Significant Predictors Of Atrial Fibrillation Recurrence Research Articles

Left Atrial Volume Index Predicts Atrial Fibrillation Recurrence after Catheter Ablation Only in Obese Patients-Brief Report.

It has been shown that obesity and a higher body mass index (BMI) are associated with a higher recurrence rate of atrial fibrillation (AF) after successful catheter ablation (CA). The same has been proven for the left atrial volume index (LAVI). It has also been shown that there is a correlation between LAVI and BMI. However, whether the LAVI's prognostic impact on AF recurrence is BMI-independent remains unclear. We prospectively included 62 patients with paroxysmal AF who were referred to our institution for CA. All patients underwent radiofrequency CA with standard pulmonary veins isolation. Transthoracic 2-D echocardiography was performed one day after CA to obtain standard measures of cardiac function and morphology. Recurrence was defined as documented AF within 6 months of the follow-up period. Patients were also instructed to visit our outpatient clinic earlier in case of symptoms suggesting AF recurrence. We observed AF recurrence in 27% of patients after 6 months. The mean BMI in our cohort was 29.65 ± 5.08 kg/cm2 and the mean LAVI was 38.04 ± 11.38 mL/m2. We further divided patients into two groups according to BMI. Even though the LAVI was similar in both groups, we found it to be a significant predictor of AF recurrence only in obese patients (BMI ≥ 30) and not in the non-obese group (BMI < 30). There was also no significant difference in AF recurrence between both cohorts. The significance of the LAVI as an AF recurrence predictor in the obesity group was also confirmed in a multivariate model. According to our results, the LAVI tends to be a significant predictor of AF recurrence after successful catheter ablation in obese patients, but not in normal-weight or overweight patients. This would suggest different mechanisms of AF in non-obese patients in comparison to obese patients. Further studies are needed in this regard.

Characterisation of ablation strategies at redo catheter ablation for atrial fibrillation and predictors of arrhythmia recurrence: results from the AFREDO registry

Abstract Background Patients who have undergone prior pulmonary vein isolation (PVI) for atrial fibrillation (AF) often require a repeat ablation for AF recurrence. The optimal ablative strategy for the redo procedure and predictors of AF recurrence thereafter remain largely unknown. Purpose We aimed to characterise the ablation strategies applied at re-PVI and identify possible predictors of AF recurrence. Methods Our single-centre, retrospective study included all consecutive patients who underwent first redo PVI at our centre from 2017 to 2022. Inclusion criteria required at least one available follow-up visit within the first 12 months after the redo procedure. Ablation strategies of the initial and redo procedure were captured. Kaplan-Meier curves were used to illustrate time of AF recurrence, as classified by predictors of outcome determined by multivariable regression analyses. Results We included 215 patients (39.1% female) with a median age of 66.6 years (IQR 58.6-73.2) at the time of redo procedure. The initial PVI was cryoablation in 39.9%, RFA in 57.7% and surgical ablation in 2.4%. After the initial procedure, 55.8% had paroxysmal AF and 44.2% had persistent AF. At the redo procedure, 25.1% of patients were found to have no PV reconnection, whereas 20.5% had a single reconnected PV, and 54.4% had two or more reconnected PVs. A left-sided flutter ablation was performed in 18.8%, a left atrial (LA) roof line in 16.9%, a posterior mitral isthmus line in 5.2%, an anterior mitral isthmus line in 27.9%, and a posterior box lesion in 8.4%. Overall, 34.4% of patients showed areas of low-voltages in the redo procedure. Patients with areas of low voltages were less likely to have any reconnected PVs in the redo-procedure (p&amp;lt;0.001). After the second ablation procedure, 54.0% experienced AF recurrence. Univariable regression analysis revealed moderate (p=0.006) or severe (p= 0.015) LA dilatation, persistent AF (p=0.005), and posterior LA low voltage areas (p=0.011) as significant predictors of AF recurrence after the redo procedure. The number of reconnected PVs at the re-PVI did not predict AF recurrence (p=0.1090). As illustrated in Fig. 1 and 2, patients with paroxysmal AF experienced less AF recurrence compared to those with persistent AF (log-rank p=0.0025). Moreover, moderate or severe LA dilatation at baseline was associated with more frequent AF recurrences (log-rank p=0.0279). Conclusion A significant proportion of patients undergoing re-PVI experienced AF recurrence. We found that persistent AF and moderate or severe LA enlargement emerged as significant predictors of AF recurrence after the redo procedure. Although PV reconnection was observed in more than two thirds of patients at the re-PVI, it did not predict AF recurrence thereafter. However, patients without PV reconnection had significantly more low-voltage areas, which may be indicative of a different AF recurrence mechanism in this subgroup.Figure 1:Type of AFFigure 2:LA dilatation

Cardiac computed tomography angiography-derived pulmonary vein volumetry as a predictor for atrial fibrillation recurrence after catheter ablation.

