259
Differential Clinical Characteristics and Prognosis of Patients with Longstanding Persistent Atrial Fibrillation Presenting with Recurrent Atrial Tachycardia versus Recurrent Atrial Fibrillation After First Ablation LIANG ZHAO, M.D., SHAOHUI WU, M.D., WEIFENG JIANG, M.D., LI ZHOU, M.D., JUN GU, M.D., YUANLONG WANG, M.D., YUGANG LIU, M.D., XIAODONG ZHANG, M.D., and XU LIU, M.D. From the Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
Baseline Characteristics and Prognosis of LS-AF Patients. Background: It is unknown if baseline characteristics and prognosis of patients with longstanding persistent (defined as history greater than 1 year) atrial fibrillation (LS-AF) differ among those with either recurrent atrial tachycardia (R-AT) or recurrent AF (R-AF) after first ablation. Methods: In 222 consecutive LS-AF patients treated for R-AT or R-AF after first ablation, activation and entrainment mapping was used to identify R-AT mechanism and to guide the following ablation, and the ablation endpoints for all patients included complete pulmonary vein isolation, bidirectional block of lines, and disappearance of complex fractionated atrial electrograms. Results: There were 102 patients in the R-AF group. LS-AF patients with R-AT as compared to R-AF had shorter AF duration and recurrence interval, smaller left atrium size and left ventricular end-diastolic diameter, and less mitral and aortic regurgitation before first ablation. During follow-up (17.7 ± 4.0 months) after R-AT/R-AF ablation, 78 LS-AF patients developed recurrent atrial tachyarrhythmia, with lower overall and recurrence as AF in R-AT versus R-AF groups. Conclusions: LS-AF patients who develop R-AT versus R-AF after first ablation have more favorable baseline characteristics and prognosis. (J Cardiovasc Electrophysiol, Vol. 25, pp. 259-265, March 2014) atrial fibrillation, atrial flutter, atrial tachycardia, catheter ablation, left atrium Introduction Atrial fibrillation (AF) recurrence is defined as that occurring more than 3 months following AF ablation, and based on guidelines1 most studies on AF ablation also have included episodes of atrial tachycardia (AT) in the “AF recurrence” group. However, in contrast to AF, with its completely disorganized atrial electrical activity and unknown mechanisms, AT presents as organized atrial electrical activity, in most cases with known mechanisms, such as focal and/or reentry, which are discernible by electrophysiological study. In studies,2-5 most AT cases could be terminated by re-ablation with favorable outcomes. Therefore, it is relevant to clinical practice and guideline formulation to determine whether patients who develop recurrent AT (R-AT) have different baseline characteristics from those who develop recurrent AF (R-AF) after first ablation for AF, and furthermore, whether there are differential prognoses after the second ablation procedure for R-AT/R-AF. This study therefore compared baseNo disclosures. Address for correspondence: Xu Liu, M.D., Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiaotong University, 241 West Huaihai Road, Shanghai, China. Fax: 86-21-22200000-2603; E-mail: [email protected] Manuscript received 27 June 2013; Revised manuscript received 8 October 2013; Accepted for publication 14 October 2013. doi: 10.1111/jce.12311
line clinical characteristics and prognoses for either R-AT or R-AF in patients with longstanding persistent AF (LS-AF). Methods Patients Overall, 222 consecutive patients with LS-AF, defined as persistent AF for over 1 year, who underwent a second ablation procedure for R-AT/R-AF at our institution were included. All R-AT/R-AF was documented by Holter monitoring, persistent, and started more than 3 months after first ablation procedure. Based on electrophysiological study, patients were divided into R-AT or R-AF groups. Exclusion criteria were: age ≥80 years; left atrium (LA) size ≥ 65 mm; rheumatic valvular disease; congenital heart disease; reduced left ventricular function (ejection fraction < 35%); any reversible cause for AF (e.g., hyperthyroidism); intracardiac thrombi documented by transesophageal echocardiography; and myocardial infarction or cardiac surgery within the previous 3 months. Written informed consent was obtained from all patients. Electrophysiological Study Patients were on oral anticoagulation (INR target range 2– 3) for at least 1 month prior to the second ablation procedure, and transesophageal echocardiography was performed to exclude LA thrombi. The second procedure was performed following discontinuation of antiarrhythmic drug (AAD)
260
Journal of Cardiovascular Electrophysiology
Vol. 25, No. 3, March 2014
TABLE 2 Comparison of Baseline Characteristics After the Second Ablation Procedure Variable
Figure 1. The distribution of AT types. CTI = cavotricuspid isthmus; MI = mitral isthmus; PVs = pulmonary veins; R-AT = recurrence as atrial tachycardia.
