Fate of left atrial function as determined by real-time three-dimensional echocardiography study after radiofrequency catheter ablation for the treatment of atrial fibrillation

Clinical value of artificial intelligence 3D echocardiography in evaluating left atrial volume and pulmonary vein structure in patients with atrial fibrillation

OBJECTIVE

To explore the clinical value of 3D Echocardiography (3DE) in evaluating the changes of left atrial volume and pulmonary vein structure in patients with Atrial Fibrillation (AF).

METHODS

Clinical data were collected from 54 AF patients. Left Atrial Anteroposterior Diameter (LADap), Left Atrial left and right Diameter (LADml), and Left Atrial upper and lower Diameter (LADsi) were measured; the maximum Left Atrial Volume (LAVmax), minimum Left Atrial Volume (LAVmin), left atrial presystolic volume (LAVpre), and Cross-Sectional Area (CSA) of each pulmonary vein were analyzed. Passive Ejection Fraction (LAPEF) was calculated. The differences in left atrial volume and pulmonary vein structure between patients with AF and healthy people were compared, and the correlation between the indexes was analyzed. The diagnostic value of the above indicators for AF patients was analyzed.

RESULTS

LADap, LADml, LADsi, LAVmax, LAVmin, LAVpre, LAPEF, LSPV CSA, LIPV CSA, RSPV CSA, and RIPV CSA of AF patients were significantly higher. There was a significant positive correlation between left atrial diameter and pulmonary vein structure. There was a significant positive correlation between left atrial volume and pulmonary vein structure. There was a negative correlation between LAPEF and pulmonary vein structure. LADap, LADml, LADsi, LAVmax, LAVmin, LAVpre, LAPEF, LSPV CSA, LIPV CSA, RSPV CSA, and RIPV CSA had a diagnostic value for AF patients.

CONCLUSION

3DE is applicable for evaluating left atrial volume and pulmonary vein structure in patients with AF.

Early rhythm control vs. rate control in atrial fibrillation: A systematic review and meta-analysis

Objective

It has long been debated whether rhythm control vs. rate control strategies have differing effects on mortality and morbidity for atrial fibrillation (AF). Recently, several randomized controlled studies (RCTs) and observational trials described that an early rhythm management method was linked to a lower likelihood of negative clinical outcomes in individuals with AF. We wanted to see if an early rhythm management method may help patients with AF.

Methods

We performed a systematic search to retrieve studies assessing the outcomes of early rhythm control vs. rate control in AF by using PubMed, Web of Science, Cochrane Library, and Embase published between 01/01/2000 and 15/04/2022.

Results

Finally, two RCTs, one retrospective analysis of RCTs, and four observational studies were identified. Compared with rate control, early rhythm control has been linked to lower all-cause mortality. [risk ratio (RR), 0.76; 95% CI 0.69-0.83; P < 0.00001; I 2 = 77%]. The early rhythm control group was also associated with a lower risk of cardiovascular mortality (RR, 0.68; 95% CI 0.63-0.74; P < 0.00001; I 2 = 33), stroke (RR, 0.77; 95% CI 0.67-0.87; P < 0.001; I 2 = 64), and heart failure hospitalization (RR, 0.74; 95% CI 0.59-0.93; P = 0.0009; I 2 = 93%). We found no significant difference in nights spent in hospital per year, acute coronary syndrome, major bleeding, and cardiac arrest/ventricular arrhythmia between the groups.

Conclusion

In this meta-analysis, early rhythm therapy was linked to a lower risk of all-cause mortality, cardiovascular mortality, stroke, and heart failure hospitalization compared with the rate control group.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022333592.

Association of pericardial effusion after pulmonary vein isolation and outcomes in patients with paroxysmal atrial fibrillation

BACKGROUND

The clinical implications of pericardial effusion (PE) after catheter ablation for atrial fibrillation (AF) are not well understood. We evaluated the association between newly developed PE after pulmonary vein isolation (PVI) for paroxysmal AF and arrhythmic recurrence.

METHODS

From a prospective AF ablation registry, 184 patients (mean age 59 ± 10 years, 65% male) who underwent first-time PV isolation using a smart touch surround flow catheter (Biosense Webster, Diamond Bar, CA) were analyzed. Postablation transthoracic echocardiography (TTE) was performed within 1-3 days after ablation, and the occurrence of PE was assessed.

RESULTS

PE developed in 91 patients (49.5%), and most were of minimal severity (minimal, 93.4%; mild, 6.6%). Patients with PE had significantly lower body mass index and underwent cavotricuspid isthmus ablation more frequently. Early arrhythmic recurrence (EAR) (within 3 months) was observed in 28.8% of patients and was not different according to the PE development (PE [+]: 29.7% vs PE [-]: 28.0%; P = .80). During a median follow-up of 696 days, the cumulative rate of the late arrhythmic recurrence (LAR) (after 3 months) was 36.4%, and there was no difference between groups (PE [+]: 36.7% vs PE [-]: 35.1%; P = .988). The only predictor of LAR was EAR, and no echocardiographic parameters showed a significant correlation with LAR.

CONCLUSIONS

Minimal or mild PE after PVI for paroxysmal AF is a frequent echocardiographic finding, and it had no significant association with AF recurrence. Routine TTE after AF ablation has no clinical implication.

