LGE and AF Recurrence After Pulmonary Vein Isolation
Is the degree of left atrial scarring predictive of recurrent atrial fibrillation (AF) after pulmonary vein isolation (PVI)?
Cardiac magnetic resonance imaging with late gadolinium enhancement (LGE) was performed in 165 patients with AF (mean age 60 years, paroxysmal in 94, persistent in 71). All patients underwent wide area circumferential PVI. Monitoring for AF was performed at 6 and 12 months of follow-up and whenever there were symptoms consistent with recurrent AF. The mean duration of follow-up was 10.2 months.
AF recurred in 36% of patients with paroxysmal AF and 41% of patients with persistent AF. Each 10% increase in LGE extent was independently associated with a higher risk of AF recurrence, regardless of AF type (hazard ratio [HR], 1.5). The mean time to recurrent AF was significantly shorter when the LGE extent was >35% than when it was ≤35% (140 vs. 288 days). The association between LGE extent >35% and recurrent AF was greater in patients with persistent AF (HR, 6.5) than in patients with paroxysmal AF (HR, 3.6).
Baseline left atrial LGE >35% is associated with early recurrence of AF after PVI in patients with paroxysmal and persistent AF.
The principal clinical implication of the findings is that LGE extent >35% identifies patients who are likely to require substrate modification, not only PVI. This is very plausible in patients with persistent AF, but less so in patients with paroxysmal AF. Many studies have reported that recurrent AF after PVI in patients with paroxysmal AF is related to recurrence of PV conduction. It is possible that PVI is less durable in patients with paroxysmal AF who have extensive scarring.
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