Higher Degree of Left Atrial Structural Remodeling in Patients with Atrial Fibrillation and Left Ventricular Systolic Dysfunction

Catheter Ablation of Atrial Fibrillation: Technique and Future Perspectives

Atrial fibrillation is the most common sustained cardiac arrhythmia with a significant impact on quality of life in terms of symptoms and reduction of functional status. Also, it is associated with an increased risk of mortality, stroke, and peripheral embolism. Catheter ablation for atrial fibrillation has become a well-established treatment, improving arrhythmia outcomes without increasing the risk of serious adverse events compared to antiarrhythmic drug therapy. The field has undergone significant advancements in recent years, yet pulmonary vein isolation continues to be the cornerstone of any atrial fibrillation ablation procedure. The purpose of this review is to provide an overview of the current techniques, emerging technologies, and future directions.

The relationship between atrial fibrillation and coronary artery disease: Understanding common denominators

Atrial fibrillation (AF) and coronary artery disease (CAD) are highly prevalent cardiovascular conditions. The coexistence of both diseases is common as they share similar risk factors and common pathophysiological characteristics. Systemic inflammatory conditions are associated with an increased incidence of both AF and CAD. The presence of both entities increases the incidence of complications and adverse outcomes. Furthermore, their coexistence poses challenges for the management of patients, particularly with respect to anticoagulation and rhythm management. In this review, we aim to better understand the relationship between AF and CAD by detailing basic molecular pathophysiology, assessing therapeutic guidelines, and describing interactions between the two conditions.

Managing arrhythmia in cardiac resynchronisation therapy

Arrhythmia is an extremely common finding in patients receiving cardiac resynchronisation therapy (CRT). Despite this, in the majority of randomised trials testing CRT efficacy, patients with a recent history of arrhythmia were excluded. Most of our knowledge into the management of arrhythmia in CRT is therefore based on arrhythmia trials in the heart failure (HF) population, rather than from trials dedicated to the CRT population. However, unique to CRT patients is the aim to reach as close to 100% biventricular pacing (BVP) as possible, with HF outcomes greatly influenced by relatively small changes in pacing percentage. Thus, in comparison to the average HF patient, there is an even greater incentive for controlling arrhythmia, to achieve minimal interference with the effective delivery of BVP. In this review, we examine both atrial and ventricular arrhythmias, addressing their impact on CRT, and discuss the available evidence regarding optimal arrhythmia management in this patient group. We review pharmacological and procedural-based approaches, and lastly explore novel ways of harnessing device data to guide treatment of arrhythmia in CRT.

Phosphatidylethanolamine aggravates Angiotensin II-induced atrial fibrosis by triggering ferroptosis in mice

As atrial fibrosis is the main feature of atrial structural remodeling, inhibiting atrial fibrosis is crucial to the prevention of atrial fibrillation (AF) progression. Research has shown the correlation between abnormal lipid metabolism and AF progression. However, the effect of specific lipids on atrial fibrosis remains unclear. In the present study, we applied ultra-high-performance lipidomics to analyze the lipid profiles in patients with AF and identify phosphatidylethanolamine (PE) as the differential lipid associated with AF. To detect the effect of the differential lipid on atrial fibrosis, we performed the intraperitoneal injection of Angiotensin II (Ang II) to mice to induce atrial fibrosis and supplemented PE in diets. We also treated atrial cells with PE to evaluate the cellular effect of PE. We found that PE supplementation aggravated atrial fibrosis and increased the expression of the fibrosis-related protein in vitro and in vivo. Moreover, we detected the effect of PE on the atrium. We found that PE increased oxidation products and regulated the expression of ferroptosis-related proteins, which could be alleviated by a ferroptosis inhibitor. PE increased peroxidation and mitochondrial damage in vitro, which promoted cardiomyocyte death induced by Ang II. Examination of protein expression in cardiomyocytes indicated that PE triggered ferroptosis and caused cell death to participate in myocardium fibrosis. In summary, our findings demonstrated the differential lipid profiles of AF patients and revealed the potential effect of PE on atrial remodelling, suggesting that inhibition of PE and ferroptosis might serve as a potential therapy to prevent AF progression.

Catheter ablation improved ejection fraction in persistent AF patients: a DECAAF-II sub analysis

AIMS

The aim of our study was to assess differences in post-ablation atrial fibrillation (AF) recurrence and burden and to quantify the change in LVEF across different congestive heart failure (CHF) subcategories of the DECAAF-II population.