There is an increasing evidence that pulmonary vein (PV) enlargement is associated with atrial fibrillation (AF); however, the predictive value of PV enlargement in AF recurrence remains unclear. This study sought to evaluate whether PV volume quantification derived from cardiac computed tomographic angiography (CCTA) could serve as a predictive indicator of the success of the catheter ablation (CA) procedure. The data of 160 patients diagnosed with AF who underwent both CCTA and CA treatments from January to June 2020 were retrospectively examined; the CCTA was conducted before the CA surgery. The study focused on documenting the PV structure, and the volume of the PV and left atrium (LA). The clinical, CCTA, and echocardiographic predictors of the recurrence and no-recurrence groups were compared. A multivariable logistic regression analysis was performed to adjust for confounders. Receiver operating characteristic (ROC) curves were analyzed to assess the predictive performance of the predictors of AF recurrence. Of the 160 patients [55.6% male, 62.00 (55.25-68.00) years, 23.1% with persistent AF], 45 (28.1%) experienced AF recurrence within a one-year period. Notably, patients with AF recurrence had elevated CHADS2 scores (P=0.020) and increased LA and PV volumes (P<0.05). Patients with persistent AF (n=37) had significantly larger LA volume indexes (P<0.001) than those with paroxysmal AF, but there was no difference between the two groups in terms of the PV maximum volume index (P=0.200). Moreover, the PV maximum volume index [odds ratio (OR): 1.244, 95% confidence interval (CI): 1.008-1.536, P=0.042] and the LA minimum volume index (OR: 1.026, 95% CI: 1.001-1.052, P=0.038) were found to be significant predictors of AF recurrence. The ROC curves revealed that the PV maximum volume index threshold for predicting AF recurrence was 7.13 mL/m2, with a sensitivity of 84.4% and a specificity of 34.8% [area under the curve (AUC): 0.635, 95% CI: 0.540-0.730, P=0.008], and the LA minimum volume index threshold for predicting AF recurrence was 46.16 mL/m2, with a sensitivity of 88.9% and a specificity of 31.3% (AUC: 0.629, 95% CI: 0.534-0.723, P=0.012). A sub-analysis of patients with a lower left atrial dimension (LAD ≤38 mm in females, LAD ≤40 mm in males, n=120) demonstrated that the PV maximum volume index was a noteworthy indicator of AF recurrence (OR: 1.443: 95% CI: 1.145-1.820, P=0.002). Conversely, no significant correlation between AF recurrence and the LA volume index was found. The AUC value for the PV maximum volume index predictive of recurrent AF was 0.680 (95% CI: 0.577-0.781, P=0.003), with a sensitivity of 75.8%, specificity of 54%, and the cut-off value of the maximum AUC was 7.89 mL/m2. PV volume, derived from CCTA, may help to predict the recurrence of AF after CA, and is superior to the LA size in patients with less pronounced LA enlargement.

Association between baseline glycated hemoglobin level and atrial fibrillation recurrence following cryoballoon ablation among patients with and without diabetes

ObjectivesThe study aims to assess the effect of baseline glycated hemoglobin (HbA1c) levels on atrial fibrillation (AF) recurrence following cryoballoon ablation in patients with and without diabetes.MethodsConsecutive AF patients receiving first cryoballoon ablation between April 2018 and April 2021 were included. AF recurrence and other clinical outcomes were recorded for a minimum of 12 months post-ablation, with regular assessments at 3, 6, and 12 months, followed by annual check-ups. The primary outcome was AF recurrence after ablation at longest follow-up. Multivariate Cox proportional hazards regression models were utilized to calculate the hazard ratio (HR) and 95% CI per standard deviation (SD) increase of baseline HbA1c level.Results335 patients were included in the analysis. The mean age was 61.7 years, 61.8% were male. 12.8% had type 2 diabetes, and 81.7% of patients had paroxysmal AF. The median level of HbA1c was 5.3%, and the mean CHA2DS2-VASc score was 1.8. All cryoballoon ablation procedures, utilizing a 28-mm balloon, achieved successful pulmonary vein isolation. Over a median follow-up of 18 months, 105 patients (31.3%) experienced AF recurrence. In multivariate Cox proportional hazards analysis, a higher HbA1c level, persistent AF (HR 1.91, 95% CI 1.08 to 3.39, P = 0.026), alcohol consumption (HR 2.67, 95% CI 1.33 to 5.37, P = 0.006), and Nadir RSPV (HR 1.04, 95% CI 1.00 to 1.08, P = 0.005) were significant predictors of AF recurrence. Per-SD increase of HbA1c was associated with a 1.75-fold increase risk of AF recurrence (HR 1.75, 95% CI 1.39 to 2.21, P < 0.001). Subgroup analysis revealed that a higher HbA1c level was associated with a higher risk of AF recurrence in patients with and without diabetes, and in patients with paroxysmal and persistent AF.ConclusionBaseline HbA1c level was an independent predictor of AF recurrence following cryoablation, both in patients with and without diabetes.

