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Association of Atrial Tissue Fibrosis Identified by Delayed Enhancement MRI and Atrial Fibrillation Catheter Ablation: The DECAAF Study
Abstract
IMPORTANCE: Left atrial fibrosis is prominent in patients with atrial fibrillation (AF). Extensive atrial tissue fibrosis identified by delayed enhancement magnetic resonance imaging (MRI) has been associated with poor outcomes of AF catheter ablation. OBJECTIVE: To characterize the feasibility of atrial tissue fibrosis estimation by delayed enhancement MRI and its association with subsequent AF ablation outcome. DESIGN, SETTING, AND PARTICIPANTS: Multicenter, prospective, observational cohort study of patients diagnosed with paroxysmal and persistent AF (undergoing their first catheter ablation) conducted between August 2010 and August 2011 at 15 centers in the United States, Europe, and Australia. Delayed enhancement MRI images were obtained up to 30 days before ablation. MAIN OUTCOMES AND MEASURES: Fibrosis quantification was performed at a core laboratory blinded to the participating center, ablation approach, and procedure outcome. Fibrosis blinded to the treating physicians was categorized as stage 1 (<10% of the atrial wall), 2 (≥10%-<20%), 3 (≥20%-<30%), and 4 (≥30%). Patients were followed up for recurrent arrhythmia per current guidelines using electrocardiography or ambulatory monitor recording and results were analyzed at a core laboratory. Cumulative incidence of recurrence was estimated by stage at days 325 and 475 after a 90-day blanking period (standard time allowed for arrhythmias related to ablation-induced inflammation to subside) and the risk of recurrence was estimated (adjusting for 10 demographic and clinical covariates). RESULTS: Atrial tissue fibrosis estimation by delayed enhancement MRI was successfully quantified in 272 of 329 enrolled patients (57 patients [17%] were excluded due to poor MRI quality). There were 260 patients who were followed up after the blanking period (mean [SD] age of 59.1 [10.7] years, 31.5% female, 64.6% with paroxysmal AF). For recurrent arrhythmia, the unadjusted overall hazard ratio per 1% increase in left atrial fibrosis was 1.06 (95% CI, 1.03-1.08; P < .001). Estimated unadjusted cumulative incidence of recurrent arrhythmia by day 325 for stage 1 fibrosis was 15.3% (95% CI, 7.6%-29.6%); stage 2, 32.6% (95% CI, 24.3%-42.9%); stage 3, 45.9% (95% CI, 35.5%-57.5%); and stage 4, 51.1% (95% CI, 32.8%-72.2%) and by day 475 was 15.3% (95% CI, 7.6%-29.6%), 35.8% (95% CI, 26.2%-47.6%), 45.9% (95% CI, 35.6%-57.5%), and 69.4% (95% CI, 48.6%-87.7%), respectively. Similar results were obtained after covariate adjustment. The addition of fibrosis to a recurrence prediction model that includes traditional clinical covariates resulted in an improved predictive accuracy with the C statistic increasing from 0.65 to 0.69 (risk difference of 0.05; 95% CI, 0.01-0.09). CONCLUSIONS AND RELEVANCE: Among patients with AF undergoing catheter ablation, atrial tissue fibrosis estimated by delayed enhancement MRI was independently associated with likelihood of recurrent arrhythmia. The clinical implications of this association warrant further investigation.
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“The rhythm outcome after catheter ablation of AF is difficult to predict in individual patients.173,227,713,728”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [173]
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Metadata
- Authors
- Marrouche, N. F., Wilber, D., Hindricks, G., Jais, P., Akoum, N., Marchlinski, F., Kholmovski, E., Burgon, N., Hu, N., Mont, L., Deneke, T., Duytschaever, M., Neumann, T., Mansour, M., Mahnkopf, C., Herweg, B., Daoud, E., Wissner, E., Bansmann, P., & Brachmann, J.
- Affiliations
- University of Utah (US)
- Loyola University Medical Center (US)
- Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- University of Barcelona, Barcelona, Spain
- Corresponding author
- Marrouche, Nassir F.
- ORCID
- Venue
- JAMA
- Publisher
- American Medical Association (AMA)
- Published
- 2014-02-05
- Volume
- 311
- Issue
- 5
- Pages
- 498
- ISSN
- 0002-9955 (ISSN-L)
- 0098-7484
- OpenAlex
- W2150866578
- Cited by
- 1,473
- References
- 42
- Citations by year
- 2026: 122 · 2025: 111 · 2024: 125 · 2023: 122 · 2022: 154 · 2021: 126 · 2020: 137 · 2019: 126 · 2018: 108 · 2017: 119 · 2016: 96 · 2015: 77 · 2014: 45
- FWCI
- 76.46
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- JAMA (publishedVersion, public-domain)
- PubMed (publishedVersion)
- Dipòsit Digital de la Universitat de Barcelona (Universitat de Barcelona) (publishedVersion)
- RECERCAT (Consorci de Serveis Universitaris de Catalunya) (publishedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Arrhythmias and Treatments
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
- Keywords
- atrial fibrillation, left atrial fibrosis, delayed enhancement MRI, cardiac magnetic resonance imaging, catheter ablation, fibrosis quantification, recurrent arrhythmia, paroxysmal atrial fibrillation, persistent atrial fibrillation, ablation outcome prediction, fibrosis staging
- MeSH terms
- Aged, Atrial Fibrillation, Female, Fibrosis, Heart Atria, Humans, Magnetic Resonance Imaging, Male, Middle Aged, Prospective Studies, Recurrence, Risk, Incidence, Treatment Outcome, Catheter Ablation
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