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Invers-Rubio E, Hernández-Romero I, Reventos-Presmanes J, Ferro E, Guichard JB, Regany-Closa M, Pellicer-Sendra B, Borras R, Prat-Gonzalez S, Tolosana JM, Porta-Sanchez A, Arbelo E, Guasch E, Sitges M, Brugada J, Guillem MS, Roca-Luque I, Climent AM, Mont L, Althoff TF. Regional conduction velocities determined by noninvasive mapping are associated with arrhythmia-free survival after atrial fibrillation ablation. Heart Rhythm 2024; 21:1570-1580. [PMID: 38636930 DOI: 10.1016/j.hrthm.2024.04.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/24/2024] [Accepted: 04/12/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Atrial arrhythmogenic substrate is a key determinant of atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI), and reduced conduction velocities have been linked to adverse outcome. However, a noninvasive method to assess such electrophysiologic substrate is not available to date. OBJECTIVE This study aimed to noninvasively assess regional conduction velocities and their association with arrhythmia-free survival after PVI. METHODS A consecutive 52 patients scheduled for AF ablation (PVI only) and 19 healthy controls were prospectively included and received electrocardiographic imaging (ECGi) to noninvasively determine regional atrial conduction velocities in sinus rhythm. A novel ECGi technology obviating the need of additional computed tomography or cardiac magnetic resonance imaging was applied and validated by invasive mapping. RESULTS Mean ECGi-determined atrial conduction velocities were significantly lower in AF patients than in healthy controls (1.45 ± 0.15 m/s vs 1.64 ± 0.15 m/s; P < .0001). Differences were particularly pronounced in a regional analysis considering only the segment with the lowest average conduction velocity in each patient (0.8 ± 0.22 m/s vs 1.08 ± 0.26 m/s; P < .0001). This average conduction velocity of the "slowest" segment was independently associated with arrhythmia recurrence and better discriminated between PVI responders and nonresponders than previously proposed predictors, including left atrial size and late gadolinium enhancement (magnetic resonance imaging). Patients without slow-conduction areas (mean conduction velocity <0.78 m/s) showed significantly higher 12-month arrhythmia-free survival than those with 1 or more slow-conduction areas (88.9% vs 48.0%; P = .002). CONCLUSION This is the first study to investigate regional atrial conduction velocities noninvasively. The absence of ECGi-determined slow-conduction areas well discriminates PVI responders from nonresponders. Such noninvasive assessment of electrical arrhythmogenic substrate may guide treatment strategies and be a step toward personalized AF therapy.
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Affiliation(s)
- Eric Invers-Rubio
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | | | - Jana Reventos-Presmanes
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain; ITACA Institute, Universitat Politècnica de València, València, Spain
| | - Elisenda Ferro
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Jean-Baptiste Guichard
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Department of Cardiology, University Hospital of Saint-Étienne, Saint-Étienne, France
| | - Mariona Regany-Closa
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Berta Pellicer-Sendra
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Roger Borras
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Susanna Prat-Gonzalez
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Jose Maria Tolosana
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain
| | - Andreu Porta-Sanchez
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain
| | - Elena Arbelo
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain
| | - Eduard Guasch
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain
| | - Marta Sitges
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain
| | - Josep Brugada
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain
| | - Maria S Guillem
- ITACA Institute, Universitat Politècnica de València, València, Spain
| | - Ivo Roca-Luque
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain
| | - Andreu M Climent
- ITACA Institute, Universitat Politècnica de València, València, Spain
| | - Lluís Mont
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Madrid, Spain
| | - Till F Althoff
- Department of Cardiology, Hospital Clinic Cardiovascular Institute (ICCV), Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.
