Slow blood-flow in the left atrial appendage is associated with stroke in atrial fibrillation patients.

Background: Atrial fibrillation (AF) patients are at high risk of stroke with ∼90% clots originating from the left atrial appendage (LAA). Clinical understanding of blood-flow based parameters and their potential association with stroke for AF patients remains poorly understood. We hypothesize that slow blood-flow either in the LA or the LAA could lead to the formation of blood clots and is associated with stroke for AF patients. Methods: We retrospectively collected cardiac CT images of paroxysmal AF patients and dichotomized them based on clinical event of previous embolic event into stroke and non-stroke groups. After image segmentation to obtain 3D LA geometry, patient-specific blood-flow analysis was performed to model LA hemodynamics. In terms of geometry, we calculated area of the pulmonary veins (PVs), mitral valve, LA and LAA, orifice area of LAA and volumes of LA and LAA and classified LAA morphologies. For hemodynamic assessment, we quantified blood flow velocity, wall shear stress (WSS, blood-friction on LA wall), oscillatory shear index (OSI, directional change of WSS) and endothelial cell activation potential (ECAP, ratio of OSI and WSS quantifying slow and oscillatory flow) in the LA as well as the LAA. Statistical analysis was performed to compare the parameters between the groups. Results: Twenty-seven patients were included in the stroke and 28 in the non-stroke group. Examining geometrical parameters, area of left inferior PV was found to be significantly higher in the stroke group as compared to non-stroke group (p = 0.026). In terms of hemodynamics, stroke group had significantly lower blood velocity (p = 0.027), WSS (p = 0.018) and higher ECAP (p = 0.032) in the LAA as compared to non-stroke group. However, LAA morphologic type did not differ between the two groups. This suggests that stroke patients had significantly slow and oscillatory circulating blood-flow in the LAA, which might expose it to potential thrombogenesis. Conclusion: Slow flow in the LAA alone was associated with stroke in this paroxysmal AF cohort. Patient-specific blood-flow analysis can potentially identify such hemodynamic conditions, aiding in clinical stroke risk stratification of AF patients.

Radiographic Identification of Cardiac Implantable Electronic Device Manufacturer: Smartphone Pacemaker-ID Application Versus X-ray Logo.

Radiographic identification of the cardiac implantable electronic device (CIED) manufacturer facilitates urgent interrogation of an unknown CIED. In the past, we relied on visualizing a manufacturer-specific X-ray logo. Recently, a free smartphone application ("Pacemaker-ID") was made available. A photograph of a chest X-ray was subjected to an artificial intelligence (AI) algorithm that uses manufacturer characteristics (canister shape, battery design) for identification. We sought to externally validate the accuracy of this smartphone application as a point-of-care (POC) diagnostic tool, compare on-axis to off-axis photo accuracy, and compare it to X-ray logo visualization for manufacturer identification. We reviewed operative reports and chest X-rays in 156 pacemaker and 144 defibrillator patients to visualize X-ray logos and to test the application with 3 standard (on-axis) and 4 non-standard (off-axis) photos (20° cranial; caudal, leftward, and rightward). Contingency tables were created and chi-squared analyses (P < .05) were completed for manufacturer and CIED type. The accuracy of the application was 91.7% and 86.3% with single and serial application(s), respectively; 80.7% with off-axis photos; and helpful for all manufacturers (range, 85.4%-96.6%). Overall, the application proved superior to the X-ray logo, visualized in 56% overall (P < .0001) but varied significantly by manufacturer (range, 7.7%-94.8%; P < .00001). The accuracy of the Pacemaker-ID application is consistent with reports from its creators and superior to X-ray logo visualization. The accuracy of the application as a POC tool can be enhanced and maintained with further AI training using recent CIED models. Some manufacturers can enhance their X-ray logos by improving placement and design.

Presence of Left Atrial Fibrosis May Contribute to Aberrant Hemodynamics and Increased Risk of Stroke in Atrial Fibrillation Patients.