Morphological and functional parameters of left atrial appendage play a greater role in atrial fibrillation relapse after radiofrequency ablation

This study was to quantitatively investigate the role of morphological and functional parameters of the left atrium (LA) and left atrial appendage (LAA) with 256-slice spiral computed tomography (CT) in the recurrence of atrial fibrillation (AF) after radiofrequency ablation (RFA). Eighty-three patients with AF who underwent RFA for the first time were divided into the recurrence (n = 27) and non-recurrence (n = 56) groups. All patients underwent a 256-slice spiral CT examination before the operation. The clinical data and quantitative measurement of the morphology and functional parameters of the LA and LAA were analyzed, including the maximal and minimal volume, ejection fraction and volume, and volume strain of LAA and LA (LAAVmax, LAAVmin, LAAEF, LAAEV, and LAA-VS, LAVmax, LAVmin, LAEF, LAEV and LA-VS, respectively). The CHA2DS2-VASc score and the proportion of patients with heart failure were significantly (P < 0.05) higher in the recurrence than non-recurrence group. The LAAVmax, LAAVmin, LAVmax, LAVmin, LAAV and LAV were all significantly greater in the recurrence than non-recurrence group (P < 0.05), and the perimeter, major and minor axes of LAA orifice and LAA depth were also significantly greater in the recurrence than non-recurrence group. The LAAEF, LAEF and LAA-VS were significantly (P < 0.05) lower in the recurrence than non-recurrence group (P < 0.05). Heart failure, CHA2DS2-VASC score, LAEF, LAV, LAAEF and LAA-VS were univariately significant (P < 0.05) risk factors for AF recurrence after ablation. Multivariate analysis revealed LAAEF (HR: 0.790, 95% CI: 0.657–0.950, P = 0.012) and LAAV (HR: 1.160, 95% CI: 1.095–1.229, P <0.001) to be two significant independent predictors of recurrence. ROC curve analysis showed that LAAEF <44.68% had the highest predictive value for recurrence after radiofrequency ablation, with the sensitivity of 90% and specificity of 67.4%, whereas LAA volume >9.25 ml had the highest predictive value for AF recurrence after RFA, with the sensitivity of 85.2% and specificity of 67.9%. In conclusion, the volume of left atrium, volume and morphology of left atrial appendage have all significantly increased while the ejection fraction and volume strain of left atrium and left atrial appendage have both significantly decreased in recurrence than in non-recurrence after radiofrequency ablation. The ejection fraction and volume of left atrial appendage are significant independent predictors of atrial fibrillation recurrence after radiofrequency ablation.

The impact of catheter ablation of atrial fibrillation on the left atrial volume and function: study using three-dimensional echocardiography

Purpose

The exact correlation between the baseline left atrial (LA) volume (LAV) and atrial fibrillation (AF) radiofrequency catheter ablation (RFCA) outcomes and changes to the LA after AF RFCA has not yet been fully understood. We sought to evaluate the serial changes in the LAV and LA function after RFCA using 3D echocardiography.

Methods

Consecutive patients who received RFCA of paroxysmal (PAF) or persistent AF (PeAF) at our center between January 2013 and March 2016 were included. Real-time 3D apical full-volume images were acquired, and a 3D volumetric assessment was performed using an automated three-beat averaging method. The LAV index (LAVI) was calculated and the LA ejection fraction (LAEF) was calculated as [LAVmax − LAVmin]/LAVmax.

Results

Ninety-nine total patients were enrolled, and the mean age was 58.0 ± 8.2 years and 75 (74.7%) were male. There were 59 (59.6%) PAF patients and the remaining 40 (40.4%) had PeAF. AF recurred in 5 of 59 (8.5%) PAF and in 10 of 40 (25%) PeAF patients. The LAVImax increased on 1 day, decreased at 3 months, and then increased again at 1 year but was lower than that at baseline. The LAEF changes were similar to the volume changes but were more prominent in PeAF than PAF patients. The baseline 3D LAVImax was an independent predictor of AF recurrence after RFCA and the cut-off value was 44.13 ml/m².

Conclusion

In our study, even after 3 months of scar formation due to ablation, structural remodeling of the LA continued. The changes were more prominent in the non-recurrent, PeAF patients.

Electronic supplementary material

The online version of this article (10.1007/s10840-019-00696-8) contains supplementary material, which is available to authorized users.

Biatrial remodelling in atrial fibrillation: A three-dimensional and strain echocardiography insight

BACKGROUND

Atrial remodelling has been poorly investigated in atrial fibrillation (AF), and few studies have focused on biatrial remodelling.

AIM

To evaluate right atrial (RA) and left atrial (LA) remodelling in AF using global atrial reservoir strain and three-dimensional (3D) atrial volumes, according to rhythm outcome at mid-term follow-up.

METHODS

Two-dimensional and 3D transthoracic echocardiography (TTE) were performed within 24hours after admission (M0) and at 6-month follow-up (M6) in patients admitted for AF. RA and LA variables were assessed: body surface area-indexed maximum 3D volume (Max 3D RA Vol_i, Max 3D LA Vol_i) and minimum 3D volume (Min 3D RA Vol_i, Min 3D LA Vol_i); atrial emptying fraction (3D RAEF, 3D LAEF); atrial expansion index (3D RAEI, 3D LAEI); and global RA and LA reservoir strain.

RESULTS

Forty-eight consecutive patients were included prospectively. Three groups were identified depending on rhythm at M0 and M6: AF at M0 and sinus rhythm (SR) at M6 (AF-SR) in 25 (52.1%) patients; AF at M0 and AF at M6 (AF-AF) in 13 (27.1%) patients; and SR at M0 (spontaneous cardioversion before first TTE) and SR at M6 (SR-SR) in 10 (20.8%) patients. Between M0 and M6 in the AF-SR group, we found: significant decreases in Max 3D RA Vol_i (P=0.020), Min 3D RA Vol_i (P=0.0008), Max 3D LA Vol_i (P=0.001) and Min 3D LA Vol_i (P=0.0021); significant increases in 3D RAEF (P=0.037) and 3D RAEI (P=0.034); no significant differences in 3D LAEF and 3D LAEI; and significant increases in global RA and LA reservoir strain (both P<0.0001). There was no significant difference with regard to these variables in the AF-AF and SR-SR groups.