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Valcher S, Villaschi A, Falasconi G, Chiarito M, Giunti F, Novelli L, Addeo L, Taormina A, Panico C, Francia P, Saglietto A, Del Monaco G, Latini AC, Carli S, Frittella S, Giaj Levra A, Antonelli G, Preda A, Guarracini F, Mazzone P, Berruezo A, Tritto M, Condorelli G, Penela D. Low-Voltage Area Ablation in Addition to Pulmonary Vein Isolation in Patients with Atrial Fibrillation: A Systematic Review and Meta-Analysis. J Clin Med 2024; 13:4541. [PMID: 39124807 PMCID: PMC11313645 DOI: 10.3390/jcm13154541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2024] [Revised: 07/26/2024] [Accepted: 07/30/2024] [Indexed: 08/12/2024] Open
Abstract
Background: Low-voltage area (LVA) ablation, in addition to pulmonary vein isolation (PVI), has been proposed as a new strategy in patients with atrial fibrillation (AF), but clinical trials have shown conflicting results. We performed a systematic review and meta-analysis to assess the impact of LVA ablation in patient undergoing AF ablation (PROSPERO-registered CRD42024537696). Methods: Randomized clinical trials investigating the role of LVA ablation in addition to PVI in patients with AF were searched on PubMed, Embase, and the Cochrane Library from inception to 22 April 2024. Primary outcome was atrial arrhythmia recurrence after the first AF ablation procedure. Secondary endpoints included procedure time, fluoroscopy time, and procedure-related complication rate. Sensitivity analysis including only patients with LVA demonstration at mapping and multiple subgroups analyses were also performed. Results: 1547 patients from 7 studies were included. LVA ablation in addition to PVI reduced atrial arrhythmia recurrence (odds ratio [OR] 0.65, 95% confidence interval [CI] 0.52-0.81, p < 0.001) with a number needed to treat to prevent recurrence of 10. No difference in procedure time (mean difference [MD] -5.32 min, 95% CI -19.01-8.46 min, p = 0.45), fluoroscopy time (MD -1.10 min, 95% CI -2.48-0.28 min, p = 0.12) and complication rate (OR 0.81, 95% CI 0.40-1.61, p = 0.54) was observed. Consistent results were demonstrated when considering only patients with LVA during mapping and in prespecified subgroups for AF type (paroxysmal vs. persistent), multicentric vs. monocentric trial, and ablation strategy in control group. Conclusions: In patients with AF, ablation of LVAs in addition to PVI reduces atrial arrhythmia recurrence without a significant increase in procedure time, fluoroscopy time, or complication rate.
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Affiliation(s)
- Stefano Valcher
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (S.V.); (A.V.); (M.C.); (F.G.); (L.N.); (C.P.); (G.D.M.); (A.C.L.); (S.C.); (S.F.); (A.G.L.); (G.A.); (M.T.); (G.C.)
- Olv Hospital, 9300 Aalst, Belgium;
| | - Alessandro Villaschi
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (S.V.); (A.V.); (M.C.); (F.G.); (L.N.); (C.P.); (G.D.M.); (A.C.L.); (S.C.); (S.F.); (A.G.L.); (G.A.); (M.T.); (G.C.)
- Department of Medicine, Karolinska Institutet, 17177 Solna, Sweden
| | - Giulio Falasconi
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (A.T.); (D.P.)
- Teknon Medical Center, 08022 Barcelona, Spain; (P.F.); (A.B.)
- Campus Clínic, University of Barcelona, 08036 Barcelona, Spain
| | - Mauro Chiarito
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (S.V.); (A.V.); (M.C.); (F.G.); (L.N.); (C.P.); (G.D.M.); (A.C.L.); (S.C.); (S.F.); (A.G.L.); (G.A.); (M.T.); (G.C.)
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (A.T.); (D.P.)
| | - Filippo Giunti
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (S.V.); (A.V.); (M.C.); (F.G.); (L.N.); (C.P.); (G.D.M.); (A.C.L.); (S.C.); (S.F.); (A.G.L.); (G.A.); (M.T.); (G.C.)
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (A.T.); (D.P.)
| | - Laura Novelli
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (S.V.); (A.V.); (M.C.); (F.G.); (L.N.); (C.P.); (G.D.M.); (A.C.L.); (S.C.); (S.F.); (A.G.L.); (G.A.); (M.T.); (G.C.)
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (A.T.); (D.P.)
| | - Lucio Addeo
- Olv Hospital, 9300 Aalst, Belgium;
- Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy
| | - Antonio Taormina
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (A.T.); (D.P.)
| | - Cristina Panico
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (S.V.); (A.V.); (M.C.); (F.G.); (L.N.); (C.P.); (G.D.M.); (A.C.L.); (S.C.); (S.F.); (A.G.L.); (G.A.); (M.T.); (G.C.)
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (A.T.); (D.P.)
| | - Pietro Francia
- Teknon Medical Center, 08022 Barcelona, Spain; (P.F.); (A.B.)
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Andrea Saglietto
- Teknon Medical Center, 08022 Barcelona, Spain; (P.F.); (A.B.)
- Department of Medical Sciences, University of Turin, 10124 Turin, Italy
| | - Guido Del Monaco
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (S.V.); (A.V.); (M.C.); (F.G.); (L.N.); (C.P.); (G.D.M.); (A.C.L.); (S.C.); (S.F.); (A.G.L.); (G.A.); (M.T.); (G.C.)
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (A.T.); (D.P.)
| | - Alessia Chiara Latini
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (S.V.); (A.V.); (M.C.); (F.G.); (L.N.); (C.P.); (G.D.M.); (A.C.L.); (S.C.); (S.F.); (A.G.L.); (G.A.); (M.T.); (G.C.)
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (A.T.); (D.P.)
| | - Sebastiano Carli
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (S.V.); (A.V.); (M.C.); (F.G.); (L.N.); (C.P.); (G.D.M.); (A.C.L.); (S.C.); (S.F.); (A.G.L.); (G.A.); (M.T.); (G.C.)
