Left Atrial LGE and Arrhythmia Recurrence Following Pulmonary Vein Isolation for Paroxysmal and Persistent AF

JACC Cardiovasc Imaging. 2016 Feb;9(2):142-8. doi: 10.1016/j.jcmg.2015.10.015. Epub 2016 Jan 6.

Abstract

Objectives: The aims of this study were to: 1) use a novel method of late gadolinium enhancement (LGE) quantification that uses normalized intensity measures to confirm the association between LGE extent and atrial fibrillation (AF) recurrence following ablation; and 2) examine the presence of interaction and effect modification between LGE and AF persistence.

Background: Recurrent AF after catheter ablation has been reported to associate with the baseline extent of left atrial LGE on cardiac magnetic resonance. Traditional methods for measurement of intensity lack an objective threshold for quantification and interpatient comparisons of LGE.

Methods: The cohort included 165 participants (mean age 60.0 ± 10.2 years, 77% men, 57% with persistent AF) who underwent initial AF ablation. The association of baseline LGE extent with AF recurrence was examined using multivariable Cox proportional hazards models. Multiplicative and additive interactions between AF type and LGE extent were examined.

Results: During 10.2 ± 5.7 months of follow-up, 63 patients (38.2%) experienced AF recurrence. Baseline LGE extent was independently associated with AF recurrence after adjusting for confounders (hazard ratio: 1.5 per 10% increased LGE; p < 0.001). The hazard ratio for AF recurrence progressively increased as a function of LGE. The magnitude of association between LGE >35% and AF recurrence was greater among patients with persistent AF (hazard ratio: 6.5 [p = 0.001] vs. 3.6 [p = 0.001]); however, there was no evidence for statistical interaction.

Conclusions: Regardless of AF persistence at baseline, participants with LGE ≤35% have favorable outcomes, whereas those with LGE >35% have a higher rate of AF recurrence in the first year after ablation. These findings suggest a role for: 1) patient selection for AF ablation using LGE extent; and 2) substrate modification in addition to pulmonary vein isolation in patients with LGE extent exceeding 35% of left atrial myocardium.

Keywords: atrial fibrillation; catheter ablation; late gadolinium enhancement; magnetic resonance imaging.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Atrial Fibrillation / diagnosis
  • Atrial Fibrillation / physiopathology
  • Atrial Fibrillation / surgery*
  • Catheter Ablation / adverse effects*
  • Chi-Square Distribution
  • Contrast Media
  • Female
  • Gadolinium DTPA
  • Heart Atria / pathology
  • Heart Atria / physiopathology
  • Heart Atria / surgery*
  • Humans
  • Kaplan-Meier Estimate
  • Magnetic Resonance Angiography*
  • Male
  • Middle Aged
  • Multivariate Analysis
  • Patient Selection
  • Predictive Value of Tests
  • Proportional Hazards Models
  • Prospective Studies
  • Pulmonary Veins / pathology
  • Pulmonary Veins / physiopathology
  • Pulmonary Veins / surgery*
  • Recurrence
  • Risk Factors
  • Time Factors
  • Treatment Outcome

Substances

  • Contrast Media
  • Gadolinium DTPA