METHODS AND RESULTS

Differences in the primary outcome of AF recurrence between CHF and non-CHF groups was calculated. The same analysis was performed for the three subgroups of CHF and the non-CHF group. Differences in AF burden after the 3-month blanking period between CHF and non-CHF groups was calculated. Improvement in LVEF was calculated and compared across the three CHF groups. Improvement was also calculated across different fibrosis stages. There was no significant differences in AF recurrence and AF burden after catheter ablation between CHF and non-CHF patients and between different CHF subcategories. Patients with heart failure with reduced ejection fraction (HFrEF) experienced the greatest improvement in EF following catheter ablation (CA, 16.66% ± 11.98, P < 0.001) compared to heart failure with moderately reduced LVEF, and heart failure with preserved EF (10.74% ± 8.34 and 2.00 ± 8.34 respectively, P-value < 0.001). Moreover, improvement in LVEF was independent of the four stages of atrial fibrosis (7.71 vs. 9.53 vs. 5.72 vs. 15.88, from Stage I to Stage IV respectively, P = 0.115).

CONCLUSION

Atrial fibrillation burden and recurrence after CA is similar between non-CHF and CHF patients, independent of the type of CHF. Of all CHF groups, those with HFrEF had the largest improvement in LVEF after CA. Moreover, the improvement in ventricular function seems to be independent of atrial fibrosis in patients with persistent AF.

The pre-ablation triglyceride-glucose index predicts late recurrence of atrial fibrillation after radiofrequency ablation in non-diabetic adults

Background

Current prognostic risk scoring systems and biomarkers are routinely used as non-invasive methods for assessing late recurrence of atrial fibrillation (AF) in patients who have undergone radiofrequency catheter ablation (RFCA). This study aimed to investigate the predictive value of the triglyceride-glucose (TyG) index for late AF recurrence after RFCA in non-diabetic patients.

Methods

In total, 275 patients with AF who underwent RFCA at the Fuwai hospital (Beijing, China) between January 2016 and December 2018 were enrolled in this study. During follow up, patients were divided into late and non-late AF recurrence groups, based on whether they had experienced late AF recurrence determined by electrocardiography (ECG) examine or 48 h Holter monitoring. The TyG index was calculated using the following equation: ln [fasting triglycerides [mg/dL] × fasting glucose [mg/dL]/2].

Results

During a median follow-up of 26.1 months, late AF recurrence event rates significantly increased in the highest TyG index tertile group (tertile 3) compared to the lowest group (tertile 1) (54% versus 12%, respectively; p < 0.001). The mean TyG index was higher in the late AF recurrence group compared to the non- late AF recurrence group (9.42 ± 0.6 versus 8.68 ± 0.70, respectively; p < 0.001). On multivariate Cox regression analysis, the pre-ablation TyG index was an independent risk factor for late recurrence of AF after RFCA (hazard ratio [HR] 2.015 [95% confidence interval (CI): 1.408–4.117]; p = 0.009). Receiver operating characteristic (ROC) curve analysis revealed that TyG index was a significant predictor of late AF recurrence after RFCA, with an area under the ROC curve (AUC) of 0.737 (95% CI: 0.657–0.816; p < 0.001). In addition, the AUC of left atrial diameter (LAD) was 0.780 (95%CI: 0.703–0.857, p < 0.001). Finally, the TyG index positively correlated with LAD (r = 0.133, p = 0.027), high sensitivity C-reactive protein (r = 0.132, p = 0.028) and N-terminal pro B-type natriuretic peptide (r = 0.291, p < 0.001) levels.

Conclusions

An elevated pre-ablation TyG index was associated with an increased risk of late AF recurrence after RFCA in non-diabetic patients. The TyG index may be potentially useful as a novel biomarker for the risk stratification of late AF recurrence in non-diabetic patients.

Mitral valve regurgitation is associated with left atrial fibrosis in patients with atrial fibrillation

BACKGROUND

Low voltage zones (LVZ) are associated with poor outcomes in patients with atrial fibrillation (AF). The APPLE and DR-FLASH scores predict LVZ in patients undergoing catheter ablation. This study aimed to assess the relationship of mitral valve regurgitation (MR) and LVZ after adjusting for APPLE or DR-FLASH scores.

METHODS

This was a retrospective study on patients with AF who underwent their first catheter ablation. All patients underwent a transthoracic echocardiographic examination before ablation. The APPLE and DR-FLASH scores were calculated at baseline. LVZ determined by high-density mapping was defined as bipolar voltage amplitude <0.5 mV. LVZ presence was defined as LVZ covering >5% of the left atrial surface area.

RESULTS

Altogether, 152 patients (mean age 62.0 ± 10.8 years, 65.8% men, and 36.2% with persistent AF) were included. Of the 152 patients, 47 (30.9%) had LVZ. The patients with LVZ had more moderate-to-severe MR (17.0% vs. 3.8%, P = 0.014) and higher APPLE scores (1.7 ± 1.1 vs. 1.2 ± 1.1, P = 0.009) and DR-FLASH scores (3.0 ± 1.5 vs. 2.4 ± 1.4, P = 0.010). Using multivariate logistic regression analysis, we found moderate-to-severe MR was related to LVZ presence after adjusting for the APPLE (OR 4.040, P = 0.034) or DR-FLASH (OR 4.487, P = 0.020) scores. Furthermore, moderate-to-severe MR had an incremental predictive value for LVZ presence in addition to the APPLE (P = 0.03) or DR-FLASH (P = 0.02) scores.