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (A.T.); (D.P.)
| | - Stefano Frittella
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (S.V.); (A.V.); (M.C.); (F.G.); (L.N.); (C.P.); (G.D.M.); (A.C.L.); (S.C.); (S.F.); (A.G.L.); (G.A.); (M.T.); (G.C.)
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (A.T.); (D.P.)
| | - Alessandro Giaj Levra
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (S.V.); (A.V.); (M.C.); (F.G.); (L.N.); (C.P.); (G.D.M.); (A.C.L.); (S.C.); (S.F.); (A.G.L.); (G.A.); (M.T.); (G.C.)
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (A.T.); (D.P.)
| | - Giulia Antonelli
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (S.V.); (A.V.); (M.C.); (F.G.); (L.N.); (C.P.); (G.D.M.); (A.C.L.); (S.C.); (S.F.); (A.G.L.); (G.A.); (M.T.); (G.C.)
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (A.T.); (D.P.)
| | - Alberto Preda
- Electrophysiology Unit, De Gasperis Cardio Center, ASST Great Metropolitan Niguarda, 20162 Milan, Italy; (A.P.); (F.G.); (P.M.)
| | - Fabrizio Guarracini
- Electrophysiology Unit, De Gasperis Cardio Center, ASST Great Metropolitan Niguarda, 20162 Milan, Italy; (A.P.); (F.G.); (P.M.)
| | - Patrizio Mazzone
- Electrophysiology Unit, De Gasperis Cardio Center, ASST Great Metropolitan Niguarda, 20162 Milan, Italy; (A.P.); (F.G.); (P.M.)
| | | | - Massimo Tritto
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (S.V.); (A.V.); (M.C.); (F.G.); (L.N.); (C.P.); (G.D.M.); (A.C.L.); (S.C.); (S.F.); (A.G.L.); (G.A.); (M.T.); (G.C.)
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (A.T.); (D.P.)
| | - Gianluigi Condorelli
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (S.V.); (A.V.); (M.C.); (F.G.); (L.N.); (C.P.); (G.D.M.); (A.C.L.); (S.C.); (S.F.); (A.G.L.); (G.A.); (M.T.); (G.C.)
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (A.T.); (D.P.)
| | - Diego Penela
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (A.T.); (D.P.)
- Teknon Medical Center, 08022 Barcelona, Spain; (P.F.); (A.B.)
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La Rosa G, Morillo CA, Quintanilla JG, Doltra A, Mont L, Rodríguez-Mañero M, Sarkozy A, Merino JL, Vivas D, Datino T, Calvo D, Pérez-Castellano N, Pérez-Villacastín J, Fauchier L, Lip G, Hatem SN, Jalife J, Sanchis L, Marín F, Filgueiras-Rama D. Practical approach for atrial cardiomyopathy characterization in patients with atrial fibrillation. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:656-666. [PMID: 38428580 DOI: 10.1016/j.rec.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/16/2024] [Indexed: 03/03/2024]
Abstract
Atrial fibrillation (AF) causes progressive structural and electrical changes in the atria that can be summarized within the general concept of atrial remodeling. In parallel, other clinical characteristics and comorbidities may also affect atrial tissue properties and make the atria susceptible to AF initiation and its long-term persistence. Overall, pathological atrial changes lead to atrial cardiomyopathy with important implications for rhythm control. Although there is general agreement on the role of the atrial substrate for successful rhythm control in AF, the current classification oversimplifies clinical management. The classification uses temporal criteria and does not establish a well-defined strategy to characterize the individual-specific degree of atrial cardiomyopathy. Better characterization of atrial cardiomyopathy may improve the decision-making process on the most appropriate therapeutic option. We review current scientific evidence and propose a practical characterization of the atrial substrate based on 3 evaluation steps starting with a clinical evaluation (step 1), then assess outpatient complementary data (step 2), and finally include information from advanced diagnostic tools (step 3). The information from each of the steps or a combination thereof can be used to classify AF patients in 4 stages of atrial cardiomyopathy, which we also use to estimate the success on effective rhythm control.
