Influence of Left Atrium Volume Index on effectiveness of Thoracoscopic Ablation in the Treatment of Atrial Fibrillation

Research objective: establish the impact of Left Atrium Volume Index (LAVI) on on effectiveness of Thoracoscopic Ablation (TSA) in the Treatment of Atrial Fibrillation (AF) and define the risk factors for manifestation of supraventricular arrhythmias in the long-term follow-up results

Methods. Prospective cohort study of 121 patients with AF (from 2018 to 2021) who performed TSA. The patients were divided into two groups: patients with increased LAVI (group I), patients with normal LAVI less than 34 ml/m² (group II).

Results. According to echocardiography, the mean LAVI was 45.48 ± 9.3 ml/m² and 28.59 ± 4.13 ml/m² in groups I and II, respectively (p = 0.012). The mean value of left ventricular ejection fraction (LVEF) according to Teicholz in group I was 61.62 ± 7.041%, in group II 63.57 ± 6.16% (p = 0.8). Spearman's сorrelation analysis showed the relationship between LAVI and LVEF before surgery and in the long-term follow-up period, that is agreed with world literature data about contribution left atrial (LA) to left ventricular (LV) function. According to our study, only LAVI < 34 ml/m² is a risk factor for arrhythmia after TSA. Effectiveness TSA in I group was 77.8%, that is lower than the II group – 88.9%. 3 months after TSA, 20 (17%) patients were required catheter ablations (CA), mainly in I group.

Conclusions. Research results showed that an increase in LAVI significantly reduces the effectiveness of TSA in the long-term period by 11.1% compared with LAVI < 34 ml/m². That are conform with other data of previously submitted works.

1. Edgerton J.R., Brinkman W.T., Weaver T. et al. Pulmonary vein isolation and autonomic denervation for the management of paroxysmal atrial fibrillation by a minimally invasive surgical approach. J. Thorac. Cardiovasc. Surg. 2010; 140: 823–828 https://doi.org/10.1016/j.jtcvs.2009.11.065

2. Chugh S.S., Havmoeller R., Narayanan K. et al. Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study. Circulation. 2014; 129 (8): 837–847. https://doi.org/10.1161/CIRCULATIONAHA.113.005119

3. Kannel W.B., Benjamin E.J. Current perceptions of the epidemiology of atrial fibrillation. Cardiol. Clin. 2009; 27 (1): 13–24, vii. https://doi.org/10.1016/j.ccl.2008.09.015

4. Benjamin E.J., Wolf P.A., D’Agostino R.B. et al. Impact of atrial fibrillation on the risk of death: the Framingham Heart Study. Circulation. 1998. 98; 10: 946–952. https://doi.org/10.1161/01.cir.98.10.946

5. Andrade J.G., Aguilar M., Atzema C. et al. The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation. Can. J. Cardiol. 2020; 36 (12): 1847–1948 https://doi.org/10.1016/j.cjca.2020.09.001

6. Hindricks G., Potpara T., Dagres N. et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur. Heart J. 2021; 42 (5): 373–498. https://doi.org/10.1093/eurheartj/ehab648

7. Artyukhina E.A., Dedukh E.V., Yashkov M.V. Stage surgical and catheter approach to the treatment of long-persistent atrial fibrillation. Russian Journal of Cardiology. 2019; 7: 96–98. https://doi.org/10.15829/1560-4071-2019-7-96-98 (In Russian)

8. Berger W.R., Meulendijks E.R., Limpens J. et al. Persistent atrial fibrillation: a systematic review and meta-analysis of invasive strategies. Int. J. Cardiol. 2019; 278: 137–143 https://doi.org/10.1016/j.ijcard.2018.11.127

9. Demarchi A., Neumann L., Rordorf R. et al. Long-term outcome of catheter ablation for atrial fibrillation in patients with severe left atrial enlargement and reduced left ventricular ejection fraction. Europace. 2021; 23 (11): 1751–1756. https://doi.org/10.1093/europace/euab213

10. Kawazoe K., Beppu S., Takahara Y. et al. Surgical treatment of giant left atrium combined with mitral valvular disease. Plication procedure for reduction of compression to the left ventricle, bronchus, and pulmonary parenchyma. J. Thorac. Cardiovasc. Surg. 1983; 85: 885–892

11. Cox J.L., Schuessler R.B., D'Agostino H.J. et al. The surgical treatment of atrial fibrillation. III. Development of a definitive surgical procedure. J. Thorac. Cardiovasc. Surg. 1991; 101: 569–583.

