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Straube F, Pongratz J, Hartl S, Brueck B, Tesche C, Ebersberger U, Helmberger T, Crispin A, Wankerl M, Dorwarth U, Hoffmann E. Cardiac computed tomography angiography-derived analysis of left atrial appendage morphology and left atrial dimensions for the prediction of atrial fibrillation recurrence after pulmonary vein isolation. Clin Cardiol 2021; 44:1636-1645. [PMID: 34651337 PMCID: PMC8571558 DOI: 10.1002/clc.23743] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/23/2021] [Accepted: 10/06/2021] [Indexed: 11/12/2022] Open
Abstract
Background Left atrial appendage (LAA) is a potential source of atrial fibrillation (AF) triggers. Hypothesis LAA morphology and dimensions are associated with AF recurrence after pulmonary vein isolation (PVI). Methods From cardiac computed tomography angiography (CCTA), left atrial (LA), pulmonary vein (PV), and LAA anatomy were assessed in cryoballoon ablation (CBA) patients. Results Among 1103 patients undergoing second‐generation CBA, 725 (65.7%) received CCTA with 473 (42.9%) qualifying for detailed LAA analysis (66.3 ± 9.5 years). Symptomatic AF reoccurred in 166 (35.1%) patients during a median follow‐up of 19 months. Independent predictors of recurrence were LA volume, female sex, and mitral regurgitation ≥°II. LAA volume and AF‐type were dependent predictors of recurrence due to their strong correlations with LA volume. LA volumes ≥122.7 ml (sensitivity 0.53, specificity 0.69, area under the curve [AUC] 0.63) and LAA volumes ≥11.25 ml (sensitivity 0.39, specificity 0.79, AUC 0.59) were associated with recurrence. LA volume was significantly smaller in females. LAA volumes showed no sex‐specific difference. LAA morphology, classified as windsock (51.4%), chicken‐wing (20.7%), cactus (12.5%), and cauliflower‐type (15.2%), did not predict successful PVI (log‐rank; p = 0.596). Conclusions LAA volume was strongly correlated to LA volume and was a dependent predictor of recurrence after CBA. Main independent predictors were LA volume, female sex, and mitral regurgitation ≥°II. Gender differences in LA volumes were observed. Individual LAA morphology was not associated with AF recurrence after cryo‐PVI. Our results indicate that preprocedural CCTA might be a useful imaging modality to evaluate ablation strategies for patients with recurrences despite successful PVI.
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Affiliation(s)
- Florian Straube
- Heart Center Munich-Bogenhausen, Department of Cardiology and Internal Intensive Care Medicine, Munich Clinic Bogenhausen, Academic Teaching Hospital of the Technical University Munich, Munich, Germany.,Faculty of Medicine and the University Hospital, Dept. of Cardiology, Ludwig-Maximilians-University, Munich, Germany
| | - Janis Pongratz
- Heart Center Munich-Bogenhausen, Department of Cardiology and Internal Intensive Care Medicine, Munich Clinic Bogenhausen, Academic Teaching Hospital of the Technical University Munich, Munich, Germany
| | - Stefan Hartl
- Heart Center Munich-Bogenhausen, Department of Cardiology and Internal Intensive Care Medicine, Munich Clinic Bogenhausen, Academic Teaching Hospital of the Technical University Munich, Munich, Germany
| | - Benedikt Brueck
- Heart Center Munich-Bogenhausen, Department of Cardiology and Internal Intensive Care Medicine, Munich Clinic Bogenhausen, Academic Teaching Hospital of the Technical University Munich, Munich, Germany.,Internal Medicine and Cardiology, Kardiologie Erkelenz, Erkelenz, Germany
| | - Christian Tesche
- Department of Cardiology, St. Johannes Hospital Dortmund, Dortmund, Germany.,Faculty of Medicine and the University Hospital, Dept. of Cardiology, Ludwig-Maximilians-University, Munich, Germany