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Affiliation(s)
- Giulio La Rosa
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Centro Neurolesi Bonino Pulejo, Messina, Italy
| | - Carlos A Morillo
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Programa Nuevos Mecanismos Arritmogénicos, Madrid, Spain; Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jorge G Quintanilla
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Programa Nuevos Mecanismos Arritmogénicos, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Adelina Doltra
- Institut Clínic Cardiovascular, Hospital Clínic, Barcelona, Spain
| | - Lluis Mont
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Institut Clínic Cardiovascular, Hospital Clínic, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Universitat de Barcelona, Barcelona, Spain
| | - Moisés Rodríguez-Mañero
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Departamento de Cardiología y Unidad Coronaria, Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Complexo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Andrea Sarkozy
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| | - José Luis Merino
- Departamento de Cardiología, Hospital Universitario La Paz, IDIPaz, Universidad Autónoma, Madrid, Spain
| | - David Vivas
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Instituto Cardiovascular, Madrid, Spain
| | - Tomás Datino
- Departamento de Cardiología, Hospitales Universitarios Quirónsalud Pozuelo y Ruber Juan Bravo, Universidad Europea de Madrid, Madrid, Spain
| | - David Calvo
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Instituto Cardiovascular, Madrid, Spain
| | - Nicasio Pérez-Castellano
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Instituto Cardiovascular, Madrid, Spain; Fundación Interhospitalaria para la Investigación Cardiovascular (FIC), Madrid, Spain
| | - Julián Pérez-Villacastín
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Instituto Cardiovascular, Madrid, Spain; Fundación Interhospitalaria para la Investigación Cardiovascular (FIC), Madrid, Spain
| | - Laurent Fauchier
- Centre Hospitalier Régional Universitaire de Tours, Tours, France
| | - Gregory Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Stéphane N Hatem
- Sorbonne Université, Foundation for Innovation in Cardiometabolism and Nutrition - ICAN, INSERM UMRS 1166, Institute of Cardiology, AP-HP Pitié-Salpêtrière Paris, France
| | - José Jalife
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Programa Nuevos Mecanismos Arritmogénicos, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States
| | - Laura Sanchis
- Institut Clínic Cardiovascular, Hospital Clínic, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Universitat de Barcelona, Barcelona, Spain.
| | - Francisco Marín
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Departamento de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), El Palmar, Murcia, Spain.
| | - David Filgueiras-Rama
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Programa Nuevos Mecanismos Arritmogénicos, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Instituto Cardiovascular, Madrid, Spain.
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Tao Y, Zhang D, Tan C, Wang Y, Shi L, Chi H, Geng S, Ma Z, Hong S, Liu XP. An artificial intelligence-enabled electrocardiogram algorithm for the prediction of left atrial low-voltage areas in persistent atrial fibrillation. J Cardiovasc Electrophysiol 2024. [PMID: 39054663 DOI: 10.1111/jce.16373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Revised: 06/19/2024] [Accepted: 07/07/2024] [Indexed: 07/27/2024]
Abstract
OBJECTIVES We aimed to construct an artificial intelligence-enabled electrocardiogram (ECG) algorithm that can accurately predict the presence of left atrial low-voltage areas (LVAs) in patients with persistent atrial fibrillation. METHODS The study included 587 patients with persistent atrial fibrillation who underwent catheter ablation procedures between March 2012 and December 2023 and 942 scanned images of 12-lead ECGs obtained before the ablation procedures were performed. Artificial intelligence-based algorithms were used to construct models for predicting the presence of LVAs. The DR-FLASH and APPLE clinical scores for LVA prediction were calculated. We used a receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis to evaluate model performance. RESULTS The data obtained from the participants were split into training (n = 469), validation (n = 58), and test sets (n = 60). LVAs were detected in 53.7% of all participants. Using ECG alone, the deep learning algorithm achieved an area under the ROC curve (AUROC) of 0.752, outperforming both the DR-FLASH score (AUROC = 0.610) and the APPLE score (AUROC = 0.510). The random forest classification model, which integrated a probabilistic deep learning model and clinical features, showed a maximum AUROC of 0.759. Moreover, the ECG-based deep learning algorithm for predicting extensive LVAs achieved an AUROC of 0.775, with a sensitivity of 0.816 and a specificity of 0.896. The random forest classification model for predicting extensive LVAs achieved an AUROC of 0.897, with a sensitivity of 0.862, and a specificity of 0.935. CONCLUSION The deep learning model based exclusively on ECG data and the machine learning model that combined a probabilistic deep learning model and clinical features both predicted the presence of LVAs with a higher degree of accuracy than the DR-FLASH and the APPLE risk scores.
