Predictor Of Sinus Rhythm Maintenance Research Articles

Noninvasive estimation of organization in atrial fibrillation as a predictor of sinus rhythm maintenance

Noninvasive estimation of organization in atrial fibrillation as a predictor of sinus rhythm maintenance

Left Atrial Appendage Flow Cycle Length Is an Important Predictor of Sinus Rhythm Maintenance after Catheter Ablation of Persistent or Long-Standing Persistent Atrial Fibrillation

Purpose: Rate of sinus rhythm (SR) maintenance after catheter ablation (CA) of persistent or long-standing persistent atrial fibrillation (perAF or ls-perAF) is inferior to paroxysmal AF. This is mainly associated with atrial remodeling, so we assumed we could select responder to CA of perAF or ls-perAF before procedure. We hypothesized left atrial appendage flow cycle length (LAAFCL) measured by trans-esophageal echocardiography (TEE) was related to the extent of atrial electrical remodeling. This time, we evaluated the relationship between the LAAFCL before procedure and the rate of SR maintenance after CA of perAF or ls-perAF. Methods: We selected 25 patients (age 60.6±9.2 years). TEE was performed during AF rhythm in all patients. All patients underwent extensive encircling pulmonary vein isolation. Substrate modifications were added as necessary. Results: 16 patients maintained SR, and 9 patients had recurrence of AF. SR maintenance group had significant longer LAAFCL (216.4±115.4 vs. 142.144±27.1 ms, p<0.05) than AF recurrence group. There were no significant differences between two groups in age (p=NS), left atrial diameter (p=NS), left ventricular ejection fraction (p=NS), left ventricular end-diastolic dimension (p=0.076), LAA peak flow velocity (p=0.105), CHADS2 score (p=0.141), follow up period (p=NS), and receiving AAD after procedure (p=NS). Conclusions: LAAFCL is useful to determine indication for CA of perAF or ls-perAF.

Noninvasive estimation of organization in atrial fibrillation as a predictor of sinus rhythm maintenance

Previous studies indicate that the predictive value of atrial fibrillatory rate in patients undergoing cardioversion of atrial fibrillation (AF) of long duration is limited. The present study investigates signal entropy in this setting. Standard 12-lead electrocardiograms (ECGs) were recorded from 66 consecutive patients with AF undergoing cardioversion and sample entropy estimated. Patients were followed for 4 weeks. At follow-up, 59% of the patients had relapsed to AF. The AF signal entropy of these patients before cardioversion was 0.099 ± 0.015, whereas it was 0.093 ± 0.012 among the 41% maintaining sinus rhythm (P = .02). As hypothesized, signal entropy was lower in patients who maintained sinus rhythm 4 weeks after cardioversion than in those who did not. However, the overlap was large, making its clinical value limited.

Left Atrial Expansion Index in Patients with Atrial Fibrillation is a Predictor of Sinus Rhythm Maintenance after Cardioversion

Left Atrial Expansion Index in Patients with Atrial Fibrillation is a Predictor of Sinus Rhythm Maintenance after Cardioversion

Abstract 6138: Two-Dimensional Atrial Strain and Strain Rate Predict Maintenance of Sinus Rhythm After Pulmonary Vein Ablation in Patients with Atrial Fibrillation