Atrial fibrillation (AF) patients are at high risk of stroke, with the left atrial appendage (LAA) found to be the most common site of clot formation. Presence of left atrial (LA) fibrosis has also been associated with higher stroke risk. However, the mechanisms for increased stroke risk in patients with atrial fibrotic remodeling are poorly understood. We sought to explore these mechanisms using fluid dynamic analysis and to test the hypothesis that the presence of LA fibrosis leads to aberrant hemodynamics in the LA, contributing to increased stroke risk in AF patients. We retrospectively collected late-gadolinium-enhanced MRI (LGE-MRI) images of eight AF patients (four persistent and four paroxysmal) and reconstructed their 3D LA surfaces. Personalized computational fluid dynamic simulations were performed, and hemodynamics at the LA wall were quantified by wall shear stress (WSS, friction of blood), oscillatory shear index (OSI, temporal directional change of WSS), endothelial cell activation potential (ECAP, ratio of OSI and WSS), and relative residence time (RRT, residence time of blood near the LA wall). For each case, these hemodynamic metrics were compared between fibrotic and non-fibrotic portions of the wall. Our results showed that WSS was lower, and OSI, ECAP, and RRT was higher in the fibrotic region as compared to the non-fibrotic region, with ECAP (p = 0.001) and RRT (p = 0.002) having significant differences. Case-wise analysis showed that these differences in hemodynamics were statistically significant for seven cases. Furthermore, patients with higher fibrotic burden were exposed to larger regions of high ECAP, which represents regions of low WSS and high OSI. Consistently, high ECAP in the vicinity of the fibrotic wall suggest that local blood flow was slow and oscillating that represents aberrant hemodynamic conditions, thus enabling prothrombotic conditions for circulating blood. AF patients with high LA fibrotic burden had more prothrombotic regions, providing more sites for potential clot formation, thus increasing their risk of stroke.

Repeat catheter ablation for recurrent atrial fibrillation: Electrophysiologic findings and clinical outcomes.

INTRODUCTION: Atrial fibrillation (AF) ablation is successful in 60%-80% of optimal candidates, with many patients requiring repeat procedures. We performed a detailed examination of electrophysiologic findings and clinical outcomes associated with first repeat AF ablations in the era of contact force-sensing radiofrequency (RF) catheters. METHODS: We retrospectively studied patients who underwent their first repeat AF ablations for symptomatic, recurrent AF at our center between 2013 and 2019. All repeat ablations were performed using contact force-sensing RF catheters. Pulmonary vein (PV) reconnections at repeat ablation and freedom from atrial arrhythmia 1 year after repeat ablation were evaluated. We further assessed these findings based on AF classification at the time of presentation for repeat ablation, index RF versus cryoballoon (CB) ablation, and duration (≥3 versus <3 years) between index and repeat procedures. RESULTS: Among 300 patients, there were 136 (45.3%) who presented for their first repeat ablations in persistent AF. During repeat ablation, at least one PV reconnection was found in 257 (85.6%) patients, while 159 (53%) had three to four reconnections. There was a similar distribution of reconnections among patients with persistent versus paroxysmal AF (mean: 2.7 ± 1.3 vs. 2.9 ± 1.2; p = .341), index RF versus CB ablation (mean: 2.8 ± 1.3 vs. 2.9 ± 1.2; p = .553), and ≥3 versus <3 years between index and repeat procedures (mean: 3.0 ± 1.1 vs. 2.7 ± 1.3; p = .119). At repeat ablation, the PVs were re-isolated in all patients, and additional non-PV ablation was performed in 171 (57%) patients. Freedom from atrial arrhythmia at 1-year follow-up after repeat ablation was 66%, similar among those with persistent versus paroxysmal AF (65.4% vs. 66.5%; p = .720), index RF versus CB ablation (66.7% vs. 68.9%; p = .930), and ≥3 versus <3 years between index and repeat ablations (64.4% vs. 66.7%; p = .760). Major complications occurred in a total of 4 (1.3%) patients. CONCLUSION: In a contemporary cohort of patients receiving their first repeat AF ablations using contact force-sensing RF catheters, PV reconnections were common, and freedom from atrial arrhythmia was 66% at 1-year follow-up. The distributions of PV reconnections and rates of freedom from atrial arrhythmia were similar, based on persistent versus paroxysmal AF at presentation for repeat ablation, index RF versus CB ablation, and duration between index and repeat procedures. The incidence of major complications was very low.