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Affiliation(s)
- Yirao Tao
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Deyun Zhang
- HeartVoice Medical Technology, Hefei, China
- HeartRhythm-HeartVoice Joint Laboratory, Beijing, China
| | - Chen Tan
- Department of Cardiology, Hebei Yanda Hospital, Hebei, Hebei Province, China
| | - Yanjiang Wang
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Liang Shi
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Hongjie Chi
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Shijia Geng
- HeartVoice Medical Technology, Hefei, China
- HeartRhythm-HeartVoice Joint Laboratory, Beijing, China
| | - Zhimin Ma
- Department of Cardiology, Heart Rhythm Cardiovascular Hospital, Shandong, China
| | - Shenda Hong
- National Institute of Health Data Science, Peking University, Beijing, China
- Health Science Center of Peking University, Institute of Medical Technology, Beijing, China
| | - Xing Peng Liu
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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5
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Rivera A, Gewehr DM, Braga MAP, Carvalho PEP, Ternes CMP, Pantaleao AN, Hincapie D, Serpa F, Romero JE, d'Avila A. Adjunctive low-voltage area ablation for patients with atrial fibrillation: An updated meta-analysis of randomized controlled trials. J Cardiovasc Electrophysiol 2024; 35:1329-1339. [PMID: 38664888 DOI: 10.1111/jce.16290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/29/2024] [Accepted: 04/16/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND The efficacy and safety of adjunctive low-voltage area (LVA) ablation on outcomes of catheter ablation (CA) for atrial fibrillation (AF) remains uncertain. METHODS PubMed, Embase, Cochrane Library, and ClinicalTrials.gov were searched for randomized controlled trials (RCTs) comparing CA with versus without LVA ablation for patients with AF. Risk ratios (RR) with 95% confidence intervals (CI) were pooled with a random-effects model. Our primary endpoint was recurrence of atrial tachyarrhythmia (ATA), including AF, atrial flutter, or atrial tachycardia. We used R version 4.3.1 for all statistical analyses. RESULTS Our meta-analysis included 10 RCTs encompassing 1780 patients, of whom 890 (50%) were randomized to LVA ablation. Adjunctive LVA ablation significantly reduced recurrence of ATA (RR 0.76; 95% CI 0.67-0.88; p < .01) and reduced the number of redo ablation procedures (RR 0.54; 95% CI 0.35-0.85; p < .01), as compared with conventional ablation. Among 691 (43%) patients with documented LVAs on baseline substrate mapping, adjunctive LVA ablation substantially reduced ATA recurrences (RR 0.57; 95% CI 0.38-0.86; p < .01). There was no significant difference between groups in terms of periprocedural adverse events (RR 0.78; 95% CI 0.39-1.56; p = .49). CONCLUSIONS Adjunctive LVA ablation is an effective and safe strategy for reducing recurrences of ATA among patients who undergo CA for AF.
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Affiliation(s)
- André Rivera
- Department of Medicine, Nove de Julho University, São Bernardo do Campo, Brazil
| | | | - Marcelo A P Braga
- Department of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Pedro E P Carvalho
- Center for Coronary Artery Disease, Minneapolis Heart Institute Foundation, Minneapolis, USA
| | - Caique M P Ternes
- Postgraduate Program in Cardiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Alexandre N Pantaleao
- Department of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniela Hincapie
- Harvard Medical School, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Cardiac Arrhythmia Service, Boston, Massachusetts, USA
| | - Frans Serpa
- Division of Cardiology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jorge E Romero
- Harvard Medical School, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Cardiac Arrhythmia Service, Boston, Massachusetts, USA
| | - André d'Avila
- Harvard Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Masuda M, Uematsu H, Matsuda Y, Sugino A, Ooka H, Kudo S, Fujii S, Okamoto S, Ishihara T, Nanto K, Tsujimura T, Hata Y, Nakao S, Mano T. Left atrial low voltage areas and heart failure in patients with atrial fibrillation: Implication of the atrial myopathy. ESC Heart Fail 2024. [PMID: 38853626 DOI: 10.1002/ehf2.14878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 04/26/2024] [Accepted: 05/12/2024] [Indexed: 06/11/2024] Open
Abstract
AIMS Atrial fibrillation (AF) and heart failure (HF) affect each other and are often co-morbid. The fact that HF development is not uncommon even after ablation suggests that we need a deeper understanding of the pathology of these conditions. Atrial myocardial degeneration is an underlying factor in AF patients and may be associated with HF development after ablation. This study aimed to investigate the impact of low-voltage areas (LVAs) on HF prognosis after AF ablation. METHODS AND RESULTS This observational study included 1481 consecutive patients undergoing initial ablation for AF. Left atrial LVAs were defined as regions with a bipolar peak-to-peak voltage of <0.50 mV. Patients were divided into three groups: no LVA (LVA size indexed to body surface area <3 cm2/m2, n = 1129), small LVA (3-10 cm2/m2, n = 217), and extensive LVA (≥10 cm2/m2, n = 135). A composite endpoint of HF hospitalization or death occurred more frequently in patients with larger LVAs (3.3% vs. 6.5% vs. 13.3%, P < 0.0001) during the 3-year follow up period. The extent of LVAs was independently related to the risk of the composite endpoint with an adjusted hazard ratio of 1.55 (95% confidence interval, 1.16-2.10) for each additional step of LVA classification (P = 0.003). CONCLUSIONS LVA presence and its extent were associated with frequent HF hospitalization and death. Underlying atrial myopathy appears to define a poor HF prognosis after AF ablation.