CONCLUSION

3D volume and strain analyses were useful in the evaluation of RA and LA reverse remodelling in successfully cardioverted patients with AF.

Effect of cryoballoon and radiofrequency ablation for pulmonary vein isolation on left atrial function in patients with nonvalvular paroxysmal atrial fibrillation: A prospective randomized study (Cryo-LAEF study)

BACKGROUND

Isolation of the pulmonary veins (PVI) has become a mainstay in atrial fibrillation (AFib) therapy. Lesions in left atrial tissue lead to scar formation and this may affect left atrial function.

METHODS

Patients with paroxysmal AFib were randomly assigned in a 1:2 allocation scheme to radiofrequency (RF) ablation or cryoballoon. Real-time three-dimensional echocardiography was performed (under sinus rhythm in all cases) before ablation and at 1 and 3 months to evaluate the left atrial functional indices. The primary outcome measure was change in left atrial ejection fraction (LAEF) at 1 month.

RESULTS

120 patients were randomized (80 to cryoballoon, 40 to RF). The absolute change in LAEF at 1 month was 4.0 (Q1-Q3, -0.1to 7.6)% in the cryoballoon group and -0.8 (Q1-Q3, -1.9 to 0.9)% in the RF group (P < 0.001 for the comparison between groups). At 3 months, the corresponding changes were 6.7 (Q1-Q3, 3.4-11.2)% and 0.7 (Q1-Q3, -0.7 to 3.5)%, respectively (P < 0.001). Overall, the rate of patients with lower LAEF at 3 months compared to baseline was 2.5% in the cryoballoon group and 32.5% in the RF group (P < 0.001). AFib recurrence rate at 6 months was higher in patients with decreased LAEF (odds ratio, 6.2; 95% confidence interval, 2.0-19.5; P = 0.002).

CONCLUSION

The Cryo-LAEF study prospectively compared the effects of RF and cryoballoon ablation on left atrial function. Both at 1 and 3 months postablation, LAEF was either improved or stable in both ablation groups.

Different Responses of Left Atrium and Left Atrial Appendage to Radiofrequency Catheter Ablation of Atrial Fibrillation: a Follow Up MRI study

Atrial fibrillation (AF) is known to cause adverse remodeling of left atrium (LA). Radiofrequency catheter ablation (RFCA) of AF is associated with decrease in LA volume. However, the impact of RFCA on left atrial appendage (LAA) volume and hemodynamic function is not fully understood. We analyzed 123 patients who underwent cardiac magnetic resonance imaging (MRI) evaluation before and after RFCA in Korea University Anam Hospital. LA and LAA volume were measured before and after RFCA based on cardiac MRI. Baseline LA volume was 99.5 ± 38.4 cm³ and decreased to 74.6 ± 28.5 cm³ after RFCA (p < 0.001). LA diameter measured with transthoracic echocardiography was also decreased after RFCA (43.3 ± 6.2 mm at baseline and 39.9 ± 5.9 mm at follow up; p < 0.001). However, LAA volume was significantly increased after RFCA (19.4 ± 8.5 cm³ at baseline and 23.7 ± 13.3 cm³ at follow up; p < 0.001). Total ablation time and additional substrate modification was associated with change in LA volume. After RFCA, average LAA velocity measured by transesophageal echocardiography was increased to 51.0 cm/sec from 41.1 cm/sec (p < 0.001). In conclusion, LAA volume was increased after RFCA in contrast to LA volume. Our data raise a concern about worsening hemodynamics of LA and LAA following RFCA and long term clinical significance of enlarged LAA after RFCA needs further evaluation.

Changes in Left Atrial Transport Function in Patients Who Maintained Sinus Rhythm After Successful Radiofrequency Catheter Ablation for Atrial Fibrillation: A 1-Year Follow-Up Multislice Computed Tomography Study

BACKGROUND

Functional remodeling of left atrium (LA) after radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF) has not been fully elucidated. This study aimed to determine the impact of RFCA on LA transport function in patients who maintained sinus rhythm (SR) after AF ablation.

METHODS AND RESULTS

A total of 96 patients (paroxysmal AF [PAF] = 52) who maintained SR during 1 year after AF ablation were enrolled. Multislice computed tomography was performed to determine LA volume (LAV) and LA emptying fraction (LAEF) at pre-RFCA and 1-year post-RFCA. Creatine kinase-MB (CK-MB) and troponin-T levels were analyzed 1-day post-RFCA. At 1-year post-RFCA, mean LAV and LAEF decreased in overall patients. Based on LAEF change (ΔLAEF) cutoff of 5.0%, LAEF reduced in 41 patients (worsened group) and improved or showed no change in 55 patients (preserved group). Compared with preserved group, worsened group had a higher proportion of PAF, higher levels of CK-MB and troponin-T, and additional LA ablation. ΔLAEF was inversely correlated with CK-MB and troponin-T levels. Subgroup analysis showed that LAEF significantly decreased in PAF patients who underwent additional LA ablation. Multivariate analysis revealed that high baseline LAEF and additional LA ablation were independent predictors for worsened LAEF.

