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. 2014 Jul;7(4):586-92.
doi: 10.1161/CIRCIMAGING.113.001472. Epub 2014 Jun 5.

Left atrial passive emptying function determined by cardiac magnetic resonance predicts atrial fibrillation recurrence after pulmonary vein isolation

John A Dodson  1 , Tomas G Neilan  1 , Ravi V Shah  1 , Hoshang Farhad  1 , Ron Blankstein  1 , Michael Steigner  1 , Gregory F Michaud  1 , Roy John  1 , Siddique A Abbasi  1 , Michael Jerosch-Herold  1 , Raymond Y Kwong  2
Affiliations

Left atrial passive emptying function determined by cardiac magnetic resonance predicts atrial fibrillation recurrence after pulmonary vein isolation

John A Dodson et al. Circ Cardiovasc Imaging. 2014 Jul.

Abstract

Background: Although pulmonary vein isolation has become a mainstream therapy for selected patients with atrial fibrillation (AF), late recurrent AF is common and its risk factors remain poorly defined. The purpose of our study was to test the hypothesis that reduced left atrial passive emptying function (LAPEF) as determined by cardiac magnetic resonance has a strong association with late recurrent AF after pulmonary vein isolation.

Methods and results: Three hundred forty-six patients with AF referred for cardiac magnetic resonance pulmonary vein mapping before pulmonary vein isolation were included. Maximum LA volumes (VOLmax) and volumes before atrial contraction (VOLbac) were measured; LAPEF was calculated as (VOLmax-VOLbac)/VOLmax×100. Kaplan-Meier curves were constructed to determine late recurrent AF stratified by LAPEF quintile. Cox proportional hazards regression was used to adjust for known markers of recurrence. During a median follow-up of 27 months, 124 patients (35.8%) experienced late recurrent AF. Patients with recurrence were more likely to have nonparoxysmal AF (75.8% versus 51.4%; P<0.01), higher mean VOLmax (60.2 versus 52.8 mL/m(2); P<0.01), and lower mean LAPEF (19.1% versus 26.0%; P<0.01). Patients in the lowest LAPEF quintile were at highest risk of developing recurrent AF (2-year recurrence for lowest versus highest: 60.5% versus 17.3%; P<0.01). After adjusting for known predictors of recurrence, patients with low LAPEF remained significantly more likely to recur (hazard ratio for lowest versus highest quintile, 3.92; 95% confidence interval, 2.01-7.65).

Conclusions: We found a strong association between LAPEF and recurrent AF after pulmonary vein isolation that persisted after multivariable adjustment.

Keywords: atrial fibrillation; catheter ablation; magnetic resonance imaging.

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Conflict of interest statement

CONFLICT OF INTEREST DISCLOSURES: None

Figures

Figure 1
Figure 1. Measurement of left atrial function by CMR
Left atrial passive emptying function (LAPEF) was determined as the difference between volumes at maximum LA size (LAVmax) and LA size before atrial contraction (LAVbac). LA volumes were determined according to the area-length method.
Figure 2
Figure 2. Rate of late recurrent AF 2 years following PVI stratified by quintile of left atrial passive emptying function (LAPEF)
There was a decrease in the AF recurrence rate from lowest to highest LAPEF (P for linear trend <0.001). Patients in the lowest quintile of LAPEF (worst function) had a 2-year recurrence rate of 60.5%, while those in the highest quintile (best function) had a 2-year recurrence rate 17.3%.
Figure 3
Figure 3. Kaplan-Meier survival curves for late recurrent AF after PVI stratified by LAPEF showing event-free survival time among five quintiles of function
Patients with the highest LAPEF (“best function”, shown in orange) had the lowest recurrence rate over a median follow-up of 27 months. Selected P values for comparisons between groups are shown (quintile 1 vs. quintile 2, P=0.0113; quintile 1 vs. quintile 3, P<0.0001).
Figure 4
Figure 4. Receiver operating characteristic (ROC) curve for prediction of 2-year late recurrent AF after PVI with clinical model (blue) and clinical model plus LAPEF (orange)
Clincial model included variables associated with late recurrent AF in prior studies (hypertension, left atrial volume adjusted for body surface area, non-paroxysmal AF, diabetes, left ventricular systolic function, and >1 ablation procedure). Addition of LAPEF to clinical model improved discrimination compared with clinical model alone (C statistics = 0.724 and 0.674 respectively, P<0.0001).
Figure 5
Figure 5. Receiver operating characteristic (ROC) curve for the prediction of late recurrent AF in model using LAPEF alone
Sensitivity and specificity for three selected cutoffs (LAPEF <20%, LAPEF <25%, LAPEF <30%) are shown. With lower LAPEF values, sensitivity for predicting late recurrent AF decreased while specificity increased. Model C statistic = 0.676.
See this image and copyright information in PMC

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