Active Atrial Function and Atrial Scar Burden After Multiple Catheter Ablations of Persistent Atrial Fibrillation

Nührich, Jana Mareike; Geisler, Anne; Steven, Daniel; Hoffmann, Boris; Schäffer, Benjamin; Lund, Gunnar; Stehning, Christian; Radunski, Ulf K; Sultan, Arian; Schwarzl, Michael; Adam, Gerhard; Willems, Stephan; Muellerleile, Kai

doi:10.1111/pace.13004

Cited by 8 publications

(8 citation statements)

References 22 publications

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“… 12 Findings of significant impairment of active LA function and its correlation with LA scar as assessed by cardiac MRI and voltage mapping by EAM in patients subjected to multiple CAs compared to ablation-naïve patients suggest that CA per se results in increased LA scar burden with consecutively impaired active LA function. 13 However, in the absence of large studies with serial measurements of atrial scars and function, one cannot completely disregard the role of underlying atriopathy contributing to the atrial scar and deteriorating function.…”

Section: Discussionmentioning

confidence: 99%

Atrial Tachycardias After “Multiple” Previous Ablations for Tachyarrhythmias: Treatment by Anti-arrhythmic Drugs or Additional Ablation?

KANTHARIA,

TUN,

SHAH

2024

J Innov Cardiac Rhythm Manage.

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Pulmonary vein (PV) isolation (PVI) ablation as the first-line therapy for atrial fibrillation (AF) and repeat PVIs for patients who had symptomatic improvement with the index PVI but who develop AF recurrence are directed by practice guidelines. How many catheter ablation (CA) procedures constitute the definition of “multiple” ablations is not known. Whether atrial tachyarrhythmias (AF, atrial tachycardia [AT], atrial flutter [AFL]) that occur post-ablation are due entirely to the proarrhythmic effects of CA or a continuum of the arrhythmia spectrum from the underlying atriopathy is debatable. Herein, we describe a case of a 65-year-old man with a CHA 2 DS 2 -VASc score of 5 points who suffered from atrial tachyarrhythmias for which seven CA procedures were performed. Because of symptomatic and drug-refractory AT/AFL that failed cardioversions, he requested another ablation procedure. During the eighth procedure, high-density three-dimensional electroanatomic mapping, including Coherent and Ripple mapping (CARTO ® 3; Biosense Webster, Diamond Bar, CA, USA), of AT/AFL was performed. Small discrete areas of relatively viable tissue within an extensively scarred left atrium and a macro–re-entrant circuit with early-meets-late activation between the left atrial anterior wall and the right superior PV were found. Radiofrequency ablation performed at this site resulted in the termination of the tachycardia, and bidirectional conduction block across the line was achieved. On clinical follow-ups and rhythm monitoring by an implantable loop recorder, the patient remained in sinus rhythm with significant clinical improvement. Our case suggests that, in patients with prior multiple CAs, additional clinically indicated ablation should be performed using high-density mapping to accurately identify arrhythmia mechanisms, elucidate the disease substrate, and restore the sinus rhythm successfully.

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Section: Discussionmentioning

confidence: 99%

Atrial Tachycardias After “Multiple” Previous Ablations for Tachyarrhythmias: Treatment by Anti-arrhythmic Drugs or Additional Ablation?

KANTHARIA,

TUN,

SHAH

2024

J Innov Cardiac Rhythm Manage.

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“…Fibrosis identified on cardiac magnetic resonance imaging was proven to be an independent factor associated with AF recurrence after CA [13]. Furthermore, a left atrial scar burden after multiple extensive CA was reported [14]. Therefore, we anticipated that the patients in the CA group would be in a more advanced atrial remodeling state with repeated CA, which might lead to a lower chance of normal sinus rhythm recovery than those in the nCA group.…”

Section: Discussionmentioning

confidence: 99%

Mid-Term Results of Totally Thoracoscopic Ablation in Patients with Recurrent Atrial Fibrillation after Catheter Ablation