| | - Ullrich Ebersberger
- Heart Center Munich-Bogenhausen, Department of Cardiology and Internal Intensive Care Medicine, Munich Clinic Bogenhausen, Academic Teaching Hospital of the Technical University Munich, Munich, Germany.,Faculty of Medicine and the University Hospital, Dept. of Cardiology, Ludwig-Maximilians-University, Munich, Germany.,KMN, Kardiologie Muenchen Nord, Munich, Germany
| | - Thomas Helmberger
- Department of Radiology, Neuroradiology and Nuclear Medicine, Munich Clinic Bogenhausen, Academic Teaching Hospital of the Technical University Munich, Munich, Germany
| | - Alexander Crispin
- Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-University, Munich, Germany
| | - Michael Wankerl
- Heart Center Munich-Bogenhausen, Department of Cardiology and Internal Intensive Care Medicine, Munich Clinic Bogenhausen, Academic Teaching Hospital of the Technical University Munich, Munich, Germany
| | - Uwe Dorwarth
- Heart Center Munich-Bogenhausen, Department of Cardiology and Internal Intensive Care Medicine, Munich Clinic Bogenhausen, Academic Teaching Hospital of the Technical University Munich, Munich, Germany
| | - Ellen Hoffmann
- Heart Center Munich-Bogenhausen, Department of Cardiology and Internal Intensive Care Medicine, Munich Clinic Bogenhausen, Academic Teaching Hospital of the Technical University Munich, Munich, Germany
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Ikenouchi T, Inaba O, Takamiya T, Inamura Y, Sato A, Matsumura Y, Sato H, Hirakawa A, Takahashi Y, Goya M, Sasano T, Nitta J. The impact of left atrium size on selection of the pulmonary vein isolation method for atrial fibrillation: Cryoballoon or radiofrequency catheter ablation. Am Heart J 2021; 231:82-92. [PMID: 33098808 DOI: 10.1016/j.ahj.2020.10.061] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 10/15/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Pulmonary vein isolation (PVI) is the cornerstone of ablation strategies for atrial fibrillation (AF), and noninferiority of cryoballoon (CB) over radiofrequency (RF) ablation has been previously reported. One of the risk factors of recurrence is left atrium (LA) enlargement. This study aimed to analyze the impact of LA enlargement on the selection of CB or RF ablation for AF patients. METHODS A total of 2,224 AF patients (64.4 ± 10.7 years, 65.5% male) who underwent PVI were analyzed retrospectively. Left atrial diameter (LAD) and volume (LAV) were measured using echocardiography before the procedures. LA enlargement was defined as LAD ≥40 mm and LAV index (LAVI) ≥35 mL/m2. Patients undergoing CB and RF ablation were propensity score matched, and 376 matched pairs were evaluated. RESULTS Cox proportional hazard analysis revealed that LAD (95% CI, 1.01-1.05), LAV (95% CI, 1.01-1.02), and LAVI (95% CI, 1.01-1.03) were independent predictors of recurrence. CB showed equivalent clinical outcomes to those of RF with shorter procedure time required for patients without LA enlargement. CB was inferior to RF in patients with LA enlargement (LAD, 74.5% vs 84.6%, P = .028; LAVI, 74.7% vs 83.4%, P = .015), and large LAVI was associated with a higher prevalence of non-PV foci (35% vs 29%, P = .008). CONCLUSIONS CB ablation may be recommended for patients without enlarged LA based on the short procedure time and efficacy, whereas RF would be more appropriate in large LAs. LAVI may be a valuable reference to predict PVI outcomes and in selecting the ablation method.
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Affiliation(s)
- Takashi Ikenouchi
- Department of Cardiology, Japanese Red Cross Saitama Hospital, 1-5 Shintoshin, Chuo-ku, Saitama City, Saitama, Japan.