CONCLUSIONS

Although SR was maintained for 1 year after AF ablation, LAEF as well as LAV decreased. The extent of LAEF deterioration was significantly associated with the amount of iatrogenic myocardial damage. Our data indicate that extensive atrial ablation may lead to LA functional deterioration, especially in patients with PAF.

Reversal of pulmonary vein remodeling after catheter ablation of atrial fibrillation

Background

Pulmonary veins (PV) and the atria undergo electrical and structural remodeling in atrial fibrillation (AF). This study aimed to determine PV and left atrial (LA) reverse remodeling after catheter ablation for AF assessed by chest computed tomography (CT).

Methods

PV electrophysiologic studies and catheter ablation were performed in 63 patients (68% male; mean ± SD age: 56 ± 10 years) with symptomatic AF (49% paroxysmal, 51% persistent). Chest CT was performed before and 3 months after catheter ablation.

Results

At baseline, patients with persistent AF had a greater LA volume (91 ± 29 cm³vs. 66 ± 27 cm³; P = 0.003) and mean PV ostial area (241 ± 43 mm²vs. 212 ± 47 mm²; P = 0.03) than patients with paroxysmal AF. There was no significant correlation between the effective refractory period and the area of the left superior PV ostium. At 3 months of follow-up after ablation, 48 patients (76%) were AF free on or off antiarrhythmic drugs. There was a significant reduction in LA volume (77 ± 31 cm³ to 70 ± 28 cm³; P < 0.001) and mean PV ostial area (224 ± 48 mm² to 182 ± 43 mm²; P < 0.001). Patients with persistent AF had more reduction in LA volume (11.8 ± 12.8 cm³vs. 4.0 ± 11.2 cm³; P = 0.04) and PV ostial area (62 mm²vs. 34 mm²; P = 0.04) than those who have paroxysmal AF. The reduction of the averaged PV ostial area was significantly correlated with the reduction of LA volume (r = 0.38, P = 0.03).

Conclusions

Catheter ablation of AF improves structural remodeling of PV ostia and left atrium. This finding is more apparent in patients with persistent AF treated by catheter ablation.

Cardiovascular Imaging in the Electrophysiology Laboratory

In recent years, rapid technological advances have allowed the development of new electrophysiological procedures that would not have been possible without the parallel development of imaging techniques used to plan and guide these procedures and monitor their outcomes. Ablation of atrial fibrillation is among the interventions with the greatest need for imaging support. Echocardiography allows the appropriate selection of patients and the detection of thrombi that would contraindicate the intervention; cardiac magnetic resonance imaging and computed tomography are also essential in planning this procedure, by allowing a detailed anatomical study of the pulmonary veins. In addition, in cardiac resynchronization therapy, echocardiography plays a central role in both patient selection and, later, in device adjustment and in assessing the effectiveness of the technique. More recently, ablation of ventricular tachycardias has been established as a treatment option; this would not be possible without planning using an imaging study such as cardiac magnetic resonance imaging of myocardial scarring.

A simple, fast and reproducible echocardiographic approach to grade left ventricular diastolic function

The American Society of Echocardiography and European Association of Echocardiography (ASE/EAE) have published an algorithm for the grading of diastolic function. However, the ability to use this algorithm effectively in daily clinical practice has not been investigated. We hypothesized that in some patients it may be difficult to grade diastolic dysfunction with this scheme, since there may be discrepancies in the assessed parameters. The aim of the current study was to test the feasibility of the ASE/EAE algorithm and to compare this with a new Thoraxcenter (TXC) algorithm. The ASE/EAE and TXC algorithms were applied to 200 patients. The ASE/EAE algorithm starts with assessment of diastolic myocardial wall velocities and left atrial (LA) volumes with subsequent assessment of E/A ratio, E-wave deceleration time and pulmonary venous flow. The TXC algorithm reverses these steps, uses LA dimension instead of volume and does not include a Valsalva manoeuvre and pulmonary venous flow. Due to inconsistencies between diastolic myocardial wall velocities and LA volumes and a not covered E/A ratio in the range of 1.5–2 it was not possible to classify 48 % of patients with the ASE/EAE algorithm, as opposed to only 10 % by the TXC algorithm. LA volume was always needed in the ASE/EAE algorithm. In only 64 % of patients LA size was necessary by the TXC algorithm. When LA volume would have been used instead of LA dimension, grading of LV diastolic function would have been different in only 2 % of patients without apparent improvement. Assessment of LA dimension was considerably faster than LA volume. The TXC algorithm to grade LV diastolic dysfunction was compared to the ASE/EAE algorithm simpler, faster, better reproducible and yields a higher diagnostic outcome.

Study on Left Atrial Dimension and Function After Modified Endoscopic Procedure for Atrial Fibrillation at Two Years' Follow-Up

BACKGROUND

Modified endoscopic procedures for atrial fibrillation (AF) have a greater success rate because of the increased number of linear lesions. Concerns have been raised about the impact of ablation scars on the left atrium. This study aimed to examine the impact of ablation on left atrial dimension and systolic function after modified endoscopic procedures with echocardiographic measurement.

METHODS

Of 107 patients undergoing modified endoscopic ablation, 58 had paroxysmal AF and 49 had persistent or long-standing AF. The procedure was performed on the beating heart through three ports on the left chest wall. Three circular and two linear lesions were made on the left atrium. The left atrial appendage was excised by stapler. Echocardiography was performed preoperatively and at the 2-year follow-up.