Introduction A novel method to measure strain and strain rate from standard 2-dimensional(2D) has been developed. However, clinical usefulness of 2D atrial strain and strain rate has been not yet investigated. Hypothesis We assessed the hypothesis that 2D strain and strain rate might be reduced in patients with atrial fibrillation (AF) and predictive of maintenance of sinus rhythm after AF ablation. Methods Echocardiographic examinations were performed in 44 patients with lone AF before AF ablation. Using a dedicated software package, bidimensional acquisitions were analyzed to measure longitudinal strain and strain rate in apical 4- and 2-chamber views. Maintenance of sinus rhythm after AF ablation was assessed during a 9 months follow-up. 2D left atrial(LA) strain and strain rate values in AF patients were compared with those of age- and sex-matched referents(N=40). Moreover, clinical and echocardiographic parameters of patients with maintenance of sinus rhythm (n=30) over the follow-up period were compared with those from patients with AF recurrence (n=14). Results All components of strain and strain rate were significantly reduced in AF patients. Average LA longitudinal strain and strain rate in patients with AF and referents were 28.1 ± 8.7 % versus 40.5 ± 6.4 and 1.8 ± 0.5 versus 2.4 ± 0.9, respectively (all p &lt; 0.001). The individual predictors of sinus rhythm maintenance after AF ablation were paroxysmal AF(80 vs. 35.7%, p = 0.007), duration of AF (3.5 ± 3.1 vs. 5.9 ± 3.4 years, p=0.037), LA volume index(29±8 vs. 36±14ml/m2, p=0.045), average LA longitudinal strain (30.9±7.9 vs. 21.9 ± 7.3, p=0.001) and strain rate (2.0 ± 0.4 vs.1.6±0.6, p=0.008) peak systolic values. Average LA longitudinal strain parameter (OR 0.85, 95% CI 0.74–0.97, p=0.016) was confirmed as independent predictor of sinus rhythm maintenance by multivariate analysis, with a contribution from paroxysmal AF (OR 8.17, 95% CI 1.03–64.85, p=0.047). Average interobserver and intraobserver variabilities for strain and strain rate were 9.2%, 10.3%, 13.2%, and 14.1%, respectively. Conclusions Patients with higher atrial strain appear to have a greater likelihood of maintenance of sinus rhythm after AF ablation. 2D strain of LA may be helpful to select candidates of AF ablation.

The Predictive Value of Transthoracic Echocardiographic Variables for Sinus Rhythm Maintenance after Electrical Cardioversion of Atrial Fibrillation

Objectives: The recurrence rate of atrial fibrillation after electrical cardioversion is disappointingly high. The aim of the present study was to prospectively investigate if standard echocardiographic variables at the day of cardioversion could predict sinus rhythm maintenance. Methods: Transthoracic echocardiographic examination was performed within 4 h after cardioversion for all the patients in the CAPRAF (Candesartan in the Prevention of Relapsing Atrial Fibrillation) study. Results: Cardioversion was successful for 137 patients not given specific antiarrhythmic therapy, and only 41 (30%) maintained sinus rhythm at 6-month follow-up. There were significant (p = 0.05) lower transmitral A wave velocities in the group with relapsing atrial fibrillation compared with the group with sinus rhythm at 6-month follow-up. All patients with the lowest A wave velocities had an early recurrence of atrial fibrillation. There were no differences between the groups regarding atrial dimensions or left ventricular function. The use of the angiotensin II receptor antagonist candesartan had no influence on the echocardiographic variables, nor on the recurrence rate of atrial fibrillation after cardioversion. Conclusions: Transthoracic echocardiographic examination performed a short time after electrical cardioversion of atrial fibrillation showed that only A wave peak velocities were significantly predictive of sinus rhythm maintenance 6 months after the procedure.

Strain rate imaging for functional quantification of the left atrium: atrial deformation predicts the maintenance of sinus rhythm after catheter ablation of atrial fibrillation

The aim of the study was to investigate the atrial myocardial deformation properties using ultrasound strain rate (SR) imaging in patients after catheter ablation of atrial fibrillation (AF) and to compare its prognostic value in maintaining sinus rhythm. A total of 118 patients with AF (74 paroxysmal AF, 44 persistent AF) underwent transthoracic echocardiography with Doppler-derived SR examinations before and after ablation as well as during 3 months of follow-up (FU). Peak SR and strain (S) were measured at each left atrium (LA) segment (septal, lateral, anterior, inferior) during systole (LAs) and at early (LAe) and late diastole (LAa). Clinical and echocardiographic parameters of patients with maintained sinus rhythm during FU were compared with those with recurrent AF and controls (n = 25 patients). Of 118 patients 82 (69%) showed stable sinus rhythm during FU. Atrial myocardial properties after catheter ablation differed significantly in patients with paroxysmal AF (SR-LAs 2.5 s(-1), S-LAs 30%, SR-LAa -2.2 s(-1)) from patients with persistent AF (SR-LAs 2.3 s(-1), S-LAs 25%, SR-LAa -1.9 s(-1)) and controls (SR-LAs 4.1 s(-1), S-LAs 88%, SR-LAa -2.9 s(-1)) (P = 0.011). Best individual predictors of sinus rhythm maintenance were cut-off values of >2.25 s(-1) for septal and inferior SR-LAs and of >19.5% for inferior S-LAs (P < 0.001). LA deformation properties increased in patients with maintained sinus rhythm during FU in contrast to patients with recurrent AF (P = 0.001). SR imaging enables the quantitative assessment of the LA function and can be considered as a potential marker of atrial reverse remodelling. Patients with higher atrial S and SR after catheter ablation appear to have a greater likelihood of maintenance of sinus rhythm. This may have further implications for the anticoagulation regime and the risk of cardioembolic complications.