| | - Osamu Inaba
- Department of Cardiology, Japanese Red Cross Saitama Hospital, 1-5 Shintoshin, Chuo-ku, Saitama City, Saitama, Japan
| | - Tomomasa Takamiya
- Department of Cardiology, Japanese Red Cross Saitama Hospital, 1-5 Shintoshin, Chuo-ku, Saitama City, Saitama, Japan
| | - Yukihiro Inamura
- Department of Cardiology, Japanese Red Cross Saitama Hospital, 1-5 Shintoshin, Chuo-ku, Saitama City, Saitama, Japan
| | - Akira Sato
- Department of Cardiology, Japanese Red Cross Saitama Hospital, 1-5 Shintoshin, Chuo-ku, Saitama City, Saitama, Japan
| | - Yutaka Matsumura
- Department of Cardiology, Japanese Red Cross Saitama Hospital, 1-5 Shintoshin, Chuo-ku, Saitama City, Saitama, Japan
| | - Hiroyuki Sato
- Division of Biostatistics and Data Science, Clinical Research Center, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Akihiro Hirakawa
- Division of Biostatistics and Data Science, Clinical Research Center, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Yoshihide Takahashi
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Masahiko Goya
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Junichi Nitta
- Department of Cardiology, Sakakibara Heart Institute, 3-16-1 Asahicho, Fuchu-shi, Tokyo, Japan
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D'Ambrosio G, Romano S, Alothman O, Frommhold M, Borisov G, El Garhy M, Issa K, Penco M, Raffa S, Geller JC. Computed tomography-derived left atrial volume index, sex, and age to predict the presence and the extent of left atrial low-voltage zones in patients with atrial fibrillation: The ZAQ score. J Cardiovasc Electrophysiol 2020; 31:895-902. [PMID: 32048774 DOI: 10.1111/jce.14391] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 02/01/2020] [Accepted: 02/07/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Pulmonary vein isolation is the cornerstone of catheter ablation in patients with atrial fibrillation (AF). However, with advanced left atrial (LA) structural changes, additional targeted catheter ablation of low-voltage zones (LVZs) has produced favorable results. Therefore, with the advent of single-shot techniques, it would be helpful to predict the presence of LVZs before an ablation procedure. OBJECTIVE We hypothesized that computed tomography (CT)-derived left atrial volume index (LAVI), in combination with other objective parameters, could be used to develop a score able to predict the presence of LVZs. METHODS In a large cohort of patients undergoing their first AF ablations, comprehensive echocardiographic evaluations and cardiac CT were performed. During the electrophysiological studies, LA geometry and electroanatomic voltage maps were created. LVZs were defined as areas ≥1 cm2 with bipolar peak-to-peak voltage amplitudes ≤0.5 mV. RESULTS In a derivation cohort of 374 patients, predictors of LVZs were identified by regression analysis and used to build the Zentralklinik Bad Berka and University of L'Aquila (ZAQ) score (age ≥65 years; female sex; and CT-LAVI ≥57 mL/m2 ). The ZAQ score of 2 points accurately identified the presence and the extent of LVZs (area under the curve [AUC], 0.809; 95% confidence interval [CI], 0.758-0.861; P < .001 and 3 [interquartile range, IQR, 1.5-4.5] vs 7 cm2 [IQR 4-9]; P = .001). In a validation cohort of 103 patients, the predictive value of the score was confirmed (AUC, 0.793; 95% CI, 0.709-0.878; P < .001 and 4 [IQR, 2-7] vs 11.5 cm2 [IQR, 8-16.5]; P = .001). CONCLUSIONS The ZAQ score identifies LVZs and may be useful for planning the ablation strategy ahead of time.
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Affiliation(s)
- Gabriele D'Ambrosio
- Arrhythmia Section, Division of Cardiology, Zentralklinik Bad Berka, Bad Berka, Germany.,Department of Life Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Silvio Romano
- Department of Life Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Obaida Alothman
- Arrhythmia Section, Division of Cardiology, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Markus Frommhold
- Arrhythmia Section, Division of Cardiology, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Georgi Borisov
- Arrhythmia Section, Division of Cardiology, Zentralklinik Bad Berka, Bad Berka, Germany
| | | | - Karam Issa
- Arrhythmia Section, Division of Cardiology, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Maria Penco
- Department of Life Health and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Santi Raffa
- Arrhythmia Section, Division of Cardiology, Zentralklinik Bad Berka, Bad Berka, Germany
| | - J Christoph Geller
- Arrhythmia Section, Division of Cardiology, Zentralklinik Bad Berka, Bad Berka, Germany.,Faculty of Medicine, Otto-von-Guericke University, Magdeburg, Germany
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