CONCLUSION

In patients with AF, MR severity was related to LVZ after adjusting the APPLE score or DR-FLASH score.

Fibrillation cycle length predicts cardiovascular events in patients with long-standing persistent atrial fibrillation

BACKGROUND

Atrial fibrillation (AF) is associated with an increased risk of heart failure (HF), stroke, and death. Although fibrillation cycle length (FCL) is used as a surrogate for atrial refractoriness, its impact on outcomes remains unclear. This study aimed to identify predictors of cardiovascular events, including FCL, in patients with long-standing persistent AF.

METHODS

The study included 190 consecutive patients with long-standing persistent AF (mean age 74 years, 74% male). Patients with valvular AF or hemodialysis-dependent end-stage renal disease and those on anti-arrhythmic drugs were excluded. The primary composite outcome was occurrence of cardiovascular events (myocardial infarction, HF), cerebrovascular events (stroke, transient ischemic attack), and all-cause death. FCL was calculated by fast Fourier transformation analysis of fibrillation waves in the surface electrocardiogram.

RESULTS

Over a median follow-up of 2.6 years, the primary outcome occurred in 31 patients (cardiovascular events, n = 18; cerebrovascular events, n = 8; all-cause death, n = 5). In multivariate analysis, longer FCL and history of HF were independent predictors of these outcomes. In a Cox proportional hazards model adjusted for age, sex, and history of HF, patients with an FCL > 160 ms (cut-off determined by receiver-operating characteristic curve analysis) were at increased risk of the outcome (hazard ratio 12.9; 95% confidence interval 4.99-44.10; p < 0.001).

CONCLUSIONS

FCL was independently associated with cardiovascular outcomes in patients with long-standing persistent AF.

Decreased estimated glomerular filtration rate predicts long-term recurrence after catheter ablation of atrial fibrillation in mild to moderate renal insufficiency

BACKGROUND

Catheter ablation is an established therapy for atrial fibrillation (AF), but recurrence after ablation remains a great challenge. Additionally, little is known about the effect of renal function on the efficiency of AF ablation. This study aimed to evaluate the predictors of the prognosis of catheter ablation for AF, especially the effect of renal function.

METHODS

A total of 306 drug-refractory symptomatic patients with AF who underwent first-time catheter ablation were enrolled in the present study. Individuals underwent circumferential pulmonary vein isolation for paroxysmal AF and stepwise ablation for persistent AF.

RESULTS

The follow-up time was 27.2 ± 19.5 months, 202 patients (66.01%) were free of atrial tachyarrhythmia (non-recurrence group), and the other 104 patients experienced recurrence (recurrence group). The recurrence group had a larger left atrial diameter (LAD) and left atrial volume (LAV), a higher LAV index (LAVI) (both, p < 0.01), and a lower estimated glomerular filtration rate (eGFR) (53.5 ± 14.4 vs. 65.5 ± 13.3 ml/min/1.732, p < 0.001) and creatinine clearance rate (CCr) (85.2 ± 26.1 vs. 101.5 ± 29.4 ml/min, p < 0.05). Multivariate logistic regression indicated both eGFR (p = 0.002) and LAVI (p < 0.001) as independent associated factors for long-term recurrence after single catheter ablation; multivariate Cox proportional hazard regression with backward feature selection identified both eGFR (HR: 0.93, 95% CI: 0.91-0.95, p < 0.001) and LAVI (HR: 1.32, 95% CI: 1.25-1.40, p < 0.001) as independent prognostic factors for recurrence when adjusting other clinical variables.

CONCLUSIONS

Decreased eGFR and elevated LAVI may facilitate the long-term recurrence of atrial tachyarrhythmia after catheter ablation for AF.

Difference in left atrial D-dimer level in patients with atrial fibrillation treated with direct oral anticoagulant

Background

Atrial fibrillation (AF) may cause cerebral and systemic embolism. An increased D-dimer level indicates hyperactivation of secondary fibrinolysis, resulting in predilection for thrombosis. To clarify the differential effects of anticoagulation therapy, we compared the D-dimer levels in peripheral and left atrial (LA) blood of atrial fibrillation patients scheduled for ablation.

Methods

We analyzed 141 patients with non-valvular AF (dabigatran, n = 30; apixaban, n = 47; edoxaban, n = 64; mean age: 68 years, male: 60%). Peripheral venous blood and LA blood was collected before pulmonary vein isolation. We examined the laboratory and echocardiographic parameters.