TABLE 1 Baseline Characteristics Between R-AT and R-AF Groups Variable Female Age (years) AF duration (months) Recurrence interval (months) Hypertension CAD Diabetes Stroke LAd (mm) LVDd (mm) LVEF (%) RAE MR TR AR PVI-1st MI line-1st Roof line-1st CTI line-1st CFAEs ablation time-1st (minutes) Cardioversion-1st
Overall (n = 222)
R-AF Group R-AT Group (n = 102) (n = 120) P Value
68 (30.6) 12 (33.3) 61.5 ± 9.7 62.0 ± 8.6 52.0 ± 47.1 71.6 ± 49.4
12 (38.3) 61.2 ± 10.6 35.4 ± 38.0
0.421 0.556
Differential Clinical Characteristics and Prognosis of Patients with Longstanding Persistent Atrial Fibrillation Presenting with Recurrent Atrial Tachycardia versus Recurrent Atrial Fibrillation After First Ablation LIANG ZHAO, M.D., SHAOHUI WU, M.D., WEIFENG JIANG, M.D., LI ZHOU, M.D., JUN GU, M.D., YUANLONG WANG, M.D., YUGANG LIU, M.D., XIAODONG ZHANG, M.D., and XU LIU, M.D. From the Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
Baseline Characteristics and Prognosis of LS-AF Patients. Background: It is unknown if baseline characteristics and prognosis of patients with longstanding persistent (defined as history greater than 1 year) atrial fibrillation (LS-AF) differ among those with either recurrent atrial tachycardia (R-AT) or recurrent AF (R-AF) after first ablation. Methods: In 222 consecutive LS-AF patients treated for R-AT or R-AF after first ablation, activation and entrainment mapping was used to identify R-AT mechanism and to guide the following ablation, and the ablation endpoints for all patients included complete pulmonary vein isolation, bidirectional block of lines, and disappearance of complex fractionated atrial electrograms. Results: There were 102 patients in the R-AF group. LS-AF patients with R-AT as compared to R-AF had shorter AF duration and recurrence interval, smaller left atrium size and left ventricular end-diastolic diameter, and less mitral and aortic regurgitation before first ablation. During follow-up (17.7 ± 4.0 months) after R-AT/R-AF ablation, 78 LS-AF patients developed recurrent atrial tachyarrhythmia, with lower overall and recurrence as AF in R-AT versus R-AF groups. Conclusions: LS-AF patients who develop R-AT versus R-AF after first ablation have more favorable baseline characteristics and prognosis. (J Cardiovasc Electrophysiol, Vol. 25, pp. 259-265, March 2014) atrial fibrillation, atrial flutter, atrial tachycardia, catheter ablation, left atrium Introduction Atrial fibrillation (AF) recurrence is defined as that occurring more than 3 months following AF ablation, and based on guidelines1 most studies on AF ablation also have included episodes of atrial tachycardia (AT) in the “AF recurrence” group. However, in contrast to AF, with its completely disorganized atrial electrical activity and unknown mechanisms, AT presents as organized atrial electrical activity, in most cases with known mechanisms, such as focal and/or reentry, which are discernible by electrophysiological study. In studies,2-5 most AT cases could be terminated by re-ablation with favorable outcomes. Therefore, it is relevant to clinical practice and guideline formulation to determine whether patients who develop recurrent AT (R-AT) have different baseline characteristics from those who develop recurrent AF (R-AF) after first ablation for AF, and furthermore, whether there are differential prognoses after the second ablation procedure for R-AT/R-AF. This study therefore compared baseNo disclosures. Address for correspondence: Xu Liu, M.D., Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiaotong University, 241 West Huaihai Road, Shanghai, China. Fax: 86-21-22200000-2603; E-mail: [email protected] Manuscript received 27 June 2013; Revised manuscript received 8 October 2013; Accepted for publication 14 October 2013. doi: 10.1111/jce.12311
line clinical characteristics and prognoses for either R-AT or R-AF in patients with longstanding persistent AF (LS-AF). Methods Patients Overall, 222 consecutive patients with LS-AF, defined as persistent AF for over 1 year, who underwent a second ablation procedure for R-AT/R-AF at our institution were included. All R-AT/R-AF was documented by Holter monitoring, persistent, and started more than 3 months after first ablation procedure. Based on electrophysiological study, patients were divided into R-AT or R-AF groups. Exclusion criteria were: age ≥80 years; left atrium (LA) size ≥ 65 mm; rheumatic valvular disease; congenital heart disease; reduced left ventricular function (ejection fraction < 35%); any reversible cause for AF (e.g., hyperthyroidism); intracardiac thrombi documented by transesophageal echocardiography; and myocardial infarction or cardiac surgery within the previous 3 months. Written informed consent was obtained from all patients. Electrophysiological Study Patients were on oral anticoagulation (INR target range 2– 3) for at least 1 month prior to the second ablation procedure, and transesophageal echocardiography was performed to exclude LA thrombi. The second procedure was performed following discontinuation of antiarrhythmic drug (AAD)
260
Journal of Cardiovascular Electrophysiology
Vol. 25, No. 3, March 2014
TABLE 2 Comparison of Baseline Characteristics After the Second Ablation Procedure Variable
Figure 1. The distribution of AT types. CTI = cavotricuspid isthmus; MI = mitral isthmus; PVs = pulmonary veins; R-AT = recurrence as atrial tachycardia.
TABLE 1 Baseline Characteristics Between R-AT and R-AF Groups Variable Female Age (years) AF duration (months) Recurrence interval (months) Hypertension CAD Diabetes Stroke LAd (mm) LVDd (mm) LVEF (%) RAE MR TR AR PVI-1st MI line-1st Roof line-1st CTI line-1st CFAEs ablation time-1st (minutes) Cardioversion-1st
Overall (n = 222)
R-AF Group R-AT Group (n = 102) (n = 120) P Value
68 (30.6) 12 (33.3) 61.5 ± 9.7 62.0 ± 8.6 52.0 ± 47.1 71.6 ± 49.4
12 (38.3) 61.2 ± 10.6 35.4 ± 38.0
0.421 0.556