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Affiliation(s)
- Masaharu Masuda
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | | | | | - Ayako Sugino
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Hirotaka Ooka
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Satoshi Kudo
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Subaru Fujii
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Shin Okamoto
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | | | - Kiyonori Nanto
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | | | - Yosuke Hata
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Sho Nakao
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Toshiaki Mano
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
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Georgi C, Bannehr M, Lochmann M, Reiners D, Haase-Fielitz A, Butter C, Seifert M. Left atrial low-voltage areas, but not volume, predict the recurrence of atrial fibrillation in repeat ablation procedures. J Cardiovasc Electrophysiol 2024; 35:1156-1164. [PMID: 38566599 DOI: 10.1111/jce.16266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 03/11/2024] [Accepted: 03/18/2024] [Indexed: 04/04/2024]
Abstract
INTRODUCTION Left atrial (LA) low voltage areas (LVA) are a controversial target in atrial fibrillation ablation procedures. However, LVA and LA volume are good predictors of arrhythmia recurrence in ablation-naïve patients. Their predictive value in progressively diseased pre-ablated atria is uncertain. METHODS Consecutive patients with recurrent atrial fibrillation (AF) or atrial tachycardia (AT), who were scheduled for repeat LA ablation, were enrolled in the prospective Bernau ablation registry between 2016 and 2020. All patients received a complete LA ultrahigh-density map before ablation. Maps were analyzed for LA size, LVA percentage and distribution. The predictive value of demographic, anatomic, and mapping variables on AF recurrence was analyzed. RESULTS 160 patients (50.6% male, 1.3 pre-ablations, 60% persistent AF) with complete LA voltage maps were included. Mean follow-up time was 16 ± 11 months. Mean recorded electrograms (EGMs) per map were 9754 ± 5808, mean LA volume was 176.1 ± 35.9 ml and mean rate of LVAs <0.5 mV was 30.6% ± 23.1%. During follow-up recurrence rate of AF or AT >30 s was 55.6%. Patients with recurrence had a significant higher percentage of LVAs (40.0% vs. 18.8%, p < .001) but no relevant difference in LA volume (172 vs. 178 mL, p = .299). ROC curves revealed LVA as a good predictor for recurrence (AUC = 0.79, p < .001) and a cut-off of 22% LVAs with highest sensitivity (73.0%) and specificity (71.8%). Based on this cut off, event free survival was significantly higher in the Low LVA group (p < .01). CONCLUSION Total LVA percentage has a good predictive power on arrhythmia recurrence in a cohort of advanced scarred left atria in repeat procedures independent of the applied ablation strategy. Left atrial volume seems to have minor impact on the rhythm outcome in our study cohort.
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Affiliation(s)
- Christian Georgi
- Department of Cardiology, Brandenburg Medical School (MHB) Theodor Fontane, University Hospital Heart Center Brandenburg, Neuruppin, Germany
| | - Marwin Bannehr
- Department of Cardiology, Brandenburg Medical School (MHB) Theodor Fontane, University Hospital Heart Center Brandenburg, Neuruppin, Germany
| | - Marlene Lochmann
- Department of Cardiology, Brandenburg Medical School (MHB) Theodor Fontane, University Hospital Heart Center Brandenburg, Neuruppin, Germany
| | - David Reiners
- Department of Cardiology, Brandenburg Medical School (MHB) Theodor Fontane, University Hospital Heart Center Brandenburg, Neuruppin, Germany
| | - Anja Haase-Fielitz
- Department of Cardiology, Brandenburg Medical School (MHB) Theodor Fontane, University Hospital Heart Center Brandenburg, Neuruppin, Germany
- Faculty of Health Sciences Brandenburg, Neuruppin, Germany
- Institute of Social Medicine and Health System Research, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Christian Butter
- Department of Cardiology, Brandenburg Medical School (MHB) Theodor Fontane, University Hospital Heart Center Brandenburg, Neuruppin, Germany
- Faculty of Health Sciences Brandenburg, Neuruppin, Germany
| | - Martin Seifert
- Department of Cardiology, Brandenburg Medical School (MHB) Theodor Fontane, University Hospital Heart Center Brandenburg, Neuruppin, Germany
- Faculty of Health Sciences Brandenburg, Neuruppin, Germany
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8
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Fumagalli C, Zocchi C, Ciabatti M, Milazzo A, Cappelli F, Fumagalli S, Pieroni M, Olivotto I. From Atrial Fibrillation Management to Atrial Myopathy Assessment: The Evolving Concept of Left Atrium Disease in Hypertrophic Cardiomyopathy. Can J Cardiol 2024; 40:876-886. [PMID: 38286174 DOI: 10.1016/j.cjca.2024.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/21/2024] [Accepted: 01/23/2024] [Indexed: 01/31/2024] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is the most prevalent genetically inherited cardiovascular disorder in adults and a significant cause of heart failure and sudden cardiac death. Historically, atrial fibrillation (AF) has been considered as a critical aspect in HCM patients as it is considered to be a marker of disease progression, escalates the frequency of heart failure hospitalisations, increases the risk of thromboembolic events, and worsens quality of life and outcome. Increasing evidence suggests that AF is the result of a subtle long-standing process that starts early in the history of HCM. The process of left atrial dilation accompanied by morphologic and functional remodelling is the quintessential prerequisite for the onset of AF. This review aims to describe the current understanding of AF pathophysiology in HCM, emphasising the role of left atrial myopathy in its development. In addition, we discuss risk factors and management strategies specific to AF in the context of HCM, providing insights into the complexities and challenges of treating this specific patient population.
