Mechanics of atrial appendages and superior vena cava area assessed by transesophageal echocardiography in prediction of atrial fibrillation recurrence after pulmonary vein isolation

    Authors

    Abstract

    **Introduction**: Pulmonary vein isolation (PVI) by catheter ablation is well established for the treatment of paroxysmal atrial fibrillation (PAF). However, atrial fibrillation recurrence (AFR) is fairly common after the index PVI. Although there are numerous studies reflecting the AFR predictive factors, including different echocardiography parameters, data on appendages’ mechanics and superior vena cava’s area is rather scarce. (1-3) Hence, this study aimed to assess left (LAA) and right atrial appendage (RAA) mechanics by transesophageal echocardiography (TEE) and to explore its value in prediction of PAF after PVI. **Patients and Methods**: We conducted a single-centre, non-randomized, prospective cohort study. Consecutive patients undergoing AF ablation by means of pulmonary vein isolation were included in a prospective registry. Transthoracic echocardiogram (TTE) and 3D TEE were obtained prior to the ablation procedure, and analyzed offline in a standardized manner, including LAA strain, LAA strain rate, LAA tissue Doppler imaging (TDI) velocity, LAA surface area, SVC surface area, RAA TDI velocity. The primary end point was freedom from any documented recurrence of atrial arrhythmia lasting > 30 seconds. A total of 55 patients with PAF in whom TTE and 3D TEE prior to index PVI was done were included (median age 59 years; IQR 52-63; female 30%; BMI 27.9±4.3 kg/m2, LVEF 60%, LA volume index 34 mL/m2). After a median follow up of 12 (IQR 10-12) months, 15 patients had AFR (R-group) and 40 patients had no recurrence (NR-group). Compared to NR-group, patients in R-group had lower LAA TDI (9.53±1.54 vs. 10.56±1.68 cm/s, p=0.014) and LAA surface area (2.55±0.62 vs. 2.84±0.66 cm2, p=0.045). RAA TDI velocity (p=0.292) and SVC surface area (p=0.361) were not different between the study groups. **Conclusion**: TEE parameters of RAA and SVC did not differ between patients with and without AFR. However, LAA TDI emptying velocity and LAA surface area could be useful in follow-up of PAF patients after index PVI in clinical settings. To our knowledge, this is the first study assessing RAA’ mechanics and SVC surface area in predicting AFR after PVI.

    Keywords

    transesophageal echocardiography, atrial fibrillation, pulmonary vein isolation

    DOI

    https://doi.org/10.15836/ccar2018.347

    Literature

    1. Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, et al. Document Reviewers. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace. 2018 Jan 1;20(1):e1–160. https://doi.org/10.1093/europace/eux274
    2. Efremidis M, Letsas KP, Georgopoulos S, Karamichalakis N, Vlachos K, Lioni L, et al. Safety, long-term outcomes and predictors of recurrence following a single catheter ablation procedure for atrial fibrillation. Acta Cardiol. 2018 Oct 10;•••:1–6.; Epub ahead of print. https://doi.org/10.1080/00015385.2018.1494114
    3. Bossard M, Knecht S, Aeschbacher S, Buechel RR, Hochgruber T, Zimmermann AJ, et al. Conventional versus 3-D Echocardiography to Predict Arrhythmia Recurrence After Atrial Fibrillation Ablation. J Cardiovasc Electrophysiol. 2017 Jun;28(6):651–8. https://doi.org/10.1111/jce.13202
    Cardiologia Croatica
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    Mechanics of atrial appendages and superior vena cava area assessed by transesophageal echocardiography in prediction of atrial fibrillation recurrence after pulmonary vein isolation

    Extended Abstract
    Issue11-12
    Published
    Pages347
    PDF via DOIhttps://doi.org/10.15836/ccar2018.347
    transesophageal echocardiography
    atrial fibrillation
    pulmonary vein isolation