RESULTS

Most patients (86.9%) patients were in sinus rhythm (SR) postoperatively. Fourteen patients (5 with paroxysmal AF and 9 with persistent/long-standing AF) failed to maintain SR. Echocardiographic data indicated that the left atrial diameter decreased only in the patients with postoperative SR but continued to increase in patients with fail SR maintenance. Left atrial function was also improved after the procedure, especially in patients with preoperative nonparoxysmal AF or with postoperative SR maintenance. Furthermore, left atrial function in patients who failed to restore SR was not worsened even with left atrial appendage excision.

CONCLUSIONS

Modified endoscopic procedure for AF improved post-procedural left atrial function of patients with SR maintenance. The left atrial function of patients with failed SR maintenance was also not worsened after left atrial appendage excision.

Atrial fibrillation ablation by single ring isolation versus wide antral isolation: Effects on left atrial size and function

BACKGROUND

Pulmonary vein isolation (PVI) by single ring isolation (SRI) has been demonstrated to reduce recurrence of atrial fibrillation (AF) compared to the standard technique of wide antral isolation (WAI). In this study, we examine the differential effect of these techniques on left atrial size and function.

METHODS

We examined left atrial (LA) size (LA maximum and LA minimum volumes) and function (LA emptying fraction and LA expansion index) over a period of 6 months following PVI as measured by transthoracic echocardiography in 187 patients that were enrolled in a randomised controlled trial of SRI vs WAI.

RESULTS

Compared to pre-ablation, at 6 months post-PVI, there was a small decrease in the LA maximum volume in the WAI group (67.3 vs 62.7 mL, p=0.02). The LA size did not change significantly over 6 months in the SRI group. Patients who underwent SRI had a small reduction in the LA expansion index at 6 months post-PVI compared to baseline (80.6 vs 66.6%, p=0.02). LA function did not change significantly over 6 months in the WAI group. However, at 6 months, there was no difference in any measure of LA size or function between the SRI and WAI groups.

CONCLUSIONS

SRI, whilst previously demonstrated to be more effective than WAI in preventing AF recurrence, is associated with minimal adverse effects on left atrial function at medium term follow-up despite the isolation of a larger region of LA myocardium.

The Effect of Catheter Ablation on Left Atrial Size and Function for Patients with Atrial Fibrillation: An Updated Meta-Analysis

BACKGROUND

Catheter ablation (CA) for atrial fibrillation (AF) is now an important therapeutic modality for patients with AF. However, data regarding changes in left atrial (LA) function after CA have indicated conflicting results depending on the AF types, follow-up period, and the analytical imaging tools. The objective of this review was to analyze the effect of CA on the LA size and function for patients with AF.

METHODS

We searched for studies regarding LA size and function pre- and post-ablation in PubMed, Embase, the Cochrane Library, and Web of Knowledge through May 2014. LA function was measured by LA ejective fraction (LAEF), LA active ejective fraction (LAAEF), or both. Total and subgroup analyses were implemented using Cochrane Review Manager Version 5.2. Weighted mean differences with 95% confidence intervals were used to express the results of continuous outcomes using fixed or random effect models. I2 was used to calculate heterogeneity. To assess publication bias, Egger's test and Begg's funnel plot were performed using Stata 12.0.

RESULTS

Twenty-five studies (2040 enrolled patients) were selected for this meta-analysis. The LA diameter (LAD), maximum LA volume, and minimal LA volume were significantly decreased post-ablation, as compared with those at a pre-ablation visit. Compared with the pre-ablation outcomes, we found no significant differences in LAEF/LAAEF at a post-ablation follow-up. Decreases in LA volume and LAEF remained significant post-ablation for paroxysmal AF (PAF); however, the LAEF was insignificant changes in persistent AF (PeAF). Heterogeneity was significant in spite which individual study was excluded. A publication bias was not found. In a meta-regression analysis, we did not find any factor that contributed to the heterogeneity.

CONCLUSION

With CA, LA volumes and LAD were decreased significantly in patients with AF; LAEF was not significant changes in patients with PeAF but decreased in those with PAF.

The effect of ablation for paroxysmal atrial fibrillation on left atrial volume and function: a one-year follow-up study

PURPOSE

The effect of radiofrequency catheter ablation (RFCA) on left atrial (LA) volume and function in patients with paroxysmal atrial fibrillation (PAF) has not been extensively studied. The aim of this study was to evaluate the long-term impact of RFCA on LA volume and function in patients with PAF.

MATERIALS AND METHODS

A total of 90 patients with drug-refractory PAF who had sinus rhythm on the initial echocardiogram were examined at baseline, 3 months and 1 year after ablation. We measured LA volume index, LA ejection fraction (LAEF; maximal-minimal LA volume/maximal LA volume), and LA active emptying fraction (LAAEF; mid-diastolic-minimal LA volume/mid-diastolic LA volume).

RESULTS

After 12±1 months, 78 patients returned, and 61 patients (78%) had sinus rhythm. After 3 months, the LA maximal volume indices decreased (from 33±13 to 28±12 mL/m²; p<0.001). But, LAEF and LAAEF also decreased (from 48±13 to 39±12; p<0.001, from 27±13 to 19±11; p<0.001). After 1 year, LA volumes, LAEF, and LAAEF remained similar at 3 months. In patients without atrial fibrillation (AF) recurrence, LAEF and LAAEF decreased after 3 months (from 50±12 to 40±11; p<0.001, from 29±13 to 22±11; p<0.001) and did not change after 1 year. However, in patients with AF recurrence, those who did not have decreased levels after 3 months had significantly decreased after 1 year (from 43±14 to 34±11; p=0.026, from 22±12 to 15±10; p=0.012).

CONCLUSION

Successful RFCA of PAF decreased LA volume and function at 3 months. At one year, LA volume and function was remained unchanged in successfully ablated patients whereas LA function in patients with AF recurrence worsened.