The predictive value of transthoracic echocardiographic variables for sinus rhythm maintenance after electrical cardioversion of atrial fibrillation

The recurrence rate of atrial fibrillation (AF) after successful electrical cardioversion (EC) is high, and the aim of the present study was to prospectively investigate in the randomized and placebo controlled CAPRAF (CAndesartan in the Prevention of Relapsing Atrial Fibrillation) population if echocardiographic variables at the day of EC could predict sinus rhythm maintenance. The study group consisted of 171 patients with persistent AF not given specific antiarrhythmic therapy; 137 had a successful EC and only 41 (30%) maintained sinus rhythm at 6 months follow-up. Transthoracic echocardiographic examination including measurements of the atria and left ventricle in addition to mitral inflow parameters, was performed within 4 h after successful EC. The use of the angiotensin II receptor antagonist candesartan had no influence on these echocardiographic parameters, neither on the recurrence rate of AF after EC. There were significant (p=0.05) lower transmitral A-wave velocities in the group with early relapsing AF compared to the group with sinus rhythm at 6 months follow-up (0.26 versus 0.30 m/s). All the patients (n=7) with the lowest A-wave velocities (=0.01 m/s) had an early recurrence of AF. There were no differences between the sinus rhythm maintenance and the relapsing AF groups regarding atrial dimensions or left ventricular function. In conclusion, our study demonstrates that only A-wave peak velocities at the day of EC were found to be significantly predictive of sinus rhythm maintenance 6 months after the procedure.

Atrial fibrillation signal organization predicts sinus rhythm maintenance in patients undergoing cardioversion of atrial fibrillation

Electrical remodelling is believed to influence the outcome following cardioversion of patients with persistent atrial fibrillation (AF). However, the results in clinical studies are conflicting. We assessed the hypothesis that non-invasively obtained atrial fibrillatory organization can be used as a predictor of sinus rhythm (SR) maintenance. Fifty-four patients (37 men, age 67+/-11) with persistent AF (median duration 3 months, 1 day to 18 months), without anti-arrhythmic drug treatment, referred for cardioversion were studied. Assessment of the atrial harmonic decay was made by time-frequency analysis of the ECG. At 1-month follow-up, 30 patients had relapsed into AF. The mean harmonic decay at inclusion of those relapsing into AF was 1.5+/-0.3 compared with 1.1+/-0.3 among those maintaining SR (P=0.0004). Using a cut-off value of harmonic decay <or=1.5 to determine suitability for cardioversion would have resulted in a clinically useful discriminator (sensitivity=92%, specificity=47%, PPV=59%, and NPV=88%). This study shows that patients relapsing rapidly to AF have a higher harmonic decay than those maintaining SR. The degree of AF signal organization (harmonic decay) was a superior discriminator to other patient parameters. Further studies are needed to confirm these results and to determine the electrophysiological correlate of harmonic decay.

