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

Douglas N. Gibson, Luigi Di Biase, Prasant Mohanty, Jigar D. Patel, Rong Bai, Javier Sanchez, J. David Burkhardt, J. Thomas Heywood, Allen D. Johnson, David S. Rubenson, Rodney Horton, G. Joseph Gallinghouse, Salwa Beheiry, Guy P. Curtis, David N. Cohen, Mark Y. Lee, Michael R. Smith, Devi Gopinath, William R. Lewis, Andrea Natale

Research output: Contribution to journalArticle

112 Citations (Scopus)

Abstract

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 socalled 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.

Original languageEnglish (US)
Pages (from-to)1364-1371
Number of pages8
JournalHeart Rhythm
Volume8
Issue number9
DOIs
StatePublished - Sep 2011
Externally publishedYes

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Catheter Ablation
Pulmonary Hypertension
Atrial Fibrillation
Atrial Pressure
Odds Ratio
Cicatrix
Cardiac Catheterization
Dyspnea
Diabetes Mellitus
Atrial Function
Pulmonary Wedge Pressure
Mitral Valve Insufficiency
Obstructive Sleep Apnea
Thoracic Surgery
Cardiac Arrhythmias
Heart Failure
Logistic Models
Hemodynamics

Keywords

  • Atrial fibrillation
  • Catheter ablation
  • Complication
  • Dyspnea
  • Stiff left atrial syndrome

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)
  • Medicine(all)

Cite this

Stiff left atrial syndrome after catheter ablation for atrial fibrillation : Clinical characterization, prevalence, and predictors. / Gibson, Douglas N.; Di Biase, Luigi; Mohanty, Prasant; Patel, Jigar D.; Bai, Rong; Sanchez, Javier; Burkhardt, J. David; Heywood, J. Thomas; Johnson, Allen D.; Rubenson, David S.; Horton, Rodney; Gallinghouse, G. Joseph; Beheiry, Salwa; Curtis, Guy P.; Cohen, David N.; Lee, Mark Y.; Smith, Michael R.; Gopinath, Devi; Lewis, William R.; Natale, Andrea.

In: Heart Rhythm, Vol. 8, No. 9, 09.2011, p. 1364-1371.

Research output: Contribution to journalArticle

Gibson, DN, Di Biase, L, Mohanty, P, Patel, JD, Bai, R, Sanchez, J, Burkhardt, JD, Heywood, JT, Johnson, AD, Rubenson, DS, Horton, R, Gallinghouse, GJ, Beheiry, S, Curtis, GP, Cohen, DN, Lee, MY, Smith, MR, Gopinath, D, Lewis, WR & Natale, A 2011, 'Stiff left atrial syndrome after catheter ablation for atrial fibrillation: Clinical characterization, prevalence, and predictors', Heart Rhythm, vol. 8, no. 9, pp. 1364-1371. https://doi.org/10.1016/j.hrthm.2011.02.026
Gibson, Douglas N. ; Di Biase, Luigi ; Mohanty, Prasant ; Patel, Jigar D. ; Bai, Rong ; Sanchez, Javier ; Burkhardt, J. David ; Heywood, J. Thomas ; Johnson, Allen D. ; Rubenson, David S. ; Horton, Rodney ; Gallinghouse, G. Joseph ; Beheiry, Salwa ; Curtis, Guy P. ; Cohen, David N. ; Lee, Mark Y. ; Smith, Michael R. ; Gopinath, Devi ; Lewis, William R. ; Natale, Andrea. / Stiff left atrial syndrome after catheter ablation for atrial fibrillation : Clinical characterization, prevalence, and predictors. In: Heart Rhythm. 2011 ; Vol. 8, No. 9. pp. 1364-1371.
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abstract = "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 socalled 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 = "Atrial fibrillation, Catheter ablation, Complication, Dyspnea, Stiff left atrial syndrome",
author = "Gibson, {Douglas N.} and {Di Biase}, Luigi and Prasant Mohanty and Patel, {Jigar D.} and Rong Bai and Javier Sanchez and Burkhardt, {J. David} and Heywood, {J. Thomas} and Johnson, {Allen D.} and Rubenson, {David S.} and Rodney Horton and Gallinghouse, {G. Joseph} and Salwa Beheiry and Curtis, {Guy P.} and Cohen, {David N.} and Lee, {Mark Y.} and Smith, {Michael R.} and Devi Gopinath and Lewis, {William R.} and Andrea Natale",
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TY - JOUR

T1 - Stiff left atrial syndrome after catheter ablation for atrial fibrillation

T2 - Clinical characterization, prevalence, and predictors

AU - Gibson, Douglas N.

AU - Di Biase, Luigi

AU - Mohanty, Prasant

AU - Patel, Jigar D.

AU - Bai, Rong

AU - Sanchez, Javier

AU - Burkhardt, J. David

AU - Heywood, J. Thomas

AU - Johnson, Allen D.

AU - Rubenson, David S.

AU - Horton, Rodney

AU - Gallinghouse, G. Joseph

AU - Beheiry, Salwa

AU - Curtis, Guy P.

AU - Cohen, David N.

AU - Lee, Mark Y.

AU - Smith, Michael R.

AU - Gopinath, Devi

AU - Lewis, William R.

AU - Natale, Andrea

PY - 2011/9

Y1 - 2011/9

N2 - 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 socalled 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.

AB - 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 socalled 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.

KW - Atrial fibrillation

KW - Catheter ablation

KW - Complication

KW - Dyspnea

KW - Stiff left atrial syndrome

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