Results

After adjusting for baseline characteristics, D-dimer level in the LA was significantly higher in patients treated with edoxaban than that in those on apixaban (0.77 ± 0.05 vs. 0.60 ± 0.05 μg/mL, P = 0.047), although there were no significant differences in peripheral D-dimer levels. We classified the D-dimer value of the LA into a normal group (< 0.9) and a high value group (≥ 1.0); the peripheral prothrombin fragment F1 + 2 level (odds ratio [OR] 1.012; 95% confidence interval [CI]: 1.003–1.022; P = 0.008) and left ventricular ejection fraction (LVEF) (OR, 0.947; 95% CI, 0.910–0.986; P = 0.008) were potential predictors of high LA D-dimer levels.

Conclusions

In apixaban-treated patients, the D-dimer level in the left atrium was lower than in edoxaban-treated patients on the day of ablation, suggesting that the anticoagulant effect of apixaban on the left atrium is better than that of edoxaban in patients with AF.

Atrial fibrillation and cardiac fibrosis

The understanding of atrial fibrillation (AF) evolved from a sole rhythm disturbance towards the complex concept of a cardiomyopathy based on arrhythmia substrates. There is evidence that atrial fibrosis can be visualized using late gadolinium enhancement cardiac magnetic resonance imaging and that it is a powerful predictor for the outcome of AF interventions. However, a strategy of an individual and fibrosis guided management of AF looks promising but results from prospective multicentre trials are pending. This review gives an overview about the relationship between cardiac fibrosis and AF focusing on translational aspects, clinical observations, and fibrosis imaging to emphasize the concept of personalized paths in AF management taking into account the individual amount and distribution of fibrosis.

Atrial Fibrillation Burden and Clinical Outcomes in Heart Failure: The CASTLE-AF Trial

OBJECTIVES

This subanalysis of the CASTLE-AF (Catheter Ablation vs. Standard Conventional Treatment in Patients With LV Dysfunction and AF) trial aimed to address the association between atrial fibrillation (AF) recurrence, AF burden, and hard clinical outcomes in heart failure (HF) patients with AF.

BACKGROUND

The CASTLE-AF trial demonstrated the benefit of CA compared to pharmacological treatment in decreasing mortality and CV hospitalizations in patients with AF and HFrEF. However, the impact of AF recurrence and AF burden after ablation on long-term treatment benefit remains unknown.

METHODS

The CASTLE-AF protocol randomized 363 patients with coexisting HF and AF in a multicenter prospective controlled fashion to catheter ablation (n = 179) versus pharmacological therapy (n = 184). Two hundred eighty patients were included in this subanalysis (as-treated), 128 of them underwent ablation and 152 received pharmacological treatment. All patients had implanted dual chamber or biventricular implantable defibrillators with activated home monitoring capabilities. The individual AF burden was calculated as the percentage of the atrial arrhythmia time per day.

RESULTS

AF burden at baseline was not predictive of the primary endpoint (p = 0.473) or all-cause mortality (p = 0.446). AF recurrence (defined as any episode >30 s) did not show any relationship with the primary endpoints of mortality and occurrence of HF, irrespective of the treatment arm. An AF burden below 50% after 6 months of catheter ablation, was associated with a significant decrease in primary composite outcome (hazard ratio [HR]: 0.33; 95% confidence interval [CI]: 0.15 to 0.71; p = 0.014) and all-cause mortality (HR: 0.23; 95% CI: 0.07 to 0.71; p = 0.031). The risk of the primary endpoint or mortality was directly related to a low (<50%) or high (≥50%) AF burden at 6 months post-ablation.

CONCLUSIONS

AF burden at 6 months was predictive of hard clinical outcomes in HF patients with AF. The first recurrent atrial tachyarrhythmia episode >30 s after ablation was not associated with improvement in mortality and hospitalization for HF. (Catheter Ablation vs. Standard Conventional Treatment in Patients With LV Dysfunction and AF [CASTLE-AF]; NCT00643188).

Circulating intermediate monocytes and atrial structural remodeling associated with atrial fibrillation recurrence after catheter ablation

BACKGROUND

Inflammation, such as that associated with intermediate CD14⁺⁺ CD16⁺ monocytes and atrial structural remodeling (SRM), may be important in the recurrence of atrial fibrillation (AF) after catheter ablation. However, the relationship between the intermediate CD14⁺⁺ CD16⁺ monocytes, SRM, and AF recurrence is unclear.

METHODS

Twenty-four patients with AF were enrolled. The proportion of intermediate monocytes (PIM) was assessed before ablation by flow cytometry. As a surrogate marker of SRM, the volume ratio (VR) of signal intensity greater than 1 standard deviation on late-gadolinium enhancement magnetic resonance imaging (LGE-MRI) was calculated. We investigated whether PIM correlated with SRM on LGE-MRI and determined the optimal cutoff value for predicting AF recurrence.