Prediction of sinus rhythm maintenance following DC-cardioversion of persistent atrial fibrillation – the role of atrial cycle length

BackgroundAtrial electrical remodeling has been shown to influence the outcome the outcome following cardioversion of atrial fibrillation (AF) in experimental studies.The aim of the present study was to find out whether a non-invasively measured atrial fibrillatory cycle length, alone or in combination with other non-invasive parameters, could predict sinus rhythm maintenance after cardioversion of AF.MethodsDominant atrial cycle length (DACL), a previously validated non-invasive index of atrial refractoriness, was measured from lead V1 and a unipolar oesophageal lead prior to cardioversion in 37 patients with persistent AF undergoing their first cardioversion.Results32 patients were successfully cardioverted to sinus rhythm. The mean DACL in the 22 patients who suffered recurrence of AF within 6 weeks was 152 ± 15 ms (V1) and 147 ± 14 ms (oesophagus) compared to 155 ± 17 ms (V1) and 151 ± 18 ms (oesophagus) in those maintaining sinus rhythm (NS). Left atrial diameter was 48 ± 4 mm and 44 ± 7 mm respectively (NS). The optimal parameter predicting maintenance of sinus rhythm after 6 weeks appeared to be the ratio of the lowest dominant atrial cycle length (oesophageal lead or V1) to left atrial diameter. This ratio was significantly higher in patients remaining in sinus rhythm (3.4 ± 0.6 vs. 3.1 ± 0.4 ms/mm respectively, p = 0.04).ConclusionIn this study neither an index of atrial refractory period nor left atrial diameter alone were predictors of AF recurrence within the 6 weeks of follow-up. The ratio of the two (combining electrophysiological and anatomical measurements) only slightly improve the identification of patients at high risk of recurrence of persistent AF. Consequently, other ways to asses electrical remodeling and / or other variables besides electrical remodeling are involved in determining the outcome following cardioversion.

The emerging role of inflammation in atrial fibrillation and the potential of anti-inflammatory interventions

We read with considerable interest the article by Engelmann and Svendsen1 providing a concise overview of the current knowledge about the association of inflammation with atrial fibrillation (AF). A continuously increasing number of investigations examine the role of inflammation in AF. Interestingly, two recent studies indicated that C-reactive protein relates to the left atrial size and AF duration before cardioversion, providing evidence of an association between inflammation and atrial structural remodelling.2,3 Moreover, it has been demonstrated that baseline C-reactive protein levels prior cardioversion of persistent AF represent an independent predictor of sinus rhythm maintenance …

Atrial Myocardial Deformation Properties Predict Maintenance of Sinus Rhythm After External Cardioversion of Recent-Onset Lone Atrial Fibrillation

Accurate echocardiographic parameters to predict maintenance of sinus rhythm in patients with atrial fibrillation (AF) are poorly defined. This study was conducted to assess the atrial myocardial properties during AF through myocardial velocity, strain rate, and strain and to compare their prognostic value in maintaining sinus rhythm in patients with lone AF with standard transthoracic (TTE) and transesophageal echocardiography (TEE). Sixty-five consecutive patients with lone AF for < or =3 months underwent TTE, TEE, and myocardial velocity and strain and strain rate imaging examinations before successful external cardioversion. Maintenance of sinus rhythm was assessed during a 9-month follow-up. Atrial myocardial velocity, strain, and strain rate values in AF patients were compared with those of age- and sex-matched referents. Moreover, clinical and echocardiographic parameters of patients with maintenance of sinus rhythm (MSR patients) over the 9-month follow-up period (n=25) were compared with those from patients with AF recurrence (AFR patients; n=40). Atrial myocardial properties assessed by myocardial velocity, strain rate, and strain were significantly reduced (P<0.0001) in patients (velocity, 3.2+/-1.4 cm/s; strain, 23.3+/-19%; strain rate, 2+/-0.9 seconds(-1)) compared with referents (velocity, 5.7+/-1.3 cm/s; strain, 92+/-26%; strain rate, 4.2+/-1.8 seconds(-1)). The individual predictors of sinus rhythm maintenance were atrial appendage flow velocity (MSR patients, 39+/-12 cm/s; AFR patients, 32+/-15 cm/s; P<0.01) assessed by TEE and atrial strain (MSR patients, 33+/-27%; AFR patients, 17+/-9%; P=0.0007) and strain rate (MSR patients, 2.7+/-1 seconds(-1); AFR patients, 1.6+/-0.6 seconds(-1); P<0.0001) peak systolic values. Atrial strain (P<0.0001; coefficient, 0.015; SE, 0.003) and strain rate (P<0.0001; coefficient, 0.372; SE, 0.075) parameters alone were confirmed as independent predictors of sinus rhythm maintenance by multivariable analysis. Patients with higher atrial strain and strain rate appear to have a greater likelihood of staying in sinus rhythm. If the current data are verified in future studies, then additional pharmacological therapy and maintenance of anticoagulants for a longer period may need to be considered in those with lower atrial strain and strain rate measurements.

