The prognostic value of soluble suppression of tumourigenicity 2 and galectin-3 for sinus rhythm maintenance after cardioversion due to persistent atrial fibrillation in patients with normal left ventricular systolic function

Predictive value of soluble suppression of tumorigenicity 2 in atrial fibrillation: a systematic review and meta-analysis

Purpose

Atrial fibrosis is the main pathological basis for the pathogenesis and progression of atrial fibrillation (AF). Soluble suppression of tumorigenicity 2 (sST2) is involved in fibrosis. Recent studies have explored its predictive value in AF outcomes. We performed this study to assess whether sST2 is an independent biomarker of AF outcomes and explore the potential mechanism.

Methods

PubMed, Web of Science, EMBASE, and Cochrane Library databases were searched systematically from inception through July 1, 2023, to identify relevant studies. Outcomes of interest included occurrence, recurrence, and major adverse cardiac events (MACEs) of AF. This meta-analysis was reported following the criteria outlined in PRISMA 2020, and the protocol was registered in PROSPERO (number: CRD42023459789). All statistical analyses were performed using the STATA version 16.

Result

Twenty four studies with 14,755 patients were included in the meta-analysis. The meta-analyses found that sST2 was significantly associated with the risk of occurrence [HR:1.04, 95% CI: 1.02-1.07, P < 0.01; I2 = 67.8%], recurrence [HR:1.09, 95% CI: 1.02-1.16, P < 0.01; I2 = 89.5%], and MACEs (HR:1.60, 95% CI: 1.13-2.27, P < 0.01; I2 = 82.0%) of AF. Furthermore, patients with AF showed higher sST2 than controls without AF (SMD: 0.41, 95% CI: 0.27-0.54, P < 0.01; I2 = 0%), and AF patients with recurrence after catheter ablation (CA) showed significantly higher sST2 than those without recurrence (SMD: 0.81, 95% CI: 0.33-1.28, P < 0.01; I2 = 83.9%). Sensitivity analyses showed that the outcomes were stable.

Conclusions

Higher sST2 was association with an increased risk of occurrence, recurrence, and MACEs of AF. Assessing sST2 can be used as a potential screening method to predict AF outcomes.

Systematic Review Registration

PROSPERO (CRD42023459789).

Insights into the Role of Galectin-3 as a Diagnostic and Prognostic Biomarker of Atrial Fibrillation

Atrial fibrillation (AF) is an irregular atrial activity and the most prevalent type of arrhythmia. Although AF is easily diagnosed with an electrocardiogram, there is a keen interest in identifying an easy-to-dose biomarker that can predict the prognosis of AF and its recurrence. Galectin-3 (Gal-3) is a beta-galactoside binding protein from the lectin family with pro-fibrotic and -inflammatory effects and a pivotal role in a variety of biological processes, cell proliferation, and differentiation; therefore, it is implicated in the pathogenesis of many cardiovascular (e.g., heart failure (HF)) and noncardiovascular diseases. However, its specificity and sensitivity as a potential marker in AF patients remain debated and controversial. This article comprehensively reviewed the evidence regarding the interplay between Gal-3 and patients with AF. Clinical implications of measuring Gal-3 in AF patients for diagnosis and prognosis are mentioned. Moreover, the role of Gal-3 as a potential biomarker for the management of AF recurrence is investigated. The association of Gal-3 and AF in special populations (coronary artery disease, HF, metabolic syndrome, chronic kidney disease, and diabetes mellitus) has been explored in this review. Overall, although further studies are needed to enlighten the role of Gal-3 in the diagnosis and treatment of AF, our study demonstrated the high potential of this molecule to be used and focused on by researchers and clinicians.

The Role of Biochemical Cardiac Markers in Atrial Fibrillation

Atrial fibrillation (AF) is the most common type of cardiac arrhythmia. Proteins are a component of cardiac biomarkers containing cell structures that are released into the circulation when a myocardial injury occurs. They are essential in the diagnosis, risk assessment, and treatment of patients who have chest pain, are thought to have acute coronary syndrome, or are experiencing acute heart failure exacerbations. There are numerous biochemical cardiac markers, but this article summarizes the basic role of major biochemical cardiac markers, including cardiac natriuretic peptides, cardiac troponins, C-reactive protein (CRP), creatine kinase-MB, heart-type fatty acid-binding protein, ischemia-modified albumin, lipoprotein (a), osteopontin (OPN), and soluble suppression of tumorigenicity 2 (sST2), in AF. Atrial natriuretic peptide may serve as an indicator of atrial integrity, which may help to select appropriate treatment approaches for AF. Higher levels of N-terminal pro-B-type natriuretic peptide and brain natriuretic peptide are predictive of incidental AF. Increased troponin T release may indicate better clinical results following AF ablation. Similarly, CRP increases the risk of the AF-increasing calcium (Ca) influx in atrial myocytes, but not because of atrial fibrosis. Patients with postoperative AF have lower FABP3 gene expression in the atrium. Lipoprotein (a) (Lp[a]) may play a causative role in the onset of AF and impact various cardiac tissues. Clinical trials for Lp(a)-lowering drugs should assess their impact on preventing AF. Also, OPN was highly expressed in the circulation of AF patients and further increased with the progression of AF. sST2 was a reliable predictor of new-onset AF and can improve the accuracy of the AF risk model. There is a greater chance that these cardiac biomarkers might be employed to enhance clinical risk stratification in AF.