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Affiliation(s)
- Carlo Fumagalli
- Cardiomyopathy Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy.
| | - Chiara Zocchi
- Cardiomyopathy Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Cardiovascular Department, San Donato Hospital, Arezzo, Italy
| | | | - Alessandra Milazzo
- Cardiomyopathy Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Francesco Cappelli
- Cardiomyopathy Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Stefano Fumagalli
- Geriatric Intensive Care Unit and Geriatric Arrhythmia Unit, Department of Experimental and Clinical Medicine, University of Florence and AOU Careggi, Florence, Italy
| | | | - Iacopo Olivotto
- Cardiomyopathy Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Meyer Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Florence, Italy
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9
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Nery PB, Nair GM, Birnie DH. Prognostic value of low-voltage area burden in atrial fibrillation. Heart Rhythm 2024; 21:387-388. [PMID: 38278500 DOI: 10.1016/j.hrthm.2024.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 01/21/2024] [Accepted: 01/23/2024] [Indexed: 01/28/2024]
Affiliation(s)
- Pablo B Nery
- Arrhythmia Service, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Canada.
| | - Girish M Nair
- Arrhythmia Service, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Canada
| | - David H Birnie
- Arrhythmia Service, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Canada
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10
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Masuda M, Matsuda Y, Uematsu H, Sugino A, Ooka H, Kudo S, Fujii S, Asai M, Okamoto S, Ishihara T, Nanto K, Tsujimura T, Hata Y, Higashino N, Nakao S, Mano T. Clinical impact of left atrial remodeling pattern in patients with atrial fibrillation: Comparison of volumetric, electrical, and combined remodeling. J Cardiovasc Electrophysiol 2024; 35:171-181. [PMID: 38018401 DOI: 10.1111/jce.16129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 10/12/2023] [Accepted: 10/28/2023] [Indexed: 11/30/2023]
Abstract
INTRODUCTION Atrial fibrillation (AF) is accompanied by various types of remodeling, including volumetric enlargement and histological degeneration. Electrical remodeling reportedly reflects histological degeneration. PURPOSE To clarify the differences in determinants and clinical impacts among types of remodeling. METHODS This observational study included 1118 consecutive patients undergoing initial ablation for AF. Patients were divided into four groups: minimal remodeling (left atrial volume index [LAVI] < mean value and no low-voltage area [LVA], n = 477); volumetric remodeling (LAVI ≥ mean value and no LVA, n = 361); electrical remodeling (LAVI < mean value and LVA presence, n = 96); and combined remodeling (LAVI ≥ mean value and LVA presence, n = 184). AF recurrence and other clinical outcomes were followed up for 2 and 5 years, respectively. RESULTS Major determinants of each remodeling pattern were high age for electrical (odds ratio = 2.32, 95% confidence interval = 1.68-3.25) and combined remodeling (2.57, 1.88-3.49); female for electrical (3.85, 2.21-6.71) and combined remodeling (4.92, 2.90-8.25); persistent AF for combined remodeling (7.09, 3.75-13.4); and heart failure for volumetric (1.71, 1.51-2.53) and combined remodeling (2.21, 1.30-3.75). Recurrence rate after initial ablation increased in the order of minimal remodeling (20.1%), volumetric (27.4%) or electrical remodeling (36.5%), and combined remodeling (50.0%, p < .0001). A composite endpoint of heart failure, stroke, and death occurred in the order of minimal (3.4%), volumetric (7.5%) or electrical (8.3%), and combined remodeling (15.2%, p < .0001). CONCLUSION Volumetric, electrical, and combined remodeling were each associated with a unique patient background, and defined rhythm and other clinical outcomes.