Prolonged PR interval and risk of recurrence of atrial fibrillation after catheter ablation

It has been demonstrated that a prolonged PR interval is associated with an increased risk of AF. However, the impact of a prolonged PR interval on recurrence of paroxysmal atrial fibrillation (AF) after catheter ablation is not clear. A total of 112 patients with a prolonged PR interval (PR > 200 ms) (PPR group) and 112 age- and gender-matched control patients (on a 1:1 basis) with a normal PR interval (NPR group) were included in this study. AF recurrence was defined as the occurrence of confirmed atrial tachyarrhythmia lasting more than 30 seconds beyond 3 months after catheter ablation in the absence of any antiarrhythmic treatment. During a mean follow-up period of 10.9 ± 5.5 months (range, 3-18 months), 61 patients (27.2%) developed recurrence of AF. The recurrence rate was higher in the PPR group than in the NPR group (33.9% versus 20.5%, respectively; P = 0.018). Cox regression analysis with adjustment for age, body mass index, valvular heart disease, left atrial diameter, and pulmonary vein isolation identified only a prolonged PR interval as an independent predictor of recurrence of AF (hazard ratio, 1.81; 95% confidence interval, 1.07-3.05; P = 0.027). Patients with a prolonged PR interval were at an increased risk of AF recurrence after catheter ablation.

Updating the evidence for the effect of radiofrequency catheter ablation on left atrial volume and function in patients with atrial fibrillation: a meta-analysis

Objectives

To systematically review the effects of radiofrequency catheter ablation (RFCA) on left atrial (LA) size, volumes and function in patients with atrial fibrillation (AF).

Methods

We searched MEDLINE, EMBASE, ScienceDirect, Highwire, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and the reference lists of retrieved reports in July 2012.

Setting

China

Participants

Twenty-six studies (enrolling 1821 patients) were included in the final analysis.

Main outcome measures

Changes of LA size or volumes and/or function in patients with AF after RFCA.

Results

Compared to pre-ablation values, there were significant decreases in LA diameter and LA volumes at post-ablation follow-up. However, compared to pre-ablation values, there were no significant differences in LA ejection fraction/LA active emptying fraction and LA strain at post-ablation follow-up. Decreases in LA diameter and LA volumes remained significant in those without AF recurrence but not in those with AF recurrence. LA ejection fraction/LA active emptying fraction did not decrease in patients without AF recurrence, whereas they decreased in patients with AF recurrence. As for LA strain, it seems that LA strain increases in patients without AF recurrence, with less fibrosis and with more LA volumes decrease, but the differences were not significant.

Conclusions

Successful RFCA in patients with AF significantly decreases LA size and volumes and does not seem to adversely affect LA function.

Three-dimensional speckle tracking echocardiography-derived left atrial strain parameters are reduced in patients with atrial fibrillation (results from the MAGYAR-path study)

OBJECTIVE

Three-dimensional (3D) speckle tracking echocardiography (3DSTE) is a novel imaging modality for assessing cardiac function. We aimed to analyze left atrial (LA) function using 3DSTE in patients with atrial fibrillation (AF).

METHODS

3DSTE was performed in 20 patients prior to their pulmonary vein isolation for AF. Every patient underwent a complete two-dimensional echocardiographic study at the same time. 3DSTE-derived circumferential (CS), longitudinal (LS), radial (RS), 3D (3DS), and area strain (AS) values were measured in the basal (b), mid (m), and superior (s) regions of the LA. 3DSTE-defined maximal (LAmax ) and minimal LA volumes (LAmin ) and LA total emptying fraction were calculated automatically. Eleven randomly selected age- and gender-matched healthy volunteers served as controls.

RESULTS

Patients with AF had significantly larger LAmax and LAmin and reduced LS, RS and CS.3DS and AS were significantly lower throughout the LA in cases with AF (3DS-b, -m, -s [AF patients vs. controls]: -18 ± 8% vs. -29 ± 8%, P = 0.001; -14 ± 6% vs. -22 ± 7%, P = 0.002; -10 ± 7% vs. -20 ± 9%, P = 0.002; AS-b, -m, -s [AF patients vs. controls]: 35 ± 15% vs. 52 ± 13%, P = 0.004; 50 ± 21% vs. 72 ± 19%, P = 0.009; 31 ± 21% vs. 65 ± 27%, P < 0.0001, respectively).

CONCLUSIONS

3DSTE-derived "uni-dimensional" LS, RS, CS, as well as novel strain parameters (3DS, AS) are significantly reduced in patients with AF compared to matched controls. 3DS and AS might be new strain parameters providing further insights into the alterations of LA function in patients developing AF.

Efficacy of catheter ablation for atrial fibrillation in patients with a permanent pacemaker for sick sinus syndrome

OBJECTIVE

To study the clinical efficacy of catheter ablation for paroxysmal atrial fibrillation (AF) in patients with a permanent pacemaker (PM) for sick sinus syndrome (SSS).

METHODS

Our prospectively established database of patients who underwent circumferential pulmonary vein (PV) ablation for paroxysmal AF was retrospectively reviewed. A total of 41 patients with a permanent PM for the treatment of SSS (SSS+PM group) and 123 age- and gender-matched control subjects (on a 1: 3 basis) without SSS or a permanent PM (no-SSS+no-PM group) were included in this study. AF recurrence was defined as the occurrence of confirmed atrial tachyarrhythmia lasting more than 30 seconds beyond three months after catheter ablation in the absence of any antiarrhythmic treatment.