Abstract 12182: Importance of Comorbidities in 24-month AF-Free Survival After Catheter Ablation

Background: Presence of cardiac and non-cardiac comorbidities is reported to affect success of catheter ablation (CA) of atrial fibrillation (AF), however their predictive value in 1 and 2 year AF free survival is not reported. Research Questions: Which cardiac and non-cardiac comorbidities are most useful in predicting AF free survival after a single CA for paroxysmal and persistent AF. Goals: Create a model to identify potential risk factors that may reduce the long term success of catheter ablation for patients with AF to allow for risk modification Methods: We included 1435 patients with symptomatic AF undergoing first time CA in 1 of 8 Hospitals of Northwell Health and follow ups for at least 24 months ablation. Baseline echocardiographic and laboratory data were extracted from our common EMR, and clinical outcomes were determined after manual review of the 6, 12 and 24 month visit. Baseline patient characteristics included age, gender, BMI, diagnoses, laboratory and echocardiographic measures used in a stepwise estimation logistic regression model using STATA /IC 16.1. Results: From our patient cohort (age 67.1±10.4, 565 female, 645 persistent), 28% of patients had AF recurrence within the 1st year, and 32.5% within 2 years. Multivariate analysis identified persistent AF as the only independent risk factor for AF recurrence within 12 months (P=.001). For 24-month recurrence the independent predictors were LVEF (p=.014), Diabetes Mellitus (p=.045), cardioversions prior to ablation (DCCV) (p=.001), and pulmonary disease (p=.001). Energy modality was not a significant predictor of AF recurrence. Hypertension (p=.008) was found to be negatively associated with AF recurrence. Our prediction model (Figure 1) for AF recurrence 24 months post-CA produced an ROC curve of 0.8048 and was 77% accurate. Conclusion: The presence of baseline comorbidities implies that such comorbidities, rather than procedural failure, are mostly related with AF recurrence after 1 year.

Efficacy and safety of atrial fibrillation ablation in heart failure patients with left ventricular ejection fraction less than 50%

IntroductionThe efficacy of catheter ablation in patients with low cardiac function has been previously reported; however, only a few studies have included mid-range ejection fraction (mrEF). This study aimed to evaluate the efficacy and safety of atrial fibrillation (AF) ablation in patients with left ventricular ejection fraction (LVEF) < 50%. MethodsThis study retrospectively analyzed 79 patients (reduced ejection fraction [rEF]/mrEF, 38/41; paroxysmal/persistent, 37/42; heart failure hospitalizations within one year before ablation, 36 [45.6%]) who underwent the first ablation procedure at our hospital from April 2017 to December 2021. Radiofrequency ablation and cryoablation were performed for 69 and 10 patients, respectively. ResultsComplications included pacemaker implantation for postoperative sick sinus syndrome in one patient and inguinal hematoma in one patient. Regarding efficacy, there were significant postoperative improvements in echocardiographic data, blood test values, and diuretic use. After a mean follow-up of 60 months, 86.1% patients had no AF recurrence. There were 9 heart failure hospitalizations (11.4%) and 5 all-cause deaths (6.3%); no significant differences were found between the rEF and mrEF groups. No significant predictors of AF recurrence were found in preoperative patient characteristics. ConclusionAF ablation in patients with LVEF <50% significantly improved cardiac and renal functions with few complications, resulting in a high non-recurrence rate and reduced heart failure.

Regional left atrial conduction velocity in the anterior wall is associated with clinical recurrence of atrial fibrillation after catheter ablation: efficacy in combination with the ipsilateral low voltage area

BackgroundLeft atrial (LA) conduction velocity (CV) is an electrical remodeling parameter of atrial fibrillation (AF) substrate. However, the pathophysiological substrate of LA-CV and its impact on outcomes after catheter ablation for AF have not been well evaluated.MethodsWe retrospectively evaluated 119 patients with AF who underwent catheter ablation and electroanatomical mapping during sinus rhythm. To measure regional LA-CV, we took triplet sites (A, B, and C) on the activation map and calculated the magnitude of the matched orthogonal projection vector between vector-AB and vector-AC, indicating two-dimensional CV. The median of the LA-CVs from four triad sites in both the anterior and posterior walls was set as the ‘model LA-CV’. We evaluated the impact of the model LA-CV on recurrence after ablation and relationship between the model LA-CV and LA-low voltage area (LVA) of < 0.5 mV.ResultsDuring the 12-month follow-up, 29 patients experienced recurrence. The LA-CV model was significantly correlated with ipsilateral LVA. The lower anterior model LA-CV was significantly associated with recurrence, with the cut-off value of 0.80 m/s having a sensitivity of 72% and specificity of 67%. Multivariable analysis revealed that the anterior model LA-CV (hazard ratio, 0.09; 95% confidence interval, 0.01–0.94; p = 0.043) and anterior LA-LVA (hazard ratio, 1.06; 95% confidence interval, 1.00–1.11; p = 0.033) were independently associated with AF recurrence. The anterior LA-LVA was mildly correlated with the anterior model LA-CV (r = -0.358; p < 0.001), and patients with both lower LA-CV and greater anterior LA-LVA based on each cut-off value had the worst prognosis. However, decreased LA-CV was more likely to be affected by the distribution pattern of the LVA rather than the total size of the LVA.ConclusionDecreased anterior LA-CV was a significant predictor of AF recurrence and was a useful electrical parameter in addition to LA-LVA for estimating AF arrhythmogenicity.

