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Koutalas E, Kallergis E, Nedios S, Kochiadakis G, Kanoupakis E. P-wave duration as a marker of atrial remodeling in patients referred to ablation for atrial fibrillation: A new stratification tool emerging? Hellenic J Cardiol 2023; 73:53-60. [PMID: 36863411 DOI: 10.1016/j.hjc.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 02/07/2023] [Accepted: 02/24/2023] [Indexed: 03/04/2023] Open
Abstract
Ablation of atrial fibrillation is one of the most widely applied invasive procedures in cardiovascular medicine, and populations with atrial fibrillation continuously rise. Recurrence rates are, however, consistently high, even in patients without severe comorbidities. Robust stratification algorithms to distinguish patients suitable for ablation are generally lacking. This is a fact caused by the inability to incorporate evidence of atrial remodeling and fibrosis, e.g., atrial remodeling, in the decision pathways. Cardiac magnetic resonance is a powerful tool in identifying fibrosis; however, it is costly and not routinely used. Electrocardiography has been generally underutilized in clinical practice during pre-ablative screening. One of the characteristics of the electrocardiogram that can give us valuable data depicting the existence and the extent of atrial remodeling and fibrosis is the duration of the P-wave. Currently, many studies support the implementation of P-wave duration in the routine practice of patient evaluation as a surrogate marker of existing atrial remodeling, that in turn predicts recurrence after ablation of atrial fibrillation. Further research is guaranteed to establish this electrocardiographic characteristic in our stratification quiver.
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Affiliation(s)
- Emmanuel Koutalas
- Department of Cardiology University Hospital of Heraklion, Crete, Greece.
| | | | - Sotirios Nedios
- Department of Arrhythmology, Leipzig Heart Center, Leipzig, Germany
| | - George Kochiadakis
- Department of Cardiology University Hospital of Heraklion, Crete, Greece
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Sudo Y, Morimoto T, Tsushima R, Sogo M, Ozaki M, Takahashi M, Okawa K. P-wave terminal force in lead V1 and outcomes in patients with persistent atrial fibrillation undergoing catheter ablation. Am Heart J 2023; 260:141-150. [PMID: 36934976 DOI: 10.1016/j.ahj.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 03/02/2023] [Accepted: 03/11/2023] [Indexed: 05/07/2023]
Abstract
AIMS The P-wave terminal force in electrocardiogram lead V1 (PTFV1) correlates with outcomes in patients with paroxysmal atrial fibrillation (AF). Nevertheless, the correlation between the PTFV1 and outcomes after AF ablation in patients with persistent AF remains unclear. This study aimed to determine whether the PTFV1 at 3 months after AF ablation could predict AF recurrence and cardiovascular events in patients with persistent AF. METHODS This historical cohort study examined 453 consecutive patients with persistent AF who underwent a first-time AF ablation. We measured the PTFV1 at 3 months after the ablation. An abnormal PTF was defined as a ≥4 mVms depression. The 3-year incidence of AF recurrence and composite cardiovascular events, including strokes, heart failure hospitalizations, and cardiovascular death, were compared between the abnormal and normal PTF groups. RESULTS Among 434 enrolled patients, 101 had an abnormal, and 333 normal PTF at 3 months after AF ablation. Compared with the normal PTF group, the abnormal PTF group had a significantly higher incidence of AF recurrence (52.6% vs 28.1%, log-rank P < .001) and cardiovascular events (13.7% vs 2.6%, log-rank P = .005). After adjusting for the risk factors, an abnormal PTF was established as an independent predictor of AF recurrence (hazard ratio [HR] 2.12, 95% confidence interval [CI]: 1.44-3.13, P < .001) and cardiovascular events (HR 3.26, 95% CI: 1.19-8.97, P = .022). CONCLUSIONS The PTFV1 at 3 months after AF ablation could be a valuable noninvasive predictor of both AF recurrence and cardiovascular events in patients with persistent AF.
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Affiliation(s)
- Yuya Sudo
- Department of Cardiovascular Medicine, Kagawa Prefectural Central Hospital, Takamatsu, Kagawa, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Ryu Tsushima
- Department of Cardiovascular Medicine, Kagawa Prefectural Central Hospital, Takamatsu, Kagawa, Japan
| | - Masahiro Sogo
- Department of Cardiovascular Medicine, Kagawa Prefectural Central Hospital, Takamatsu, Kagawa, Japan
| | - Masatomo Ozaki
- Department of Cardiovascular Medicine, Kagawa Prefectural Central Hospital, Takamatsu, Kagawa, Japan
| | - Masahiko Takahashi
- Department of Cardiovascular Medicine, Kagawa Prefectural Central Hospital, Takamatsu, Kagawa, Japan
| | - Keisuke Okawa
- Department of Cardiovascular Medicine, Kagawa Prefectural Central Hospital, Takamatsu, Kagawa, Japan.
