Reverse electrical remodeling of the atria post cardioversion in patients who remain in sinus rhythm assessed by signal averaging of the P-wave

Objectives: This study was designed to determine whether the signal-averaged electrocardiogram of the P-wave (SAPW) is an independent predictor of recurrence of atrial fibrillation (AF) post cardioversion (CV), and to assess atrial remodeling using SAPW. Background: There are limited electrophysiologic data to predict the recurrence of AF post-CV. The electrical remodeling that occurs post-CV is poorly understood. Methods: Sixty-four patients with persistent AF undergoing CV were prospectively enrolled. SAPW parameters were measured the day of CV and repeated at 1 month. These SAPW parameters were compared to other baseline indices for the recurrence of AF. Results: Sixty patients (94%) had successful CV. At 1 month, 22 (37%) maintained sinus rhythm (SR). The SAPW total duration decreased significantly in those who remained in SR (159 ms ± 19 to 146 ms ± 17; P < 0.0001). Only the duration of AF (46 ± 50 days vs 147 ± 227 days, P = 0.03) and the presence of left ventricular hypertrophy (LVH, 12% vs 65%, P = 0.0006) were significantly associated with recurrence of AF. Atrial size strongly correlated with the SAPW duration in patients who remained in SR (R² = 0.67, P = 0.003) but not in those who returned to AF (R² = 0.11, P = 0.65). Conclusions: Atrial electrical reverse remodeling occurs in patients with AF who maintain SR post-CV. This remodeling is likely inversely related to the duration of AF and LVH. SAPW duration does not predict recurrence of AF post-CV.