Impact of advanced liver fibrosis on atrial fibrillation recurrence after ablation in non-alcoholic fatty liver disease patients

Abstract

Aim: Advanced liver fibrosis is independently associated with new onset of atrial fibrillation (AF). Non-invasive liver fibrosis scores are considered an effective strategy for assessing liver fibrosis. This study aimed to investigate the association between advanced liver fibrosis and AF recurrence after ablation in patients with non-alcoholic fatty liver disease (NAFLD).

Materials and methods: A total of 345 AF patients with NAFLD who underwent de novo ablation between 2019 and 2020 at two large hospitals in China were included in this study. AF recurrence was defined as the occurrence of atrial arrhythmia for more than 30 s by electrocardiogram or 24 h Holter monitoring after the first 3 months of ablation. Predictive values of non-alcoholic fatty liver disease fibrosis score (NFS) and Fibrosis-4 (FIB-4) scores for AF burden and recurrence after ablation were assessed.

Results: At the 1 year follow-up after ablation, 38.8% of patients showed recurrence. Patients with recurrence who had higher FIB-4 and NFS scores were more likely to have persistent AF and a duration of AF ≥ 3 years. In Kaplan-Meier analysis, patients with intermediate and high NFS and FIB-4 risk categories had a higher risk of AF recurrence. Compared to patients with the low risk, intermediate and high NFS, and FIB-4 risk were independently associated with AF recurrence in multivariate Cox regression analysis (high risk: NFS, hazard ratio (HR): 3.11, 95% confidence interval (CI): 1.68∼5.76, p < 0.001; FIB-4, HR: 3.91, 95% CI: 2.19∼6.98, p < 0.001; intermediate risk: NFS, HR: 1.85, 95% CI: 1.10∼3.10, p = 0.020; FIB-4, HR: 2.08, 95% CI: 1.27∼3.41, p = 0.003).

Conclusion: NFS and FIB-4 scores for advanced liver fibrosis are associated with AF burden. Advanced liver fibrosis is independently associated with AF recurrence following ablation. Advanced liver fibrosis might be meaningful in risk classification for patients after AF ablation.

Keywords: atrial fibrillation; liver fibrosis; non-alcoholic fatty liver disease; radiofrequency ablation; recurrence.

FIGURE 1

(A,B) Distribution of the patients with a duration of atrial fibrillation (AF) ≥ 3 years, and persistent atrial fibrillation (PeAF) according to fibrosis-4 (FIB-4), and non-alcoholic fatty liver disease fibrosis score (NFS) risk categories. AF, atrial fibrillation; PeAF, persistent atrial fibrillation; NFS, non-alcoholic fatty liver disease fibrosis score; FIB-4, fibrosis-4.

FIGURE 2

Kaplan–Meier curve of risk categories of non-alcoholic fatty liver disease fibrosis score (NFS) for atrial fibrillation (AF) recurrence in patients with non-alcoholic fatty liver disease (NAFLD). NFS, non-alcoholic fatty liver disease fibrosis score; AF, atrial fibrillation; NAFLD, non-alcoholic fatty liver disease.

FIGURE 3

Kaplan–Meier curve of risk categories of fibrosis-4 (FIB-4) for atrial fibrillation (AF) recurrence in patients with non-alcoholic fatty liver disease (NAFLD). FIB-4, fibrosis-4; AF, atrial fibrillation; NAFLD, non-alcoholic fatty liver disease.

FIGURE 4

Hazard ratio (HR) by interquartile (IQR) of fibrosis-4 (FIB-4) and non-alcoholic fatty liver disease fibrosis score (NFS). Filled circles and vertical lines indicate the HR and 95% confidence interval (CI) for IQR 2–4 of FIB-4 and NFS, relative to IQR 1 of FIB-4 and NFS. IQR 1 of FIB-4: FIB-4 < 1.238; IQR 2 of FIB-4: 1.238 ≤ FIB-4 < 1.614; IQR 3 of FIB-4: 1.614 ≤ FIB-4 < 2.098; IQR 4 of FIB-4: 2.098 ≤ FIB-4. IQR 1 of NFS: NFS < −1.520; IQR 2 of NFS: −1.520 ≤ NFS < −0.746; IQR 3 of NFS: −0.746 ≤ NFS < 0.058; IQR 4 of NFS: 0.058 ≤ NFS. NFS, non-alcoholic fatty liver disease fibrosis score; FIB-4, fibrosis-4; IQR, interquartile; HR hazard ratio; CI, confidence interval.