Left atrial function parameters as predictors of atrial fibrillation recurrence after pulmonary vein isolation

Abstract Background The aim of the study was to test the relationship between left atrial (LA) function parameters and the results of the pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF). Patients and methods Consecutive patients undergoing first time PVI in years 2019–2021 were qualified to the study. The patients underwent radiofrequency ablation using contact-force catheters and electroanatomical system. LA pressure was measured directly just after transseptal puncture. Follow-up was based on ambulatory visits/televisits and 7-day holter monitoring (6 and 12 month after ablation). On the day of ablation all the patients underwent transesophageal and transthoracic echocardiography. The primary endpoint was any atrial tachyarrhythmia recurrence during follow-up period. Results A total of 210 patients were included in the study. Median of follow-up was 12 months, AF recurrence was observed in 71 patients (33.8%) after mean of 1.03 procedures per patient. In univariate Cox regression analysis several echocardiographic parameters were significant predictors of AF recurrence after catheter ablation: left and right atrial area, LA volume, average e' and average E/e' values, LA reservoir strain, LA conduit strain, LA appendage emptying velocity. AF recurrence was also predicted by mean LA pressure, age, body mass index and calculated eGFR. Interestingly, LA contraction strain and LA emptying fraction were not predictors of results of AF ablation. In multivariate Cox regression analysis (that included all parameters significant in univariate analysis) LA reservoir strain (hazard ratio (HR) 1.076, 95% confidence interval (CI) 1.014–1.141; p=0.014) and LA appendage emptying velocity (HR 0.968, 95% CI 0.947–0.988; p=0.002) were significant predictors of AF ablation results. Conclusions LA reservoir strain and LA appendage emptying velocity are predicting factors of AF ablation results. LA contraction strain and LA emptying function were not predictors of effective AF ablation. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Statutory Grant of Military Institute of Medicine

The Predictive Value of the Left Atrial Kinetic Energy for Atrial Fibrillation Recurrence.

Background and aimDetermining which patients will experience recurrence of atrial fibrillation (AF) is crucial for treatment modification. This study aimed to investigate the predictive value of left atrial kinetic energy (LAKE) in AF recurrence.Materials and methodsA total of 120 consecutive patients who achieved sinus rhythm (SR) with electrical direct current cardioversion and met the inclusion criteria were included in the study. Transthoracic echocardiography (TTE) and LAKE values were calculated on the first day after cardioversion. Rhythm control was performed with 12-lead electrocardiography in the first-month follow-up.ResultsWhile 81 (67.5%) patients were in SR at one month, AF recurrence was detected in 39 (32.5%) patients. In the AF group, AF duration, cardioversion energy, number of diabetic patients, left atrium (LA) diameter, LA pre-mitral A wave volume, LA minimum volume, and pulmonary artery pressure values were significantly higher than in the SR group, while mitral A wave velocity and LAKE values were significantly lower. In multivariate regression analysis, AF duration (OR: 1.54; 95% CI: 1.22 - 1.93; p < 0.001), LA diameter (OR: 1.33; 95% CI: 1.10 - 1.61; p = 0.002), and LAKE (OR: 0.96; 95% CI: 0.94 - 0.99; p = 0.007) were determined to be independent predictors of AF recurrence at one month.ConclusionsLA diameter, AF duration, and LAKE were found to be significant predictors of AF recurrence after cardioversion.

Impact of heart rate reduction on recurrence after catheter ablation of persistent atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Johnson &amp; Johnson KK OnBehalf OCVC Arrhythmia Investigators Background Predicting heart rate (HR) after restoration of sinus rhythm (SR) remains one of the challenges when performing catheter ablation (CA) of persistent atrial fibrillation (AF). Purpose To evaluate the association between pre-ablation HR during AF and post-ablation HR during SR, and whether the HR reduction is associated with AF recurrence. Methods The analysis was performed from the EARNEST-PVI trial, a randomized controlled trial designed to assess a CA strategy for persistent AF, which was conducted in the Osaka region of Japan. After excluding patients with beta-blocker prescription, a total of 216 patients (median age, 67 years; 20% female; 23% long-standing persistent AF) with AF rhythm at baseline and SR at discharge were enrolled in this study. Baseline HR during AF and post-ablation HR during SR was measured on admission and at discharge using the 12-lead electrocardiograms, respectively. Results There was a mild correlation between baseline HR (median 82 [interquartile range 72-95] bpm) and post-ablation HR (78 [48-117] bpm) (r = 0.27, p &amp;lt;0.001). Reduction in HR was positively associated with baseline HR (r = 0.79, p &amp;lt;0.001) and was negatively associated with post-ablation HR (r = - 0.37, p &amp;lt;0.001). During the follow-up of 1 year, 56 patients (25.9%) experienced AF recurrence. HR reduction had the higher diagnostic accuracy in predicting AF recurrence than HR at baseline and HR after CA (area under the curve, 0.625; 95% confidence interval, 0.557–0.690; p = 0.003). AF recurrence rate was significantly higher in 141 patients with smaller HR reduction (cut-off, &amp;lt;14bpm) than those with larger HR reduction (31.9% vs. 14.7%, p = 0.009). After adjustment of age, gender, long-standing persistent AF, and CA strategy, HR reduction of &amp;lt;14 bpm was a significant predictor of AF recurrence (hazard ratio, 2.32; 95% confidence interval, 1.20–4.51; p = 0.013). Conclusions There was a mild correlation between HR during AF and HR after restoration of SR in patients underwent CA of persistent AF. HR reduction after restoration of SR predicted AF recurrence.