12. Gaynor S.L., Diodato M.D., Prasad S.M. et al. A prospective, singlecenter clinical trial of a modified Cox maze procedure with bipolar radiofrequency ablation. J. Thorac. Cardiovasc. Surg. 2004; 128: 535–542. https://doi.org/10.1016/j.jtcvs.2004.02.044

13. Khiabani A.J., MacGregor R.M., Bakir N.H. et al. The longterm outcomes and durability of the Cox Maze IV procedure for atrial fibrillation. J. Thorac. Cardiovasc. Surg. 2020. https://doi.org/10.1016/j.jtcvs.2020.04.100

14. Gurina V.I., Kondrat’ev E.V., Karmazanovsky G.G., Khatsayuk E.A. MDCT Evaluation of Left Atrial Volume in Patients with Cardiac Diseases. Medical Visualization. 2017; 6: 13–18. https://doi.org/10.24835/1607-0763- 2017-6-13-18 (In Russian)

15. Lang R.M., Badano L.P., Mor-Avi V. et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the american society of echocardiography and the European association of cardiovascular imaging. J. Am. Soc. Echocardiogr. 2015; 28 (1): 1–39. https://doi.org/10.1093/ehjci/jev014

16. Sangsriwong M., Cismaru G., Puiu M. et al. Formula to estimate left atrial volume using antero-posterior diameter in patients with catheter ablation of atrial fibrillation. Medicine (Baltimore). 2021; 100 (29): e26513. https://doi.org/10.1097/MD.0000000000026513

17. Gaynor S.L., Diodato M.D., Prasad S.M. et al. A prospective, singlecenter clinical trial of a modified Cox maze procedure with bipolar radiofrequency ablation. J. Thorac. Cardiovasc. Surg. 2004; 128: 535–542. https://doi.org/10.1016/j.jtcvs.2004.02.044

18. Go A.S., Hylek E.M., Phillips K.A. et al. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA. 2001, 285: 2370–2375. https://doi.org/10.1001/jama.285.18.2370

19. Lang R.M., Badano L.P., Mor-Avi V. et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J. Am. Soc. Echocardiogr. 2015; 28 (1): 1–39.e14. https://doi.org/10.1016/j.echo.2014.10.003

20. Korodi S., Toganel R., Benedek T. et al. Impact of inflammation-mediated myocardial fibrosis on the risk of recurrence after successful ablation of atrial fibrillation – the FIBRO-RISK study: Protocol for a non-randomized clinical trial. Medicine (Baltimore). 2019; 98 (9): e14504 https://doi.org/10.1097/MD.0000000000014504

21. McGann C., Akoum N., Patel A. et al. Atrial fibrillation ablation outcome is predicted by left atrial remodeling on MRI. Circ. Arrhythm. Electrophysiol. 2014; 7: 23–30. https://doi.org/10.1161/CIRCEP.113.000689

22. Pavlyukova E.N., Kuzhel D.A., Matyushin G.V. Left atrial function: modern assessment methods and clinical significance. Rational Pharmacotherapy in Cardiology. 2017; 13 (5): 675–683. https://doi.org/10.20996/1819-6446-2017-13-5-675-683 (In Russian)

23. Revishvili A.S., Taimasova I.A., Artyukhina E.A., Malishenko E.S., Novikov M.V., Strebkova E.D. Mid-term outcomes of thoracoscopic and hybrid therapy of atrial fibrillation. Journal of Arrhythmology. 2021; 28 (3): 5–12. https://doi.org/10.35336/VA-2021-3-5-12 (In Russian)