RESULTS

Univariate analysis revealed positive correlations between PIM and BNP with SRM (PIM: r = .593, p = .002; BNP: r = .567, p = .004). Multivariable analysis revealed that PIM was independently associated with VR on LGE-MRI (β = .522; p = .033). The finding of an area under the receiver operating characteristic curve of 0.750 revealed that a VR ≥ 13.3% on LGE-MRI as the optimal cutoff value to predict AF recurrence with 80% sensitivity and 71% specificity, which was associated with PIM ≥ 10.0%.

CONCLUSION

Intermediate monocytes were significantly positively correlated with SRM. PIM ≥ 10% was associated with a VR ≥ 13.3% on LGE-MRI, which predicted AF recurrence after catheter ablation.

Cardiac MRI and Fibrosis Quantification

Left atrial fibrosis plays an important role in the pathophysiology of atrial fibrillation. Left atrial ablation is an effective and increasingly used strategy to restore and maintain sinus rhythm in patients with atrial fibrillation. Late gadolinium enhancement (LGE) MRI and custom image analysis software have been used to visualize and quantify preablation atrial fibrosis and postablation scar and new fibrosis formation. This article reviews technical aspects of imaging atrial fibrosis/scar by LGE-MRI; use of atrial fibrosis and scar in predicting outcomes; applications of LGE-MRI to assess ablation lesions and optimize ablation parameters while avoiding collateral damage.

Left Atrial Structural Remodelling in Non-Valvular Atrial Fibrillation: What Have We Learnt from CMR?

Left atrial structural, functional and electrical remodelling are linked to atrial fibrillation (AF) pathophysiology and mirror the phrase “AF begets AF”. A structurally remodelled left atrium (LA) is fibrotic, dysfunctional and enlarged. Fibrosis is the hallmark of LA structural remodelling and is associated with increased risk of stroke, heart failure development and/or progression and poorer catheter ablation outcomes with increased recurrence rates. Moreover, increased atrial fibrosis has been associated with higher rates of stroke even in sinus-rhythm individuals. As such, properly assessing the fibrotic atrial cardiomyopathy in AF patients becomes necessary. In this respect, late-gadolinium enhancement cardiac magnetic resonance (LGE-CMR) imaging is the gold standard in imaging myocardial fibrosis. LA structural remodelling extension offers both diagnostic and prognostic information and influences therapeutic choices. LGE-CMR scans can be used before the procedure to better select candidates and to aid in choosing the ablation technique, during the procedure (full CMR-guided ablations) and after the ablation (to assess the ablation scar). This review focuses on imaging several LA structural remodelling CMR parameters, including size, shape and fibrosis (both extension and architecture) and their impact on procedure outcomes, recurrence risk, as well as their utility in relation to the index procedure timing.

[The effect of angiotensin receptors and neprilysin inhibitors on myocardial remodeling in patients with chronic heart failure and atrial fibrillation]

AIM

To evaluate the effect of angiotensin-neprilysin receptor inhibitors on myocardial remodeling in patients with chronic heart failure and atrial fibrillation.

MATERIALS AND METHODS

We studied dynamics of the parameters of ultrasound structural and functional parameters of the left atrium and left ventricle of the heart was during 3-month therapy with sacubitryl-valsartan in a group of 15 patients with a combination of chronic heart failure due to dilated and paroxysmal paroxysmal forms of atrial fibrillation.

RESULTS

Showed a statistically significant positive effect of the use of angiotensin receptors and neprilysin inhibitors on the parameters of remodeling of the left atrium (according to transthoracic and transesophageal echocardiography), left ventricle, as well as levels of natriuretic peptides ANP and NT-pro-BNP.

CONCLUSION

The use of ARNI may be promising in terms of treatment and prevention of AF in patients with heart failure.

Clinical scores used for the prediction of negative events in patients undergoing catheter ablation for atrial fibrillation

Atrial fibrillation (AF) is the most prevalent sustained cardiac arrhythmia in adults. Catheter ablation (CA) is one of the most important management strategies to reduce AF burden and AF-associated complications. In order to stratify the risk of adverse events and to predict treatment success in AF patients undergoing CA, several risk stratification scores had been developed during the last decade. The aim of this review is to provide an overview of the most important clinical risk scores predicting rhythm outcomes, electro-anatomical substrate and mortality in AF.

