Left Ventricular Filling Pressure as Assessed by the E/e' Ratio Is a Determinant of Atrial Fibrillation Recurrence after Cardioversion

Abstract

Purpose: Left ventricular (LV) filling pressure affects atrial fibrillation (AF) recurrence. We investigated the relationship between diastolic dysfunction and AF recurrence after cardioversion, and whether LV filling pressure was predictive of AF recurrence.

Materials and methods: Sixty-six patients (mean 58±12 years) with newly diagnosed persistent AF were retrospectively enrolled. We excluded patients with left atrial (LA) diameters larger than 50 mm, thereby isolating the effect of LV filling pressure. We evaluated the differences between the patients with (group 1) and without AF recurrence (group 2).

Results: Group 1 showed increased LA volume index (LAVI) and E/e' compared to group 2 (p<0.05). During a mean follow-up period of 25±19 months, AF recurrence after cardioversion was 60.6% (40/66). The area under the receiver operating characteristics curve of E/e' for AF recurrence was 0.780 [95% confidence interval (CI): 0.657-0.903], and the optimal cut-off value of the E/e' was 9.15 with 75.0% of sensitivity and 73.1% of specificity. A Kaplan-Meier survival curve showed that the cumulative recurrence-free survival rate was significantly lower in patients with higher LV filling pressure (E/e'>9.15) compared with patients with lower LV filling pressure (E/e'≤9.15) (log rank p=0.008). Cox regression analysis revealed that E/e' [hazards ratio (HR): 1.100, 95% CI: 1.017-1.190] and LAVI (HR: 1.042, 95% CI: 1.002-1.084) were independent predictors for AF recurrence after cardioversion.

Conclusion: LV filling pressure predicts the risk of AF recurrence in persistent AF patients after cardioversion.

Keywords: Diastolic dysfunction; atrial fibrillation; cardioversion; left ventricular filling pressure.

Fig. 1. The representative cases which reveal the difference of E/e' between two groups. (A) In patients without recurrence, early (E) diastolic mitral inflow peak velocity and early diastolic mitral annulus peak velocity (e') were measured, and the ratio of E/e' was calculated. (B) In patients with recurrence, the ratio of E/e' was calculated by the same way.

Fig. 2. The scatter plots of E/e' with or without AF recurrence. AF, atrial fibrillation; E/e', the ratio of mitral peak velocity of early filling (E) to early diastolic mitral annular velocity (e').

Fig. 3. Receiver operating characteristic (ROC) curves for E/e' for AF recurrence after cardioversion. Area under the ROC curve for E/e' was 0.780 (95% confidence interval: 0.657-0.903, p<0.001). AF, atrial fibrillation; E/e', the ratio of mitral peak velocity of early filling (E) to early diastolic mitral annular velocity (e').

Fig. 4. The Kaplan-Meier survival curves for AF recurrence in patients after cardioversion with or without increased LV filling pressure. AF, atrial fibrillation; E/e', the ratio of mitral peak velocity of early filling (E) to early diastolic mitral annular velocity (e'); LV, left ventricle.