Clin Res Cardiol (2021) DOI DOI https://doi.org/10.1007/s00392-021-01843-w

Left Atrial STRAin in Patients undergoing Atrial Fibrillation Ablation and Recurrence of Arrhythmia: Results of the ASTRA-AF Pilot study

J. Vogler1, D. Knappe2, J. Weimann2, V. Banas2, S. Yildirim2, J. Senftinger2, L. Keil2, D. Ismaili2, M. Nies2, S. Willems3, A. Metzner2, S. Blankenberg2, P. Kirchhof2, C. Sinning2

1Medizinische Klinik II / Kardiologie, Angiologie, Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Lübeck; 2Klinik und Poliklinik für Kardiologie, Universitäres Herz- und Gefäßzentrum Hamburg GmbH, Hamburg; 3Kardiologie, Asklepios Klinik St. Georg, Hamburg;

Background: Recurrence of atrial fibrillation (AF) remains common after AF ablation. In addition to technical differences, underlying atrial cardiomyopathy can contribute to recurrent AF after ablation. Left atrial stain (LA-S) is a simple speckle tracking echocardiography-derived parameter to assess impaired LA function as a surrogate of atrial cardiomyopathy. The value of LA-S for predicting recurrent AF has not been prospectively evaluated. Purpose: To quantify left atrial strain in consecutive patients undergoing a first AF ablation and to investigate its potential influence as a predictor of atrial arrhythmia recurrences in context with known clinical and echocardiographic predictors of recurrent AF. Methods: The ASTRA AF pilot study prospectively enrolled n=132 consecutive patients with paroxysmal or persistent AF undergoing a first AF ablation targeting isolation of the pulmonary veins. A baseline transthoracic echocardiography was performed in every patient prior to AF ablation. LA-S was quantified by two-dimensional speckle tracking echocardiography using post processing software (Image-com, TOMTEC-ARENA, Tomtec Imaging Systems GmbH). Patients with atrial fibrillation at presentation or poor 2D imaging quality were excluded. Baseline characteristics and echocardiographic parameters were compared between patients with AF recurrence and no recurrence over a projected follow-up of one year. Results: A total of 132 patients (63.6% male, median age: 66 years [55; 73]) with symptomatic paroxysmal (n=94) or persistent (n=38) AF underwent cryoballoon PVI (n=60) or radiofrequency PVI (n=73) preceded by a transthoracic echocardiography with LA-S assessment. Median follow-up for recurrent AF was 834 days (95% Confidence Interval: [785;865]) Median baseline left ventricular ejection fraction was 56%, median left atrial volume index (LAVI) was 29.9 ml/m2 and CHA2DS2-VASc-Score was 2. During a follow-up of 12 months 53 of 132 patients (48.6%) developed an AF recurrence. Patients with AF recurrence had a significantly lower median reservoir LA-S (21.6 vs. 30.1, p = 0.048) and a longer T-Q-interval in TDI (90 ms vs. 69 ms, p = 0.015) compared to patients without AF recurrence. There was no difference in median LAVI (29.0 ml/m2 vs. 30.2 ml/m2, p = 0.19), peak LA-S (20.0% vs. 20.9%) and LVEF (56% vs. 56%). Multivariate logistic regression identified reservoir LA-S as a predictor of AF recurrence (HR 0.95 [0.92;0.99]; p = 0.022). A receiver operating characteristics curve (ROC) revealed a reservoir LA-S cut-off of 27.6% as a possible predictor of AF recurrences. The estimated rate of AF recurrences after 12 months was significantly higher in patients with a reservoir LA-S < 27.6 compared to those with a reservoir LA-S > 27.6 (figure 1). Conclusion: Quantifying LA strain could improve estimation of the risk of recurrent AF after AF ablation. Figure 1    Kaplan-Meier survival curves showing the arrhythmia-free survival 12 months after PVI (multiple procedures) for patients with a reservoir LA-S of > and < 27.6 and a LVAI of > and < 27.7 ml/m2. Cut-offs for reservoir LA-S and LAVI are derived from a ROC analysis. LAr-S: Left atrial reservoir strain. LAVI: Left atrial volume index.

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