Profibrotic, Electrical, and Calcium-Handling Remodeling of the Atria in Heart Failure Patients With and Without Atrial Fibrillation

Atrial fibrillation (AF) and heart failure (HF) are common cardiovascular diseases that often co-exist. Animal models have suggested complex AF-promoting atrial structural, electrical, and Ca²⁺-handling remodeling in the setting of HF, but data in human samples are scarce, particularly regarding Ca²⁺-handling remodeling. Here, we evaluated atrial remodeling in patients with severe left ventricular (LV) dysfunction (HFrEF), long-standing persistent ('chronic') AF (cAF) or both (HFrEF-cAF), and sinus rhythm controls with normal LV function (Ctl) using western blot in right-atrial tissue, sharp-electrode action potential (AP) measurements in atrial trabeculae and voltage-clamp experiments in isolated right-atrial cardiomyocytes. Compared to Ctl, expression of profibrotic markers (collagen-1a, fibronectin, periostin) was higher in HFrEF and HFrEF-cAF patients, indicative of structural remodeling. Connexin-43 expression was reduced in HFrEF patients, but not HFrEF-cAF patients. AP characteristics were unchanged in HFrEF, but showed classical indices of electrical remodeling in cAF and HFrEF-cAF (prolonged AP duration at 20% and shorter AP duration at 50% and 90% repolarization). L-type Ca²⁺ current (I_Ca,L) was significantly reduced in HFrEF, cAF and HFrEF-cAF, without changes in voltage-dependence. Potentially proarrhythmic spontaneous transient-inward currents were significantly more frequent in HFrEF and HFrEF-cAF compared to Ctl, likely resulting from increased sarcoplasmic reticulum (SR) Ca²⁺ load (integrated caffeine-induced current) in HFrEF and increased ryanodine-receptor (RyR2) single-channel open probability in HFrEF and HFrEF-cAF. Although expression and phosphorylation of the SR Ca²⁺-ATPase type-2a (SERCA2a) regulator phospholamban were unchanged in HFrEF and HFrEF-cAF patients, protein levels of SERCA2a were increased in HFrEF-cAF and sarcolipin expression was decreased in both HFrEF and HFrEF-cAF, likely increasing SR Ca²⁺ uptake and load. RyR2 protein levels were decreased in HFrEF and HFrEF-cAF patients, but junctin levels were higher in HFrEF and relative Ser2814-RyR2 phosphorylation levels were increased in HFrEF-cAF, both potentially contributing to the greater RyR2 open probability. These novel insights into the molecular substrate for atrial arrhythmias in HF-patients position Ca²⁺-handling abnormalities as a likely trigger of AF in HF patients, which subsequently produces electrical remodeling that promotes the maintenance of the arrhythmia. Our new findings may have important implications for the development of novel treatment options for AF in the context of HF.

Calcium in the Pathophysiology of Atrial Fibrillation and Heart Failure

Atrial fibrillation (AF) is commonly associated with heart failure. A bidirectional relationship exists between the two-AF exacerbates heart failure causing a significant increase in heart failure symptoms, admissions to hospital and cardiovascular death, while pathological remodeling of the atria as a result of heart failure increases the risk of AF. A comprehensive understanding of the pathophysiology of AF is essential if we are to break this vicious circle. In this review, the latest evidence will be presented showing a fundamental role for calcium in both the induction and maintenance of AF. After outlining atrial electrophysiology and calcium handling, the role of calcium-dependent afterdepolarizations and atrial repolarization alternans in triggering AF will be considered. The atrial response to rapid stimulation will be discussed, including the short-term protection from calcium overload in the form of calcium signaling silencing and the eventual progression to diastolic calcium leak causing afterdepolarizations and the development of an electrical substrate that perpetuates AF. The role of calcium in the bidirectional relationship between heart failure and AF will then be covered. The effects of heart failure on atrial calcium handling that promote AF will be reviewed, including effects on both atrial myocytes and the pulmonary veins, before the aspects of AF which exacerbate heart failure are discussed. Finally, the limitations of human and animal studies will be explored allowing contextualization of what are sometimes discordant results.

Is extensive atrial fibrosis in the setting of heart failure associated with a reduced atrial fibrillation burden?

Atrial fibrillation (AF) affects 10-50% of patients with chronic heart failure (HF) and is associated with poor long-term prognosis. AF is commonly associated with atrial structural remodeling (ASR), principally characterized by atrial dilatation and fibrosis. However, the occurrence of AF in the full spectrum of ASR encountered in patients with HF is poorly defined. Experimental studies have presented evidence that extensive ASR can be accompanied with a reduced burden of AF, secondary to a prominent depression of atrial excitability. This reduction in AF burden is associated with severe atrial fibrosis rather than with dilatation. Clinical studies of patients with HF point to the possibility that advanced ASR is associated with a less frequent AF occurrence than moderate ASR. Our goal in this review is to introduce the hypothesis that AF is less likely to occur in severe versus moderate atrial ASR in the setting of HF and that it is severe atrial fibrosis-associated depression of atrial excitability that reduces AF burden.