Safety and Efficacy of Cryoballoon Ablation of Atrial Fibrillation in relation to the Patients' Age: Results from a Large Real-World Multicenter Observational Project.

Background The real-world efficacy and safety of atrial fibrillation (AF) ablation in particularly young and elderly patients are still under debate. The aim of the analysis was to investigate the effect of age on the efficacy and safety of cryoballoon ablation (CBA). Methods 2,534 patients underwent pulmonary vein isolation (PVI) by way of CBA for paroxysmal or persistent drug-resistant and symptomatic AF. The population was divided into age quartiles for evaluation, including (1) <53 years, (2) ≥53 and <61 years, (3) ≥61 and <67 years, and (4) ≥67 years. Furthermore, outcomes were analyzed in patients <41 years, ≥41 and ≤74, and >74 years old. Procedural data and complications were collected, and atrial fibrillation recurrences were evaluated during follow-up. Results Procedural-related complications (4.1%) were similar in the four subgroups according to age. At the 12-month follow-up, freedom from AF recurrence was 79.2%, 77.4%, 76.8%, and 75.2% (p=0.21), respectively (with increasing age). At 24-month follow-up, similar incidences of AF recurrence were observed in the four subgroups. When the sample was arbitrarily divided into the three age groups, a higher rate of recurrence was observed in older patients with regard to long-term follow-up (freedom from AF recurrence was 71.8% and 40.9%, respectively, at 12 and 24-month follow-up). In the univariate and multivariate analysis, age did not result in a significant predictor of AF recurrence during follow-up; however, a trend toward higher AF recurrences rates in patients ≥67 years was observed. Conclusion The data demonstrated a high degree of safety during CBA across all patient ages. Procedural performance and complications were similar between different ages; AF recurrences seem to be more frequent in patients over 74 years.

Abstract 11138: Impact of Heart Rate Reduction on Recurrence After Catheter Ablation of Persistent Atrial Fibrillation

Introduction: Predicting heart rate (HR) after restoration of sinus rhythm (SR) remains one of the challenges when performing catheter ablation (CA) of persistent atrial fibrillation (AF). Objectives: To evaluate the association between pre-ablation HR during AF and post-ablation HR during SR, and whether the HR reduction is associated with AF recurrence. Methods: The analysis was performed from the EARNEST-PVI trial, a randomized controlled trial designed to assess a CA strategy for persistent AF, which was conducted in the Osaka region of Japan. After excluding patients with beta-blocker prescription, a total of 216 patients (median age, 67 years; 20% female; 23% long-standing persistent AF) with AF rhythm at baseline and SR at discharge were enrolled in this study. Baseline HR during AF and post-ablation HR during SR was measured on admission and at discharge using the 12-lead electrocardiograms, respectively. Results: There was a mild correlation between baseline HR (median 82 [interquartile range 72-95] bpm) and post-ablation HR (78 [48-117] bpm) (r = 0.27, p &lt;0.001). Reduction in HR was positively associated with baseline HR (r = 0.79, p &lt;0.001) and was negatively associated with post-ablation HR (r = - 0.37, p &lt;0.001). During the follow-up of 1 year, 56 patients (25.9%) experienced AF recurrence. HR reduction had the higher diagnostic accuracy in predicting AF recurrence than HR at baseline and HR after CA (area under the curve, 0.625; 95% confidence interval, 0.557-0.690; p = 0.003). AF recurrence rate was significantly higher in 141 patients with smaller HR reduction (cut-off, &lt;14bpm) than those with larger HR reduction (31.9% vs. 14.7%, p = 0.009). After adjustment of age, gender, long-standing persistent AF, and CA strategy, HR reduction of &amp;lt;14 bpm was a significant predictor of AF recurrence (hazard ratio, 2.32; 95% confidence interval, 1.20-4.51; p = 0.013). Conclusions: There was a mild correlation between HR during AF and HR after restoration of SR in patients underwent CA of persistent AF. HR reduction after restoration of SR predicted AF recurrence.

Reappraising the role of baseline plasma C-reactive protein levels on recurrence after catheter ablation of persistent atrial fibrillation: insight from EARNEST-PVI trial

Abstract Background Subclinical inflammation is an important pathogenesis of developing and sustaining atrial fibrillation (AF). Because AF itself contribute to the inflammatory response, the role of baseline subclinical inflammation on AF recurrence after catheter ablation (CA) remains controversial in patients with persistent AF. Purpose To evaluate whether baseline plasma C-reactive protein (CRP) levels, a sensitive marker of inflammation, are associated with AF recurrence following CA. Methods The analysis was performed from the EARNEST-PVI trial, a randomized controlled trial designed to assess a CA strategy for persistent AF, which was conducted in the Osaka region of Japan. A total of 441 patients (median age, 67 years; 26% female; 25% long-standing persistent AF) whose plasma CRP levels were measured at baseline were included in this study. Results At baseline, a median (interquartile range) of plasma CRP level was 0.10 [0.06–0.19] mg/dl. Plasma CRP levels significantly increased at discharge (0.83 [0.21–1.84] mg/dl, p&amp;lt;0.001) and decreased 1 year after CA (0.10 [0.05–0.20] mg/dl, p=0.040) compared to the baseline value. During the follow-up of 1 year, 115 patients (26%) experienced AF recurrence, and the incidence was significantly higher in 124 patients with low CRP levels at baseline (cut-off ≤0.06 mg/dl) than the other 317 patients (33.9% vs. 23.0%, p=0.017). After adjustment of age, gender, body mass index, long-standing persistent AF, CA strategy, and plasma brain natriuretic peptide levels, low plasma CRP levels was a significant predictor of AF recurrence (hazard ratio, 1.51; 95% confidence interval, 1.02–2.24; p=0.042). Conclusions Low plasma CRP levels at baseline predicted AF recurrence in the EARNEST-PVI trial. Reappraising the role of CRP on AF recurrence may be needed in patients with persistent AF. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Johnson &amp; Johnson KK

