Clinical utility of left atrial strain in predicting atrial fibrillation recurrence after catheter ablation: An up-to-date review

Table 1 Predictors of atrial fibrillation recurrence after catheter ablation

Methods		Parameters
Biomarkers		C-reactive protein
		Fibrinogen
		B-type natriuretic peptide
		Oxidative stress
		Homocysteine and endothelin-1
		Renin-angiotensin-aldosterone system
ECG parameters		P-wave duration
		Intra-atrial conduction time
		Dispersion of atrial fibrillation cycle lengths
Imaging parameters	Echocardiographic parameters	Left atrial diameter
		Left atrial volume
		Mitral inflow patterns
		E/e’ index
		Left atrial electromechanical conduction time
		LA appendage ejectionfraction
		Left atrial expansion index
		Strain/strain rate
	MRI and CT imaging	Pericardial fat
		Left atrial fibrosis
		Ablation-related scarring
		Pulmonary vein anatomy

ECG: Electrocardiogram; LA: Left atrium; MRI: Magnetic resonance imaging; CT: Computed tomography; E: Early trans-mitral flow velocity; e’: Early diastolic mitral annular velocity.

Table 2 Left atrial strain in the prediction of atrial fibrillation recurrence after catheter ablation

Ref.	Year (of data acquisition)	Population	Sample size (n)	Technology	Conclusion
Wen et al[77] (2021)	2009-2011	America	144	2D-STE	Patients with recurrence had higher LASct 1-d than that in non-recurrence subjects LASct 1-d post-procedure predicts arrhythmia recurrence at long-term follow-up
Uziębło-Życzkowska et al[72] (2021)	2019-2020	Poland	172	2D-STE	LASr and LASct were all associated with LA increased pressure in AF patients after CA
Pilichowska-Paszkiet et al[71] (2021)	July 2011 to January 2014	Poland	208	2D-STE	In patients with PAF, parameters reflecting LA compliance LASr and LAScd are independent and strong predictors of CA outcome
Koca et al[76] (2020)	follow-up 1 yr	Turkey	190	2D-STE	LA strain in both 2 chambers and 4 chambers, and GALS were significantly lower in patients with AF recurrence. GALS should be included in routine evaluations to determine long-term AF recurrence preoperatively
Hanaki et al[74] (2020)	January 2013 to December 2016	Japan	100	2D-STE	In patients with long-standing PeAF, the inability to restore SR and lower LASr after AAD/ECV treatment independently and incrementally predicts the recurrence after CA
Csécs et al[65] (2020)	Follow-up 3 mo	America	55	CMR	Peak longitudinal atrial strain was significant predictor of arrhythmia recurrence and arrhythmia recurrence
Yan et al[64] (2019)	October 2016 to December 2017	China	32	2D-STE	The strain rates in the lateral wall base segment, interval middle segment, and middle segment of the lateral wall and GALS were significantly decreased in the patients with AF recurrence
Chen et al[6] (2019)	May 2015 to June 2016	China	40	2D-STE	The LA reservoir, conduit and contractile strain in septal segments significantly decreased in the PAF patients with low-voltage zone after CA. Besides, global strain tended to be an independent determinant of LA fibrosis
Bai et al[78] (2018)	2013-2014	China	87	2D-STE	Peak right atrial longitudinal strain, peak LA longitudinal strain, and combined both are important factors associated with AF recurrence following CA in patients with chronic lung diseases
Parwani et al[62] (2017)	January 2010 to January 2013	Germany	102	2D-STE	Patients with recurrence of atrial arrhythmias after both the first and the second CA procedure had significantly lowered LA strain than those without recurrence
Mochizuki et al[39] (2017)	February 2013 to December 2014	Japan	42	3D-STE	In both the PAF and PeAF populations, patients with recurrence presented with significantly impaired GALS compared with patients without recurrence. LA strain determined by 3D-STE is a novel and better predictor of AF recurrence after CA than that determined by 2D-STE or other known predictors
Ma et al[57] (2017)	March 2013 to March 2015	China	115	2D-STE	Patients with recurrence presented with significantly impaired GALS compared with patients without recurrence. In both PAF and PeAF, decreased baseline LA deformation capabilities assessed by 2D-STE can help to identify patients at high risk of AF recurrence after catheter ablation
Habibi et al[66] (2016)	January 2011 to September 2013	America	121	CMR	LA reservoir function was independently associated with recurrent AF/AT after PVI. Peak LA strain improved prediction of recurrent AT/AF compared to the baseline clinical model
Gucuk Ipek et al[69] (2016)	2010-2013	America	119	CMR	Baseline reservoir, conduit, and contractile function of the LA were significantly impaired in patients with incident LA flutter
Yasuda et al[63](2015)	July 2010 to March 2012	Japan	100	2D-STE	Patients with AF recurrence had significantly a lower LA global strain and lower LA lateral total strain than those who maintained sinus rhythm. LA global strain could predict AF recurrence after CA
Montserrat et al[24] (2015)	Follow-up 6 mo	Spain	83	2D-STE	LASr and LASct were significantly lower in the second RFCA patients. LASr independent predictor of arrhythmia suppression after first RFCA and after a second RFCA
Motoki et al[75] (2014)	June 2008 to May 2010	Australia	319	2D-STE	Patients with LA total strain < 23.2% showed a higher incidence of AF recurrence. baseline LA total strain was associated with rhythm outcome after catheter ablation
La Meir et al[59] (2013)	2007-2011	Netherlands	33	2D-STE	The peak systolic strain and the peak strain rate were lower in patients with atrial fibrillation than in the controls. It had increased significantly at 3 mo and 12 mo after surgery
Hammerstingl et al[23] (2012)	2008-2010	Germany	103	2D-STE	The assessment of global LA strain with 2D-STE identifies patients with a high risk for AF recurrence after ablation procedures
Tops et al[60] (2011)	Follow-up 12 mo	Netherlands	122	2D-STE	63% of the patients exhibited LA reverse remodeling after CA for AF, with a concomitant improvement in LA strain. LA strain at baseline was an independent predictor of LA reverse remodeling
Mirza et al[79] (2011)	January 2005 to April 2009	America	63	2D-STE	global and regional systolic and diastolic strains and SR were reduced in patients with recurrent AF. Regional LA lateral wall LS is a preprocedural determinant of AFR in patients undergoing CA, independent of LA enlargement
Hwang et al[73] (2009)	Follow-up 9 mo	Korea	40	2D- STE	The lower systolic strain of LA was strongly associated with recurrence after catheter ablation
Schneider et al)[61] (2008)	March 2003 to October 2006	Germany	118	2D-STE	Patients with higher atrial strain and SR after catheter ablation appear to have a greater likelihood of maintenance of sinus rhythm

STE: Speckle tracking echocardiography; CA: Catheter ablation; RFCA: Radiofrequency catheter ablation; LASct: Left atrial strain contractile; LASr: Left atrial strain reservoir; LAScd: Left atrial strain conduit; LA: Left atrium; AF: Atrial fibrillation; GALS: Global atrial longitudinal strain; SR: Strain rate; PeAF: Persistent AF; AAD: Antiarrhythmic drugs; EVC: Electrical cardioversion; CMR: Cardiac magnetic resonance; PAF: Paroxysmal AF; PVI: Pulmonary veins isolation.