High liver fibrosis scores in metabolic dysfunction-associated fatty liver disease patients are associated with adverse atrial remodeling and atrial fibrillation recurrence following catheter ablation

Abstract

BackgroundA number of epidemiological studies have suggested an association between metabolic dysfunction-associated fatty liver disease (MAFLD) and the incidence of atrial fibrillation (AF). However, the pathogenesis leading to AF in the context of MAFLD remains unclear. We therefore aimed at assessing the impact of MAFLD and liver fibrosis status on left atrium (LA) structure and function.MethodsPatients with a Fatty Liver Index (FLI) >60 and the presence of metabolic comorbidities were classified as MAFLD+. In MAFLD+ patients, liver fibrosis severity was defined using the non-alcoholic fatty liver disease (NAFLD) Fibrosis Score (NFS), as follows: MAFLD w/o fibrosis (NFS ≦ −1.455), MAFLD w/indeterminate fibrosis (−1.455 < NFS < 0.675), and MAFLD w/fibrosis (NFS ≧ 0.675). In the first cohort of patients undergoing AF ablation, the structural and functional impact on LA of MAFLD was assessed by LA strain analysis and endocardial voltage mapping. Histopathological assessment of atrial fibrosis was performed in the second cohort of patients undergoing cardiac surgery. Finally, the impact of MAFLD on AF recurrence following catheter ablation was assessed.ResultsIn the AF ablation cohort (NoMAFLD n = 123; MAFLD w/o fibrosis n = 37; MAFLD indeterm. fibrosis n = 75; MAFLD w/severe fibrosis n = 10), MAFLD patients with high risk of F3–F4 liver fibrosis presented more LA low-voltage areas as compared to patients without MAFLD (16.5 [10.25; 28] vs 5.0 [1; 11] low-voltage areas p = 0.0115), impaired LA reservoir function assessed by peak left atrial longitudinal strain (19.7% ± 8% vs 8.9% ± 0.89% p = 0.0268), and increased LA volume (52.9 ± 11.7 vs 43.5 ± 18.0 ml/m2 p = 0.0168). Accordingly, among the MAFLD patients, those with a high risk of F3–F4 liver fibrosis presented a higher rate of AF recurrence during follow-up (p = 0.0179). In the cardiac surgery cohort (NoMAFLD n = 12; MAFLD w/o fibrosis n = 5; MAFLD w/fibrosis n = 3), an increase in histopathological atrial fibrosis was observed in MAFLD patients with a high risk of F3–F4 liver fibrosis (p = 0.0206 vs NoMAFLD; p = 0.0595 vs MAFLD w/o fibrosis).ConclusionIn conclusion, we found that liver fibrosis scoring in MAFLD patients is associated with adverse atrial remodeling and AF recurrences following catheter ablation. The impact of the management of MAFLD on LA remodeling and AF ablation outcomes should be assessed in dedicated studies.

An international multidisciplinary consensus statement on MAFLD and the risk of CVD

“…In a nationwide health check-up population in China (including more than 2 million individuals), Lei et al found that MAFLD was associated with a higher risk of having and developing permanent AF [ 62 ]. Decoin et al [ 63 ] analyzed a cohort of United States patients after AF ablation and found that advanced liver fibrosis (estimated by non-invasive fibrosis biomarkers) in those with MAFLD was associated with adverse atrial remodeling and AF recurrence following catheter ablation.…”

The Liver-Heart Connection: A Literature Review of Liver Disease as a Risk Factor for Atrial Fibrillation

“…Furthermore, the findings revealed that, as determined by NFS throughout the follow-up period, patients with "MAFLD w/severe fibrosis" had a considerably greater rate of AFib recurrence (77%) compared to those with ambiguous fibrosis (32.5%) or without hepatic fibrosis (17.5%). Remarkably, the authors found that atrial fibrosis, a chief component for the development of AFib, was especially increased in patients presenting MAFLD with a high liver fibrosis score [ 5 ].…”

“…According to a study on the potential processes relating NAFLD and AFib, obesity, insulin resistance, inflammation, oxidative stress, autonomic dysfunction, and changes in gut microbiota may be common risk factors causing both diseases. As a result, lifestyle changes like losing weight and exercising, as well as drugs that target inflammation and insulin resistance, may have therapeutic potential for both NAFLD and AFib [ 5 ]. One mechanism linking AFib and NAFLD in obese individuals is the inflammatory and oxidative system.…”

“…This suggests that atrial remodeling caused by adipose tissue may also be a factor in MAFLD. These patients exhibit a higher risk for AFib recurrence following catheter ablation, indicating the importance of the management of MAFLD on left atrium remodeling and AFib ablation outcomes [ 5 ].…”

Taiwan Association for the Study of the Liver-Taiwan Society of Cardiology Taiwan position statement for the management of metabolic dysfunction- associated fatty liver disease and cardiovascular diseases

“…Ventricular arrhythmias, atrioventricular blocks, and atrial fibrillation (AF) are more frequent in patients with MAFLD [ 75 , 84 ]. After catheter ablation, liver fibrosis is linked to adverse atrial remodeling and recurrent AF in patients with MAFLD [ 85 ]. The Rotterdam study reported an association between AF and liver stiffness, but not steatosis [ 86 , 87 ].…”