This was a single-center, retrospective analysis of patients with AF who
had impaired LV function (LVEF <50%) on the initial or worst
echocardiogram before ablation and who underwent catheter ablation for
the AF at Saiseikai Yokohamashi Tobu Hospital from June 2016 to January
2020. We excluded patients receiving hemodialysis or who had structural
heart disease and suspicion of other cardiomyopathies by
echocardiography. After control of the AF, the patients were divided
into two groups based on whether the LVEF was <60% (Group 1)
or ≧60% (Group 2) more than 3 months after
ablation.
If the patient’s LVEF became ≧60% within 3 months after ablation, the
patient was included in Group 2. We compared the baseline
characteristics between the two groups. This study was conducted at
Saiseikai Yokohamashi Tobu Hospital and was approved by the
institutional review board of Saiseikai Yokohamashi Tobu Hospital (IRB
# 20200050).
2.2 Echocardiographic data
Echocardiography was performed using various devices (Vivid E95, GE
Healthcare Japan Corp.; APLIO Artida, APLIO I900, and APLIO 300, Canon
Medical Systems Corp.; and iE, Philips Japan, Ltd.). LVEF and LAV were
measured by the modified Simpson’s method and by the prolate-ellipsoid
method (LAV-echo), respectively. Division of the LAV-echo by the BSA
resulted in LAV index of echocardiography (LAVI-echo). If LVEF became
≧60% within 3 months after ablation, the data were adopted. If the
patient had a recurrence after ablation, echocardiography was performed
over 3 months after the arrhythmia resolved.
2.3 CT data
We performed CT before ablation. We utilized the CT data, and the
anatomy of LA and PVs was constructed by Ziostation2 Version 2.9.7.1
(Ziosoft, Inc). Vertical and horizontal rotation was performed to
maximize the length between the PV roof and the first bifurcation of PV.
The LA‐PV junction was determined as previously
reported6,7,8. The LA-LAA junction was defined as the
root of LAA. LAV determined by CT (LAV-CT) was removed of the LAA and
PVs by a manual procedure at these junctions (Figure 1). Division of the
LAV by the BSA resulted in the LAV index of CT (LAVI-CT).
2.4 Ablation procedure
Patients received intravenous heparin with a target minimum activated
clotting time of 300 seconds. AF ablation was performed using a
cryoballoon (Arctic Front Advance; Medtronic, Inc) for PVI and a
3-dimentional electroanatomic mapping system (EnSite Precision; Abbott,
Inc) in all patients. If the PVI was incomplete, complete PVI was
performed with an irrigated radiofrequency catheter (FlexAbility;
Abbott, Inc). Cavotricuspid isthmus line ablation was completed with the
radiofrequency catheter.
2.5 Post-ablation follow-up
A 12-lead electrocardiogram was performed at every visit. 24-hour Holter
monitoring and echocardiography were performed according to the
physician’s judgment. If patients had a CIED, AF was monitored. Biopsy
and CMR imaging were not performed. Recurrence of AF is defined as
longer than 30 seconds of AF or atrial tachycardia/flutter episode more
than 3 months after ablation.
2.6 Statistical analysis
Continuous data were described as median and interquartile range and
categorical data as numbers and percentages. The Mann–Whitney U test
and Fisher exact test were used to compare differences across groups.
All tests were 2 sided, and a p value < 0.05 was considered to
indicate statistical significance. A ROC curve was calculated to
identify the optimal cutoff point where sensitivity and specificity
would be maximal for the prediction of improved LVEF. The AUC and its
95% CI were calculated as measures of the accuracy of the data.
Statistical analysis was performed using IBM SPSS Advanced Statistics 24
(IBM, Inc). We could not perform multivariable analysis because of the
small amount of data.