Biomarkers of Atrial Fibrillation Recurrence in Patients with Paroxysmal or Persistent Atrial Fibrillation Following External Direct Current Electrical Cardioversion

Atrial fibrillation (AF) is associated with atrial remodeling, cardiac dysfunction, and poor clinical outcomes. External direct current electrical cardioversion is a well-developed urgent treatment strategy for patients presenting with recent-onset AF. However, there is a lack of accurate predictive serum biomarkers to identify the risks of AF relapse after electrical cardioversion. We reviewed the currently available data and interpreted the findings of several studies revealing biomarkers for crucial elements in the pathogenesis of AF and affecting cardiac remodeling, fibrosis, inflammation, endothelial dysfunction, oxidative stress, adipose tissue dysfunction, myopathy, and mitochondrial dysfunction. Although there is ample strong evidence that elevated levels of numerous biomarkers (such as natriuretic peptides, C-reactive protein, galectin-3, soluble suppressor tumorigenicity-2, fibroblast growth factor-23, turn-over collagen biomarkers, growth differential factor-15) are associated with AF occurrence, the data obtained in clinical studies seem to be controversial in terms of their predictive ability for post-cardioversion outcomes. Novel circulating biomarkers are needed to elucidate the modality of this approach compared with conventional predictive tools. Conclusions: Biomarker-based strategies for predicting events after AF treatment require extensive investigation in the future, especially in the presence of different gender and variable comorbidity profiles. Perhaps, a multiple biomarker approach exerts more utilization for patients with different forms of AF than single biomarker use.

Left Atrial Wall Motion Velocity Assessed during Atrial Fibrillation Predicts Sinus Rhythm Maintenance after Electrical Cardioversion in Patients with Persistent Atrial Fibrillation

Reduced left atrial wall motion velocity measured during AF (LAWMV) indicates left atrial remodeling. The aim of this study was to investigate whether LAWMV assessed with tissue Doppler imaging during atrial fibrillation (AF) predicts sinus rhythm (SR) maintenance after direct current cardioversion (DCCV) for persistent AF. The study included 126 patients who underwent DCCV and were followed for 12 months. At 12 months, maintained SR was reported in 55 patients (43.7%). We noted that LAWMV was higher in patients with maintained SR at 12 months than in those with recurrent AF (3.69 ± 0.84 vs. 2.86 ± 1.09; p < 0.001). In the multivariable regression model containing echocardiographic variables, LAWMV was an independent predictor of SR maintenance at 12 months (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.1-2.69; p = 0.017). Similarly, LAWMW was an independent predictor of SR maintenance at 12 months (OR 1.81, 95% CI 1.19-2.77; p = 0.006) in the multivariate regression model containing both echocardiographic and clinical variables. LAWMV predicts SR maintenance after DCCV for persistent AF. Echocardiographic markers of left atrial mechanical remodeling are better at predicting SR maintenance than markers of structural remodeling.

Higher serum sST2 is associated with increased left atrial low-voltage areas and atrial fibrillation recurrence in patients undergoing radiofrequency ablation

OBJECTIVE

To conduct a comprehensive analysis of prospectively measuring the concentration of soluble suppression of tumorigenicity 2 (sST2) to predict left atrial (LA) low-voltage areas (LVAs) and atrial fibrillation (AF) recurrence after radiofrequency catheter ablation (RFA).

METHODS

This was a prospective cohort study. A total of 84 patients, including 54 paroxysmal AF cases and 30 persistent AF cases who underwent RFA, were recruited. Electroanatomical voltage mapping determined the extent of LVAs. The serum level of sST2 was measured by enzyme-linked immunosorbent assay. All patients were followed for 12 months after the RFA procedure to verify AF recurrence.

RESULTS

The concentration of sST2 measured in the sample was 17.90-198.77 pg/mL, and the range of LA LVAs was 0-85.6%. The sST2 level positively correlated with LVAs (r = 0.40; P = 0.005). When comparing the top and bottom quartile, sST2 is significantly associated with LA LVAs (OR = 1.833, 95% CI: 1.582-2.011, P = 0.004). When compared with the 1st quartile group, the multivariable adjusted hazard ratios for AF recurrence after RFA were 1.57 (95% CI: 1.182-1.795) for the 4th quartile group, 1.44 (95% CI: 1.085-1.598) for the 3rd quartile group, and 1.27 (95% CI: 0.954-1.318) for the 2nd quartile group. The AF-free survival rates of patients with 1st quartile and 4th quartile sST2 levels after ablation were 95% and 59.6%, respectively (Log Rank test, P = 0.027).

CONCLUSION

Elevated sST2 levels of AF patients were associated with higher LA LVAs and a significantly increased risk of recurrence. The circulating sST2 concentration might be a pre-diagnostic marker of AF recurrence after RFA.

