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Assessment and Impact of Cardiac Fibrosis on Atrial Fibrillation

  • Invasive Electrophysiology and Pacing (EK Heist, Section Editor)
  • Published:
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Abstract

Fibrosis is an essential component of structural remodeling that accompanies different cardiovascular disease conditions. In cardiac arrhythmias, fibrosis plays an important role in creating the necessary substrate for these arrhythmias to persist. Non-invasive evaluation of the arrhythmia substrate has seen significant advancements in the past several years. Cardiac MRI characterizes tissue changes including fibrosis and scarring and has seen its role expand significantly in cardiac electrophysiology. We have used late-gadolinium enhancement MRI (LGE-MRI) to study tissue changes in the left atrium of patients with atrial fibrillation (AF) and demonstrated its utility in identifying poor responders to catheter ablation, as well as its association with stroke risk and significant sinus node dysfunction. Following ablation, we also studied atrial scarring and demonstrated the utility of scar imaging in guiding repeat ablation procedures.

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References

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  1. Kim RJ, Fieno DS, Parrish TB, Harris K, Chen E-L, Simonetti O, et al. Relationship of MRI delayed contrast enhancement to irreversible injury, infarct age, and contractile function. Circulation. 1999;100(19):1992–2002.

    Article  CAS  PubMed  Google Scholar 

  2. Simonetti OP, Kim RJ, Fieno DS, Hillenbrand HB, Wu E, Bundy JM, et al. An improved MR imaging technique for the visualization of myocardial infarction. Radiology. 2001;218(1):215–23.

    Article  CAS  PubMed  Google Scholar 

  3. Oakes RS, Badger TJ, Kholmovski EG, Akoum N, Burgon NS, Fish EN, et al. Detection and quantification of left atrial structural remodeling with delayed-enhancement magnetic resonance imaging in patients with atrial fibrillation. Circulation. 2009;119(13):1758–67.

    Article  PubMed Central  PubMed  Google Scholar 

  4. Akoum N, Daccarett M, McGann C, Segerson N, Vergara G, Kuppahally S, et al. Atrial fibrosis helps select the appropriate patient and strategy in catheter ablation of atrial fibrillation: a DE-MRI guided approach. J Cardiovasc Electrophysiol. 2011;22(1):16–22.

    Article  PubMed Central  PubMed  Google Scholar 

  5. McGann C, Akoum N, Patel A, Kholmovski E, Revelo P, Damal K, et al. Atrial fibrillation ablation outcome is predicted by left atrial remodeling on MRI. Circ Arrhythmia Electrophysiol. 2014;7(1):23–30. This study demonstrates the correlation between LGE-MRI enhancement and tissue changes from cardiac biopsy. It also included a control group of non-AF patients demonstrated a significantly lower burden of fibrosis compared to AF patients.

    Article  Google Scholar 

  6. Marrouche NF, Wilber D, Hindricks G, Jais P, Akoum N, Marchlinski F, et al. Association of atrial tissue fibrosis identified by delayed enhancement MRI and atrial fibrillation catheter ablation: the DECAAF study. JAMA. 2014;31((5):498–506. This is a very important study that demonstrated the feasibility of LGE-MRI quantification of atrial fibrosis in different centers from the U.S. and Europe. It also showed that extensive atrial fibrosis was associated with reduced catheter ablation success.

    Article  Google Scholar 

  7. Platonov PG, Mitrofanova LB, Orshanskaya V, Ho SY. Structural abnormalities in atrial walls are associated with presence and persistency of atrial fibrillation but not with age. J Am Coll Cardiol. 2011;58(21):2225–32. This study evaluated atrial tissue post mortem and demonstrated that the presence of atrial fibrillation was associated with tissue fibrosis independent of age.

    Article  PubMed  Google Scholar 

  8. Kottkamp H. Fibrotic atrial cardiomyopathy: a specific disease/syndrome supplying substrates for atrial fibrillation, atrial tachycardia, sinus node disease, AV node disease, and thromboembolic complications. J Cardiovasc Electrophysiol. 2012;23(7):797–9.

    Article  PubMed  Google Scholar 

  9. Kottkamp H. Human atrial fibrillation substrate: towards a specific fibrotic atrial cardiomyopathy. Eur Heart J. 2013;34(35):2731–8.

    Article  PubMed  Google Scholar 

  10. Ausma J, Wijffels M, Thone F, Wouters L, Allessie M, Borgers M. Structural changes of atrial myocardium due to sustained atrial fibrillation in the goat. Circulation. 1997;96(9):3157–63.

    Article  CAS  PubMed  Google Scholar 

  11. Calkins H, Kuck KH, Cappato R, Brugada J, Camm AJ, Chen SA, et al. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design: a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology (ESC) and the European Cardiac Arrhythmia Society (ECAS); and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). Endorsed by the governing bodies of the American College of Cardiology Foundation, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, the Asia Pacific Heart Rhythm Society, and the Heart Rhythm Society. Heart Rhythm: Off J Heart Rhythm Soc. 2012;9(4):632-96 e21.

  12. Mahnkopf C, Badger TJ, Burgon NS, Daccarett M, Haslam TS, Badger CT, et al. Evaluation of the left atrial substrate in patients with lone atrial fibrillation using delayed-enhanced MRI: implications for disease progression and response to catheter ablation. Heart Rhythm: Off J Heart Rhythm Soc. 2010;7(10):1475–81.

