What is the clinical evidence from this study?

Study design: Cohort. Population: Atrial fibrillation (n=1720). Intervention: Empirical extra-pulmonary vein left atrial ablation vs. No empirical extra-pulmonary vein ablation. Primary outcome: Stiff left atrial physiology 1 year after AFCA (OR 2.60, 95% CI 1.17-5.74, p=0.018).

September 20, 2021Open Access

Risk Factors for Stiff Left Atrial Physiology 1 Year After Catheter Ablation of Atrial Fibrillation

Key Result

Empirical extra-pulmonary vein left atrial ablation was independently associated with an increased risk of stiff left atrial physiology 1 year after catheter ablation for atrial fibrillation (OR 2.60).

Study Design

Type

Cohort (n=1,720)

Multicenter

Structured PICO

What are the incidence and risk factors for developing stiff left atrial physiology 1 year after catheter ablation of atrial fibrillation?

Population

1,720 consecutive patients who underwent de novo atrial fibrillation catheter ablation (AFCA) and echocardiography before and 1-year after the procedure. Median age 60.0, 69.1% male, 66.2% with paroxysmal AF. Single-center (South Korea).

Intervention

De novo atrial fibrillation catheter ablation (AFCA), specifically evaluating the impact of empirical extra-pulmonary vein (PV) left atrial ablation and radiofrequency ablation duration.

Outcome

Incidence of stiff left atrial (LA) physiology (defined as estimated pulmonary arterial pressure increase >10 mmHg and right ventricular systolic pressure >35 mmHg at 1-year follow-up echocardiography) and its risk factors.surrogate

Empirical extra-pulmonary vein ablation during atrial fibrillation catheter ablation increases the risk of developing stiff left atrial physiology, which is associated with worse rhythm outcomes.

Main Result

Effect estimate: OR 2.60 (95% CI 1.17-5.74)

p-value: p=0.018

Limitations

Observational prospective cohort study of a highly selective group of patients
Lack of data on patient symptoms to exactly define stiff LA syndrome
Stiff LA physiology was estimated using RVSP change on echocardiography without a gold-standard method
Potential selection bias due to exclusion of patients lacking pre-procedural and follow-up echocardiography data
Echocardiography measurements could be inaccurate when measured during AF due to beat-to-beat variability
Mechanical stunning of LA after cardioversion may have affected the LA pressure measurements

Abstract

Catheter ablation is the most effective rhythm control method for patients with atrial fibrillation (AF); however, it inevitably causes atrial tissue damage. We previously reported that AF catheter ablation (AFCA) increases left atrial (LA) pressure without changes in symptom scores. We hypothesized that extensive LA ablation increased the risk of stiff LA physiology. We included 1,720 patients (69.1% male, 60.0 53.0–68.0 years old, 66.2% with paroxysmal AF) who underwent de novo AFCA and echocardiography before and 1-year after the procedure. Stiff LA physiology was defined, when the amount of the estimated pulmonary arterial pressure increase between the pre-procedural and the 1-year post-procedural follow-up echocardiography was 10 mmHg and when right ventricular systolic pressure (RVSP) was 35 mmHg at 1-year follow-up echocardiography. The failed rhythm control within 1 year was defined as recurrent AF despite using anti-arrhythmic drugs or cardioversion within a year of AFCA. We explored the incidence and risk factors for stiff LA physiology and the rhythm outcome of AFCA. Among the 1,720 patients, 64 (3.7%) had stiff LA physiology 1 year after AFCA. Stiff LA physiology was independently associated with diabetes (odds ratio OR, 2.36 95% CI, 1.14–4.87, p = 0.020), the ratio of the peak mitral flow velocity of the early rapid filling to the early diastolic velocity of the mitral annulus (E/Em; OR, 1.04 95% CI, 1.00–1.10, p = 0.049), LA pulse pressure (Model 2: OR, 1.05 95% CI, 1.00–1.11, p = 0.049), low LA voltage (OR, 0.36 95% CI, 0.18–0.74, p = 0.005), empirical extra-pulmonary vein (PV) LA ablation (OR, 2.60 95% CI, 1.17–5.74, p = 0.018), and radiofrequency (RF) ablation duration (Model 2: OR, 1.02 95% CI, 1.01–1.03, p = 0.003). Although the incidence of post-AFCA stiff LA physiology was 3.7% and most of the cases were subclinical, the empirical extra-PV ablation was associated with this undesirable condition. In addition, patients who had low mean LA voltage before AFCA could be susceptible to stiff LA physiology.

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