y ，Fujii M ，Miyagi Y ，Sakamoto S ，Hiromoto A ，Imura H ... -  《-》

Long-Term Outcome of Left Atrial Voltage-Guided Substrate Ablation During Atrial Fibrillation: A Novel Adjunctive Ablation Strategy.

Left atrium (LA) low voltage area (LVA) on 3-D electroanatomic bipolar voltage mapping (EAVM), as a surrogate for scar, is associated with poor AF ablation outcome. We evaluated the long-term outcome of an LVA-guided atrial fibrillation (AF) substrate modification strategy as an adjunct to pulmonary vein isolation (PVI). Two hundred and one consecutive patients with AF (82% persistent/Non-PAF, age 65 years), who underwent EAVM during AF prior to PVI, were divided into 2 groups according to the presence or absence of LVA outside the PV antra, defined as bipolar voltage of <0.5 mV. LVA-guided substrate modification was performed after PVI in patients with LVA. LVA was found in 159 patients (79%). Non-PAF (OR 3.851, P = 0.002) and CHA2 DS2 -VASc score (OR 1.815, P < 0.001) were independent predictors for the LVA. After the index procedure, 144 patients (72%) were free from AF at 12 months. With multiple procedures, 148 patients (74%) during a median follow-up of 3.1 years were free from the recurrence. There was no difference in the recurrence (log-rank P = 0.746), and complications (0% vs. 7%, P = 0.125) between the groups. Neither LVA nor Non-PAF was an independent predictor for the recurrence in a multivariate analysis. Patients with LVA had an equally favorable long-term ablation outcome compared to those without. As an adjunct to PVI, voltage-guided substrate modification may be an important ablation strategy in patients with LA structural remodeling.

Yagishita A ，Gimbel JR ，DE Oliveira S ，Manyam H ，Sparano D ，Cakulev I ，Mackall J ，Arruda M ... -  《-》