24. Neefs J., Wesselink R., van den Berg N.W.E. et al. Thoracoscopic surgical atrial fibrillation ablation in patients with an extremely enlarged left atrium. J. Interv. Card. Electrophysiol. 2021 Sep 16. https://doi.org/10.1007/s10840-021-01056-1

25. Khazhbieva S.M., Tembotova Zh.Kh., Serguladze S.Yu., Pronicheva I.V., Kvasha B.I., Khankishieva F.R., Mustapaeva Z.V. Evaluation of geometric, functional and mechanical parameters of left atrium remodeling after surgical treatment of isolated atrial fibrillation. Annaly aritmologii. 2018; 15 (1): 12–23. https://doi.org/10.15275/ annaritmol.2018.1.2 (In Russian)

26. Inciardi R.M., Giugliano R.P., Claggett B. et al. Left atrial structure and function and the risk of death or heart failure in atrial fibrillation. Eur. J. Heart. Fail. 2019; 21 (12): 1571–1579. https://doi.org/10.1002/ejhf.1606

27. Bouzas-Mosquera A., Broull n F.J., lvarez-Garc a N. et al. Left atrial size and risk for all-cause mortality and ischemic stroke. CMAJ. 2011; 183 (10): E657–664. https://doi.org/10.1503/cmaj.091688

28. Han F.T., Kasirajan V., Kowalski M. et al. Results of a minimally invasive surgical pulmonary vein isolation and ganglionic plexi ablation for atrial fibrillation: single-center experience with 12-month follow-up. Circ. Arrhythm. Electrophysiol. 2009; 2: 370–377. https://doi.org/10.1161/CIRCEP.109.854828

29. Jeevanantham V., Ntim W., Navaneethan S.D. et al. Metaanalysis of the effect of radiofrequency catheter ablation on left atrial size, volumes and function in patients with atrial fibrillation. Am. J. Cardiol. 2010; 105 (9): 1317–1326. https://doi.org/10.1016/j.amjcard.2009.12.046

30. Krul S.P., Driessen A.H., Zwinderman A.H. et al. Navigating the mini-maze: systematic review of the first results and progress of minimally-invasive surgery in the treatment of atrial fibrillation. Int. J. Cardiol. 2013; 166: 132–140. https://doi.org/10.1016/j.ijcard.2011.10.011

31. Lee S.H., Kim J.B., Cho W.C. et al. The influence of age on atrial fibrillation recurrence after the maze procedure in patients with giant left atrium. J. Thorac. Cardiovasc. Surg. 2011; 141: 1015–1019. https://doi.org/10.1016/j.jtcvs.2010.08.036

32. Njoku A., Kannabhiran M., Arora R. et al. Left atrial volume predicts atrial fibrillation recurrence after radiofrequency ablation: a meta-analysis. Europace. 2018; 20: 33–42 https://doi.org/10.1093/europace/eux013

33. Kuppahally S.S., Akoum N., Burgon N.S. et al. Left atrial strain and strain rate in patients with paroxysmal and persistent atrial fibrillation: relationship to left atrial structural remodeling detected by delayed-enhancement MRI. Circ. Cardiovasc. Imaging. 2010; 3: 231–239. https://doi.org/10.1161/CIRCIMAGING.109.865683

34. Alfuhied A., Kanagala P., McCann G.P., Singh A. Multimodality assessment and role of left atrial function as an imaging biomarker in cardiovascular disease. Int. J. Cardiovasc. Imaging. 2021; 37 (11): 3355–3369. https://doi.org/10.1007/s10554-021-02316-x

35. Castella M., Pereda D., Mestres C.A. et al. Thoracoscopic pulmonary vein isolation in patients with atrial fibrillation and failed percutaneous ablation. J. Thorac. Cardiovasc. Surg. 2010; 140: 633–638. https://doi.org/10.1016/j.jtcvs.2009.11.009