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Stiff left atrial syndrome after catheter ablation for atrial fibrillation: Clinical characterization, prevalence, and predictors

Published:February 25, 2011DOI:https://doi.org/10.1016/j.hrthm.2011.02.026

      Background

      There have been no studies of atrial diastolic function after catheter ablation of atrial fibrillation (AF). We encountered a few patients with symptomatic left atrial (LA) diastolic dysfunction and associated pulmonary hypertension (PH) that developed after catheter ablation for atrial fibrillation. Similar findings were described in patients after cardiac surgery and were referred to as the “stiff left atrial syndrome.”

      Objective

      The purpose of this study was to prospectively quantify the incidence of patients developing PH associated with diastolic hemodynamic abnormalities of the LA after radiofrequency ablation of AF and to identify the possible predictors.

      Methods

      Between January 2009 and July 2010, data on 1,380 consecutive patients were prospectively collected. Before ablation and at follow-up, all patients had an echocardiogram to assess for the presence of PH. Patients with no echocardiographic evidence of PH but complaining of unexplained dyspnea with LA diastolic abnormalities were evaluated with right heart catheterization (RHC). Patients were included in the analysis if they developed new or worsening PH postablation with evidence of LA diastolic dysfunction by RHC or direct LA pressure measurement. All patients were evaluated for pulmonary vein stenosis and excluded if this condition was identified.

      Results

      The mean age was 62 ± 11 (75% male), and nonparoxysmal AF was the predominant arrhythmia (71%). New or worsening PH with associated LA diastolic abnormalities was detected in 19 (1.4%) patients after ablation. The prevalence of PH did not differ between AF types (P = .612). Compared with patients who did not develop PH, LA scarring (P <.001), diabetes (P = .026), and obstructive sleep apnea (OSA; P = .006) were more frequently observed among those who developed PH. In a multivariable logistic model, preprocedure LA size ≤45 mm (odds ratio [OR] = 6.13; P = .033), mean LA pressure (OR 1.14; P = .025), severe LA scarring (OR = 4.4; P = .046), diabetes mellitus (OR = 9.5; P = .004), and OSA (OR = 6.2; P = .009) were independently associated with the development of PH postablation.

      Conclusions

      After radiofrequency catheter ablation of atrial fibrillation (RFCAF), PH with LA diastolic dysfunction or the so-called stiff LA syndrome is a rare but potentially significant complication of AF ablation. Severe LA scarring, LA ≤45 mm, diabetes mellitus, OSA, and high LA pressure are clinical variables that predict the development of this syndrome. The main clinical findings include dyspnea, congestive heart failure, PH, and large V waves on pulmonary capillary wedge pressure (PCWP) or LA pressure tracings in the absence of mitral regurgitation.

      Keywords

      Abbreviations:

      AAD (antiarrhythmic drug), AF (atrial fibrillation), AUC (area under the curve), BMI (body mass index), CAD (coronary artery disease), CI (confidence interval), LA (left atrial, atrium), LVEF (left ventricular ejection fraction), NYHA (New York Heart Association), OR (odds ratio), OSA (obstructive sleep apnea), PAF (paroxysmal AF), PAP (pulmonary artery pressure), PH (pulmonary hypertension), PV (pulmonary vein), RA (right atrial, atrium), RHC (right heart catheterization)
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      References

