Atrial fibrillation risk scores to evaluate left atrial substrate based on voltage analysis in long-standing persistent type of arrhythmia

Abstract

Background: Pre-ablation identification of left atrial (LA) low voltage areas (LVA) among long-standing persistent atrial fibrillation (LSPAF) population remains challenging.
Aims: The aim of the study was to analyze the potential of selected scores originally developed to assess arrhythmia recurrences, thromboembolic complications, or progression from paroxysmal to persistent AF to predict the presence of LA-LVA in LSPAF patients.
Methods: One hundred and fifty-two patients underwent pulmonary vein isolation followed by high-density-high-resolution LA voltage mapping. AF risk scores, such as APPLE, ATLAS, CAAP-AF, DR-FLASH, CHA2DS2-VASc, and HATCH were retrospectively calculated. A receiver operating characteristic curve analysis was performed to evaluate the ability of the scores to predict LVA.
Results: Low voltage areas were detected in 52% of the patients. 28% of the patients with LVA presented severe global LVA burden, whereas 56% of the patients showed a disseminated pattern of remodeling. CAAP-AF ≥7, DR-FLASH ≥4, and CHA2DS2-VASc ≥3 predicted the presence of LVA, whereas ATLAS ≤7 indicated the absence of LVA. ATLAS ≤8, CAAP-AF ≤9, DR-FLASH ≤4, and CHA2DS2-VASc ≤3 predicted the absence of severe LVA. APPLE ≤3 and CHA2DS2-VASc ≤2 predicted the absence of a LVA disseminated pattern. Among predictive scores, ATLAS (AUC, 0.633, 95% CI, 0.543–0.723, P = 0.004), DR-FLASH (AUC, 0.696; 95% CI, 0.594–0.81; P <0.001), and CHA2DS2-VASc (AUC, 0.644; 95% CI 0.518–0.77; P = 0.025) were the best predictors for the absence of LVA, severe LVA and a disseminated pattern of LVA, respectively.
Conclusions: Atrial fibrillation risk stratification with specific scoring systems can unmask the presence of LA-LVA in the LSPAF population.