Prediction of electro-anatomical substrate and arrhythmia recurrences using APPLE, DR-FLASH and MB-LATER scores in patients with atrial fibrillation undergoing catheter ablation

Arrhythmia recurrences after catheter ablation of atrial fibrillation (AF) cause intensive treatment costs. Left atrial electro-anatomical remodeling measured as low voltage areas (LVA) during catheter ablation indicates advanced disease stage and is associated with poor ablation success. The aim of this study was to analyze the prediction of LVA and arrhythmia recurrences using APPLE, DR-FLASH and MB-LATER scores. APPLE, DR-FLASH scores were calculated at baseline and MB-LATER at 3 months post-ablation in AF patients undergoing first catheter ablation. LVA was determined using high-density maps and defined as <0.5 mV. Early (ERAF, <3 months) and late (LRAF, 3–12 months) were analyzed during follow-up. The study population included 241 patients (age 64 ± 11 years, 59% males, 59% persistent AF, 27% LVA, 27% LRAF). LVA were significantly associated with recurrences (OR 2.081, p = 0.026). While on univariable analysis, all scores were significantly associated with LVA, on multivariable analysis only APPLE (OR 1.789, p < 0.001) and DR-FLASH (OR 2.144, p < 0.001) remained significant predictors. However, MB-LATER (OR 1.445, p = 0.034) and ERAF (OR 5.078, p < 0.001) remained associated with LRAF on the multivariable analysis. These results were validated in a subgroup of 873 patients (age 61 ± 10, 63% males, 39% persistent AF, 34% LRAF, 27% LVA) from The Leipzig Heart Center AF Ablation Registry. All scores were significantly associated with recurrences. However, ERAF was the most powerful predictor for later rhythm outcomes. Summarizing, a clinical score useful for prediction for both LVA and rhythm outcomes in AF patients remains a clinical unmet need.

Assessment of Left Atrial Fibrosis by Late Gadolinium Enhancement Magnetic Resonance Imaging: Methodology and Clinical Implications

Recently, studies using late gadolinium enhancement (LGE) magnetic resonance imaging (MRI) to identify structural changes of atrial tissue have contributed significantly to understanding the pathophysiology and progression of atrial fibrillation (AF). Moreover, imaging of atrial fibrosis using MRI has evolved to be a tool to improve clinical outcome of AF ablation procedures by allowing a patient-specific individualized management approach. LGE-MRI has been shown to predict AF ablation outcome based on pre-procedural imaging to define the extent of atrial fibrosis. The results of the ongoing DECAAF II (Delayed-Enhancement MRI Determinant of Successful Radiofrequency Catheter Ablation of Atrial Fibrillation) trial might extend ablation strategies from pulmonary vein isolation alone to a substrate-based approach. Furthermore, an improved understanding of the underlying mechanisms of atrial structural remodeling is crucial in order to reduce the occurrence of AF-associated complications (e.g., ischemic stroke and heart failure). This review article provides current methodology of atrial fibrosis imaging using LGE-MRI and delineates actual clinical implications and future directions for this imaging approach.

How to Improve Cardiac Resynchronization Therapy Benefit in Atrial Fibrillation Patients: Pulmonary Vein Isolation (and Beyond)

Although cardiac resynchronization therapy (CRT) is an important treatment of symptomatic heart failure patients in sinus rhythm with low left ventricular ejection fraction and ventricular dyssynchrony, its role is not well defined in patients with atrial fibrillation (AF). CRT is not as effective in patients with AF because of inadequate biventricular capture and loss of atrioventricular synchrony. Both can be addressed with catheter ablation of AF. It is still unclear if these therapies offer additive benefits in patients with ventricular dyssynchrony. This article discusses the role and techniques of catheter ablation of AF in patients with heart failure, and its application in CRT recipients.

Atrial Electrophysiological Remodeling and Fibrillation in Heart Failure

Heart failure (HF) causes complex, chronic changes in atrial structure and function, which can cause substantial electrophysiological remodeling and predispose the individual to atrial fibrillation (AF). Pharmacological treatments for preventing AF in patients with HF are limited. Improved understanding of the atrial electrical and ionic/molecular mechanisms that promote AF in these patients could lead to the identification of novel therapeutic targets. Animal models of HF have identified numerous changes in atrial ion currents, intracellular calcium handling, action potential waveform and conduction, as well as expression and signaling of associated proteins. These studies have shown that the pattern of electrophysiological remodeling likely depends on the duration of HF, the underlying cardiac pathology, and the species studied. In atrial myocytes and tissues obtained from patients with HF or left ventricular systolic dysfunction, the data on changes in ion currents and action potentials are largely equivocal, probably owing mainly to difficulties in controlling for the confounding influences of multiple variables, such as patient’s age, sex, disease history, and drug treatments, as well as the technical challenges in obtaining such data. In this review, we provide a summary and comparison of the main animal and human electrophysiological studies to date, with the aim of highlighting the consistencies in some of the remodeling patterns, as well as identifying areas of contention and gaps in the knowledge, which warrant further investigation.

