Risk Factors for Stiff Left Atrial Physiology 1 Year After Catheter Ablation of Atrial Fibrillation

Abstract

Catheter ablation is the most effective rhythm control method for patients with atrial fibrillation (AF); however, it inevitably causes atrial tissue damage. We previously reported that AF catheter ablation (AFCA) increases left atrial (LA) pressure without changes in symptom scores. We hypothesized that extensive LA ablation increased the risk of stiff LA physiology. We included 1,720 patients (69.1% male, 60.0 [53.0–68.0] years old, 66.2% with paroxysmal AF) who underwent de novo AFCA and echocardiography before and 1-year after the procedure. Stiff LA physiology was defined, when the amount of the estimated pulmonary arterial pressure increase between the pre-procedural and the 1-year post-procedural follow-up echocardiography was >10 mmHg and when right ventricular systolic pressure (RVSP) was >35 mmHg at 1-year follow-up echocardiography. The failed rhythm control within 1 year was defined as recurrent AF despite using anti-arrhythmic drugs or cardioversion within a year of AFCA. We explored the incidence and risk factors for stiff LA physiology and the rhythm outcome of AFCA. Among the 1,720 patients, 64 (3.7%) had stiff LA physiology 1 year after AFCA. Stiff LA physiology was independently associated with diabetes (odds ratio [OR], 2.36 [95% CI, 1.14–4.87], p = 0.020), the ratio of the peak mitral flow velocity of the early rapid filling to the early diastolic velocity of the mitral annulus (E/Em; OR, 1.04 [95% CI, 1.00–1.10], p = 0.049), LA pulse pressure (Model 2: OR, 1.05 [95% CI, 1.00–1.11], p = 0.049), low LA voltage (OR, 0.36 [95% CI, 0.18–0.74], p = 0.005), empirical extra-pulmonary vein (PV) LA ablation (OR, 2.60 [95% CI, 1.17–5.74], p = 0.018), and radiofrequency (RF) ablation duration (Model 2: OR, 1.02 [95% CI, 1.01–1.03], p = 0.003). Although the incidence of post-AFCA stiff LA physiology was 3.7% and most of the cases were subclinical, the empirical extra-PV ablation was associated with this undesirable condition. In addition, patients who had low mean LA voltage before AFCA could be susceptible to stiff LA physiology.

Diabetes Mellitus Is an Independent Risk Factor for a Stiff Left Atrial Physiology After Catheter Ablation for Atrial Fibrillation

“…In addition, we recently conducted a study on a stiff LA physiology defined using the RVSP. Similar to previous findings, DM, a low mean LA voltage, and extra-PV LA ablation were identified as risk factors ( 4 ).…”

“…However, AFCA is a destructive procedure that uses heating or freezing as an energy source ( 4 ) and inevitably leads to atrial tissue damage, resulting in necrosis, and scarring. Previous studies have reported that AFCA, particularly extra-pulmonary vein (PV) left atrium (LA) ablation, increases LA stiffness, and worsens post-ablation diastolic function.…”

Late recurrence of atrial fibrillation 5 years after catheter ablation: predictors and outcome

“… 20 , 21 A low mean LA voltage was independently associated with stiff LA physiology, which had a lower compliance and increased LA pressure. 22 In the current study, the LA volumes measured by CT were smaller and LA voltages lower in patients with recurrences beyond 5 years. These features may represent the slow progression of atrial myopathy, which may be a major risk factor for very late CRs.…”

Left atrial calcification on chest CT: atrial ablation replaces rheumatic heart disease as the most identified etiology

“…Importantly, the body of literature gives other possible causes of left atrial calcification, including mitral valve disease and mitral valve replacement, end-stage renal disease, history of radiation therapy, and non-specific endocarditis, but no study has demonstrated modern distribution of pathology [4][5][6][7][8][9][10][11][12]. Indeed, the modern proliferation of endomyocardial ablation techniques and catheter-directed therapies for structural heart disease, raises the question of iatrogenic damage [13,14]. Therefore, updated data about the etiology of left atrial calcification may provide clinically useful information about patient risk for subsequent cardiac sequelae and systemic comorbidity [15,16].…”

“…Left atrial calcification can predispose or manifest cardiac conditions, including mitral valvular disease, bradyarrhythmia, and "stiff left atrial syndrome", a hemodynamic manifestation of atrial diastolic dysfunction associated with radiofrequency ablation of the left atrium. Left atrial calcification and its associated conditions may have important clinical consequences, including sudden cardiac death, mortality after mitral valve replacement, recurrent atrial fibrillation, and congestive heart failure [17][18][19][20][21]. Although the clinical relationship between atrial calcification and stiff left atrial syndrome is uncertain, the rise in atrial ablation procedures and identification of subsequent stiff left atrial syndrome as a complication suggests a potential relationship and poses a disagreement from established view regarding left atrial calcifications [13,22,23].…”