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. 2021 Jan 4;37(1):79-87.
doi: 10.1002/joa3.12492. eCollection 2021 Feb.

Responsiveness to bepridil predicts atrial substrate in patients with persistent atrial fibrillation

Daisuke Yakabe  1 , Yusuke Fukuyama  1 , Masahiro Araki  1 , Toshihiro Nakamura  1
Affiliations

Responsiveness to bepridil predicts atrial substrate in patients with persistent atrial fibrillation

Daisuke Yakabe et al. J Arrhythm. .

Abstract

Background: The low voltage zone (LVZ) detected with three-dimensional electroanatomical mapping is a surrogate marker of atrial scar in patients with persistent atrial fibrillation (PeAF) and is associated with poor clinical outcomes after catheter ablation. However, fewer studies have reported the relationship between responsiveness to antiarrhythmic drugs and the LVZ.

Methods: We retrospectively analyzed 76 patients who underwent catheter ablation for PeAF at our center. Rhythm control with bepridil was initiated before ablation in all patients, and electrical cardioversion was performed in cases of failure to restore sinus rhythm with bepridil alone. Patients with successful sinus restoration with bepridil alone (≤200 mg/d) were defined as "responders", while those who required electrical cardioversion as well were defined as "non-responders". We compared the LVZ ratio (ratio of the LVZ surface area to the left atrium surface area on three-dimensional electroanatomical mapping) and the recurrence-free rate after ablation between the two groups.

Results: Of the 76 patients, 48 (63.2%) were responders to bepridil. The median LVZ ratio was significantly lower in the responder group than in the nonresponder group (7.5% vs 14.0%, P = .009). Multivariate analysis revealed that response to bepridil was an independent predictor of normal voltage (P = .02, odds ratio = 0.20, 95% confidence interval = 0.04-0.76). The recurrence-free rate at 1 year after catheter ablation was significantly higher in the responder group than in the nonresponder group (87.1% vs 62.3%, P = .03).

Conclusions: Response to bepridil is a marker of normal voltage in electroanatomical mapping and is significantly associated with better clinical outcomes after catheter ablation.

Keywords: atrial fibrillation; atrial remodeling; bepridil hydrochloride; catheter ablation; low voltage zone.

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Conflict of interest statement

The authors declare no conflicts of interests for this article. The protocol for this study was approved by the Ethics Committee of our center on 22 April 2020 (Approval number: 20C009).

Figures

FIGURE 1
FIGURE 1
Patient flow until catheter ablation. ABL, ablation; AF, atrial fibrillation; ECV, electrical cardioversion; RC, rhythm control; SR, sinus rhythm
FIGURE 2
FIGURE 2
Voltage map of the responder and nonresponder groups. This figure includes the voltage maps of the two representative cases (above). The map on the left is of a 60‐year‐old male who was successfully restored to sinus rhythm with 100 mg per day of bepridil. The LVZ ratio was 2.6%. The map on the right is of a 72‐year‐old female who consumed 200 mg per day of bepridil and required electrical cardioversion for achieving sinus rhythm. The LVZ ratio was 38.2%. AP, anterior‐posterior view; LVZ, low voltage zone; PA, posterior anterior view
FIGURE 3
FIGURE 3
Recurrence‐free rates after catheter ablation. The gray zone indicates the blanking period. (A) A comparison of the responsiveness to bepridil revealed that the recurrence‐free rate after catheter ablation was significantly lower in the nonresponder group than in the responder group (P = .03). (B) On the other hand, there were no significant differences between the sinus rhythms before and after ablation (P = .2). ABL, catheter ablation; AF, atrial fibrillation; SR, sinus rhythm
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