TY - JOUR
T1 - Preprocedural Screening Tool to Guide Nonpulmonary Vein Trigger Testing in First-Time Atrial Fibrillation Ablation
AU - Oraii, Alireza
AU - Chaumont, Corentin
AU - Rodriguez-Queralto, Oriol
AU - Wasiak, Michal
AU - Thind, Munveer
AU - Peters, Carli J.
AU - Zado, Erica
AU - Hanumanthu, Balaram Krishna J.
AU - Markman, Timothy M.
AU - Hyman, Matthew C.
AU - Tschabrunn, Cory M.
AU - Guandalini, Gustavo
AU - Enriquez, Andres
AU - Shivamurthy, Poojita
AU - Kumareswaran, Ramanan
AU - Riley, Michael P.
AU - Lin, David
AU - Schaller, Robert D.
AU - Nazarian, Saman
AU - Callans, David J.
AU - Supple, Gregory E.
AU - Garcia, Fermin C.
AU - Frankel, David S.
AU - Dixit, Sanjay
AU - Marchlinski, Francis E.
N1 - Publisher Copyright:
© 2024 American Heart Association, Inc.
PY - 2025/1/1
Y1 - 2025/1/1
N2 - BACKGROUND: Patients undergoing first-time atrial fibrillation (AF) ablation can benefit from targeting non-pulmonary vein (PV) triggers. Preprocedural identification of high-risk individuals can guide planning of ablation strategy. This study aimed to create a preprocedural screening tool to identify patients at risk of non-PV triggers during first-time AF ablation. METHODS: All patients who underwent first-time AF ablation at the Hospital of the University of Pennsylvania between 2018 and 2022 were identified. Those who underwent non-PV trigger provocative maneuvers or had spontaneous non-PV trigger firing were included. Non-PV triggers were defined as non-PV ectopic beats triggering AF or sustained focal atrial tachycardia that occurred spontaneously, after AF cardioversion, or after standard provocative maneuvers. The provocative maneuvers included incremental isoproterenol infusion (3, 6, 12, and 20-30 µg/min) and an atrial burst pacing protocol. Risk factors associated with non-PV triggers in a stepwise multivariable logistic regression model with backward elimination were used to create a risk score. RESULTS: A total of 163 (8.0%) of 2038 patients had non-PV triggers during first-time AF ablation. Based on the multivariable model, we created a risk score using female sex (1 point; odds ratio [OR], 1.90 [95% CI, 1.36-2.67]), sinus node dysfunction (1 point; OR, 1.84 [95% CI, 1.04-3.24]), prior cardiac surgery (1 point; OR, 2.26 [95% CI, 1.45-3.53]), moderate to severe left atrial enlargement (2 points; OR, 3.43 [95% CI, 2.46-4.79]), and cardiac sarcoidosis/amyloidosis (4 points; OR, 7.24 [95% CI, 3.03-17.33]). Internal validation using bootstrap resampling showed an optimism-adjusted C statistic of 0.715 (95% CI, 0.678-0.751). Among all first-time AF ablations, 68.1% of procedures were low-risk for non-PV triggers (scores 0-1, 4.3% risk), 17.8% were intermediate-risk (score 2, 10.5% risk), and 14.1% were high-risk (score ≥3, 22.6% risk). CONCLUSIONS: A preprocedural screening tool can classify patients based on their risk of non-PV triggers during first-time AF ablation. This risk score can guide operators to identify patients who would benefit most from adjunctive non-PV trigger testing. However, further validation is needed to confirm these findings.
AB - BACKGROUND: Patients undergoing first-time atrial fibrillation (AF) ablation can benefit from targeting non-pulmonary vein (PV) triggers. Preprocedural identification of high-risk individuals can guide planning of ablation strategy. This study aimed to create a preprocedural screening tool to identify patients at risk of non-PV triggers during first-time AF ablation. METHODS: All patients who underwent first-time AF ablation at the Hospital of the University of Pennsylvania between 2018 and 2022 were identified. Those who underwent non-PV trigger provocative maneuvers or had spontaneous non-PV trigger firing were included. Non-PV triggers were defined as non-PV ectopic beats triggering AF or sustained focal atrial tachycardia that occurred spontaneously, after AF cardioversion, or after standard provocative maneuvers. The provocative maneuvers included incremental isoproterenol infusion (3, 6, 12, and 20-30 µg/min) and an atrial burst pacing protocol. Risk factors associated with non-PV triggers in a stepwise multivariable logistic regression model with backward elimination were used to create a risk score. RESULTS: A total of 163 (8.0%) of 2038 patients had non-PV triggers during first-time AF ablation. Based on the multivariable model, we created a risk score using female sex (1 point; odds ratio [OR], 1.90 [95% CI, 1.36-2.67]), sinus node dysfunction (1 point; OR, 1.84 [95% CI, 1.04-3.24]), prior cardiac surgery (1 point; OR, 2.26 [95% CI, 1.45-3.53]), moderate to severe left atrial enlargement (2 points; OR, 3.43 [95% CI, 2.46-4.79]), and cardiac sarcoidosis/amyloidosis (4 points; OR, 7.24 [95% CI, 3.03-17.33]). Internal validation using bootstrap resampling showed an optimism-adjusted C statistic of 0.715 (95% CI, 0.678-0.751). Among all first-time AF ablations, 68.1% of procedures were low-risk for non-PV triggers (scores 0-1, 4.3% risk), 17.8% were intermediate-risk (score 2, 10.5% risk), and 14.1% were high-risk (score ≥3, 22.6% risk). CONCLUSIONS: A preprocedural screening tool can classify patients based on their risk of non-PV triggers during first-time AF ablation. This risk score can guide operators to identify patients who would benefit most from adjunctive non-PV trigger testing. However, further validation is needed to confirm these findings.
KW - atrial fibrillation
KW - cardiac surgical procedures
KW - catheter ablation
KW - isoproterenol
KW - risk factors
KW - sick sinus syndrome
UR - http://www.scopus.com/inward/record.url?scp=85212970871&partnerID=8YFLogxK
U2 - 10.1161/CIRCEP.124.013351
DO - 10.1161/CIRCEP.124.013351
M3 - Article
AN - SCOPUS:85212970871
SN - 1941-3149
VL - 18
SP - e013351
JO - Circulation: Arrhythmia and Electrophysiology
JF - Circulation: Arrhythmia and Electrophysiology
IS - 1
ER -