RESULTS

During a mean follow-up period of 18.3±10.6 months (range 3-30 months), 50 patients (30.5%) developed recurrence of AF. The recurrence rate was higher in the SSS+PM group than in the no-SSS+no-PM group (43.9% vs. 26.3%, p=0.011). A Cox regression analysis adjusted for age, valvular heart disease, left atrial (LA) diameter and PV isolation identified only SSS and the use of a PM together as an independent predictor of recurrence of AF (hazard ratio 2.02, 95% confidence interval 1.10-3.69, p=0.023).

CONCLUSION

Patients with a permanent PM for SSS are at an increased risk of recurrence of AF after catheter ablation.

Advanced echocardiographic techniques

Echocardiography has advanced significantly since its first clinical use. The move towards more accurate imaging and quantification has driven this advancement. In this review, we will briefly focus on three distinct but important recent advances, three‐dimensional (3D) echocardiography, contrast echocardiography and myocardial tissue imaging. The basic principles of these techniques will be discussed as well as current and future clinical applications.

Left atrium reverse remodeling in patients with mitral valve stenosis after percutaneous valvuloplasty: a 2- and 3-dimensional echocardiographic study

INTRODUCTION AND OBJECTIVES

The left atrium is clinically relevant in patients with mitral valve stenosis. The objective of this study was to analyze the effects of percutaneous balloon valvuloplasty on left atrium volumes and the left atrium emptying fraction in symptomatic mitral valve stenosis patients using 2-dimensional and real-time 3 -dimensional transthoracic echocardiography.

METHODS

We carried out a prospective study of 28 consecutive symptomatic mitral valve stenosis patients, aged 22-72 (39 [11.5]) years, 24/28 (85.6%) women, who underwent to percutaneous balloon valvuloplasty between March 2009 and May 2011. Patients underwent 2- and 3-dimensional transthoracic and transesophageal echocardiography (atrial fibrillation) and invasive mitral valve area measurement. Echocardiographic analysis was performed before, 72 h after and 12 months after percutaneous balloon valvuloplasty. The following parameters were analyzed: a) mitral valve area (2-dimensional planimetry, pressure half-time, 3-dimensional echocardiography, invasive hemodynamic measurement); b) indexed left atrium maximum and indexed minimum volumes, and c) left atrium emptying fraction.

RESULTS

The 3-dimensional parameters of the mitral valve stenosis patients before and 72 h and 12 months after percutaneous balloon valvuloplasty were as follows: a) mitral valve area: 0.9 (0.1) cm(2); 1.8 (0.2) cm(2) (P<.001); 1.7 (0.2) cm(2) (P<.001); b) left atrium maximum volumes: 49.9 (12) mL/m(2); 42 (11.4) mL/m(2) (P<.001); 40.3 (10.2) mL/m(2) (P<.001), and c) left atrium emptying fraction: 30.1 (9.4%); 40.6 (7.4%) (P<.001); 44.1 (8%) (P<.001), respectively.

CONCLUSIONS

In symptomatic mitral valve stenosis patients who underwent percutaneous balloon valvuloplasty analysis by 2- and 3-dimensional echocardiography, improvements in left atrium reverse remodeling and left atrium emptying fraction were observed 72 h and 12 months after the procedure.

Current clinical applications of transthoracic three-dimensional echocardiography

The advent of three-dimensional echocardiography (3DE) has significantly improved the impact of non-invasive imaging on our understanding and management of cardiac diseases in clinical practice. Transthoracic 3DE enables an easier, more accurate and reproducible interpretation of the complex cardiac anatomy, overcoming the intrinsic limitations of conventional echocardiography. The availability of unprecedented views of cardiac structures from any perspective in the beating heart provides valuable clinical information and new levels of confidence in diagnosing heart disease. One major advantage of the third dimension is the improvement in the accuracy and reproducibility of chamber volume measurement by eliminating geometric assumptions and errors caused by foreshortened views. Another benefit of 3DE is the realistic en face views of heart valves, enabling a better appreciation of the severity and mechanisms of valve diseases in a unique, noninvasive manner. The purpose of this review is to provide readers with an update on the current clinical applications of transthoracic 3DE, emphasizing the incremental benefits of 3DE over conventional two-dimensional echocardiography.

Comprehensive risk reduction in patients with atrial fibrillation: emerging diagnostic and therapeutic options--a report from the 3rd Atrial Fibrillation Competence NETwork/European Heart Rhythm Association consensus conference

While management of atrial fibrillation (AF) patients is improved by guideline-conform application of anticoagulant therapy, rate control, rhythm control, and therapy of accompanying heart disease, the morbidity and mortality associated with AF remain unacceptably high. This paper describes the proceedings of the 3rd Atrial Fibrillation NETwork (AFNET)/European Heart Rhythm Association (EHRA) consensus conference that convened over 60 scientists and representatives from industry to jointly discuss emerging therapeutic and diagnostic improvements to achieve better management of AF patients. The paper covers four chapters: (i) risk factors and risk markers for AF; (ii) pathophysiological classification of AF; (iii) relevance of monitored AF duration for AF-related outcomes; and (iv) perspectives and needs for implementing better antithrombotic therapy. Relevant published literature for each section is covered, and suggestions for the improvement of management in each area are put forward. Combined, the propositions formulate a perspective to implement comprehensive management in AF.

