Global Left Atrial Strain in the Prediction of Sinus Rhythm Maintenance after Catheter Ablation for Atrial Fibrillation

doi:10.1016/j.echo.2014.08.017

Journal of the American Society of Echocardiography

Volume 27, Issue 11, November 2014, Pages 1184-1192

https://doi.org/10.1016/j.echo.2014.08.017 Get rights and content

Background

Left atrial (LA) strain is a sensitive measure of LA mechanics. However, its relationship with rhythm outcomes after catheter ablation in patients with atrial fibrillation (AF) is not well established. The aim of this study was to evaluate whether baseline LA global longitudinal strain (LAε) predicts rhythm outcomes in patients who undergo catheter ablation for AF.

Methods

In 256 patients with AF (paroxysmal, 204; persistent, 52), comprehensive echocardiography was performed with assessment of LAε by using Velocity Vector Imaging to calculate average strain values from apical four- and two-chamber views before ablation (median, 41 days; interquartile range, 1–95 days).

Results

After a median of 8.0 months (interquartile range, 4.0–23.3 months) of follow-up, 149 patients (58%) had maintained sinus rhythm and 107 patients (42%) had recurrence of AF. In our study cohort (mean age 59 ± 11 years; mean left ventricular ejection fraction, 58 ± 10%), impaired total LAε (LAε_total) was associated with greater left ventricular mass index (r = −0.245, P < .001) and worsening left ventricular diastolic function (ratio of transmitral flow peak early diastolic velocity to peak early diastolic velocity of the mitral annulus: r = −0.357, P < .001; maximal LA volume index: r = −0.393, P < .001). Patients with LAε_total < 23.2% showed a higher incidence of AF recurrence compared with patients with LAε_total ≥ 23.2% (log-rank P < .001). In multivariate Cox proportional-hazards analysis, LAε_total was independently related to rhythm outcomes (hazard ratio, 0.944; 95% confidence interval, 0.915–0.975; P < .001) after AF ablation. Moreover, LAε_total provided incremental predictive value for rhythm outcomes over clinical features (increment in global χ² = 14.63, P < .001).

Conclusions

In patients with AF, baseline LAε_total was associated with rhythm outcome after catheter ablation.

Section snippets

Study Population

We studied 319 patients with paroxysmal or persistent AF who underwent radiofrequency catheter ablation for AF from June 2008 to May 2010 and underwent preprocedural echocardiography <6 months before the procedure and were in normal sinus rhythm during echocardiography. Of this group, patients were excluded because of valvular heart disease or surgery (n = 18) or a history of cardiac surgery (n = 9), absence of clinical follow-up data (n = 15), and uninterpretable images (n = 21). This study

Study Population

Of the 277 patients, 256 (92.4%) had LAε that could be measured in both four- and two-chamber views. Echocardiography was performed a median of 41 days (interquartile range, 1–95 days) before catheter ablation. The average frame rate of the clips for LAε analysis was 39 ± 12 frames/sec. The coefficient of variation for intraobserver variability for LAε_total was 5.8 ± 4%. The coefficient of variation of interobserver variability was 7.5 ± 4.5%. The bias and limits of agreement of intra- and

Discussion

This study demonstrated the prognostic significance of LAε for predicting sinus rhythm maintenance in patients with AF after catheter ablation. We showed that (1) baseline LAε_total was an independent predictor of rhythm outcome after AF ablation; (2) LAε_total was significantly associated with age, LV mass, and LV diastolic function; (3) LAε_total ≥ 23.2% predicted long-term sinus rhythm maintenance; and (4) the measurement of LAε_total was highly feasible and showed good reproducibility.

Conclusions

In patients with AF, baseline LAε_total was an independent predictor of sinus rhythm maintenance after catheter ablation. LAε_total provided incremental predictive value for rhythm outcomes over clinical features. Further long-term prospective studies are needed to evaluate the clinical utility of LAε analysis.

Acknowledgments

The authors acknowledge the secretarial assistance of Marie Campbell.

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Citation Excerpt :
Even though the reservoir function of the LA is so far the most investigated of the LA strain measurements, the contractile function has previously demonstrated to provide prognostic value. In a cohort of 256 patients with AF, Motoki et al. [12] focused on the value of LASr to predict recurrence after CA, but also investigated LASct and LAScd. They found LASct to have a comparable predictive value of AF recurrence to LASr.
Despite improvement in treatment strategies of atrial fibrillation (AF), a considerable number of patients still experience recurrence of atrial tachyarrhythmia (ATA) following catheter ablation (CA). This study aimed to investigate the prognostic value of left atrial (LA) deformation analysis in a large group of patients undergoing CA for AF.
This study included 678 patients with AF. Echocardiography including two-dimensional speckle tracking echocardiography (2DSTE) was performed in all patients prior to CA. Logistic regression analysis was used to assess the association between ATA recurrence and LA strain during reservoir phase (LASr), LA strain during contraction phase (LASct), and LA strain during conduit phase (LAScd).
During one-year follow-up, 274 (40%) experienced ATA recurrence. Median age of the included study population was 63.2 years (IQR: 55.5, 69.5) and 485 (72%) were male. Patients with recurrence had lower LASr (22.6% vs. 25.1%, p = 0.001) and LASct (10.7% vs. 12.4%, p < 0.001). No difference in LAScd was observed. After adjusting for potential clinical and echocardiographic confounders LASr (OR = 1.04, CI95% [1.01; 1.07], p = 0.015, per 1% decrease) and LASct (OR = 1.06, CI95% [1.02; 1.11], p = 0.007, per 1% decrease) remained independent predictors of recurrence. However, in patients with a normal-sized LA (LA volume index<34 mL/m²), only LASct remained an independent predictor of recurrence (OR = 1.07, CI95% [1.01; 1.12], p = 0.012, per 1% decrease).
In patients undergoing CA for AF, LA deformation analysis by 2DSTE could be of use in risk stratification in clinical practice regarding ATA recurrence, even in patients with a normal-sized LA.
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Clinical InvestigationAtrial FibrillationGlobal Left Atrial Strain in the Prediction of Sinus Rhythm Maintenance after Catheter Ablation for Atrial Fibrillation

Background

Methods

Results

Conclusions

Section snippets

Study Population

Study Population

Discussion

Conclusions

Acknowledgments

J Am Coll Cardiol

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Soc Echocardiogr

Am J Cardiol

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Soc Echocardiogr

Heart Rhythm

Control Clin Trials

J Am Soc Echocardiogr

Am J Cardiol

Am J Cardiol

J Am Soc Echocardiogr

J Am Coll Cardiol

J Am Soc Echocardiogr

Am J Cardiol

J Am Coll Cardiol

Clinical Investigation
Atrial Fibrillation
Global Left Atrial Strain in the Prediction of Sinus Rhythm Maintenance after Catheter Ablation for Atrial Fibrillation