The role of timing in treatment of atrial fibrillation: An AFFIRM substudy.

BACKGROUND: In contrast to historical trials, the Early Treatment of Atrial Fibrillation for Stroke Prevention Trial (EAST-AFNET 4) suggests the superiority of early rhythm control over rate control in patients with recent-onset atrial fibrillation (AF). The relative contribution of timing vs improvement in AF therapeutics over time is unclear. OBJECTIVE: This study aimed to isolate the assessment of early intervention for AF from temporal changes in AF treatments through a secondary analysis of subjects from the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study. METHODS: We compared rate and rhythm control treatments in AFFIRM subjects stratified by time from their diagnosis of AF. Time-to-event analysis was performed to compare all-cause mortality, cardiovascular hospitalizations, stroke, and number of hospitalization days. RESULTS: Of the 4060 AFFIRM subjects, 2526 subjects (62.2%) had their first episode of AF within 6 months of study enrollment. Participants with "new" AF had a decreased risk of all-cause mortality (P = .001) than did those with prior AF diagnoses. Individuals previously diagnosed with AF were similar in age and demographic characteristics, but had more medical comorbidities, including myocardial infarction (P = .006), diabetes mellitus (P = .002), smoking (P = .003), and hepatic or renal comorbidities (P = .008). There were no differences in mortality, cardiovascular hospitalizations, or stroke between rate and rhythm control strategies in either AF subgroup. CONCLUSION: AFFIRM subjects diagnosed with AF within 6 months of study enrollment showed no difference in survival, cardiovascular hospitalization, or ischemic stroke between rate and rhythm control strategies. Superiority of rhythm control strategies reported by newer AF trials may be more attributable to the refinement of AF therapies and less related to the timing of intervention.

Managing cardiac implantable electronic device patients during a health care crisis: Practical guidance.

Our world is faced with a global pandemic that threatens to overwhelm many national health care systems for a prolonged period. Consequently, the elective long-term cardiac implantable electronic device (CIED) management of millions of patients is potentially compromised, raising the likelihood of patients experiencing major adverse events owing to loss of CIED therapy. This review gives practical guidance to health care providers to help promptly recognize the requirement for expert consultation for urgent interrogation and/or surgery in CIED patients.

Association between interatrial block, left atrial fibrosis, and mechanical dyssynchrony: Electrocardiography-magnetic resonance imaging correlation.

INTRODUCTION: Advanced interatrial block (IAB) on a 12-lead electrocardiogram (ECG) is a predictor of stroke, incident atrial fibrillation (AF), and AF recurrence after catheter ablation. The objective of this study was to determine which features of IAB structural remodeling is associated with left atrium (LA) magnetic resonance imaging structure and function. METHODS/RESULTS: We included 152 consecutive patients (23% nonparoxysmal AF) who underwent preprocedural ECG and cardiac magnetic resonance (CMR) in sinus rhythm before catheter ablation of AF. IAB was defined as P-wave duration ≥120 ms, and was considered partial if P-wave was positive and advanced if P-wave had a biphasic morphology in inferior leads. From cine CMR and late gadolinium enhancement, we derived LA maximum and minimum volume indices, strain, LA fibrosis, and LA dyssynchrony. A total of 77 patients (50.7% paroxysmal) had normal P-wave, 52 (34.2%) partial IAB, and 23 (15.1%) advanced IAB. Patients with advanced IAB had significantly higher LA minimum volume index (25.7 vs 19.9 mL/m2 , P = .010), more LA fibrosis (21.9% vs 13.1%, P = .020), and lower LA maximum strain rate (0.99 vs 1.18, P = .007) than those without. Advanced IAB was independently associated with LA (minimum [P = .032] and fibrosis [P = .009]). P-wave duration was also independently associated with LA fibrosis (ß = .33; P = .049) and LA mechanical dyssynchrony (ß = 2.01; P = .007). CONCLUSION: Advanced IAB is associated with larger LA volumes, lower emptying fraction, and more fibrosis. Longer P-wave duration is also associated with more LA fibrosis and higher LA mechanical dyssynchrony.

