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Published on: July 20, 2022
Multimodal Evaluation of Arrhythmogenic Substrate Predicts Atrial Fibrosis and Atrial Fibrillation Recurrence After
Ioan-Alexandru Minciună1,2, Raluca Tomoaia1,2, Patricia Vajda3
15th Department of Internal Medicine, Faculty of Medicine, "Iuliu Hațieganu" University of Medicine and Pharmacy, 400347 Cluj-Napoca, Romania.
Insights
Non-invasive amplified P-wave duration (PWD) parameters, including Pmax, Pmin, and left atrial P-wave (LAP), effectively predict atrial fibrillation (AF) recurrence after catheter ablation (CA). These simple markers, alongside other assessments, can improve risk stratification for personalized CA strategies.
Area of Science:
- Cardiology
- Electrophysiology
- Medical Imaging
Background:
- Catheter ablation (CA) is a key therapy for atrial fibrillation (AF) rhythm control, but recurrence rates remain high.
- Predicting long-term outcomes after CA is challenging due to a lack of reliable markers for the AF arrhythmogenic substrate.
- Non-invasive methods like amplified P-wave duration (PWD), echocardiography, and biomarkers are being explored to assess left atrial (LA) fibrosis and predict recurrence.
Purpose of the Study:
- To evaluate the predictive value of non-invasive amplified P-wave duration (PWD) parameters for left atrial (LA) fibrosis and arrhythmia recurrence post-catheter ablation (CA).
- To assess the association between PWD, echocardiographic parameters, biomarkers, and electroanatomical mapping (EAM) findings indicative of LA fibrosis.
- To determine independent predictors of AF recurrence after CA.
Main Methods:
- A study included 196 patients undergoing their first CA for paroxysmal or persistent AF.
- Pre-procedure assessments included amplified 12-lead ECG PWD parameters (Pmax, Pmin, LAP), echocardiography, and biomarkers.
- Low-voltage areas (LVA) on high-density voltage EAM during sinus rhythm were measured as a surrogate for LA fibrosis. Arrhythmia recurrence was assessed at 6 and 12 months.
Main Results:
- Patients with LVA on EAM exhibited significantly prolonged Pmax, Pmin, and LAP, along with larger LA dimensions, higher E/E' and E/A ratios, increased mitral regurgitation, and elevated pro-BNP levels.
- Univariate analysis revealed higher 12-month recurrence rates associated with increased Pmax, Pmin, LAP, and the presence/extent of LVA.
- Multivariate analysis identified PWD parameters (Pmax, Pmin, LAP) as independent predictors of AF recurrence, while LA size, diastolic dysfunction, mitral regurgitation, and pro-BNP were associated with LA fibrosis.
Conclusions:
- Prolonged PWD parameters (Pmax, Pmin, LAP) are strong indicators of LA substrate and independently predict AF recurrence after CA.
- Echocardiographic findings and pro-BNP levels correlate with LA fibrosis and, in the case of pro-BNP, also with arrhythmia recurrence.
- Integrating simple, non-invasive PWD markers into a multimodal assessment with EAM can enhance pre-procedural risk stratification and guide personalized ablation strategies for AF.
Abstract:
Background/Objectives: For many years, catheter ablation (CA) has been a cornerstone in atrial fibrillation (AF) rhythm control therapy; however, recurrence remains common. Multiple parameters have been proposed to quantify AF arrhythmogenic substrate, yet reliable predictors of long-term outcomes are lacking. To assess the value of non-invasive amplified P-wave duration (PWD), echocardiographic parameters, biomarkers, and electroanatomical mapping (EAM) were used in predicting left atrial (LA) fibrosis and arrhythmia recurrence after CA. Methods: We included 196 patients undergoing first CA for paroxysmal or persistent AF. Amplified 12-lead ECG PWD parameters [Pmax, Pmin and left atrial P-wave (LAP)], echocardiographic parameters, and biomarkers were assessed pre-procedure. We measured low-voltage areas (LVA, 0.2-0.5 mV) on high-density voltage EAM during sinus rhythm as a surrogate of fibrosis. Freedom from arrhythmia was evaluated at 6 and 12 months. Results: Patients with LVA on EAM had prolonged Pmax (148 vs. 135 ms, p < 0.0001), Pmin (111 vs. 101.5 ms, p = 0.0001), LAP (73.5 vs. 55.5 ms, p < 0.0001), larger LA diameter (p = 0.0002), area (p = 0.0365) and volume (p = 0.004), higher E/E' (p = 0.0007) and E/A ratios (p = 0.037), more mitral regurgitation (p = 0.0315), and higher pro-BNP levels (p = 0.0094). Univariate analysis showed 12-month recurrence rates higher with greater Pmax, Pmin, LAP, LVA presence and extent; however, in multivariate analysis, only P-wave parameters remained independently associated with recurrence. Conclusions: Prolonged PWD parameters strongly reflect LA substrate (Pmax, Pmin) and independently predict post-ablation AF recurrence (Pmax, Pmin, and LAP). LA size, diastolic dysfunction, and mitral regurgitation were associated with LA fibrosis, while pro-BNP was associated with both fibrosis and arrhythmia recurrence. Integrating these simple, non-invasive markers into a multimodal assessment alongside EAM could improve pre-procedural risk stratification and guide individualized ablation strategies.
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