3 Results
3.1 Characteristics of 2 groups at
baseline and predictors for improving LVEF
A total of 31 patients (nine in Group1 and 22 in Group 2) were included
in this study. One patient in Group 1 and eight patients in Group 2 had
AF controlled by cardioversion and/or medications before ablation. In
Group 1, one patient had a CIED before ablation and two patients had it
after ablation. In Group 2, nobody
had CIED. LAV-CT, LAVI-CT, LAVI-echo, and LAD were significant between
the groups. Small LAV-CT, LAVI-CT, LAV-echo, and LAD were predictors for
improving LVEF. All other characteristics were not significantly
different between the groups (Table 1). The AUCs of LAV-CT, LAVI-CT,
LVAI-echo, and LAD were 0.859 (95% CI 0.729-0.991, p=0.002), 0.869
(95% CI 0.741-0.997, p=0.001), 0.798 (95% CI 0.640-0.956, p=0.010),
and 0.750 (95% CI 0.545-0.955, p=0.031), respectively. The cutoff
values were 147 ml, 79 ml/m2, 37
ml/mm2, and 45.8 mm, respectively (Figure 2).
3.2 Characteristics of 2 groups after ablation
Post-ablation echocardiographic data were not significantly different
between the groups except for the follow up period of echocardiography
and LAD. Recurrence of arrhythmia
was not significantly different between the groups (Table 2).
4 Discussion
4.1 Major finding
Several pieces of previous literature reported that small LV dimensions,
younger age, and male sex may help to differentiate TCM from
DCM3,4,9,10. These parameters in this study were not
significantly different between the two groups. LAV-CT, LAVI-CT,
LAVI-echo, and LAD were significantly different, whereas the difference
in the LAV-echo was close to significant (p = 0.0583). LA dilation is
frequently observed in DCM because of diastolic dysfunction, functional
mitral regurgitation, AF, and LV cavity enlargement11.
Therefore, small LA volume and dimension may be predictors of TCM with
AF. Small LAV-echo and LAD (LAV-echo <67 ml and LAD
<45.8 mm, which were the optimal cutoff values) may be helpful
for the diagnosis of TCM with AF, because echocardiography is
noninvasive and easy. However, these results of this study may not apply
to TCM with other arrhythmias.
4.2 AF ablation
AF is the most prevalent arrhythmia and the most common cause of
TCM1,2, but there is no clear data on the prevalence
of TCM12. TCM in 4% of patients referred for PVI was
reported13. Ventricular rate during AF does not
predict for LVEF improvement14. Thus, it is difficult
the diagnosis of TCM with AF. In case of other supraventricular
arrhythmias, we can recognize that they cause TCM and we can recommend
ablation3,15,16,17. All patients with HF and AF should
have ablation for AF18,19, but it is prevented by the
risk of the procedure’s complications20,21,22,23:
Phrenic nerve injury, PV stenosis, Atrioesophageal fistula, and so on.
Hence, we recognize some characteristics of TCM before ablation, and we
are willing to recommend patients with possible TCM for ablation.
4.3 Variety in Group 1
Patients in Group 1 were classified into two groups. In Group A, their
LVEF improved a little. In group B, their LVEF remained the same or
decreased. Group A was composed of the following patients: (1) those
whose LVEF had been improving, (2) those with overlapping DCM and
TCM1, and (3) those with recurrence of AF. Group B was
composed of just DCM or other cardiomyopathies. Accordingly, we should
have followed Group 1 longer.
4.4 Limitations
This study has several limitations. It was a single-center study and
included a small number of patients. LAV-CT was measured by hand and it
might not be exact. Some tests, such as echocardiography, were performed
according to individual judgment. Although three patients (33%) in
Group 1 had CIED in the end, we did not notice the occult recurrence of
AF.
5 Conclusion
LAV-CT <147 ml, LAVI-CT <79 ml/m2,
LAVI- echo <37 ml/m2, and LAD
<45.8 mm were predictors of LVEF improvement.
The parameters measured by CT were
more useful than by echocardiography. Small LAV and dimension before
ablation may be predictors for TCM with AF and may be helpful for its
diagnosis.
Conflict of interests
The authors declare that there are no conflicts of interests.
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