        • Wilber D.J.
        • Pappone C.
        • Neuzil P.
        • et al.
        Comparison of antiarrhythmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation: a randomized controlled trial.
        JAMA. 2010; 30: 333-340
        • Elayi C.S.
        • Verma A.
        • Di Biase L.
        • et al.
        Ablation for longstanding permanent atrial fibrillation: results from a randomized study comparing three different strategies.
        Heart Rhythm. 2008; 5: 1658-1664
        • Di Biase L.
        • Burkhardt J.D.
        • Mohanty P.
        • et al.
        Left atrial appendage: an underrecognized trigger site of atrial fibrillation.
        Circulation. 2010; 122: 109-118
        • Jeevanantham V.
        • Ntim W.
        • Navaneethan S.D.
        • et al.
        Meta-analysis of the effect of radiofrequency catheter ablation of left atrial size, volumes and function in patients with atrial fibrillation.
        Am J Cardiol. 2010; 105: 1317-1326
        • Pilote L.
        • Hunter I.
        • Marpole D.
        • Sniderman A.
        Stiff left atrial syndrome.
        Can J Cardiol. 1988; 4: 255-257
        • Mehta S.
        • Charbonneau F.
        • Fitchett D.H.
        • Marpole D.G.
        • Patton R.
        • Sniderman A.D.
        The clinical consequences of a stiff left atrium.
        Am Heart J. 1991; 122: 1184-1191
        • McLaughlin V.V.
        • Archer S.L.
        • Badesch D.B.
        • et al.
        ACCF/AHA 2009 expert consensus document on pulmonary hypertension: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association: developed in collaboration with the American College of Chest Physicians, American Thoracic Society, Inc., and the Pulmonary Hypertension Association.
        Circulation. 2009; 119: 2250-2294
        • McGoon M.
        • Gutterman D.
        • Steen
        • et al.
        • American College of Chest Physicians
        Screening, early detection, and diagnosis of pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines.
        Chest. 2004; 126: 14S-34S
        • Badesch D.B.
        • Champion H.C.
        • Sanchez M.A.
        • et al.
        Diagnosis and assessment of pulmonary arterial hypertension.
        J Am Coll Cardiol. 2009; 54: S55-S66
        • Chemla D.
        • Castelain V.
        • Provencher S.
        • Humbert M.
        • Simonneau G.
        • Herve P.
        Evaluation of various empirical formulas for estimating mean pulmonary artery pressure by using systolic pulmonary artery pressure in adults.
        Chest. 2009; 135: 760-768
        • Verma A.
        • Wazni O.M.
        • Marrouche N.F.
        • et al.
        Pre-existent left atrial scarring in patients undergoing pulmonary vein antrum isolation an independent predictor of procedural failure.
        J Am Coll Cardiol. 2005; 45: 285-292
        • Di Biase L.
        • Burkhardt J.D.
        • Mohanty P.
        • et al.
        Periprocedural stroke and management of major bleeding complications in patients undergoing catheter ablation of atrial fibrillation: the impact of periprocedural therapeutic international normalized ratio.
        Circulation. 2010; 121: 2550-2556
        • Urzua J.
        • Kiraly R.J.
        • Wright J.I.
        • Cloesmeyer R.
        • Nose Y.
        A rationally designed artificial heart for calves.
        Trans Am Soc Artif Intern Organs. 1974; 20: 660-666
        • Parr G.V.S.
        • Kirklin J.W.
        • Pacifico A.D.
        • Blackstone E.H.
        • Lauridsen P.
        Cardiac performance in infants after repair of total anomalous venous connection.
        Ann Thorac Surg. 1974; 17: II-2-II-8
        • Pilote L.
        • Hunter I.
        • Marpole D.
        • Sniderman A.
        Stiff left atrial syndrome.
        Can J Cardiol. 1988; 4: 255-257
        • Kahn T.A.
        • Heywood J.T.
        • Johnson A.D.
        • Smith M.R.
        • Rubenson D.
        Left atrial diastolic dysfunction and pulmonary venous hypertension: hemodynamic and echocardiographic characteristics.
        J Cardiac Failure. 2009; 15: S25

      Linked Article

      • Erratum
        Heart RhythmVol. 8Issue 11
        • Preview
          In the article titled, “Stiff left atrial syndrome after catheter ablation for atrial fibrillation: Clinical characterization, prevalence, and predictors” by Gibson et al that published in the September issue of HeartRhythm journal (2011;8: 1364−1371) there is an error on page 1365 in the “Methods” section where the word “and” is inadvertently printed after “10mm of Hg”in the sentence below. The correct sentence should read: Abnormal LA diastolic function was defined as V waves greater than or equal to 10mm of Hg greater than the electronic mean of the LA pressure tracing in the absence of mitral regurgitation.
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