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. 2022 Dec 29;3(1):oeac085.
doi: 10.1093/ehjopen/oeac085. eCollection 2023 Jan.

Predictive value of late gadolinium enhancement cardiovascular magnetic resonance in patients with persistent atrial fibrillation: dual-centre validation of a standardized method

Till F Althoff  1   2   3   4 , Martin Eichenlaub  5 , David Padilla-Cueto  1 , Heiko Lehrmann  5 , Paz Garre  1 , Simon Schoechlin  5 , Elisenda Ferro  1 , Eric Invers  1 , Philipp Ruile  5 , Manuel Hein  5 , Christopher Schlett  5 , Rosa M Figueras I Ventura  6 , Susanna Prat-Gonzalez  1   2 , Bjoern Mueller-Edenborn  5 , Marius Bohnen  5 , Andreu Porta-Sanchez  1   2   7 , Jose Maria Tolosana  1   2   7 , Eduard Guasch  1   2   7 , Ivo Roca-Luque  1   2   7 , Elena Arbelo  1   2   7 , Franz-Josef Neumann  5 , Dirk Westermann  5 , Marta Sitges  1   2   7 , Josep Brugada  1   2   7 , Thomas Arentz  5 , Lluís Mont  1   2   7 , Amir Jadidi  5
Affiliations

Predictive value of late gadolinium enhancement cardiovascular magnetic resonance in patients with persistent atrial fibrillation: dual-centre validation of a standardized method

Till F Althoff et al. Eur Heart J Open. .

Abstract

Aims: With recurrence rates up to 50% after pulmonary vein isolation (PVI) in persistent atrial fibrillation (AF), predictive tools to improve patient selection are needed. Patient selection based on left atrial late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) has been proposed previously (UTAH-classification). However, this approach has not been widely established, in part owed to the lack of standardization of the LGE quantification method. We have recently established a standardized LGE-CMR method enabling reproducible LGE-quantification. Here, the ability of this method to predict outcome after PVI was evaluated.

Methods and results: This dual-centre study (n = 219) consists of a prospective derivation cohort (n = 37, all persistent AF) and an external validation cohort (n = 182; 66 persistent, 116 paroxysmal AF). All patients received an LGE-CMR prior to first-time PVI-only ablation. LGE was quantified based on the signal-intensity-ratio relative to the blood pool, applying a uniform LGE-defining threshold of >1.2. In patients with persistent AF in the derivation cohort, left atrial LGE-extent above a cut-off value of 12% was found to best predict relevant low-voltage substrate (≥2 cm two with <0.5 mV during sinus rhythm) and arrhythmia-free survival 12 months post-PVI. When applied to the external validation cohort, this cut-off value was also predictive of arrhythmia-free survival for both, the total cohort and the subgroup with persistent AF (LGE < 12%: 80% and 76%; LGE > 12%: 55% and 44%; P = 0.007 and P = 0.029, respectively).

Conclusion: This dual-centre study established and validated a standardized, reproducible LGE-CMR method discriminating PVI responders from non-responders, which may improve choice of therapeutic approach or ablation strategy for patients with persistent AF.

Keywords: Atrial fibrillation; Cardiovascular magnetic resonance; Late gadolinium enhancement; Patient selection; Pulmonary vein isolation.

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Conflict of interest statement

Conflict of interest Dr Till Althoff has received research grants for investigator-initiated trials not related to this study from Biosense Webster. Rosa M. Figueras i Ventura is employee of Adas 3D Medical Inc. Dr Franz-Josef Neumann has received honoraria as lecturer and consultant from Boston Scientific, Biotronik, Medtronic, Edwards life science, Abbott Vascular, Pfizer, Boehringer-Ingelheim. Dr Dirk Westermann has received honoraria as lecturer and consultant from Abiomed, AstraZeneca, Bayer, Berlin-Chemie, Boehringer, Edwards, Novartis and Medtronic. Dr Lluís Mont has received honoraria as a lecturer and consultant and has received research grants from Abbott Medical, Biosense Webster, Boston Scientific and Medtronic. He is a shareholder of Galgo Medical SL.

Figures

Graphical abstract
Graphical abstract
Risk stratification of patients with persistent AF based on the individual extent of left atrial late gadolinium enhancement. In the derivation cohort (University Heart Center Freiburg, Germany), a cut-off value of 12% LA LGE was found to best discriminate between responders and non-responders to catheter ablation (PVI only). Application of this cut-off value to LGE-CMR performed in the validation cohort (n = 182, 36% paroxysmal AF, Hospital Clínic, University of Barcelona), confirmed its predictive value with equal discriminating power in patients with persistent AF. Shown are three-dimensional left atrial LGE-CMR reconstructions (postero-anterior view) with colour-coding based on LGE (blue: image intensity ratio ≤1.2; yellow: image intensity ratio >1.2; red: image intensity ratio ≤1.32). AF, atrial fibrillation; LA, left atrial; LGE, late gadolinium enhancement; PVI, pulmonary vein isolation; CMR, cardiac magnetic resonance.
Figure 1
Figure 1
Predictive value of LGE with respect to relevant low-voltage substrate. (A) Representative examples of a patient without (upper panel, green frame) and with relevant left atrial low-voltage substrate (lower panel, red frame). Relevant low-voltage substrate was defined as ≥2 cm2 of the left atrium with <0.5 mV signal amplitude during sinus rhythm. Shown are left atrial bipolar voltage maps applying the indicated voltage thresholds and LGE-maps (three-dimensional reconstruction of left atria with colour-coding based on signal intensity ratios applying thresholds of ≥1.2 and >1.32 using ADAS 3D software (Adas3D Medical Barcelona, Spain)) of the same patients head-to-head. The upper case illustrates an example for a good match and the lower case an example for a suboptimal agreement regarding both the regional distribution and extent of diseased areas between left atrial low-voltage substrate and LGE. (B) Receiver-operating characteristic (ROC) analysis identified the best trade-off between sensitivity and specificity for an LGE-threshold of 12% as a predictor of relevant left atrial low-voltage substrate. (C) Application of the determined cut-off value of 12% left atrial LGE-extent allows for differentiation of patients with significant variability of left atrial low-voltage extent. Whisker plots depict median with 25% and 75% interquartile range. LA-LVS, left atrial low-voltage substrate; LGE, late gadolinium enhancement.
Figure 2
Figure 2
Freedom from arrhythmia recurrence according to left atrial LGE (derivation cohort). Kaplan–Meier curves for freedom from arrhythmia recurrence in patients with LGE <12% vs. ≥12% of left atrial surface area. Statistical significance (P-value) based on log-rank test. LGE, late gadolinium enhancement.
Figure 3
Figure 3
Freedom from arrhythmia recurrence according to left atrial LGE (validation cohort, persistent AF patients). Kaplan–Meier curves for freedom from arrhythmia recurrence in patients with LGE <12% vs. ≥12% of left atrial surface area. Statistical significance (P-value) based on log-rank test. LGE, late gadolinium enhancement.
Figure 4
Figure 4
Arrhythmia-free survival rates according to LGE-extent and AF type. 12-month arrhythmia-free survival rates in per cent in patients with LGE <12% vs. ≥12% of left atrial surface area. Statistical significance (P-values) based on Fisher exact test. AF, atrial fibrillation; LGE, late gadolinium enhancement.
See this image and copyright information in PMC

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