Preprocedure Application of Machine Learning and Mechanistic Simulations Predicts Likelihood of Paroxysmal Atrial Fibrillation Recurrence Following Pulmonary Vein Isolation.

BACKGROUND: Pulmonary vein isolation (PVI) is an effective treatment strategy for patients with atrial fibrillation (AF), but many experience AF recurrence and require repeat ablation procedures. The goal of this study was to develop and evaluate a methodology that combines machine learning (ML) and personalized computational modeling to predict, before PVI, which patients are most likely to experience AF recurrence after PVI. METHODS: This single-center retrospective proof-of-concept study included 32 patients with documented paroxysmal AF who underwent PVI and had preprocedural late gadolinium enhanced magnetic resonance imaging. For each patient, a personalized computational model of the left atrium simulated AF induction via rapid pacing. Features were derived from pre-PVI late gadolinium enhanced magnetic resonance images and from results of simulations of AF induction. The most predictive features were used as input to a quadratic discriminant analysis ML classifier, which was trained, optimized, and evaluated with 10-fold nested cross-validation to predict the probability of AF recurrence post-PVI. RESULTS: In our cohort, the ML classifier predicted probability of AF recurrence with an average validation sensitivity and specificity of 82% and 89%, respectively, and a validation area under the curve of 0.82. Dissecting the relative contributions of simulations of AF induction and raw images to the predictive capability of the ML classifier, we found that when only features from simulations of AF induction were used to train the ML classifier, its performance remained similar (validation area under the curve, 0.81). However, when only features extracted from raw images were used for training, the validation area under the curve significantly decreased (0.47). CONCLUSIONS: ML and personalized computational modeling can be used together to accurately predict, using only pre-PVI late gadolinium enhanced magnetic resonance imaging scans as input, whether a patient is likely to experience AF recurrence following PVI, even when the patient cohort is small.

Utility of Cardiac MRI in Atrial Fibrillation Management.

Advances in cardiac magnetic resonance (CMR) techniques and image acquisition have made it an excellent tool in the assessment of atrial myopathy. Remolding of the left atrium is the mainstay of atrial fibrillation (AF) development and its progression. CMR can detect phasic atrial volumes, atrial function, and atrial fibrosis using cine, and contrast-enhanced or non-contrast-enhanced images. These abilities make CMR a versatile and extraordinary tool in management of patients with AF including for risk stratification, ablation prognostication and planning, and assessment of stroke risk. We review the latest advancements in utility of CMR in management of patients with AF.

Unregulated online sales of cardiac implantable electronic devices in the United States: A six-month assessment.

BACKGROUND: An estimated 1 million patients require cardiac implantable electronic devices (CIEDs) but go without annually. This disparity exists in low-to-middle-income nations largely owing to the cost of CIED hardware. Humanitarian reuse of CIEDs has been shown to be safe and feasible. However, recent publications have raised concern that promotion of CIED reuse may foster a CIED "black market," to the dismay of manufacturers, regulators, and clinicians alike. OBJECTIVE: To determine if unregulated CIED sales for potential human use is a real issue by investigating unregulated public online CIED sale listings in the United States of America. METHODS: An observational study was undertaken over 6 months using multiple internet search engines from May 1 to November 1, 2019. We cataloged usable CIEDs (still in packaging, manufactured <7 years) and pricing. Manufacturers were contacted to determine status of sellers and unregulated CIEDs using model/serial numbers. RESULTS: In total, 58 CIEDs-47 implantable cardioverter-defibrillators and 11 permanent pacemakers-from 4 manufacturers were listed for sale on 3 websites. During the study period, 8 of 11 pacemakers and 37 of 47 implantable cardioverter-defibrillators were sold (price range: $100-$1500 [US dollars]). No new listings were seen in the last 3 months of observation, possibly owing to concomitant industry investigation. CONCLUSION: There does exist a public online market for unregulated CIED sales in the United States. This specific market seems to be small and unlikely to significantly expand with active monitoring by manufacturers and regulators.

Electrocardiographic predictors of pacemaker battery depletion: Diagnostic sensitivity, specificity, and clinical risk.