How to Improve Cardiac Resynchronization Therapy Benefit in Atrial Fibrillation Patients: Pulmonary Vein Isolation (and Beyond)

Although cardiac resynchronization therapy (CRT) is an important treatment of symptomatic heart failure patients in sinus rhythm with low left ventricular ejection fraction and ventricular dyssynchrony, its role is not well defined in patients with atrial fibrillation (AF). CRT is not as effective in patients with AF because of inadequate biventricular capture and loss of atrioventricular synchrony. Both can be addressed with catheter ablation of AF. It is still unclear if these therapies offer additive benefits in patients with ventricular dyssynchrony. This article discusses the role and techniques of catheter ablation of AF in patients with heart failure, and its application in CRT recipients.

An atrial fibrosis-based approach for atrial fibrillation ablation

Since the emergence of atrial fibrillation (AF) ablation as a reliable method of restoring sinus rhythm, various approaches have been used to improve the efficacy while maximizing the safety of ablation. A major hurdle to optimizing outcomes for AF ablation has been the failure to recognize that the substrate of the individual patient plays a significant role in optimizing AF treatment. Using delayed-enhancement MRI for the detection of left atrial fibrosis, our group has been able to correlate these structural remodeling changes to outcomes of stroke, AF recurrence and congestive heart failure. This has provided us with information to optimize care of our AF patients based on screening for a fibrotic atrial cardiomyopathy, for which AF is the arrhythmic manifestation. By employing an MRI-guided approach for AF ablation, we have been able to optimize AF management and enhance the delivery of personalized medicine for our patients.

Predictors of conversion of recent-onset atrial fibrillation treated with vernakalant

BACKGROUND

Vernakalant is an available drug for the treatment of recent-onset atrial fibrillation, producing conversion between 55% and 87% of the patients treated. In this sense, little is known about the predictors of conversion with this agent. The aim of our study was to analyze the predictors of conversion in our 2-year experience using vernakalant for the treatment of recent-onset atrial fibrillation.

METHODS

One hundred twenty-one patients with recent-onset atrial fibrillation without hemodynamic impairment received pharmacological treatment with vernakalant. Clinical variables, history of cardiovascular diseases, and echocardiographic data were recorded.

RESULTS

Mean age was 58.1 ± 13.9 years and 13.4% of patients had structural heart disease. Conversion to sinus rhythm was achieved in 84.5% of patients, and 46% required the second dose of vernakalant. After analyzing the predictors of conversion, the presence of structural heart disease was significantly larger in the group without conversion (35.3 vs 9.7%; P = 0.02). The mean ejection fraction in the group with conversion was 61.05 ± 5.7% versus 54.9 ± 8.4% in the group without conversion (P = 0.016). After dichotomizing the variable ejection fraction, patients with ejection fraction <55% had a lower conversion rate (P = 0.001).

CONCLUSION

In our study, the absence of any kind of structural heart disease and preserved systolic function were associated with greater conversion rate with vernakalant.

Evaluation of quantification methods for left arial late gadolinium enhancement based on different references in patients with atrial fibrillation

By using late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) imaging, we compared left atrial late gadolinium enhancement (LA-LGE) quantification methods based on different references to characterize the left atrial wall in patients with atrial fibrillation (AF). Thirty-eight patients who underwent three-dimensional LGE-CMR imaging before catheter ablation for AF were classified into three groups depending on their clinical AF type: (1) paroxysmal AF (PAF; n = 12); (2) persistent AF (PeAF; n = 16); and (3) recurrent AF after catheter ablation (RAF; n = 10). To quantify LA-LGE on LGE-CMR imaging, we used the thresholds of 2 standard deviations (2-SD), 3-SD, 4-SD, 5-SD, or 6-SD above the mean signal from the unenhanced left ventricular myocardium, and we used the full width at half maximum (FWHM) technique, which was based on the maximum signal from the mitral valve with high signal intensity. The 6-SD threshold and FWHM techniques were statistically reproducible with an intraclass correlation coefficient >0.7. On applying the FWHM technique, the normalized LA-LGE volume by LA wall area showed a significant difference between the RAF, PeAF, and PAF groups (0.22 ± 0.04, 0.16 ± 0.06, and 0.09 ± 0.03 mL/cm(2), respectively) (P < 0.05). Furthermore, most of the fibrotic scarring and low-voltage tissue on the electroanatomic map corresponded well with the extent of LA-LGE. The FWHM technique based on the mitral valve can provide a reproducible quantification of LA-LGE related to AF in the thin LA wall.