C-reactive protein and atrial fibrillation: “Evidence for the presence of inflammation in the perpetuation of the arrhythmia”

Background Atrial fibrillation (AF) is associated to a high risk of systemic embolism. The mechanisms that contribute to thrombogenesis in these patients are still poorly understood. Systemic and/or local inflammation could be involved in the process of thrombogenesis and contribute to the perpetuation of the arrhythmia. The purpose of the study was to evaluate the role of inflammation and its relation to thrombogenesis and cardiac rhythm in AF. Methods We prospectively studied 130 patients with newly diagnosed non-valvular AF in absence of antithrombotic therapy. Determinations of C-reactive protein (CRP) and thrombin–antithrombin complex (TAT) plasma levels, along with a transesophageal echocardiogram were performed in all the patients at admission. Results Mean age of the group was 67 ± 14 years. CRP levels were significantly elevated in AF patients versus controls (matched by age, gender and cardiovascular risk factors) (1.0 ± 1.8 versus 0.3 ± 0.4 mg/dl, respectively, p < 0.01). Baseline TAT levels were also significantly elevated in AF patients but no correlation was found between CRP and TAT. At 1-year of follow-up, mean CRP levels were still elevated in patients that remained in AF compared to those who converted to sinus rhythm (1.2 ± 1.8 compared to 0.5 ± 1.5 mg/dl, p = 0.03). CRP was the only biochemical predictor of sinus rhythm maintenance at 1-year follow-up independently of clinical (including adjustment for risk factors and antiarrhythmic drugs), biochemical and echo parameters. Conclusions There is evidence for the presence of inflammation in patients with non-valvular AF, which is not related to activation of the coagulation cascade. The persistence of inflammation is associated with chronic AF at 1-year follow up.

542 Low variaility of RR intervals during atrial fibrillation predicts sinus rhythm maintenance after direct current countershock during long-term observation

542 Low variaility of RR intervals during atrial fibrillation predicts sinus rhythm maintenance after direct current countershock during long-term observation

542 Low variaility of RR intervals during atrial fibrillation predicts sinus rhythm maintenance after direct current countershock during long-term observation

542 Low variaility of RR intervals during atrial fibrillation predicts sinus rhythm maintenance after direct current countershock during long-term observation

P-wave dispersion for predicting maintenance of sinus rhythm after cardioversion of atrial fibrillation

P-wave measurements and left atrial function were investigated to predict the maintenance of sinus rhythm after cardioversion of atrial fibrillation. Left atrial dimension <45 mm (p = 0.02) and P-wave dispersion <46 ms (p <0.001) were independent predictors of sinus rhythm maintenance, with a sensitivity of 89% and 96%, respectively. Duration of atrial fibrillation, maximum P-wave duration, and no spontaneous echocardiographic contrast were also univariate predictors.

Left Atrial Appendage Outflow Velocity Index is Superior to Conventional Criteria for Prediction of Maintenance of Sinus Rhythm after Cardioversion. An Echocardiographic Study in Patients with Atrial Fibrillation of a Few Months' Duration

