Left Ventricular Filling Pressure as Assessed by the E/e' Ratio Is a Determinant of Atrial Fibrillation Recurrence after Cardioversion

Abstract

PurposeLeft ventricular (LV) filling pressure affects atrial fibrillation (AF) recurrence. We investigated the relationship between diastolic dysfunction and AF recurrence after cardioversion, and whether LV filling pressure was predictive of AF recurrence.Materials and MethodsSixty-six patients (mean 58±12 years) with newly diagnosed persistent AF were retrospectively enrolled. We excluded patients with left atrial (LA) diameters larger than 50 mm, thereby isolating the effect of LV filling pressure. We evaluated the differences between the patients with (group 1) and without AF recurrence (group 2).ResultsGroup 1 showed increased LA volume index (LAVI) and E/e' compared to group 2 (p<0.05). During a mean follow-up period of 25±19 months, AF recurrence after cardioversion was 60.6% (40/66). The area under the receiver operating characteristics curve of E/e' for AF recurrence was 0.780 [95% confidence interval (CI): 0.657-0.903], and the optimal cut-off value of the E/e' was 9.15 with 75.0% of sensitivity and 73.1% of specificity. A Kaplan-Meier survival curve showed that the cumulative recurrence-free survival rate was significantly lower in patients with higher LV filling pressure (E/e'>9.15) compared with patients with lower LV filling pressure (E/e'≤9.15) (log rank p=0.008). Cox regression analysis revealed that E/e' [hazards ratio (HR): 1.100, 95% CI: 1.017-1.190] and LAVI (HR: 1.042, 95% CI: 1.002-1.084) were independent predictors for AF recurrence after cardioversion.ConclusionLV filling pressure predicts the risk of AF recurrence in persistent AF patients after cardioversion.

Do most patients with obesity or type 2 diabetes, and atrial fibrillation, also have undiagnosed heart failure? A critical conceptual framework for understanding mechanisms and improving diagnosis and treatment

“…216 Indicators of an underlying HFpEF (increases in LA chamber size, decreases in LA conduit function, abnormal LV diastolic filling dynamics or biomarkers of systemic inflammation) identify those individuals who are unlikely to maintain sinus rhythm, whether the AF is treated electrically or pharmacologically. [217][218][219][220][221][222][223] Furthermore, the intensive post-procedural use of membrane-active anti-arrhythmic drugs carries its own risk for proarrhythmia and worsening HF, particularly in patients with AF and an underlying ventricular myopathy (i.e. HFpEF).…”

“…However, both obesity and type 2 diabetes diminish the likelihood that sinus rhythm will be maintained following electrical cardioversion, because greater epicardial adipose tissue volumes and the resulting inflammation are important determinants of AF recurrence . Indicators of an underlying HFpEF (increases in LA chamber size, decreases in LA conduit function, abnormal LV diastolic filling dynamics or biomarkers of systemic inflammation) identify those individuals who are unlikely to maintain sinus rhythm, whether the AF is treated electrically or pharmacologically . Furthermore, the intensive post‐procedural use of membrane‐active anti‐arrhythmic drugs carries its own risk for proarrhythmia and worsening HF, particularly in patients with AF and an underlying ventricular myopathy (i.e.…”

Clinical Relevance of the Spectral Tissue Doppler E/e’ Ratio in the Management of Patients with Atrial Fibrillation: a Comprehensive Review of the Literature.

“…In one study that included 127 patients with left atrial dilatation, septal E/e' >11 predicted recurrence of AF after cardioversion (p = 0.001) in multivariate analysis, after adjusting for duration of arrhythmia before cardioversion (p = 0.04) and systolic pulmonary arterial pressure (p = 0.001) [66] . In another study that included 66 patients with AF and left atrial diameter <50 mm, septal E/e' was independently associated with recurrence of arrhythmia after cardioversion (p = 0.017), after adjusting for left atrial volume (p = 0.04) [67] .…”

Left atrial emptying fraction determined during atrial fibrillation predicts maintenance of sinus rhythm after direct current cardioversion in patients with persistent atrial fibrillation

“…Clinical, echocardiographic, and biochemical parameters are currently sought to help assess the prognosis of SR maintenance after DCCV [5][6][7]. The echocardiographic parameters most frequently mentioned as prognostic factors for SR maintenance are those assessing the structural remodeling of the left atrium, including the LA antero-posterior diameter (LAAP) and the LA volume index (LAVI); those assessing mechanical remodeling, such as the LA emptying fraction (LAEF) assessed during SR; and those assessing the left ventricular filling pressure (LVFP) [8][9][10][11][12][13][14][15][16][17][18][19]. Most studies have focused on the echocardiographic parameters measured during SR, following a successful DCCV.…”