BACKGROUND: Pacemaker battery depletion triggers alert for replacement notification and results in automatic reprogramming, which has been shown to be associated with relevant cardiorespiratory symptoms and adverse clinical events. OBJECTIVE: Determine if electrocardiogram (ECG) pacing features may be predictive of pacemaker battery depletion and clinical risk. METHODS: This is an ECG substudy of a cohort analysis of 298 subjects referred for pacemaker generator replacement from 2006 to 2017. Electronic medical record review was performed; clinical, ECG, and pacemaker characteristics were abstracted. We applied two ECG prediction rules for pacemaker battery depletion that are relevant to all major pacemaker manufacturers except Boston Scientific and MicroPort: (1) atrial pacing not at a multiple of 10 and (2) nonsynchronous ventricular pacing not at a multiple of 10, to determine diagnostic sensitivity, specificity, and risk in applicable ECG subjects. RESULTS: We excluded 32 subjects not at replacement notification or duplicate surgeries. Overall, 176 of 266 subjects (66.2%) demonstrated atrial pacing or nonsynchronous ventricular pacing on preoperative ECG. When utilizing both rules, 139 of 176 preoperative ECGs and 12 of 163 postoperative ECGs met criteria for battery depletion yielding reasonable sensitivity (79.0%), high specificity (92.6%), and a positive likelihood ratio of 11.6:1. These rules were associated with significant increase in cardiorespiratory symptoms (P < .001) and adverse clinical events (P < .025). CONCLUSIONS: The "Rules of Ten" provided reasonable sensitivity and specificity for detecting replacement notification in pacemaker subjects with an applicable ECG. This ECG tool may help clinicians identify most patients with pacemaker battery depletion at significant clinical risk.

Heart rate increase after pulmonary vein isolation predicts freedom from atrial fibrillation at 1 year.

INTRODUCTION: Ablation of atrial vagal ganglia has been associated with improved pulmonary vein isolation (PVI) outcomes. Disruption of vagal reflexes results in heart rate (HR) increase. We investigated the association between HR change after PVI and freedom from atrial fibrillation (AF) at 1 year. METHODS AND RESULTS: Patients who underwent PVI for paroxysmal AF were identified from the Johns Hopkins Hospital AF registry. Electrocardiograms taken pre-PVI and post-PVI were used to determine the change in HR. Patients followed-up at 3, 6, and 12 months. Of 257 patients (66% male, age 59+/-11 years), 134 (52%) remained free from AF at 1 year. The average HR increased from 60.6 ± 11.3 beats per minute (bpm) pre-PVI to 70.7 ± 12.0 bpm post-PVI. Patients with recurrence of AF had lower post-PVI HR than those who remained free from AF (67.8 ± 0.2 vs 73.3 ± 13.0 bpm; P <.001). The probability of AF recurrence at 1-year decreased as the change in HR increased (estimated odds ratio [OR], 0.83; 95% confidence interval [CI, 0.74-0.93]; P = .002). HR increase more than 15 bpm was associated with the lowest odds of AF recurrence (estimated OR, 0.39; 95% [0.17-0.85]; P = .018) compared to HR decrease. CONCLUSIONS: Resting HR was found to increase after PVI. Increase in HR more than 15 bpm has a positive association with remaining free from atrial fibrillation at 1 year.

Computationally guided personalized targeted ablation of persistent atrial fibrillation.

Atrial fibrillation (AF)-the most common arrhythmia-significantly increases the risk of stroke and heart failure. Although catheter ablation can restore normal heart rhythms, patients with persistent AF who develop atrial fibrosis often undergo multiple failed ablations, and thus increased procedural risks. Here, we present personalized computational modelling for the reliable predetermination of ablation targets, which are then used to guide the ablation procedure in patients with persistent AF and atrial fibrosis. First, we show that a computational model of the atria of patients identifies fibrotic tissue that, if ablated, will not sustain AF. Then, we report the results of integrating the target ablation sites in a clinical mapping system and testing its feasibility in ten patients with persistent AF. The computational prediction of ablation targets avoids lengthy electrical mapping and could improve the accuracy and efficacy of targeted AF ablation in patients while eliminating the need for repeat procedures.

Periatrial Fat Quality Predicts Atrial Fibrillation Ablation Outcome.