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Intzes S, Zagoridis K, Symeonidou M, Spanoudakis E, Arya A, Dinov B, Dagres N, Hindricks G, Bollmann A, Kanoupakis E, Koutalas E, Nedios S. P-wave duration and atrial fibrillation recurrence after catheter ablation: a systematic review and meta-analysis. Europace 2022; 25:450-459. [PMID: 36413611 PMCID: PMC9935015 DOI: 10.1093/europace/euac210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 09/18/2022] [Indexed: 11/23/2022] Open
Abstract
AIMS Atrial fibrillation (AF) is a global health problem with high morbidity and mortality. Catheter ablation (CA) can reduce AF burden and symptoms, but AF recurrence (AFr) remains an issue. Simple AFr predictors like P-wave duration (PWD) could help improve AF therapy. This updated meta-analysis reviews the increasing evidence for the association of AFr with PWD and offers practical implications. METHODS AND RESULTS Publication databases were systematically searched and cohort studies reporting PWD and/or morphology at baseline and AFr after CA were included. Advanced interatrial block (aIAB) was defined as PWD ≥ 120 ms and biphasic morphology in inferior leads. Random-effects analysis was performed using the Review Manager 5.3 and R programs after study selection, quality assessment, and data extraction, to report odds ratio (OR) and confidence intervals. : Among 4175 patients in 22 studies, 1138 (27%) experienced AFr. Patients with AFr had longer PWD with a mean pooled difference of 7.8 ms (19 studies, P < 0.001). Pooled OR was 2.04 (1.16-3.58) for PWD > 120 ms (13 studies, P = 0.01), 2.42 (1.12-5.21) for PWD > 140 ms (2 studies, P = 0.02), 3.97 (1.79-8.85) for aIAB (5 studies, P < 0.001), and 10.89 (4.53-26.15) for PWD > 150 ms (4 studies, P < 0.001). There was significant heterogeneity but no publication bias detected. CONCLUSION P-wave duration is an independent predictor for AF recurrence after left atrium ablation. The AFr risk is increasing exponentially with PWD prolongation. This could facilitate risk stratification by identifying high-risk patients (aIAB, PWD > 150 ms) and adjusting follow up or interventions.
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Affiliation(s)
| | | | | | | | - Arash Arya
- Department of Electrophysiology, Heart Center, University of Leipzig, Struempellstr. 39, 04289 Leipzig, Germany
| | - Borislav Dinov
- Department of Electrophysiology, Heart Center, University of Leipzig, Struempellstr. 39, 04289 Leipzig, Germany
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center, University of Leipzig, Struempellstr. 39, 04289 Leipzig, Germany
| | - Gerhard Hindricks
- Department of Electrophysiology, Heart Center, University of Leipzig, Struempellstr. 39, 04289 Leipzig, Germany
| | - Andreas Bollmann
- Department of Electrophysiology, Heart Center, University of Leipzig, Struempellstr. 39, 04289 Leipzig, Germany
| | | | - Emmanuel Koutalas
- Department of Cardiology, Heraklion University Hospital, Crete, Greece
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Murase Y, Imai H, Ogawa Y, Kano N, Mamiya K, Ikeda T, Okabe K, Arai K, Yamazoe S, Torii J, Kawaguchi K. Usefulness of P-wave duration in patients with sick sinus syndrome as a predictor of atrial fibrillation. J Arrhythm 2021; 37:1220-1226. [PMID: 34621420 PMCID: PMC8485803 DOI: 10.1002/joa3.12604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 06/23/2021] [Accepted: 07/06/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND This study aimed to clarify P-wave duration (PWD) ability before pacemaker implantation to predict worsening atrial fibrillation (AF) burden after the procedure. METHODS We retrospectively investigated 75 patients who underwent permanent pacemaker implantation due to sick sinus syndrome (SSS) at Komaki City Hospital between January 2006 and May 2019. Worsening AF burden was defined as an increase in the number of AF episodes, each lasting ≥5.5 hours a day. RESULTS In the study population, 17 patients (23%) had worsening AF burden during the follow-up period. These patients had significantly longer PWD in lead Ⅱ (117.9 ± 19.9 ms vs 101.3 ± 20.0 ms, P = .002) than the patients without worsening AF burden. The best discriminative cutoff value for PWD in lead Ⅱ was 108 ms (sensitivity, 77%; specificity, 67%). In multivariate analysis, PWD in lead II ≥108 ms (hazard ratio, 5.395; 95% confidence interval, 1.352-21.523; P = .017) was an independent predictor of worsening AF burden. Patients with PWD in lead II <108 ms showed a significantly higher event-free rate against worsening AF burden than those with PWD in lead II ≥108 ms (81% vs 9%, P = .005). CONCLUSIONS Prolonged PWD before pacemaker implantation was the most important independent predictor of worsening AF burden after the procedure. In patients with SSS, prolonged PWD can be a useful marker for predicting worsening of AF burden after pacemaker implantation.