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Affiliation(s)
- Masaharu Masuda
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Yasuhiro Matsuda
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Hiroyuki Uematsu
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Ayako Sugino
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Hirotaka Ooka
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Satoshi Kudo
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Subaru Fujii
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Mitsutoshi Asai
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Shin Okamoto
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Takayuki Ishihara
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Kiyonori Nanto
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Takuya Tsujimura
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Yosuke Hata
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Naoko Higashino
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Sho Nakao
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
| | - Toshiaki Mano
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
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11
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Marcon L, Bergonti M, Spera F, Saenen J, Huybrechts W, Miljoen H, Van Leuven O, Vandaele L, Wittock A, Heidbuchel H, Sarkozy A. Dynamic changes of left atrial substrate over time following pulmonary vein isolation: the Progress-AF study. Europace 2023; 25:euad299. [PMID: 37787610 PMCID: PMC10629715 DOI: 10.1093/europace/euad299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 09/25/2023] [Indexed: 10/04/2023] Open
Abstract
AIMS Little is known about dynamic changes of the left atrial (LA) substrate over time in patients with atrial fibrillation (AF). This study aims to evaluate substrate changes following pulmonary vein isolation (PVI). METHODS AND RESULTS In our prospective observational study, consecutive patients undergoing first PVI-only and redo ablation were included. High-density maps of the two procedures were compared. Progression or regression was diagnosed if a significant concordant decrease or increase in bipolar voltages in ≥2 segments was observed, respectively. In 28 patients (61.2 ± 9.5 years, 39% female, 53.5% persistent AF), 111.013 voltage points from 56 high-density LA maps (1.982 points/patient) were analysed. Comparing the high-density maps of the first and second procedures, in the progression group (17 patients, 61%), there was a decrease in global (-35%, P < 0.001) and all regional voltages. In the regression group (11 patients, 39%), there was an increase in global (+43%, P < 0.001) and regional voltages. Comparing the progression with the regression group, the area of low-voltage zone (LVZ) increased (+3.5 vs. -4.5 cm2, P < 0.001) and LA activation time prolonged (+8.0 vs. -9.1 ms, P = 0.005). Baseline clinical parameters did not predict progression or regression. In patients with substrate progression, pulmonary veins (PVs) were more frequently isolated (P = 0.02) and the AF pattern at recurrence was more frequently persistent (P = 0.005). CONCLUSION Our study describes bidirectional dynamic properties of the LA substrate with concordant either progressive or regressive changes. Regression occurs with reduced AF burden after the first procedure, while progression is associated with persistent AF recurrence despite durable PV isolation. The dynamic nature of LA substrate poses questions about LVZ-based ablation strategies.
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Affiliation(s)
- Lorenzo Marcon
- Cardiology Department, University Hospital Antwerp, Wilrijkstraat 10, Edegem, Antwerp 2650, Belgium
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel,1090 Brussels, Belgium
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Marco Bergonti
- Cardiology Department, University Hospital Antwerp, Wilrijkstraat 10, Edegem, Antwerp 2650, Belgium
- Division of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Francesco Spera
- Cardiology Department, University Hospital Antwerp, Wilrijkstraat 10, Edegem, Antwerp 2650, Belgium
| | - Johan Saenen
- Cardiology Department, University Hospital Antwerp, Wilrijkstraat 10, Edegem, Antwerp 2650, Belgium
| | - Wim Huybrechts
- Cardiology Department, University Hospital Antwerp, Wilrijkstraat 10, Edegem, Antwerp 2650, Belgium
| | - Hielko Miljoen
- Cardiology Department, University Hospital Antwerp, Wilrijkstraat 10, Edegem, Antwerp 2650, Belgium
| | - Olivier Van Leuven
- Cardiology Department, University Hospital Antwerp, Wilrijkstraat 10, Edegem, Antwerp 2650, Belgium
| | - Lien Vandaele
- Cardiology Department, University Hospital Antwerp, Wilrijkstraat 10, Edegem, Antwerp 2650, Belgium
| | - Anouk Wittock
- Anesthesiology Department, University Hospital Antwerp, Antwerp, Belgium
| | - Hein Heidbuchel
- Cardiology Department, University Hospital Antwerp, Wilrijkstraat 10, Edegem, Antwerp 2650, Belgium
- University of Antwerp, Faculty Medicine and Health Sciences, Universiteitsplein 1, Wilrijk, Antwerpen 2610, Belgium
| | - Andrea Sarkozy
- Cardiology Department, University Hospital Antwerp, Wilrijkstraat 10, Edegem, Antwerp 2650, Belgium
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel,1090 Brussels, Belgium
- University of Antwerp, Faculty Medicine and Health Sciences, Universiteitsplein 1, Wilrijk, Antwerpen 2610, Belgium
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12
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Althoff TF, Porta-Sanchez A. Does the spatial distribution of atrial arrhythmogenic substrate matter? Insights from the DECAAF II trial. Europace 2023; 25:euad282. [PMID: 37713184 PMCID: PMC10519619 DOI: 10.1093/europace/euad282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 09/06/2023] [Accepted: 09/13/2023] [Indexed: 09/16/2023] Open
Affiliation(s)
- Till F Althoff
- Arrhythmia Section, Clínic Cardiovascular Institute (ICCV), Clínic Barcelona University Hospital, C/Villarroel N° 170, 08036 Barcelona, Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Carrer del Rosselló 149, 08036 Barcelona, Catalonia, Spain
| | - Andreu Porta-Sanchez
- Arrhythmia Section, Clínic Cardiovascular Institute (ICCV), Clínic Barcelona University Hospital, C/Villarroel N° 170, 08036 Barcelona, Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Carrer del Rosselló 149, 08036 Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Av. Monforte de Lemos 3-5, 28029 Madrid, Spain
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