Background Previous studies showed that the quantity of the left atrial (LA) periatrial fat tissue predicts recurrence after catheter ablation of atrial fibrillation (AF). We hypothesized that the quality of the LA periatrial fat tissue, measured by the mean computed tomography attenuation, predicts recurrence after AF ablation independent of the quantity of the LA periatrial fat tissue. Methods We included 143 consecutive patients with drug-refractory AF referred for the first catheter ablation of AF (62.2±10 years, 40% nonparoxysmal AF). All participants had a preablation cardiac computed tomography. We measured the quantity of the LA periatrial fat tissue by the area (millimeter square) and the quality by the mean computed tomography attenuation (Hounsfield units) in a standard 4-chamber view. Results Patients with AF recurrence after ablation (n=57) had a significantly larger fat area (167.6 [interquartile range, 124.1-255] versus 145.4 [95.6-229.3] mm2; P=0.018) and a higher fat attenuation (-92.0±9.8 versus -96.5±9.4 Hounsfield units; P=0.006) than those without recurrence (controls). LA fat attenuation was correlated with LA fat volume and LA bipolar voltage by invasive mapping and was associated with AF recurrence after adjusting for clinical risk factors, including body mass index, AF type, LA dimension, and fat area (hazard ratio, 2.65; P=0.001). Conclusions The quality of the LA periatrial fat tissue is an independent predictor of recurrence after the first AF ablation. Assessment of LA periatrial fat attenuation can improve AF ablation outcomes by refining patient selection.

Machine Learning Prediction of Response to Cardiac Resynchronization Therapy: Improvement Versus Current Guidelines.

BACKGROUND: Cardiac resynchronization therapy (CRT) has significant nonresponse rates. We assessed whether machine learning (ML) could predict CRT response beyond current guidelines. METHODS: We analyzed CRT patients from Cleveland Clinic and Johns Hopkins. A training cohort was created from all Johns Hopkins patients and an equal number of randomly sampled Cleveland Clinic patients. All remaining patients comprised the testing cohort. Response was defined as ≥10% increase in left ventricular ejection fraction. ML models were developed to predict CRT response using different combinations of classification algorithms and clinical variable sets on the training cohort. The model with the highest area under the curve was evaluated on the testing cohort. Probability of response was used to predict survival free from a composite end point of death, heart transplant, or placement of left ventricular assist device. Predictions were compared with current guidelines. RESULTS: Nine hundred twenty-five patients were included. On the training cohort (n=470: 235, Johns Hopkins; 235, Cleveland Clinic), the best ML model was a naive Bayes classifier including 9 variables (QRS morphology, QRS duration, New York Heart Association classification, left ventricular ejection fraction and end-diastolic diameter, sex, ischemic cardiomyopathy, atrial fibrillation, and epicardial left ventricular lead). On the testing cohort (n=455, Cleveland Clinic), ML demonstrated better response prediction than guidelines (area under the curve, 0.70 versus 0.65; P=0.012) and greater discrimination of event-free survival (concordance index, 0.61 versus 0.56; P<0.001). The fourth quartile of the ML model had the greatest risk of reaching the composite end point, whereas the first quartile had the least (hazard ratio, 0.34; P<0.001). CONCLUSIONS: ML with 9 variables incrementally improved prediction of echocardiographic CRT response and survival beyond guidelines. Performance was not improved by incorporating more variables. The model offers potential for improved shared decision-making in CRT (online calculator: http://riskcalc.org:3838/CRTResponseScore ). Significant remaining limitations confirm the need to identify better variables to predict CRT response.

Intra-Atrial Dyssynchrony Using Cardiac Magnetic Resonance to Quantify Tissue Remodeling in Patients with Atrial Fibrillation.