Lim

Kim

et al. 2020

Korean J Thorac Cardiovasc Surg

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Background: We investigated the impact of previous catheter ablation (CA) on the midterm outcomes of totally thoracoscopic ablation in patients with lone atrial fibrillation (AF). Methods: Between February 2012 and July 2018, 332 patients underwent totally thoracoscopic ablation for the treatment of AF (persistent AF; n=264, 80%). The patients were stratified into CA (n=47, 14%) and non-CA (nCA; n=285, 86%) groups according to their CA history. Results: All the baseline clinical characteristics and risk factors were similar between the groups except for age, percentage of male patients, prevalence of paroxysmal AF, prior percutaneous coronary intervention, and left atrial volume index (LAVI). No significant intergroup differences were observed in the incidence of early and late complications. At late follow-up, normal sinus rhythm was observed in 92% (43 of 47) of the patients in the CA group and 85% (242 of 285) of the patients in the nCA group (p=0.268). The rate of freedom from AF recurrence at 5 years was 55.3%±11.0% in the CA group, which was similar to that in the nCA group (55.7%±5.1%, p=0.690). In Cox regression analysis, preoperative brain natriuretic peptide levels and LAVI were associated with AF recurrence, but CA history was not significant. Conclusion: Totally thoracoscopic ablation was safe and effective in treating AF irrespective of CA history. A history of CA did not appear to affect the procedural complexity.

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“…As the duration of AF increases, there tends to be more adverse LA remodelling, resulting in more scar formation, and greater LA stunning despite restoration of SR following ablation. 102,154,155 Using echocardiography, this LA substrate remodelling may be assessed most effectively by measuring strain and less so by evaluating myocardial tissue velocities using TDI 156,157 or volume-derived measurements of left atrial function. Left atrial function as assessed by volumes and strain analysis in our study population was markedly reduced at baseline and improved following ablation.…”

Section: Predictors Of Atrial Fibrillation Recurrencementioning

confidence: 99%

“…It is thought that, in LSPAF patients, the advanced electroanatomical remodelling, along with metabolic and neurohormonal alterations, cause irreversible changes in the LA through fibrosis and post-ablation stunning, which often accompanies early recurrences of AF following ablation. 89,90,99,100 Timely assessment of the left atrial function helps determine the best treatment strategy, as well as the success of ablation 87,[101][102][103][104] or cardioversion. [105][106][107][108][109] Evaluating left atrial reservoir, conduit and contractile function can also be helpful in predicting left atrial electromechanical stunning, which can lead to thromboembolic events.…”

Section: Introductionmentioning

confidence: 99%

Thoracoscopic surgical ablation versus catheter ablation as first-line treatment for long-standing persistent atrial fibrillation: the CASA-AF RCT