    Article  Google Scholar 

  13. January CT, Wann LS, Alpert JS, Calkins H, Cleveland JC, Cigarroa JE, et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial FibrillationA Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014.

  14. Deshmukh A, Patel NJ, Pant S, Shah N, Chothani A, Mehta K, et al. In-hospital complications associated with catheter ablation of atrial fibrillation in the United States between 2000 and 2010: analysis of 93 801 procedures. Circulation. 2013;128(19):2104–12.

    Article  PubMed  Google Scholar 

  15. Wilber DJ, Pappone C, Neuzil P, De Paola A, Marchlinski F, Natale A, et al. Comparison of antiarrhythmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation: a randomized controlled trial. JAMA. 2010;303(4):333–40.

    Article  CAS  PubMed  Google Scholar 

  16. Oral H, Scharf C, Chugh A, Hall B, Cheung P, Good E, et al. Catheter ablation for paroxysmal atrial fibrillation. Circulation. 2003;108(19):2355–60.

    Article  PubMed  Google Scholar 

  17. Verma A, Wazni OM, Marrouche NF, Martin DO, Kilicaslan F, Minor S, 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(2):285–92.

    Article  PubMed  Google Scholar 

  18. Peters DC, Wylie JV, Hauser TH, Kissinger KV, Botnar RM, Essebag V, et al. Detection of pulmonary vein and left atrial scar after catheter ablation with three-dimensional navigator-gated delayed enhancement mr imaging: initial experience1. Radiology. 2007;243(3):690–5.

    Article  PubMed  Google Scholar 

  19. McGann CJ, Kholmovski EG, Oakes RS, Blauer JJ, Daccarett M, Segerson N, et al. New magnetic resonance imaging-based method for defining the extent of left atrial wall injury after the ablation of atrial fibrillation. J Am Coll Cardiol. 2008;52(15):1263–71.

    Article  PubMed  Google Scholar 

  20. Badger TJ, Daccarett M, Akoum NW, Adjei-Poku YA, Burgon NS, Haslam TS, et al. Evaluation of left atrial lesions after initial and repeat atrial fibrillation ablation: lessons learned from delayed-enhancement MRI in repeat ablation procedures. Circ Arrhythmia Electrophysiol. 2010;3(3):249–59.

    Article  Google Scholar 

  21. Dulli DA, Stanko H, Levine RL. Atrial fibrillation is associated with severe acute ischemic stroke. Neuroepidemiology. 2003;22(2):118–23.

    Article  PubMed  Google Scholar 

  22. Fang MC, Go AS, Chang Y, Borowsky L, Pomernacki NK, Singer DE. Comparison of risk stratification schemes to predict thromboembolism in people with nonvalvular atrial fibrillation. J Am Coll Cardiol. 2008;51(8):810–5.

    Article  PubMed Central  PubMed  Google Scholar 

  23. Daccarett M, Badger TJ, Akoum N, Burgon NS, Mahnkopf C, Vergara G, et al. Association of left atrial fibrosis detected by delayed-enhancement magnetic resonance imaging and the risk of stroke in patients with atrial fibrillation. J Am Coll Cardiol. 2011;57(7):831–8.

    Article  PubMed Central  PubMed  Google Scholar 

  24. Akoum N, Fernandez G, Wilson B, McGann C, Kholmovski E, Marrouche N. Association of Atrial Fibrosis Quantified Using LGE-MRI with Atrial Appendage Thrombus and Spontaneous Contrast on Transesophageal Echocardiography in Patients with Atrial Fibrillation. J Cardiovasc Electrophysiol. 2013.

  25. Akoum N, McGann C, Vergara G, Badger T, Ranjan R, Mahnkopf C, et al. Atrial fibrosis quantified using late gadolinium enhancement MRI is associated with sinus node dysfunction requiring pacemaker implant. J Cardiovasc Electrophysiol. 2012;23(1):44–50.

    Article  PubMed  Google Scholar 

  26. Sanders P, Morton JB, Kistler PM, Spence SJ, Davidson NC, Hussin A, et al. Electrophysiological and electroanatomic characterization of the atria in sinus node disease: evidence of diffuse atrial remodeling. Circulation. 2004;109(12):1514–22.

    Article  PubMed  Google Scholar 

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Conflict of Interest

Nazem Akoum declares that he has no conflict of interest.

Nassir Marrouche reports grants and personal fees from Biosense Webster, grants and personal fees from Sanofi, grants and other from MRI Interventions, grants and personal fees from Boehringer Ingelheim, grants and personal fees from Biotronik, grants and personal fees from eCardio, grants from NIH, grants and other from Marrek, other from Arapeen Medical, personal fees from Daiichi Sankyo, grants from Medtronic, grants from Boston Scientific, and grants from Catheter Robotics, other from Cardiac Designs. In addition, Dr. Marrouche has a patent on Therapeutic Outcome Assessment for Atrial Fibrillation pending, and a patent on Magnetic Resonance Pulse Sequences in Cardiac Imaging pending.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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Correspondence to Nazem Akoum.

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This article is part of the Topical Collection on Invasive Electrophysiology and Pacing

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Akoum, N., Marrouche, N. Assessment and Impact of Cardiac Fibrosis on Atrial Fibrillation. Curr Cardiol Rep 16, 518 (2014). https://doi.org/10.1007/s11886-014-0518-z

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