BACKGROUND: Recent studies suggest that left atrial (LA) late gadolinium enhancement (LGE) can quantify the underlying tissue remodeling that harbors atrial fibrillation (AF). However, quantification of LA-LGE requires labor-intensive magnetic resonance imaging acquisition and postprocessing at experienced centers. LA intra-atrial dyssynchrony assessment is an emerging imaging technique that predicts AF recurrence after catheter ablation. We hypothesized that 1) LA intra-atrial dyssynchrony is associated with LA-LGE in patients with AF and 2) LA intra-atrial dyssynchrony is greater in patients with persistent AF than in those with paroxysmal AF. METHOD: We conducted a cross-sectional study comparing LA intra-atrial dyssynchrony and LA-LGE in 146 patients with a history of AF (60.0 ± 10.0 years, 30.1% nonparoxysmal AF) who underwent pre-AF ablation cardiac magnetic resonance (CMR) in sinus rhythm. Using tissue-tracking CMR, we measured the LA longitudinal strain in two- and four-chamber views. We defined intra-atrial dyssynchrony as the standard deviation (SD) of the time to peak longitudinal strain (SD-TPS, in %) and the SD of the time to the peak pre-atrial contraction strain corrected by the cycle length (SD-TPSpreA, in %). We used the image intensity ratio (IIR) to quantify LA-LGE. RESULTS: Intra-atrial dyssynchrony analysis took 5 ± 9 minutes per case. Multivariable analysis showed that LA intra-atrial dyssynchrony was independently associated with LA-LGE. In addition, LA intra-atrial dyssynchrony was significantly greater in patients with persistent AF than those with paroxysmal AF. In contrast, there was no significant difference in LA-LGE between patients with persistent and paroxysmal AF. LA intra-atrial dyssynchrony showed excellent reproducibility and its analysis was less time-consuming (5 ± 9 minutes) than the LA-LGE (60 ± 20 minutes). CONCLUSION: LA Intra-atrial dyssynchrony is a quick and reproducible index that is independently associated with LA-LGE to reflect the underlying tissue remodeling.

Arrhythmogenic propensity of the fibrotic substrate after atrial fibrillation ablation: a longitudinal study using magnetic resonance imaging-based atrial models.

AIMS: Inadequate modification of the atrial fibrotic substrate necessary to sustain re-entrant drivers (RDs) may explain atrial fibrillation (AF) recurrence following failed pulmonary vein isolation (PVI). Personalized computational models of the fibrotic atrial substrate derived from late gadolinium enhanced (LGE)-magnetic resonance imaging (MRI) can be used to non-invasively determine the presence of RDs. The objective of this study is to assess the changes of the arrhythmogenic propensity of the fibrotic substrate after PVI. METHODS AND RESULTS: Pre- and post-ablation individualized left atrial models were constructed from 12 AF patients who underwent pre- and post-PVI LGE-MRI, in six of whom PVI failed. Pre-ablation AF sustained by RDs was induced in 10 models. RDs in the post-ablation models were classified as either preserved or emergent. Pre-ablation models derived from patients for whom the procedure failed exhibited a higher number of RDs and larger areas defined as promoting RD formation when compared with atrial models from patients who had successful ablation, 2.6 ± 0.9 vs. 1.8 ± 0.2 and 18.9 ± 1.6% vs. 13.8 ± 1.5%, respectively. In cases of successful ablation, PVI eliminated completely the RDs sustaining AF. Preserved RDs unaffected by ablation were documented only in post-ablation models of patients who experienced recurrent AF (2/5 models); all of these models had also one or more emergent RDs at locations distinct from those of pre-ablation RDs. Emergent RDs occurred in regions that had the same characteristics of the fibrosis spatial distribution (entropy and density) as regions that harboured RDs in pre-ablation models. CONCLUSION: Recurrent AF after PVI in the fibrotic atria may be attributable to both preserved RDs that sustain AF pre- and post-ablation, and the emergence of new RDs following ablation. The same levels of fibrosis entropy and density underlie the pro-RD propensity in both pre- and post-ablation substrates.

