Incremental value of left atrial strain to predict atrial fibrillation recurrence after cryoballoon ablation

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Atrial fibrillation (paroxysmal or persistent) (n=172). Intervention: Peak atrial longitudinal strain (PALS) ≤ 17% vs. PALS > 17%. Primary outcome: Atrial fibrillation recurrence after the 3-month blanking period (HR 9.45, 95% CI 3.17-28.13, p=<0.001).

Andreea Motoc; Maria–Luiza Luchian; Esther Scheirlynck; Bram Roosens; Hadischat Chameleva; Maxim Gevers; Xavier Galloo; Berlinde von Kemp; Robbert Ramak; Juan Sieira; Carlo de Asmundis; Gian‐Battista Chierchia; Julien Magné; Caroline Weytjens; Steven Droogmans; Bernard Cosyns

doi:10.1371/journal.pone.0259999

November 19, 2021PLoS ONEOpen Access

Incremental value of left atrial strain to predict atrial fibrillation recurrence after cryoballoon ablation

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Key result

Peak atrial longitudinal strain ≤ 17% strongly predicted atrial fibrillation recurrence after cryoballoon ablation (HR 9.45), providing incremental prognostic value over left atrial enlargement.

Figures

Why the study?

AF recurrence occurs in approximately 25% of patients after cryoballoon ablation, and while LA dilation predicts recurrence, LA strain may detect mechanical dysfunction before enlargement occurs.

Does left atrial strain assessment using PALS predict atrial fibrillation recurrence after cryoballoon ablation in patients with paroxysmal or persistent AF?

Study Design

Type

Cohort (n=172)

Multicenter

No

Structured PICO

Does left atrial strain assessment using PALS predict atrial fibrillation recurrence after cryoballoon ablation in patients with paroxysmal or persistent AF?

P

Population

172 patients (mean age 62.6 years, 39% female) with paroxysmal or persistent atrial fibrillation undergoing index cryoballoon ablation, followed for a mean of 11.7 months.

E

Exposure

Left atrial strain assessment (specifically peak atrial longitudinal strain, PALS) using speckle-tracking echocardiography before cryoballoon ablation

C

Comparator

Left atrial size assessment (left atrium anterior-posterior diameter index and left atrial volume index)

O

Outcome

Atrial fibrillation recurrence after the 3-month blanking periodhard clinical

Main Result

Hazard Ratio: 9.45 (95% CI 3.17–28.13)

p-value: p=<0.001

Left atrial strain assessment using PALS provides incremental predictive value over LA enlargement for identifying patients at high risk of AF recurrence after cryoballoon ablation, even in those with normal LA size.

Limitations

Single center study with a relatively small sample size
Lack of continuous monitoring devices during follow-up, potentially missing asymptomatic AF episodes
Follow-up period was limited to approximately 1 year
Software used for LA strain was originally designed for left ventricle strain analysis
Small proportion of patients with persistent AF limits extrapolation to this subgroup
Lack of continuous monitoring device during follow-up, meaning asymptomatic AF episodes might have occurred unnoticed
Follow-up period not beyond 1 year
LA strain measured on software designed for left ventricle strain analysis
Low proportion of persistent AF (16.3%)
Majority of subjects had preserved left ventricle ejection fraction

Implication

PALS ≤17% may refine post-CBA recurrence risk stratification beyond LA size; leaves open prospective validation before clinical adoption.

Abstract

OBJECTIVE: Atrial fibrillation (AF) recurrence occurs in approximately 25% of the patients undergoing cryoballoon ablation (CBA), leading to repeated ablations and complications. Left atrial (LA) dilation has been proposed as a predictor of AF recurrence. However, LA strain is a surrogate marker of LA mechanical dysfunction, which might appear before the enlargement of the LA. The purpose of this study was to evaluate the additional predictive value of LA function assessed using strain echocardiography for AF recurrence after CBA. METHODS: 172 consecutive patients (62.2 ± 12.2 years, 61% male) were prospectively analyzed. Echocardiography was performed before CBA. Blanking period was defined as the first three months post-ablation. The primary endpoint was AF recurrence after the blanking period. RESULTS: 50 (29%) patients had AF recurrence. In the overall study population, peak atrial longitudinal strain (PALS) ≤ 17% had the highest incremental predictive value for AF recurrence (HR = 9.45, 95%CI: 3.17-28.13, p < 0.001). In patients with non-dilated LA, PALS≤17% remained an independent predictor of AF recurrence (HR = 5.39, 95%CI: 1.66-17.52, p = 0.005). CONCLUSIONS: This study showed that LA function assessed by PALS provided an additional predictive value for AF recurrence after CBA, over LA enlargement. In patients with non-dilated LA, PALS also predicted AF recurrence. These findings emphasize the added value of LA strain, suggesting that it should be implemented in the systematic evaluation of AF patients before CBA.

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Cite This Study

Motoc et al. (2021) conducted a cohort in Atrial fibrillation (paroxysmal or persistent) (n=172). Peak atrial longitudinal strain (PALS) ≤ 17% vs. PALS > 17% was evaluated on Atrial fibrillation recurrence after the 3-month blanking period (HR 9.45, 95% CI 3.17-28.13, p=<0.001). Peak atrial longitudinal strain ≤ 17% strongly predicted atrial fibrillation recurrence after cryoballoon ablation (HR 9.45), providing incremental prognostic value over left atrial enlargement.

synapsesocial.com/papers/6a2981e1eff1696fc49ff7c3 https://doi.org/10.1371/journal.pone.0259999