Does left atrial epicardial conduction time reflect atrial fibrosis and the risk of atrial fibrillation recurrence after thoracoscopic ablation? Post hoc analysis of the AFACT trial

R Wesselink, J Neefs, N W E van den Berg, E R Meulendijks, M M Terpstra, M Kawasaki, F A Nariswari, F R Piersma, W J P van Boven, A H G Driessen, J R de Groot, R Wesselink, J Neefs, N W E van den Berg, E R Meulendijks, M M Terpstra, M Kawasaki, F A Nariswari, F R Piersma, W J P van Boven, A H G Driessen, J R de Groot

Abstract

Objectives: To determine the association between left atrial epicardial conduction time (LAECT), fibrosis and atrial fibrillation (AF) recurrence after thoracoscopic surgical ablation of persistent AF.

Setting: Single tertiary care centre in the Netherlands.

Participants: Patients with persistent AF from the randomised Atrial Fibrillation Ablation and Autonomic Modulation via Thoracoscopic Surgery (AFACT)-trial were included. Patients eligible for thoracoscopic AF ablation were included, full inclusion and exclusion criteria were previously published. All patients underwent thoracoscopic ablation, encompassing pulmonary vein isolation with an additional roof and trigone lesion. In patients with conduction block across the roof and trigone lesion, LAECT was measured. LAECT was defined as the time to local activation at one side of the roofline on pacing from the opposite side. Collagen fibre density was quantified from left atrial appendage histology.

Outcome measures: Primary outcome: AF recurrence during 2 years of follow-up.

Results: 121 patients were included, of whom 35(29%) were women, age was 60.4±7.8 and 51% (62) had at least one AF recurrence during 2 years of follow-up. LAECT was longer in patients with versus without AF recurrence (182±43 ms vs 147±29 ms, p<0.001). LAECT was longer in older patients, in patients with a higher body mass index (BMI) and in patients using class IC antiarrhythmic drugs. LAECT was shorter in patients with higher collagen fibre density. A previously failed catheter ablation, LAECT and BMI were independently associated with AF recurrence.

Conclusion: LAECT is correlated with collagen fibre density and BMI and is independently associated with AF recurrence in patients with persistent AF. In these patients, LAECT appears to reflect substrate characteristics beyond clinical AF type and left atrial volume.

Trial registration number: NCT01091389.

Keywords: cardiology; cardiothoracic surgery; pacing & electrophysiology.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Schematic image of the posterior left atrium. A partial roofline is constructed, connected to the trigone line. The trigone line is connected to the left fibrous trigone. Evaluation of conduction block by the roofline by determining conduction time close to the roofline (position A), and further downward (position B) from the roofline. Red dotted line represents the direction of the activation front in case of conduction block by the roof- and trigone line. LAECT was defined as the conduction time at position A, close to the roofline, in case of proven conduction block by the roof- and trigone line. LAECT, left atrial epicardial conduction time.
Figure 2
Figure 2
Typical example of collagen fibre analysis in six screens. (1) Selection of ± 4600 by 4600 pixels. (2) Manual removal of endocardial, epicardial and perivascular fibrosis(blue=excluded area). (3) Binarized (black and white) image, identification and removal of large interconnected areas of collagen (yellow). (4) Final input for fibre analysis algorithm. 5 and 6 are a magnification of the red aligned section of image 4. (5) Result of skeletonization, (6) fibres with a red centreline, reflecting the length of the fibre.
Figure 3
Figure 3
Univariate and multivariable Cox regression analysis of LAECT and other preselected risk factors for AF recurrence. AF, atrial fibrillation; BMI, body mass index; GP, ganglion plexus; LAECT, left atrial epicardial conduction time; LAVI, left atrial volume index; NT-proBNP, n-terminal pro natriuretic peptide; y, years.
Figure 4
Figure 4
Univariate and multivariable linear regression of patient characteristics and LAECT. AAD, antiarrhythmic drugs; BMI, body mass index; GP, ganglion plexus; LAECT, left atrial epicardial conduction time; LAVI, left atrial volume index; RL, roof line; y, years.

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