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Affiliation(s)
- Yosuke Murase
- Department of Cardiology Komaki City Hospital Komaki Japan
| | - Hajime Imai
- Department of Cardiology Komaki City Hospital Komaki Japan
| | - Yasuhiro Ogawa
- Department of Cardiology Komaki City Hospital Komaki Japan
| | - Naoaki Kano
- Department of Cardiology Komaki City Hospital Komaki Japan
| | - Keita Mamiya
- Department of Cardiology Komaki City Hospital Komaki Japan
| | - Tomoyo Ikeda
- Department of Cardiology Komaki City Hospital Komaki Japan
| | - Kei Okabe
- Department of Cardiology Komaki City Hospital Komaki Japan
| | - Kenji Arai
- Department of Cardiology Komaki City Hospital Komaki Japan
| | - Shinji Yamazoe
- Department of Cardiology Komaki City Hospital Komaki Japan
| | - Jun Torii
- Department of Cardiology Komaki City Hospital Komaki Japan
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Long P-wave duration immediately after pulmonary vein isolation on radiofrequency catheter ablation for atrial fibrillation predicts clinical recurrence: correlation with atrial remodeling in persistent atrial fibrillation. Heart Vessels 2021; 37:476-488. [PMID: 34432100 DOI: 10.1007/s00380-021-01932-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 08/20/2021] [Indexed: 01/22/2023]
Abstract
P-wave morphology reflects atrial remodeling and indicates prognosis after radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF). The impact of p-wave morphology after excluding the effect of pulmonary vein (PV) substrate on outcomes is unknown. We evaluated the p-wave morphology on electrocardiography immediately after PV isolation for clinical outcomes. Eighty-four consecutive patients (47 with paroxysmal AF and 37 with persistent AF) who underwent RFCA were included. P-wave duration (PWD) and amplitude in all leads were examined during sinus rhythm immediately after PV isolation. We evaluated the relationship between electrocardiogram parameters and AF recurrence, according to the type of AF and following ablation, and the correlation with left atrial (LA) volume, low voltage ratio, and fixed conduction time. During 12 months of follow-up, 20 patients experienced recurrence. The cut-off value of PWD > 120 ms in lead I showed a sensitivity of 75% and specificity of 69% for predicting recurrence. PWD was significantly correlated with LA volume, low voltage, and conduction velocity. Significantly higher recurrence rates were observed in patients with PWD > 120 ms than in those with PWD ≤ 120 ms (p < 0.001), and the difference was more pronounced in patients with persistent AF. Multivariate analysis demonstrated that PWD > 120 ms was independently associated with recurrence in the total population (hazard ratio 2.00; 95% confidence interval 1.27-3.22; p = 0.003) and in patients with persistent AF. In conclusion, long PWD after PV isolation predicts AF recurrence, which might be associated with the extent of the LA substrate in persistent AF.
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Yanagisawa S, Inden Y, Okamoto H, Fujii A, Sakamoto Y, Mamiya K, Tomomatsu T, Shibata R, Murohara T. Electrocardiogram characteristics of P wave associated with successful pulmonary vein isolation in patients with paroxysmal atrial fibrillation: Significance of changes in P-wave duration and notched P wave. Ann Noninvasive Electrocardiol 2019; 25:e12712. [PMID: 31566884 PMCID: PMC7358886 DOI: 10.1111/anec.12712] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 08/22/2019] [Accepted: 09/05/2019] [Indexed: 11/29/2022] Open
Abstract
Background The mechanisms involved in changes in P wave following catheter ablation for atrial fibrillation (AF) are uncertain. This study aimed to assess the relationship between changes in P‐wave morphology and pulmonary vein (PV) reconnection following ablation by the assessment of 12‐lead surface electrocardiogram and signal‐averaged electrocardiogram. Methods This retrospective study included 115 consecutive patients with paroxysmal AF that underwent repeat ablation for recurrence following initial ablation. We investigated changes in P‐wave morphology between baseline and repeat procedure in patients with and without PV reconnection. The study also included as validation group without recurrence (n = 67) following initial ablation. Results The maximum P‐wave duration (PWD) was significantly decreased from baseline to just after the procedure in all groups. However, for the PV reconnection group (n = 100), the maximum PWD was significantly increased again at the repeat procedure. In contrast, the maximum PWD was significantly reduced between baseline and repeat procedure in the non‐PV reconnection group (n = 15). The signal‐averaged PWD was significantly decreased from baseline to repeat procedure in the non‐PV reconnection group, but, conversely, was increased in the PV reconnection group. In the non‐PV reconnection group, the disappearance of notched P wave was detected in 8 of 15 patients (53%), which was significantly higher than in other groups (p = .001). A new or delayed notched P wave was identified in the PV reconnection group only. These results were confirmed in the validation group. Conclusions The reverse dynamics of PWD after initial shortening directly following ablation were significantly associated with PV reconnection.
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Affiliation(s)
- Satoshi Yanagisawa
- Department of Advanced Cardiovascular Therapeutics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroya Okamoto
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Aya Fujii
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yusuke Sakamoto
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Keita Mamiya
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toshiro Tomomatsu
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Rei Shibata
- Department of Advanced Cardiovascular Therapeutics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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