Objective - To investigate whether left atrial appendage outflow velocity alone or in relation to left atrial diameter is a superior predictor of sinus rhythm maintenance after cardioversion compared with traditional clinical or echocardiography parameters. Design - Sixty-two patients with their first episode of atrial fibrillation were examined using echocardiography before DC-cardioversion. At one month's follow-up, 42 patients had maintained sinus rhythm (group A), and 20 had relapsed into atrial fibrillation (group B). There were no differences in arrhythmia duration or antiarrhythmic therapy between the groups. Results - Left atrial diameter measured by echocardiography was smaller in group A (42 mm, 95% CI 40.9-44.1 mm) compared with group B (46 mm, 95% CI 43.4-48.2, p < 0.05). Patients in group A had a higher left atrial appendage outflow velocity at 0.44 m/s (95% CI 0.39-0.49) compared with 0.34 m/s (95% CI 0.30-0.37) in group B (p < 0.01). The ratio of left atrial appendage flow to left atrial diameter was 0.011 (95% CI 0.009-0.012) in group A compared with 0.008 (95% CI 0.007-0.009) in group B, and 63% (95% CI 33-78) of the patients in group A had velocity ratio >0.009 compared with 20% (95% CI 2-38) in group B, (p < 0.01). Stepwise multiple logistic regression analysis showed that a velocity ratio >0.009 was the only predictor for maintenance of sinus rhythm one month after cardioversion with an odds ratio of 6.4 (95% CI 1.9-23.8), (p = 0.004). Conclusion - The ratio of left atrial appendage outflow velocity to left atrial diameter is superior to the traditionally used criteria for prediction of maintenance of sinus rhythm following DC-conversion of first-episode atrial fibrillation.

Clinical, adrenergic and heart endocrine measures in chronic atrial fibrillation as predictors of conversion and maintenance of sinus rhythm after direct current cardioversion.

The aim of this study was to evaluate clinical, adrenergic and endocrine factors that could predict sinus rhythm maintenance after direct current cardioversion in chronic atrial fibrillation. Nineteen patients with chronic non-rheumatic atrial fibrillation (mean duration 6 +/- 5 months) were studied. They were exercised 24 h before cardioversion at maximum effort with the Naughton protocol. Heart rate and blood pressure at rest and exercise were recorded and blood samples were taken for the assessment of adrenergic activity, by measuring cyclic adenosine monophosphate, heart endocrine function, atrial natriuretic peptide and its second messenger, cyclic guanosine monophosphate. Fifteen of the 19 patients were initially converted to sinus rhythm (eight patients with external and seven patients with internal DC shocks). After 3 months eight patients remained in sinus rhythm and 11 had relapsed, most of them within the first month. On exercise the chronotropic response was lower in the group who remained in sinus rhythm than in the group in atrial fibrillation (peak heart rate 147 +/- 11 beats.min-1 vs 165 +/- 24 beats.min-1 P = 0.02). During exercise, the systolic blood pressure in the sinus group reached higher values than in the group who relapsed (192 +/- 17 mmHg vs 176 +/- 18 mmHg, P = 0.03). Cyclic adenosine monophosphate increased significantly from rest to peak exercise in the sinus rhythm group (from 23 +/- 9 pmol.ml-1 to 31 +/- 15 mol.ml-1, P = 0.02) while it remained unchanged in the atrial fibrillation group (25 +/- 10 pmol.ml-1 to 24 +/- 8 pmol.ml-1, P = 0.02). For all 19 patients the difference in cyclic adenosine monophosphate between rest and exercise was negatively correlated with maximum heart rate (r = 0.58, P = 0.009). Atrial natriuretic peptide increased from rest to peak exercise in the sinus rhythm group (from 129 +/- 58 fmol.ml-1 to 140 +/- 66 fmol.ml-1) while it remained unchanged in the group in which atrial fibrillation persisted or recurred (from 112 +/- 58 fmol.ml-1 to 111 +/- 53 fmol.ml-1, P = 0.002). A significant correlation between atrial natriuretic peptide and cyclic guanosine monophosphate levels at exercise before cardioversion was found for the sinus rhythm group only (r = 0.76, P = 0.02). In patients with non-rheumatic chronic atrial fibrillation evaluation of clinical parameters such as heart rate and blood pressure changes during maximal exercise can be useful in the choice of suitable therapy. An inadequate increase in plasma cyclic-adenosine monophosphate and atrial natriuretic peptide on exercise could predict patients with more severe underlying disease, where cardioversion should not be recommended.