    Authors

    Ivan Zeljković*ORCIDKlinički bolnički centar Sestre milosrdnice, Zagreb, Hrvatska
    Nikola PavlovićORCIDKlinički bolnički centar Sestre milosrdnice, Zagreb, Hrvatska
    Krešimir KordićORCIDKlinički bolnički centar Sestre milosrdnice, Zagreb, Hrvatska
    Nikola KosORCIDKlinički bolnički centar Sestre milosrdnice, Zagreb, Hrvatska
    Ivica BenkoORCIDKlinički bolnički centar Sestre milosrdnice, Zagreb, Hrvatska
    Karlo GolubićORCIDKlinički bolnički centar Sestre milosrdnice, Zagreb, Hrvatska
    Kristijan ĐulaORCIDKlinički bolnički centar Sestre milosrdnice, Zagreb, Hrvatska
    Diana Delić-BrkljačićORCIDKlinički bolnički centar Sestre milosrdnice, Zagreb, Hrvatska
    Vjekoslav RadeljićORCIDKlinički bolnički centar Sestre milosrdnice, Zagreb, Hrvatska
    Šime ManolaORCIDKlinički bolnički centar Sestre milosrdnice, Zagreb, Hrvatska
    Nikola BuljORCIDKlinički bolnički centar Sestre milosrdnice, Zagreb, Hrvatska

    *Correspondence email: ivanzeljkov@gmail.com

    Abstract

    **Introduction**: Pulmonary vein isolation (PVI) by catheter ablation is well established for the treatment of paroxysmal atrial fibrillation (PAF). However, atrial fibrillation recurrence (AFR) is fairly common after the index PVI. Although there are numerous studies reflecting the AFR predictive factors, including different echocardiography parameters, data on appendages’ mechanics and superior vena cava’s area is rather scarce. (1-3) Hence, this study aimed to assess left (LAA) and right atrial appendage (RAA) mechanics by transesophageal echocardiography (TEE) and to explore its value in prediction of PAF after PVI. **Patients and Methods**: We conducted a single-centre, non-randomized, prospective cohort study. Consecutive patients undergoing AF ablation by means of pulmonary vein isolation were included in a prospective registry. Transthoracic echocardiogram (TTE) and 3D TEE were obtained prior to the ablation procedure, and analyzed offline in a standardized manner, including LAA strain, LAA strain rate, LAA tissue Doppler imaging (TDI) velocity, LAA surface area, SVC surface area, RAA TDI velocity. The primary end point was freedom from any documented recurrence of atrial arrhythmia lasting > 30 seconds. A total of 55 patients with PAF in whom TTE and 3D TEE prior to index PVI was done were included (median age 59 years; IQR 52-63; female 30%; BMI 27.9±4.3 kg/m2, LVEF 60%, LA volume index 34 mL/m2). After a median follow up of 12 (IQR 10-12) months, 15 patients had AFR (R-group) and 40 patients had no recurrence (NR-group). Compared to NR-group, patients in R-group had lower LAA TDI (9.53±1.54 vs. 10.56±1.68 cm/s, p=0.014) and LAA surface area (2.55±0.62 vs. 2.84±0.66 cm2, p=0.045). RAA TDI velocity (p=0.292) and SVC surface area (p=0.361) were not different between the study groups. **Conclusion**: TEE parameters of RAA and SVC did not differ between patients with and without AFR. However, LAA TDI emptying velocity and LAA surface area could be useful in follow-up of PAF patients after index PVI in clinical settings. To our knowledge, this is the first study assessing RAA’ mechanics and SVC surface area in predicting AFR after PVI.

    Literature

    1. 1.
      Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, et al. Document Reviewers. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace. 2018 Jan 1;20(1):e1–160.DOI
    2. 2.
      Efremidis M, Letsas KP, Georgopoulos S, Karamichalakis N, Vlachos K, Lioni L, et al. Safety, long-term outcomes and predictors of recurrence following a single catheter ablation procedure for atrial fibrillation. Acta Cardiol. 2018 Oct 10;•••:1–6.; Epub ahead of print.DOI
    3. 3.
      Bossard M, Knecht S, Aeschbacher S, Buechel RR, Hochgruber T, Zimmermann AJ, et al. Conventional versus 3-D Echocardiography to Predict Arrhythmia Recurrence After Atrial Fibrillation Ablation. J Cardiovasc Electrophysiol. 2017 Jun;28(6):651–8.DOI