Abutting left atrial appendage and left superior pulmonary vein predicts recurrence of atrial fibrillation after point-by-point pulmonary vein isolation

Abstract Funding Acknowledgements Type of funding sources: None. Background Catheter ablation is the cornerstone for rhythm control in patients with drug-refractory atrial fibrillation (AF). Baseline predictors of AF recurrence after catheter ablation are well established, such as female gender and left atrial enlargement. The role of the spatial relationship between the left superior pulmonary vein (LSPV) and left atrial appendage (LAA) is unknown. Purpose We sought to evaluate whether juxtaposed LSPV and LAA plays a role in AF recurrence after catheter ablation for paroxysmal AF. Methods Consecutive patients, who underwent point-by-point radiofrequency catheter ablation for paroxysmal AF at our hospital between January of 2014 and December of 2017, were enrolled in the study. All patients underwent pre-procedural cardiac CT-angiography (CTA) for the assessment of left atrial (LA) and pulmonary vein (PV) anatomy. Abutting LAA-LSPV was defined as cases when LSPV touched the posterior aspect of LAA (distance less than 2 mm). Results We included 428 patients (60.7 ± 10.8 years, 35.5% female). AF recurrence rate was 33.4% with a median recurrence-free time of 21.2 (IQR = 8.8-43.0) months. In the univariate analysis, female sex (HR = 1.45; 95%CI = 1.04-2.01; p = 0.028), LA volume (HR = 1.01; 95%CI = 1.00-1.01; p = 0.042), and cases when LSPV touched the posterior wall of LAA (HR = 1.53; 95%CI = 1.09-2.14; p = 0.013) were associated with AF recurrence. In the multivariate analysis, female sex (adjusted HR = 1.55; 95%CI = 1.06-2.28; p = 0.024), LA volume (adjusted HR = 1.01; 95%CI = 1.00-1.02; p = 0.028), and abutting LAA-LSPV (adjusted HR = 1.60; 95%CI = 1.13-2.50; p = 0.008) remained significant predictors of AF recurrence. Conclusion Female gender, higher LA volume, and abutting LSPV and LAA predispose patients to have a higher chance for arrhythmia recurrence after catheter ablation for paroxysmal AF.

Usefulness of Post-Procedural Plasma Brain Natriuretic Peptide Levels to Predict Recurrence After Catheter Ablation of Atrial Fibrillation in Patients With Left Ventricular Systolic Dysfunction

Catheter ablation (CA) of atrial fibrillation (AF) improves cardiac function, resulting in a decrease in plasma brain natriuretic peptide (BNP) levels in patients with reduced left ventricular ejection fraction (LVEF). This study sought to examine the pre-procedural and post-procedural correlations between BNP levels and cardiac function and the associations between the BNP levels and recurrence after CA in patients with AF and reduced LVEF. Of 3142 consecutive patients who underwent first-time CA of AF at our institute, a total of 217 patients with LVEF <50% were enrolled. Significant decrease in BNP levels (from a median of 198 [interquartile range 113 to 355] to 47.7 [22.7 to 135] pg/ml, p <0.001) and improvement in LVEF (from 39±9% to 61±16%, p <0.001) were observed 3 months after CA. There was a linear correlation between log-transformed BNP levels and cardiac measures (LVEF: r = -0.64; LV end-diastolic volume: r = 0.25; LV end-systolic volume: r = 0.43; left atrial volume: r = 0.52; all p <0.001). During a median follow-up of 35 months, AF recurrence after a 3-month blanking period was observed in 80 patients (37%). Cox proportional hazard regression analysis after adjustment for cardiac measures significant in univariate analysis revealed that early recurrence within the blanking period (hazard ratio, 4.88; 95% confidence interval, 2.89 to 8.25) and elevated post-procedural BNP levels (2.02 per unit log increase; 1.14 to 3.56) were significant predictors of AF recurrence, but pre-procedural BNP was not. In conclusion, post-procedural BNP levels at the end of the blanking period predicted subsequent AF recurrence in patients with reduced LVEF, independent of early recurrence.

