Left atrial longitudinal strain by speckle tracking as independent predictor of recurrence after electrical cardioversion in persistent and long standing persistent non-valvular atrial fibrillation

Abstract

Atrial fibrillation (AF) is the most common arrhythmia in humans. After successful cardioversion, there is a recurrence of 60% due to atrial remodeling, and it has been shown that the global peak atrial longitudinal strain (GPALS) is decreased in these subjects. The aim of this study was to evaluate the predictive value of GPALS for AF recurrence. A prospective cohort of patients with persistent (PnVAF) and long standing persistent non-valvular AF (LSPnVAF) which underwent electrical cardioversion was evaluated with standard echocardiographic variables and GPALS quantification. The primary endpoint was AF recurrence at 6 months. We included PnVAF (n = 50, aged 68.4 ± 10.2 years, female 46%, lasted AF 6 months) and LSPnVAF (n = 81, aged 66.5 ± 13.1 years, female 36%, lasted AF 18 months). At 6 months there were a 68% of recurrence of AF in PnVAF and 53% in LSPnVAF group. GPALS was lower in recurrence 7.8 ± 2.0% versus 21.2 ± 8.9% (p < 0.001) for PnVAF and 7.3 ± 2.7% versus 20.7 ± 7.6% (p < 0.001) in LSPnVAF. GPALS ≤ 10.75% discriminates recurrence at 6 months with a sensitivity of 85%, specificity 99%, PPV 85%, NPV 90%, LR + 8.5 and LR- 0.17. The independent predictors of recurrence in PnVAF were GPALS ≤ 10.75% HR 8.89 [(2.2-35.7), p < 0.01] meanwhile in LSPnVAF were age HR 1.039 [(1.007-1.071), p = 0.01], and GPALS ≤ 10.75% HR 28.1 [(7.2-109.1), p < 0.001]. In subjects with PnVAF and LSPnVAF with successful electrical cardioversion, GPALS ≤ 10.75% predicts arrhythmia recurrence at 6-month follow-up.

Keywords: Atrial fibrillation; Longitudinal atrial strain; Recurrence.

Fig. 1

Representative global peak atrial longitudinal strain (GPALS) images. Apical long axes of four (a) and two chambers (b) with tracing the atrial endocardial border. Automated GPALS quantification with two-dimensional speckle tracking in apical views of four (c) and two chambers (d). We defined GPALS as the average of three beats each, in this case GPALS was 6.8% in a subject with AF recurrence. GPALS global peak atrial longitudinal strain, AF atrial fibrillation

Fig. 2

Atrial deformation according to the presence or absence of recurrence after cardioversion, GPALS is lower in subjects with recurrence versus subjects who remained in sinus rhythm in both groups of AF. *U Mann–Whitney. GPALS global peak atrial longitudinal strain, PnVAF persistent non-valvular AF, LSPnVAF long standing persistent non-valvular AF

Fig. 3

ROC curve for GPALS and risk of recurrence after cardioversion in subjects with PnVAF and LSPnVAF. A cut-point of GPALS ≤ 10.75% identifies recurrence with S 85%, E 99%, PPV 85%, NPV 90%, LR+ 8.5 and LR− 0.17. GPALS global peak atrial longitudinal strain, PnVAF persistent non-valvular AF, LSPnVAF long standing persistent non-valvular AF, PPV positive predictive value, NPV negative predictive value, LR+ positive likelihood ratio, LR− negative likelihood ratio

Fig. 4

Recurrence-free survival curve of subjects with PnVAF (a) and LSPnVAF (b) according to the GPALS cut-point obtained by Youden index. The subjects with GPALS ≤ 10.75% have greater recurrence at 6 months versus subjects with GPALS ≥ 10.76%. PnVAF persistent non-valvular AF, LSPnVAF long standing persistent non-valvular AF, GPALS global peak atrial longitudinal strain