et al. 2021

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Background Standalone thoracoscopic surgical ablation may be more effective than catheter ablation in patients with long-standing persistent atrial fibrillation. Objectives To determine whether or not surgical ablation is clinically superior to catheter ablation as the first-line treatment strategy in long-standing persistent atrial fibrillation. Design This was a prospective, multicentre, randomised control trial. Setting Four NHS tertiary centres in England. Participants Adults with long-standing persistent atrial fibrillation, who had European Heart Rhythm Association symptom scores > 2 and who were naive to previous catheter ablation or thoracic/cardiac surgery. Interventions Minimally invasive thoracoscopic surgical ablation and conventional catheter ablation (control intervention). Main outcome measures The primary outcome was freedom from atrial fibrillation/tachycardia ≥ 30 seconds after a single procedure without antiarrhythmic drugs (class 1C/3) at 1 year, excluding a 3-month blanking period. The secondary outcomes include the intervention-related major complication rate; clinical success (≥ 75% reduction in arrhythmia burden); and changes in symptoms, quality of life and cost-effectiveness. Methods Patients (n = 120) were randomised to surgical ablation (n = 60) or catheter ablation (n = 60). An implanted loop recorder provided continuous cardiac monitoring following ablation. Follow-up visits were at 3, 6, 9 and 12 months. Loop recorder data were reviewed monthly by a physiologist who was blinded to the randomisation outcome. Results The study treatment was received by 55 patients in the surgical ablation arm and 60 patients in the catheter ablation arm; five patients withdrew from surgical ablation before treatment. Data from randomised and treated patients were analysed as per intention to treat. Patients had a mean age of 62.3 (standard deviation 9.6) years, were predominantly male (74%), had a mean left atrial diameter of 44.6 mm (standard deviation 6 mm) and were in continuous atrial fibrillation for 22 months (range 16–31 months). At 12 months, 26% of patients in the surgical ablation arm (14/54) and 28% of patients in the catheter ablation arm (17/60) were free from atrial arrhythmias after a single procedure without antiarrhythmic drugs (odds ratio 1.13, 95% confidence interval 0.46 to 2.83; p = 0.84). An arrhythmia burden reduction of ≥ 75% was seen in 36 out of 54 (67%) patients in the surgical ablation arm, compared with 46 out of 60 (77%) patients in the catheter ablation arm (odds ratio 1.64, 95% confidence interval 0.67 to 4.08; p = 0.3). Procedure-related serious complications within 30 days of the intervention occurred in 15% (8/55) of patients in the surgical ablation arm (including one death) compared with 10% (6/60) of patients in the catheter ablation arm (p = 0.46). Surgical ablation was associated with significantly higher costs (£23,221 vs. £18,186; p = 0.02) and fewer quality-adjusted life-years than catheter ablation (0.76 vs. 0.83; p = 0.02). Limitations This study was conducted in four highly specialised cardiology centres that have substantial experience in both treatment modalities; therefore, the results may not be widely generalisable. The study was not powered to detect small differences in efficacy. Conclusions We found no evidence to suggest that standalone thoracoscopic surgical ablation outcomes were superior to catheter ablation outcomes in achieving freedom from atrial arrhythmia after a single procedure without antiarrhythmic drugs. Moreover, surgical ablation is associated with a longer hospital stay, smaller improvements in quality of life and higher health-care costs than catheter ablation (standard care therapy). Future work Evaluation of the impact of ablation treatments on sinus rhythm maintenance and quality of life with extended follow-up to 3 years. Model-based economic analysis to estimate long-term benefits, harms and costs of surgical and catheter ablation compared with antiarrhythmic drug therapy in long-standing persistent atrial fibrillation patients. Trial registration Current Controlled Trials ISRCTN18250790 and ClinicalTrials.gov NCT02755688. Funding This project was funded by the Efficacy and Mechanism Evaluation (EME) programme, a Medical Research Council (MRC) and National Institute for Health Research (NIHR) partnership. This study was supported by the UK Clinical Research Collaboration-registered King’s Clinical Trials Unit at King’s Health Partners, which is part funded by the NIHR Biomedical Research Centre for Mental Health at South London and Maudsley NHS Foundation Trust and King’s College London and the NIHR Evaluation, Trials and Studies Coordinating Centre. This will be published in full in Efficacy and Mechanism Evaluation; Vol. 8, No. 18. See the NIHR Journals Library website for further project information.

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Active Atrial Function and Atrial Scar Burden After Multiple Catheter Ablations of Persistent Atrial Fibrillation

Abstract: Active LA function is preserved but significantly impaired and associated with ablation-related LA scar burden after multiple extensive persAF ablations.

Cited by 8 publications

References 22 publications

Atrial Tachycardias After “Multiple” Previous Ablations for Tachyarrhythmias: Treatment by Anti-arrhythmic Drugs or Additional Ablation?

Atrial Tachycardias After “Multiple” Previous Ablations for Tachyarrhythmias: Treatment by Anti-arrhythmic Drugs or Additional Ablation?

Mid-Term Results of Totally Thoracoscopic Ablation in Patients with Recurrent Atrial Fibrillation after Catheter Ablation

Thoracoscopic surgical ablation versus catheter ablation as first-line treatment for long-standing persistent atrial fibrillation: the CASA-AF RCT

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