Abstract 16663: Importance of Assessment for Diffuse Ventricular Fibrosis in Atrial Fibrillation Using Cardiac Ct-Derived Myocardial Extracellular Volume Fraction

Introduction: Previous cardiac MRI studies reported that the baseline diffuse LV fibrosis status should be evaluated before performing catheter ablation (CA) to identify the responders early and triage them with appropriate treatment. However, no study has been conducted to evaluate diffuse LV fibrosis in conjunction with pre-ablation planning cardiac CT. Objectives: The purpose of this study was to quantify diffuse left ventricular (LV) fibrosis by the CT-derived extracellular volume fraction (CT-ECV%) in conjunction with cardiac CT performed for CA planning and evaluate its determinants in patients with atrial fibrillation (AF). Methods: Prior to AF ablation, 98 patients (50 patients with paroxysmal AF and 48 patients with persistent AF) underwent pre-ablation planning cardiac CT. Additionally, delayed cardiac CT was performed to measure CT-ECV% as an index of diffuse myocardial fibrosis. Results: Persistent AF patients more frequently had a history of heart failure. Left atrial (LA) volume index was greater in persistent AF patients compared with paroxysmal AF patients. CT-ECV% of persistent AF patients was significantly higher than that of paroxysmal AF patients (30 ± 5 % vs. 26 ± 5 %, p &lt; 0.001). Univariate and multivariate analysis revealed that only persistent AF was independent associated with CT-ECV%. Furthermore, CT-ECV% in recurrence group after CA for AF was higher than that in non-recurrence group (29 ± 4 % vs. 26 ± 5 %, p = 0.013). Multivariate logistic regression analysis revealed that CT-ECV% was significantly correlated with AF recurrence after CA for AF. Receiver operating characteristic analysis showed that more than 28 % in the CT-ECV% was a significant predictor of AF recurrence (area under the curve 0.692, log-rank test: p &lt; 0.001). Conclusions: The quantification of diffuse LV fibrosis by CT-ECV% in conjunction with pre-ablation planning cardiac CT is feasible in AF patients, and persistent AF is independently associated with increasing diffuse LV fibrosis. Furthermore, CT-ECV% was significantly associated with AF recurrence after CA for AF. These findings suggested that it was more important to evaluate cardiac remodeling using CT and intervene early in AF.

Abstract 15925: Efficacy and Safety of Pulmonary Vein Isolation in Active Duty Military Members With Atrial Fibrillation

Introduction: The efficacy and safety of pulmonary vein isolation (PVI) for atrial fibrillation (AF) in the active duty (AD) military population has not been previously reported. Hypothesis: We postulate that PVI is an efficacious and safe treatment for young AD service members with AF. Methods: AD military personnel with AF who underwent PVI from 2004 to 2019 were retrospectively analyzed in four age groups (group 1, n=26, 18 to 27 years; group 2, n=38, 28 to 37 years; group 3, n=28, 38 to 49 years; group 4, n=12, ≥50 years). Primary endpoints were (1) PVI procedural efficacy defined as no or rare AF recurrence (&lt;6 episodes) 12 months after last PVI with or without antiarrhythmic drugs (AAD) and (2) procedure-related adverse events and complications. Results: 104 personnel (mean age 35.6+9 years, 84.6% paroxysmal AF, mean LVEF 60.2+6%, 19.2% maintained on AAD after PVI) underwent 142 PVI procedures with a mean follow up of 55.8+47 months. Procedural efficacy was attained in 96.2% of group 1, 78.9% of group 2, 75.0% of group 3, and 66.7% of group 4 (P=0.004, Figure 1). Freedom from AF was reached in 80.3% of group 1, 55.3% of group 2, 46.4% of group 3, 41.7% of group 4 (P=0.02). AADs were maintained in 11.5% of group 1, 21.0% of group 2, 14.3% of group 3, 41.7% of group 4 (P=0.144) and there was no difference in AF recurrence rates between those with AADs and those without (P=0.091). LVEF &lt;50% trended towards being a significant predictor of AF recurrence (OR, 7; 95% CI, 0.75-65; P=0.051). Complications occurred in only 4 (3.8%) cases (pulmonary vein stenosis, cardiac tamponade, arteriovenous fistula) with no complications in the youngest group. Conclusions: This study suggests that PVI is an effective and safe therapy for younger military personnel with AF desiring to decrease their individual AF burden.

Sex differences in the predictors of recurrent atrial fibrillation after catheter ablation: insights from the Kansai Plus Atrial Fibrillation (KPAF) registry