Mechanism of Sevoflurane Anesthesia under Hypothermic Cardiopulmonary Bypass on Postoperative Atrial Fibrillation Rhythm in Patients Undergoing Mitral Valve Replacement

Objective

It was to investigate the mechanism of atrial fibrillation after mitral valve replacement under extracorporeal circulation in patients with rheumatic heart disease under sevoflurane anesthesia maintenance and to provide scientific and effective basis for clinical treatment.

Methods

Forty patients with rheumatic heart disease who underwent mitral valve replacement were randomly rolled into group I (sinus rhythm of propofol anesthesia, n = 10), group II (atrial fibrillation rhythm of propofol anesthesia, n = 10), group III (sinus rhythm of sevoflurane anesthesia, n = 10), and group IV (atrial fibrillation rhythm of sevoflurane anesthesia, n = 10). Inflammatory factors, free tissue of right atrium, and incidence of postoperative atrial fibrillation were compared among all groups.

Results

(i) The serum levels of NT-proBNP, CRP, sST-2, IL-6, TNF-α, and TGF-β1 in group II were higher than those in group I, group III, and group IV, and the indexes in group III were higher than those in group IV (P < 0.05). (ii) The relative expression levels of PLB, CaMK II, Bax, and TP53 in the free tissue of right atrium in group II were higher than those in group I, III, and IV, and the index levels in group IV were higher than those in group III (P < 0.05). (iii) The incidence of postoperative atrial fibrillation in group III (0.00%) was significantly lower than that in group I (30%), group II (50%), and group IV (40.0%), and group II (50%) was the highest (P < 0.05).

Conclusion

The maintenance of sevoflurane anesthesia can improve the inflammatory response and myocardial tissue autophagy in patients with sinus rhythm and atrial fibrillation rhythm and can reduce the incidence of postoperative atrial fibrillation in patients.

Analysis of the Correlation of Galectin-3 Concentration with the Measurements of Echocardiographic Parameters Assessing Left Atrial Remodeling and Function in Patients with Persistent Atrial Fibrillation

Galectin-3 (gal-3) is a fibrosis marker and may play a role in fibrosis of the left atrium (LA). Left atrial wall fibrosis may influence the transition from paroxysmal to non-paroxysmal atrial fibrillation (AF). In this study, we assessed the correlation of gal-3 concentration with the main echocardio-graphic parameters evaluating dimensions, volume, compliance, and left atrial contractility during AF and after successful electrical cardioversion (DCCV). The study included 63 patients with left atrial enlargement who qualified for DCCV due to persistent AF. The procedure recovered sinus rhythm in 43 (68.3%) patients. The concentration of gal-3 was negatively correlated with the echocardiographic parameters of LA including dimensions (LA length pre, rho = −0.38; p = 0.003), volume (LAV pre, rho = −0.39; p = 0.003), compliance (LASr mean post, rho = −0.33) and contractility (pLASRct mean post, rho = −0.33; p = 0.038). Negative correlations of gal-3 concentration were also observed in relation to the volume and contractility of the left ventricle. The concentration of gal-3 significantly negatively correlates with the size, systolic function, and compliance of the LA wall in patients with persistent AF. Determining gal-3 concentration in patients with persistent AF may help in the assessment of remodeling of the LA wall.

Circulating Soluble Suppression of Tumorigenicity 2 Predicts Recurrence After Radiofrequency Ablation of Persistent Atrial Fibrillation

Objective: A more extensively fibrotic left atrium contributes to atrial fibrillation (AF) occurrence, persistence, and recurrence. The soluble suppression of tumorigenicity 2 (sST2) has emerged as a ventricular fibrotic biomarker for patients with heart failure. The present study is to investigate associations between circulating sST2 and risk of recurrence after ablation in AF patients.

Methods: We measured the baseline plasma level of sST2 from patients with persistent AF (n = 117) and paroxysmal AF (n = 93) patients. Patients were followed up for 15 months after ablation. The relationship between circulating sST2 and recurrence was assessed by multivariable Cox regression. The cutoff value of sST2 was determined by receiver operating characteristic curve. The relationship between baseline sST2 level and left atrial volume index (LAVI) was assessed by multivariate linear regression analysis. Serial sST2 measurements were also conducted after 24 h, 6 months, and 15 months of ablation. ST2 localization was examined in left atrial appendages of persistent AF patients by immunohistochemistry and Western blot.

Results: Baseline sST2 positively associated with LAVI in the persistent AF group, and elevated sST2 (≥39.25 ng/ml) independently increased the risk of recurrence after ablation (area under the curve = 0.748), with hazard ratio of 1.038 (95% confidence interval 1.017–1.060, P < 0.001) when adjusted for co-variables. In contrast, elevated sST2 cannot predict recurrence in paroxysmal AF.

Conclusions: In persistent AF patients, increased sST2 serves as a marker of recurrence after radiofrequency ablation. Patients with sST2 ≥ 39.25 ng/ml are more likely to develop recurrence within a year.