Impact of unipolar voltage criteria for left atrial posterior wall on atrial fibrillation recurrence after pulmonary vein isolation

Abstract

Introduction Beyond pulmonary vein isolation (PVI), additional therapeutic strategies for atrial fibrillation (AF) have not been established. Remodeling of the left atrium (LA) could impact AF recurrence post‐PVI. We investigated the impact of unipolar voltage (UV) criteria for the LA posterior wall (LA‐PW) on AF recurrence post‐PVI. Methods We reviewed the cases of 106 AF patients (mean age 63.8 years, nonparoxysmal AF: 59%) who underwent extensive encircling PVI by radiofrequency ablation guided by a 3‐dimension mapping system, investigating the impact on AF recurrence of the UV criteria of the LA. Results Out of all patients, 26 patients had AF recurrence during post‐PVI follow‐up [median 603 days]. They showed a higher percentage of nonparoxysmal AF (80.8 vs. 52.5%, p = .011), longer AF duration (2.9 ± 2.7 vs. 1.0 ± 1.7 years, p = .002), and larger area size of UV < 2.0 mV in LA‐PW (2.8 ± 1.8 vs. 1.0 ± 1.5 cm2, p < .001) than those without recurrence. Cox Hazard analysis for AF recurrence adjusted by age, gender, AF duration, body mass index and left atrial volume index revealed that an area size over 2.0 cm2 of UV < 2.0 mV in LA‐PW (HR 6.9 [95% CI:1.3–35.5], p = .021) posed independent risks for AF recurrence post‐PVI. The atrial arrhythmia‐free survival rate was higher in those with no area of UV < 3.0 mV in LA‐PW compared to those with a sizable area (>2.0 cm2) of UV < 3.0 mV and <2.0 mV (95.0% vs. 74.2% vs. 57.1%, Log‐Rank: p < .001). In the AF etiology of patients with AF recurrence, 9 of 14 patients who underwent the 2nd procedure had no PV reconnection, and 8 patients required the LA‐PW isolation for their non‐PV AF. Conclusion UV criteria of LA‐PW is a useful parameter for AF‐recurrence post‐PVI. Lower UV in LA‐PW as an indication of electrical remodeling could indicate a higher risk of AF recurrence and the need for further therapeutic strategies.

Notched P‐wave on digital electrocardiogram predicts the recurrence of atrial fibrillation in patients who have undergone catheter ablation

“…Age, left atrial size, and duration were not included in the exclusion criteria. Details of ablation procedure and follow‐up are reported elsewhere 13 . All antiarrhythmic drugs were discontinued for at least five half‐lives before the procedure.…”

“…The catheter ablation was performed using an irrigated‐tip contact force‐sensing catheter through a deflectable sheath in all cases guided by the three‐dimensional mapping system. If the patients had clinically documented typical atrial flutter, a cavo‐tricuspid isthmus block line was created 13 …”

“…All patients were followed‐up by a clinical interview, ECGs every 3 months, and 24‐h Holter monitoring every 3–6 months at our clinic to evaluate AF recurrence. Patients with palpitations were encouraged to visit our hospital 13 …”

“…Details of ablation procedure and follow‐up are reported elsewhere. 13 All antiarrhythmic drugs were discontinued for at least five half‐lives before the procedure. The procedure was performed under moderate sedation by dexmedetomidine and fentanyl.…”

Atrial Fibrillation and Chronic Coronary Ischemia: A Challenging Vicious Circle

“…For patients with persistent forms of AF, it is more likely to have non-PV triggers, such as the left atrial posterior free wall [ 18 , 19 , 20 ], the left atrial appendage [ 21 ], the superior vena cava (young patients with AF had a higher incidence of only non-PV foci, mostly located here) [ 22 , 23 , 24 , 25 ], the coronary sinus [ 26 , 27 ], and the ligament of Marshall [ 28 , 29 ]. For non-PV foci patients, the isolation of them was a significant factor affecting the achievement of better clinical outcomes following AF ablation [ 30 ].…”