Abstract Background The impact of sex differences on the clinical outcomes of radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) is controversial. We previously reported that females experienced more frequent AF recurrences than males after the index and last RFCA procedures. Purpose To identify the risk factors associated with recurrent AF in females and males after RFCA of AF. Methods We conducted a large-scale, prospective, multicenter, observational study (Kansai Plus Atrial Fibrillation Registry). We enrolled 5010 consecutive patients who underwent an initial RFCA of AF at 26 centers (64±10 years; 1369 [27.3%] females; non-paroxysmal AF, 35.7%). The median follow-up duration was 2.9 years. Results The incidence of AF recurrences after a single procedure was 43.3% in females and 39.0% in males. After a multivariate adjustment at baseline, the significant predictors of AF recurrence in females after the index RFCA were non-paroxysmal AF (hazard ration [HR],1.59; 95% confidence interval [CI],1.31–1.93, p&amp;lt;0.0001), a history of AF ≥2 years (HR,1.47; 95% CI,1.24–1.74, p&amp;lt;0.0001), coronary artery disease (HR,1.43; 95% CI,1.03–1.98, p=0.0035), and an estimated glomerular filtration rate (eGFR)&amp;lt;60 mL/min/1.73m2 (HR,1.46; 95% CI,1.10–1.95, p=0.0086). On the other hand, significant predictors of AF recurrence in males after the index RFCA were non-paroxysmal AF (HR,1.54; 95% CI,1.37–1.73, p&amp;lt;0.0001), a history of AF ≥2 years (HR,1.40; 95% CI,1.26–1.56, p&amp;lt;0.0001), the number of antiarrhythmic drugs (HR,1.06; 95% CI,1.003–1.13, p=0.040), a left atrial diameter≥40mm (HR,1.13; 95% CI,1.007–1.27, p=0.038), and dilated cardiomyopathy (HR,1.55; 95% CI,1.07–2.26, p=0.021), however, an eGFR&amp;lt;60 mL/min/1.73m2 was not associated with AF recurrence in males (HR, 1.00; 95% CI, 0.88–1.13, p=0.97). Conclusion The Kansai Plus Atrial Fibrillation Registry revealed a distinct sex difference in terms of the predictors of recurrent AF after RFCA. Non-Paroxysmal AF and a long history of AF were common risk factors both in females and males. However, renal dysfunction was a significant predictor of AF recurrence in females, while it was not a risk of recurrence in males. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Research Institute for Production Development in Kyoto, Japan.

The Predictive Value of Tissue Doppler Indices for Early Recurrence of Atrial Fibrillation After Electrical Cardioversion.

PurposeSpectral tissue Doppler-derived E/e’ ratio has been proposed as the best parameter for prediction of atrial fibrillation (AF). Relaxation and contraction are equivalent parts of a continuous cardiac cycle, where systolic and diastolic abnormalities have a variable contribution to the left ventricle (LV) failure. The aim of this study was to investigate whether the E/(e’xs’) ratio is a better index than E/e‘ to predict AF recurrence and to determine the changes of spectral tissue Doppler indices 1 month after the electrical cardioversion (ECV).Patients and MethodsThe study included 77 persistent AF patients with restored sinus rhythm (SR) after ECV. Only patients with normal LV ejection fraction (EF) were included. Echocardiography and NT-proBNP laboratory findings were performed. A primary outcome was the early (within 1 month) recurrence of AF.ResultsAfter a 1 month follow-up period, 39 patients (50.6%) were in SR. E/e′ (HR=1.74, P=0.001) and E/(e’×s’) ratios (HR=8.17, P=0.01) were significant predictors of AF recurrence. E/(e’×s’) in combination with LV end-diastolic diameter >49.3 mm and NT-proBNP >2000 ng/L demonstrated a higher contribution in the model to predict AF recurrence compared to the E/e’ ratio (18.94, P=0.005 vs 1.95, P=0.001). On ROC analysis, E/(e’×s’) and E/e′ showed similar diagnostic accuracy (E/(e’×s’), AUC=0.71, P=0.002 and E/e′, AUC=0.75, P<0.0001). Average e‘ value significantly decreased after 1 month in SR (from 10.76±1.24 to 8.96±1.47 cm/s, P=0.01), E wave did not change significantly and E/e′ ratio tended to improve. A decrease of average e‘ and an increase of average s‘ values led to significant improvement of E/(e’xs’) ratio.ConclusionE/(e’xs’) and E/e’ ratios are comparable to predict early AF recurrence after ECV in patients with persistent AF. The e’ value decreased significantly after 1 month follow-up period after ECV for persistent AF patients.

Echocardiographic assessment of left atrial morphology and function to predict maintenance of sinus rhythm after electrical cardioversion in patients with non-valvular persistent atrial fibrillation and normal function or mild dysfunction of left ventricle.

The aim of this study was to assess whether echocardiographic measurements of left atrial (LA) morphology and function could predict sinus rhythm maintenance after electrical cardioversion among patients with atrial fibrillation (AF) and normal function or mild dysfunction of the left ventricle (LV). One hundred seventeen patients with persistent AF who underwent successful electrical cardioversion were prospectively enrolled. Echocardiography was performed one day subsequent to successful cardioversion. Patients were followed up clinically and electrocardiographically at 1, 6, and 12 months. At 12 months, 61 (52%) patients had maintained sinus rhythm (SR). Compared to patients who maintained SR, those with AF recurrence had larger LAs, worse LA systolic function, and increased LV filling pressure. On multivariate stepwise logistic regression, E/A ratios (odds ratio [OR] 0.550, 95% confidence interval [CI] 0.341-0.886; p = 0.014) and E/e' ratios (OR 0.871, 95% CI 0.771-0.985; p = 0.027) were significant predictors of AF recurrence. On receiver operator characteristic curve analysis of AF recurrence at 12 months, the area under curve for both E/A and E/e' ratios were 0.726. With an E/A cutoff of 2.2, the sensitivity for predicting AF recur-rence at 12 months was 72%, and specificity was 73%. With an E/e' cutoff of 9.17, the sensitivity for predicting AF recurrence at 12 months was 72%, and specificity was 74%. Left ventricular filling pressure assessed with E/A and E/e' ratios predict AF recurrence after electrical cardioversions among patients with AF and normal function of LV.