Key result
Left atrial LGE-extent >12% on CMR predicted lower 12-month arrhythmia-free survival compared to LGE <12% in the total cohort (55% vs 80%, P=0.007) and persistent AF subgroup (44% vs 76%, P=0.029).
Why the study?
Tools to improve patient selection for PVI in persistent AF are needed, but left atrial LGE-CMR patient selection has lacked standardized, reproducible quantification.
Does a standardized left atrial LGE-CMR quantification method predict arrhythmia-free survival in patients undergoing first-time PVI for atrial fibrillation?
Cohort (n=219)
Yes
Does a standardized left atrial LGE-CMR quantification method predict arrhythmia-free survival in patients undergoing first-time PVI for atrial fibrillation?
A standardized LGE-CMR quantification method using a 12% extent cut-off successfully predicts arrhythmia-free survival after first-time PVI, which may help improve patient selection for ablation.
May support LGE-CMR risk stratification before PVI; hypothesis-generating pending prospective validation.
Aims With recurrence rates up to 50% after pulmonary vein isolation (PVI) in persistent atrial fibrillation (AF), predictive tools to improve patient selection are needed. Patient selection based on left atrial late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) has been proposed previously (UTAH-classification). However, this approach has not been widely established, in part owed to the lack of standardization of the LGE quantification method. We have recently established a standardized LGE-CMR method enabling reproducible LGE-quantification. Here, the ability of this method to predict outcome after PVI was evaluated. Methods and results This dual-centre study (n = 219) consists of a prospective derivation cohort (n = 37, all persistent AF) and an external validation cohort (n = 182; 66 persistent, 116 paroxysmal AF). All patients received an LGE-CMR prior to first-time PVI-only ablation. LGE was quantified based on the signal-intensity-ratio relative to the blood pool, applying a uniform LGE-defining threshold of >1.2. In patients with persistent AF in the derivation cohort, left atrial LGE-extent above a cut-off value of 12% was found to best predict relevant low-voltage substrate (≥2 cm two with <0.5 mV during sinus rhythm) and arrhythmia-free survival 12 months post-PVI. When applied to the external validation cohort, this cut-off value was also predictive of arrhythmia-free survival for both, the total cohort and the subgroup with persistent AF (LGE < 12%: 80% and 76%; LGE > 12%: 55% and 44%; P = 0.007 and P = 0.029, respectively). Conclusion This dual-centre study established and validated a standardized, reproducible LGE-CMR method discriminating PVI responders from non-responders, which may improve choice of therapeutic approach or ablation strategy for patients with persistent AF.
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Althoff et al. (2022) conducted a cohort in Atrial fibrillation (persistent and paroxysmal) (n=219). Left atrial late gadolinium enhancement (LGE) CMR extent >12% vs. LGE extent <12% was evaluated on Arrhythmia-free survival 12 months post-PVI (p=0.007). Left atrial LGE-extent >12% on CMR predicted lower 12-month arrhythmia-free survival compared to LGE <12% in the total cohort (55% vs 80%, P=0.007) and persistent AF subgroup (44% vs 76%, P=0.029).
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