What is the clinical evidence from this study?

Study design: Cohort. Population: Persistent Atrial Fibrillation (n=510). Intervention: Extensive left atrial low-voltage areas (>20 cm2) vs. No or smaller left atrial low-voltage areas (≤20 cm2). Primary outcome: AF-free survival after the last procedure (HR 7.94, 95% CI 2.91-21.67, p=<0.001).

August 1, 2021Journal of Atrial Fibrillation3 citationsOpen Access

Extensive Left Atrial Low-Voltage Area During Initial Ablation is Associated with A Poor Clinical Outcome Even Following Multiple Procedures

Q: What are the key findings of this study?

Extensive left atrial low-voltage areas (>20 cm2) after initial pulmonary vein isolation were independently associated with a higher risk of atrial fibrillation recurrence (HR 7.94) despite multiple ablation procedures.

Key Result

Extensive left atrial low-voltage areas (>20 cm2) after initial pulmonary vein isolation were independently associated with a higher risk of atrial fibrillation recurrence (HR 7.94) despite multiple ablation procedures.

Study Design

Type

Cohort (n=510)

Multicenter

Structured PICO

Does the extent of left atrial low-voltage area (LVA) predict atrial fibrillation recurrence in patients with persistent AF undergoing multiple catheter ablation procedures?

Population

510 patients with persistent atrial fibrillation undergoing initial catheter ablation, categorized by left atrial low-voltage area size, followed for a median of 25 months.

Exposure

Catheter ablation for persistent AF with extensive left atrial low-voltage areas (>20 cm2), including pulmonary vein isolation (PVI) and additional substrate modification (e.g., LVA ablation, linear ablation, CFAE ablation) at operator discretion, often requiring multiple procedures.

Comparator

Catheter ablation in patients with no or small left atrial low-voltage areas (0-5 cm2) or moderate low-voltage areas (5-20 cm2).

Outcome

Atrial fibrillation-free survival after the last procedure without antiarrhythmic drugs.hard clinical

Extensive left atrial low-voltage areas (>20 cm2) identified during initial ablation for persistent atrial fibrillation strongly predict arrhythmia recurrence, even after multiple ablation procedures.

Main Result

Hazard Ratio: 7.94 (95% CI 2.91–21.67)

p-value: p=<0.001

Limitations

Retrospective design with non-standardized procedures at the discretion of the operator
Follow-up did not include routine continuous monitoring with implanted devices or transtelephonic electrocardiographic monitoring
Use of different mapping catheters (bipolar 3.5-mm tip vs multi-electrode) might have influenced LVA measurements
Voltage mapping was conducted after completion of PV isolation and only in the left atrium
Exclusion of patients with the worst prognosis in whom a voltage map could not be obtained
Arbitrary cut-off values (5 cm2 and 20 cm2) used for grouping
Relatively small size of the study population
Retrospective design with non-standardized procedures at operator discretion
Follow-up did not include routine continuous monitoring with implanted devices
Distribution of LVAs might have changed due to use of different mapping catheters
Voltage mapping was conducted after completion of PVI and only in the left atrium
Excluded patients with the worst prognosis (unstable rhythm preventing mapping)
Arbitrary cut-off values for LVA grouping (5 cm2 and 20 cm2)
Relatively small study population

Abstract

BACKGROUND: Some patients fail to respond to persistent atrial fibrillation (PeAF) catheter ablation in spite of multiple procedures and ablation strategies, including low voltage area (LVA)-guided, linear, and complex fractionated atrial electrogram (CFAE)-guided ablation procedures. We hypothesized that LVA extent could predict non-responseto Pe AF catheter ablation in spite of multiple procedures. METHODS: ). The primary endpoint was AF-free survival after the last procedure. RESULTS: During a median follow-up of 25 (17, 36) months, AF recurrence was observed in 101 (20%) patients after 1.4±0.6 ablation procedures (maximum 4). Comparison of clinical outcomes after multiple procedures in the three groups showed that the results depended on the extent of LVA. Multivariate analysis of AF-free survival after the last procedure showed that LVAs > 20 cm2 was an independent factor associated with AF recurrence after the final procedure(Hazard ratio, 7.94; 95% confidence interval, 2.91 to 21.67, P <0.001). CONCLUSIONS: Extensive LVA after initial PVI was associated with poor clinical benefit despite multiple catheter based ablations.

KI fragen

Bookmark

View Full Paper