Early Remodeling of the Left Atrium Following Catheter Ablation of Atrial Fibrillation: Insights From DECAAFII.

Background: Left atrial (LA) enlargement is prevalent among atrial fibrillation (AF) patients and constitutes an important marker of atrial myopathy. Several studies have described reduction in LA volume post-catheter ablation (CA) of AF, however, none have investigated differences related to additional ablation outside the pulmonary veins (PVs).

Objectives: The authors sought to study early LA remodeling following CA of persistent AF and the impact of additional, fibrosis-guided extra-PV ablation.

Methods: In this DECAAF II (Effect of MRI-Guided Fibrosis Ablation vs Conventional Catheter Ablation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation) trial subanalysis, patients with persistent AF were randomized to receive pulmonary vein isolation (PVI) only or PVI + fibrosis-guided ablation. Late gadolinium enhancement magnetic resonance imaging (LGE-MRI) was performed before and 3 months after CA. Patients were followed up with single-lead electrocardiogram devices for 12 to18 months. AF burden was calculated as days with AF divided by days monitored.

Results: This analysis included 733 patients. The mean LA volume index (LAVI) before ablation was 62.0 mm/m and after ablation was 51.3 mm/m, with a mean reduction of 10.7 mm/m (P < 0.001). Patients in the fibrosis-guided ablation arm had more volume reduction than did those in the PVI-only group (12.1 mm/m vs 9.3 mm/m; P = 0.02). LAVI reduction was greater in patients with heart failure (15.7 vs 8.9; P = 0.001) and was associated with improved left ventricular ejection fraction (LVEF) (r = 0.23; P < 0.001), reduced AF burden (r = -0.173; P < 0.001), improved LVEF, and improved quality of life (r = 0.146; P < 0.001).

Conclusions: We confirmed the presence of LA remodeling within 3 months after ablation for persistent AF. Importantly, we saw more LA volume reductions in patients in the PVI + fibrosis-guided ablation arm in comparison with PVI only, and in patients with LV dysfunction. LA volume reduction in response to CA is associated with decreased arrhythmia recurrence, reduced AF burden, and improved LVEF and quality of life.