Effect of repeated radiofrequency catheter ablation on left atrial function for the treatment of atrial fibrillation

Radiofrequency catheter ablation (RFCA) is a potential curative treatment for atrial fibrillation (AF) by eliminating the arrhythmia and inducing left atrial (LA) reverse remodeling. However, the effect on LA function, especially after repeated procedures, has scarcely been studied. The aim of this study was to evaluate the impact of RFCA on LA size and function in patients with AF after a first and a repeated procedure. RFCA was performed in 154 patients with symptomatic drug-refractory AF. LA volumes and function were assessed with real-time 3-dimensional echocardiography before and 6 months after the procedure. Recurrence of the arrhythmia was defined as any atrial tachyarrhythmia lasting >30 seconds, clinically documented or by 24-hour Holter recording, after the first 6 months after ablation. Of the 154 patients, 104 (67%) required only a first ablation, and 50 (33%) required redo RFCA. LA volume was reduced after first RFCA (from 60 ± 19 to 52 ± 17 ml for 3-dimensional LA maximum volume, p <0.001, and from 38 ± 18 to 33 ± 15 ml for 3-dimensional LA minimum volume, p <0.000) without impairment of LA contractile function, measured as the active emptying percentage of total volume (39 ± 25% vs 43 ± 26%, p = NS). After repeated RFCA procedures, 3-dimensional LA maximum volume was reduced (from 57 ± 18 to 52 ± 18 ml, p = 0.04), also without further LA contractile function impairment (active emptying percentage of total volume) (36 ± 24% vs 36 ± 25% of total volume, p = NS). This effect was similar in paroxysmal and persistent AF. In conclusion, RFCA induces reductions in LA volumes without a deleterious impact on contractile function, even after repeated ablation.

Pulmonary vein antrum isolation leads to a significant decrease of left atrial size

AIMS

Pulmonary vein antrum isolation (PVAI) is an effective treatment for atrial fibrillation (AF); however, its impact on left atrial (LA) size is unknown. This study evaluates the impact of PVAI on LA size, and whether LA size differs between patients with a successful outcome and patients with AF recurrences.

METHODS AND RESULTS

Seventy-nine patients (76% male, mean age 56 ± 8 years) with symptomatic, drug refractory AF (70% paroxysmal, 30% persistent/permanent) underwent radiofrequency PVAI. Ablation lesions were created encircling right and left pulmonary venous ostia in pairs. The endpoint was complete isolation of all pulmonary veins. Magnetic resonance imaging was performed before and 4 months after PVAI and LA volume was measured by manually tracing the LA area. Clinical follow-up was at 1, 3, 6, 12, and 24 months. Rhythm status was determined by history, electrocardiogram, and 48 h Holter monitoring. After a mean follow-up of 12 ± 5 months, 62 patients (78%) were free of AF (72% without antiarrhythmic drugs). In the total group, LA volume decreased from 104 ± 27 mL to 91 ± 25 mL, P < 0.001. Patients with a successful outcome showed a decrease in LA volume of 103 ± 27 mL to 89 ± 24 mL, P < 0.001. Among patients with AF recurrences, LA volume decreased from 105 ± 29 mL to 95 ± 27 mL, P = 0.012. No significant difference was seen between the change in LA volume in both subgroups, P = 0.27.

CONCLUSION

Pulmonary vein antrum isolation in patients with AF resulted in a significant decrease of LA size. There was no relation between the decrease in LA size and the recurrence of AF after PVAI.

Meta-analysis of the effect of radiofrequency catheter ablation on left atrial size, volumes and function in patients with atrial fibrillation

The effects of radiofrequency catheter ablation (RFCA) on left atrial (LA) size, volumes, and function in patients with atrial fibrillation (AF) are not well understood. The aim of this study was to systematically review the effects of RFCA on LA size, volumes, and function in patients with AF. Medline, the Web of Science, the Cochrane Central Register of Controlled Trials, and the reference lists of retrieved reports were searched for relevant studies through April 2009. Studies conducted in patients with AF were included if their primary outcomes were changes in LA size or volumes and/or function before and after RFCA. Weighted mean differences for changes in LA diameter, LA maximum volume, LA minimum volume, LA ejection fraction, and LA active emptying fraction were estimated using fixed- and random-effects meta-analyses. Seventeen relevant studies (enrolling 869 patients) among 192 identified studies were included in the final analysis. Compared to preablation values, there were significant decreases in LA diameter and LA volumes at postablation follow-up. However, compared to preablation values, there were no significant differences in LA ejection fraction and LA active emptying fraction at postablation follow-up. Decreases in LA diameter and LA volumes remained significant in those without AF recurrence but not in those with AF recurrence. LA ejection fraction and LA active emptying fraction did not decrease in patients without AF recurrence, whereas they decreased in patients with AF recurrence. In conclusion, successful RFCA in patients with AF significantly decreases LA size and volumes and does not seem to adversely affect LA function.

Imaging and atrial fibrillation: the role of multimodality imaging in patient evaluation and management of atrial fibrillation

Atrial fibrillation (AF) is the most common cardiac arrhythmia, and is associated with an increased risk of cardiac morbidity and mortality. In this review, the role of multimodality imaging in the evaluation and treatment of AF is discussed in two main parts. First, an overview of the initial assessment of an AF patient is provided, including the role of different imaging techniques. Conditions that are associated with AF (coronary artery disease, heart failure, valvular heart disease, and left ventricular hypertrophy), and the assessment with various imaging modalities, will be reviewed. Furthermore, left atrial size assessment and the screening for thrombus formation are addressed. Secondly, the role of imaging in the invasive treatment of AF with catheter ablation is reviewed. Issues that should be considered before the procedure including contra-indications and pulmonary vein and left atrial anatomy will be discussed. Furthermore, the integration of different imaging modalities during catheter ablation is explored. Finally, an overview of the role of imaging in the follow-up of patients treated with catheter ablation will be provided.