Preprocedural restoration of sinus rhythm and left atrial strain predict outcomes of catheter ablation for long-standing persistent atrial fibrillation

Introduction: Catheter ablation (CA) for long-standing persistent atrial fibrillation (LS-AF) remains challenging. We aimed to explore whether sinus rhythm (SR) restoration and left atrium (LA) function after pretreatment with antiarrhythmic drugs (AAD's) and electrical cardioversion (ECV) predict procedural outcomes. Methods and Results: We included 100 consecutive patients with LS-AF who were treated with AAD/ECV for at least 3 months before CA. The echocardiographic LA strain during reservoir phase (LASr) was assessed after pretreatment as a marker of LA fibrosis. The recurrence was recorded for ≥1 year after the last procedure. During a 34 ± 16-month follow-up period, the single and multiple procedures and pharmaceutically assisted success rates were 40% and 71%, respectively. Patients with preprocedural SR restoration and higher LASr showed a significantly higher recurrence-free probability after the last CA (logrank P =.001 and P <.001, respectively). Failure of preprocedural SR restoration and LASr ≤8.6% were independently associated with recurrence after the last CA (hazard ratio [HR]: 3.13, 95% confidence interval [CI]: 1.42-6.91, P =.005; HR: 3.89, 95% CI: 1.65-9.17, P =.002, respectively). These parameters added incrementally to the predictive value of AF duration and LA dilatation (P =.03 and P =.002, respectively) and improved the recurrence-risk stratification (net reclassification improvement = 0.39; 95% CI = 0.13-0.65; P =.003). Conclusion: In patients with LS-AF, the inability to restore SR and lower LASr after AAD/ECV treatment independently and incrementally predicts the recurrence after CA. These findings might be useful for determining LS-AF ablation candidates.