Intra-Atrial Dyssynchrony Using Cardiac Magnetic Resonance to Quantify Tissue Remodeling in Patients with Atrial Fibrillation / Dessincronia Intra-atrial à Ressonância Magnética Cardíaca para Quantificação da Remodelação Tecidual em Pacientes com Fibrilação Atrial

Abstract Background: Recent studies suggest that left atrial (LA) late gadolinium enhancement (LGE) can quantify the underlying tissue remodeling that harbors atrial fibrillation (AF). However, quantification of LA-LGE requires labor-intensive magnetic resonance imaging acquisition and postprocessing at experienced centers. LA intra-atrial dyssynchrony assessment is an emerging imaging technique that predicts AF recurrence after catheter ablation. We hypothesized that 1) LA intra-atrial dyssynchrony is associated with LA-LGE in patients with AF and 2) LA intra-atrial dyssynchrony is greater in patients with persistent AF than in those with paroxysmal AF. Method: We conducted a cross-sectional study comparing LA intra-atrial dyssynchrony and LA-LGE in 146 patients with a history of AF (60.0 ± 10.0 years, 30.1% nonparoxysmal AF) who underwent pre-AF ablation cardiac magnetic resonance (CMR) in sinus rhythm. Using tissue-tracking CMR, we measured the LA longitudinal strain in two- and four-chamber views. We defined intra-atrial dyssynchrony as the standard deviation (SD) of the time to peak longitudinal strain (SD-TPS, in %) and the SD of the time to the peak pre-atrial contraction strain corrected by the cycle length (SD-TPSpreA, in %). We used the image intensity ratio (IIR) to quantify LA-LGE. Results: Intra-atrial dyssynchrony analysis took 5 ± 9 minutes per case. Multivariable analysis showed that LA intra-atrial dyssynchrony was independently associated with LA-LGE. In addition, LA intra-atrial dyssynchrony was significantly greater in patients with persistent AF than those with paroxysmal AF. In contrast, there was no significant difference in LA-LGE between patients with persistent and paroxysmal AF. LA intra-atrial dyssynchrony showed excellent reproducibility and its analysis was less time-consuming (5 ± 9 minutes) than the LA-LGE (60 ± 20 minutes). Conclusion: LA Intra-atrial dyssynchrony is a quick and reproducible index that is independently associated with LA-LGE to reflect the underlying tissue remodeling.

Resumo Fundamento: Estudos recentes sugerem que o realce tardio com gadolínio (RTG) no átrio esquerdo (AE) pode quantificar a remodelação tecidual subjacente que abriga a fibrilação atrial (FA). No entanto, a quantificação do RTG-AE requer um trabalho intenso de aquisição por ressonância magnética e pós-processamento em centros experientes. A avaliação da dessincronia intra-atrial no AE é uma técnica de imagem emergente que prediz a recorrência da FA após ablação por cateter. Nós levantamos as hipóteses de que 1) a dessincronia intra-atrial está associada ao RTG-AE em pacientes com FA e 2) a dessincronia intra-atrial é maior em pacientes com FA persistente do que naqueles com FA paroxística. Método: Realizamos um estudo transversal comparando a dessincronia intra-atrial no AE e o RTG-AE em 146 pacientes com história de FA (60,0 ± 10,0 anos, 30,1% com FA não paroxística) submetidos à ressonância magnética cardíaca (RMC) durante ritmo sinusal antes da ablação da FA. Com utilização de RMC com tissue tracking, medimos o strain longitudinal do AE em cortes de duas e quatro câmaras. Definimos a dessincronia intra-atrial como o desvio padrão (DP) do tempo até o pico do strain longitudinal (DP-TPS, em %) e o DP do tempo até o pico do strain antes da contração atrial corrigido pela duração do ciclo (DP-TPSpreA, em %). Utilizamos a razão da intensidade da imagem (RIM) para quantificar o RTG-AE. Resultados: A análise da dessincronia intra-atrial levou 9 ± 5 minutos por caso. A análise multivariada mostrou que a dessincronia intra-atrial no AE esteve independentemente associada ao RTG-AE. Além disso, a dessincronia intra-atrial no AE foi significativamente maior em pacientes com FA persistente do que naqueles com FA paroxística. Por outro lado, não houve diferença significativa no RTG-AE entre pacientes com FA persistente e paroxística. A dessincronia intra-atrial no AE mostrou excelente reprodutibilidade e sua análise foi menos demorada (5 ± 9 minutos) do que o RTG-AE (60 ± 20 minutos). Conclusão: A dessincronia intra-atrial no AE é um índice rápido, reprodutível e independentemente associado ao RTG-AE para indicar remodelação tecidual subjacente. (Arq Bras Cardiol. 2019; 112(4):441-450)