Patent foramen ovale and left atrial appendage flow velocity predict atrial fibrillation recurrence post cryoballoon ablation

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Paroxysmal atrial fibrillation (n=417). Intervention: Patent foramen ovale (PFO) and left atrial appendage flow velocity (LAA-FV) 30 seconds after a 3-month blanking period) (HR 1.79, 95% CI 1.02-3.15, p=0.04).

Grzegorz Kiełbasa; Agnieszka Bednarek; Adam Bednarski; Agnieszka Olszanecka; Tomasz Sondej; Aleksander Kusiak; Wiktoria Wojciechowska; Marek Rajzer; Marek Jastrzębski

doi:10.33963/kp.a2021.0004

May 18, 2021Kardiologia PolskaOpen Access

Patent foramen ovale and left atrial appendage flow velocity predict atrial fibrillation recurrence post cryoballoon ablation

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Key result

The presence of a patent foramen ovale (HR 1.79) and left atrial appendage flow velocity <45 cm/s (HR 1.63) independently predicted atrial fibrillation recurrence after cryoballoon ablation.

Why the study?

TEE allows detailed characterization of the AF substrate, but the prognostic value of TEE-derived LA and LAA features for predicting AF recurrence after cryoballoon-based ablation needed assessment.

Do pre-procedural transesophageal echocardiography features (patent foramen ovale and left atrial appendage flow velocity) predict atrial fibrillation recurrence in patients with paroxysmal atrial fibrillation undergoing cryoballoon ablation?

Study Design

Type

Cohort (n=417)

Multicenter

No

Structured PICO

Do pre-procedural transesophageal echocardiography features (patent foramen ovale and left atrial appendage flow velocity) predict atrial fibrillation recurrence in patients with paroxysmal atrial fibrillation undergoing cryoballoon ablation?

P

Population

417 patients (mean age 59 years, 39.3% female) with paroxysmal atrial fibrillation undergoing their first cryoballoon-based pulmonary vein isolation, followed for a median of 24 months.

E

Exposure

Pre-procedural transesophageal echocardiography (TEE) to assess left atrial appendage flow velocity (LAA-FV) and patent foramen ovale (PFO) prior to cryoballoon-based pulmonary vein isolation.

O

Outcome

Freedom from atrial fibrillation recurrence (defined as the first episode of AF lasting >30 seconds diagnosed after a 3-month blanking period) at median 24 months follow-up.hard clinical

Main Result

Hazard Ratio: 1.79 (95% CI 1.02–3.15)

p-value: p=0.04

The presence of a patent foramen ovale and reduced left atrial appendage flow velocity (<45 cm/s) on pre-procedural TEE are independent predictors of atrial fibrillation recurrence after cryoballoon ablation.

Limitations

Single-center observational study with potential referral and treatment bias
Asymptomatic atrial fibrillation episodes might have been missed due to imperfect periodic ECG monitoring
Potential underestimation of the true prevalence of patent foramen ovale using transesophageal echocardiography
The cut-off point for left atrial appendage flow velocity was estimated based on post hoc data analysis
Some episodes of asymptomatic AF were likely missed due to imperfect periodic ECG monitoring
Possible underestimation of the true prevalence of PFO compared to catheter-based assessment
The cut-off point of LAA flow velocity was estimated on the basis of post hoc data analysis

Implication

May identify higher-risk patients for closer monitoring; leaves open whether TEE should guide ablation decisions.

Abstract

BACKGROUND: Transesophageal echocardiography (TEE) allows detailed characterization of atrial fibrillation (AF) substrate and could be valuable for predicting pulmonary vein isolation (PVI) procedure outcomes. AIMS: We aimed at assessing the value of TEE-derived left atrial (LA) and LA appendage (LAA) features as prognostic markers for AF recurrence after cryoballoon-based ablation. METHODS: Patients were enrolled using a prospective database of consecutive PVI procedures performed over a 7-year period. The following TEE-derived parameters were investigated: LAA emptying flow velocity (LAA-FV), the presence of patent foramen ovale (PFO), LA spontaneous echo contrast, and mitral regurgitation. Diagnosis of AF recurrence was based on scheduled and symptoms triggered ECG monitoring. The Cox's regression model and Kaplan-Meier survival curves were applied for statistical analysis. RESULTS: A total of 417 consecutive patients who underwent their first PVI using cryoballoon were analyzed (mean age: 59 years). AF recurrence was noted in 25.7% of patients (median follow-up of 24 months). Four TEE-derived variables had predictive values for AF recurrence: LAA-FV <45 cm/s, presence of PFO at resting state, LA spontaneous echo contrast, and mitral regurgitation. In the multivariable model, apart from the transthoracic echocardiography-derived LA size, two TEE-derived features (LAA-FV <45 cm/s and the presence of PFO) remained as independent predictors. CONCLUSIONS: This study proposed a novel TEE-derived AF recurrence risk factor - the presence of PFO - and confirmed the prognostic value of LAA flow velocity in patients undergoing cryoballoon-based AF ablation. These risk factors could be useful in the global assessment of AF recurrence risk and potentially helpful in planning the ablation strategy.

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Cite This Study

Kiełbasa et al. (2021) conducted a cohort in Paroxysmal atrial fibrillation (n=417). Patent foramen ovale (PFO) and left atrial appendage flow velocity (LAA-FV) <45 cm/s vs. Absence of PFO and LAA-FV ≥45 cm/s was evaluated on Freedom from atrial fibrillation recurrence (first episode >30 seconds after a 3-month blanking period) (HR 1.79, 95% CI 1.02-3.15, p=0.04). The presence of a patent foramen ovale (HR 1.79) and left atrial appendage flow velocity <45 cm/s (HR 1.63) independently predicted atrial fibrillation recurrence after cryoballoon ablation.

synapsesocial.com/papers/6a2088f7fedcec2fd6301b82 https://doi.org/10.33963/kp.a2021.0004