TY - JOUR
T1 - Characterization of Atrial Substrate to Predict the Success of Pulmonary Vein Isolation
T2 - The Prospective, Multicenter MASH-AF II (Multipolar Atrial Substrate High Density Mapping in Atrial Fibrillation) Study
AU - Bergonti, Marco
AU - Spera, Francesco Raffaele
AU - Ferrero, Teba Gonzalez
AU - Nsahlai, Michelle
AU - Bonomi, Alice
AU - Tijskens, Maxime
AU - Boris, Wim
AU - Saenen, Johan
AU - Huybrechts, Wim
AU - Miljoen, Hielko
AU - González-Juanatey, Jose Ramón
AU - Martínez-Sande, Jose Luis
AU - Vandaele, Lien
AU - Wittock, Anouk
AU - Heidbuchel, Hein
AU - Valderrábano, Miguel
AU - Rodríguez-Mañero, Moises
AU - Sarkozy, Andrea
N1 - Funding Information:
The study has been financially supported by an investigator-initiated research grant by Biosense Webster (Study ID – IIS-532) (M.R.M.).
Publisher Copyright:
© 2023 American Heart Association Inc. All rights reserved.
PY - 2023/1/3
Y1 - 2023/1/3
N2 - BACKGROUND: Left atrial substrate may have mechanistic relevance for ablation of atrial fibrillation (AF). We sought to analyze the relationship between low-voltage zones (LVZs), transition zones, and AF recurrence in patients undergoing pulmonary vein isolation. METHODS AND RESULTS: We conducted a prospective multicenter study on consecutive patients undergoing pulmonary vein isolation-only approach. LVZs and transition zones (0.5–1 mV) were analyzed offline on high-density electroanatomical maps collected before pulmonary vein isolation. Overall, 262 patients (61±11 years, 31% female) with paroxysmal (130 pts) or persistent (132 pts) AF were included. After 28 months of follow-up, 73 (28%) patients experienced recurrence. An extension of more than 5% LVZ in paroxysmal AF and more than 15% in persistent AF was associated with recurrence (hazard ratio [HR], 4.4 [95% CI, 2.0– 9.8], P<0.001 and HR, 1.9 [95% CI, 1.1– 3.7], P=0.04, respectively). Significant association was found between LVZs and transition zones and between LVZs and left atrial volume index (LAVI) (both P<0.001). Thirty percent of patients had significantly increased LAVI without LVZs. Eight percent of patients had LVZs despite normal LAVI. Older age, female sex, oncological history, and increased AF recurrence characterized the latter subgroup. CONCLUSIONS: In patients undergoing first pulmonary vein isolation, the impact of LVZs on outcomes occurs with lower burden in paroxysmal than persistent AF, suggesting that not all LVZs have equal prognostic implications. A proportional area of moderately decreased voltages accompanies LVZs, suggesting a continuous substrate instead of the dichotomous division of healthy or diseased tissue. LAVI generally correlates with LVZs, but a small subgroup of patients may present with dispro-portionate atrial remodeling, despite normal LAVI.
AB - BACKGROUND: Left atrial substrate may have mechanistic relevance for ablation of atrial fibrillation (AF). We sought to analyze the relationship between low-voltage zones (LVZs), transition zones, and AF recurrence in patients undergoing pulmonary vein isolation. METHODS AND RESULTS: We conducted a prospective multicenter study on consecutive patients undergoing pulmonary vein isolation-only approach. LVZs and transition zones (0.5–1 mV) were analyzed offline on high-density electroanatomical maps collected before pulmonary vein isolation. Overall, 262 patients (61±11 years, 31% female) with paroxysmal (130 pts) or persistent (132 pts) AF were included. After 28 months of follow-up, 73 (28%) patients experienced recurrence. An extension of more than 5% LVZ in paroxysmal AF and more than 15% in persistent AF was associated with recurrence (hazard ratio [HR], 4.4 [95% CI, 2.0– 9.8], P<0.001 and HR, 1.9 [95% CI, 1.1– 3.7], P=0.04, respectively). Significant association was found between LVZs and transition zones and between LVZs and left atrial volume index (LAVI) (both P<0.001). Thirty percent of patients had significantly increased LAVI without LVZs. Eight percent of patients had LVZs despite normal LAVI. Older age, female sex, oncological history, and increased AF recurrence characterized the latter subgroup. CONCLUSIONS: In patients undergoing first pulmonary vein isolation, the impact of LVZs on outcomes occurs with lower burden in paroxysmal than persistent AF, suggesting that not all LVZs have equal prognostic implications. A proportional area of moderately decreased voltages accompanies LVZs, suggesting a continuous substrate instead of the dichotomous division of healthy or diseased tissue. LAVI generally correlates with LVZs, but a small subgroup of patients may present with dispro-portionate atrial remodeling, despite normal LAVI.
KW - atrial fibrillation
KW - atrial volume
KW - fibrosis
KW - low-voltage zones
KW - pulmonary vein isolation
KW - scar
KW - transition zone
KW - Recurrence
KW - Prospective Studies
KW - Humans
KW - Catheter Ablation/methods
KW - Male
KW - Treatment Outcome
KW - Heart Atria/diagnostic imaging
KW - Female
KW - Pulmonary Veins/surgery
KW - Atrial Fibrillation/diagnosis
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U2 - 10.1161/JAHA.122.027795
DO - 10.1161/JAHA.122.027795
M3 - Article
C2 - 36565183
AN - SCOPUS:85145492130
SN - 2047-9980
VL - 12
SP - e027795
JO - Journal of the American Heart Association
JF - Journal of the American Heart Association
IS - 1
M1 - e027795
ER -