Stiff Left Atrial Syndrome After Catheter Ablation for Atrial Fibrillation: Clinical Characterization, Prevalence, and Predictors

Study Questions:

Does radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) affect left atrial (LA) diastolic function?

Methods:

Echocardiograms were performed before and after RFCA with an open irrigated-tip ablation catheter in 1,380 patients (mean age 62 years) with AF (persistent in 71%). The ablation strategy was pulmonary vein antral isolation plus RFCA of the posterior wall, left septum, and complex fractionated electrograms, as indicated. Patients with pulmonary hypertension (PH) and evidence of LA diastolic dysfunction based on LA pressure measurements or right heart catheterization and with no evidence of mitral regurgitation or pulmonary vein stenosis were identified.

Results:

The prevalence of PH post-RFCA was 1.4%. The PH (mean pulmonary artery pressure 45 mm Hg, range 26-78 mm Hg) was mild in 53%, moderate in 32%, and severe in 15%. The patients with severe PH all had moderate PH pre-RFCA. The independent predictors of PH were LA size ≤45 mm, diabetes, obstructive sleep apnea, LA pressure, and severe LA scarring.

Conclusions:

The authors concluded that LA diastolic dysfunction is a potential complication of RFCA of AF, and should be in the differential diagnosis of patients with dyspnea following LA ablation.

Perspective:

The most common cause of dyspnea after extensive RFCA of AF using an irrigated-tip ablation catheter is fluid overload related to the irrigant. Pulmonary vein stenosis and pulmonary embolism should be ruled out if there is evidence of PH. This study demonstrates that LA diastolic dysfunction caused by RFCA is another possible cause of dyspnea. A characteristic finding is a large V wave in the pulmonary capillary wedge or LA pressure tracing in the absence of mitral regurgitation. Treatment with diuretics typically results in symptomatic improvement.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Valvular Heart Disease, Vascular Medicine, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Echocardiography/Ultrasound, Hypertension, Sleep Apnea, Mitral Regurgitation

Keywords: Constriction, Mitral Valve Insufficiency, Pulmonary Embolism, Pulmonary Veins, Diuretics, Atrial Function, Dyspnea, Pressure, Heart Rate, Pulmonary Artery, Sleep Apnea Syndromes, Capillaries, Prevalence, Cicatrix, Diastole, Catheter Ablation, Hypertension, Diabetes Mellitus, Echocardiography, Atrial Flutter


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