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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

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

No

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?

P
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.
E
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.
C
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).
O
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.

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Cite This Study

A 2021 study conducted a cohort in Persistent Atrial Fibrillation (n=510). Extensive left atrial low-voltage areas (>20 cm2) vs. No or smaller left atrial low-voltage areas (≤20 cm2) was evaluated on AF-free survival after the last procedure (HR 7.94, 95% CI 2.91-21.67, p=<0.001). 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.

synapsesocial.com/papers/6a9988392f144aa394157f99https://doi.org/10.4022/jafib.20200491
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