Introduction
Regarding patients with atrial fibrillation (AF) and heart failure (HF) with preserved and reduced ejection fraction,1 when AF and HF are present in combination, they confer a worse prognosis than either condition alone.2,3 Catheter ablation (CA) in AF patients with HF is significantly associated with better clinical outcomes than medical therapy.4 Previous studies have shown that CA of AF can improve left ventricular ejection fraction (LVEF) and reduce mortality among patients with HF with reduced ejection fraction (HFrEF).5,6 On the other hand, ST-segment depression during AF rhythm is occasionally observed and several reports have showed that ST-segment depression during AF rhythm is associated with subsequent HF risk and late arrhythmia recurrence after CA.7,8 However, whether there is a clinical impact of ST-segment depression during AF rhythm on the improvement in the LVEF after CA in persistent AF (PerAF) with HFrEF remains unknown. Therefore, in the present study, we aimed to investigate the relationship between ST-segment depression during AF rhythm before CA and improvement in the LVEF and clinical outcomes in PerAF patients with HFrEF.
Methods
Study population
PerAF patients who had symptoms of HF based on the Framingham criteria9 and reduced LVEF (<50%) measured by transthoracic echocardiography (TTE) during AF rhythm within 2 months before CA and underwent an initial CA between January 2016 and July 2022 from the ORAF (Osaka Rosai Atrial Fibrillation ablation) registry10,11 were enrolled. The patients who underwent percutaneous coronary intervention or coronary artery bypass grafting within the past 1 month were not included in the enrolled patients. Significant coronary artery stenosis was ruled out by computed tomography or coronary angiography before CA. In the present study, ischaemic heart disease was defined as history of percutaneous coronary intervention or coronary artery bypass grafting more than 1 month before CA. They underwent follow-up TTE during sinus rhythm at 12 months after CA. Patients who underwent follow-up TTE during only AF rhythm were excluded from the present study. PerAF was defined as AF persisting for more than 1 week. All patients received a detailed informed consent and the study protocol was approved by the hospital's institutional review board. The procedure was in accordance with the ‘Declaration of Helsinki’ and the ethical standards of the responsible committee on human experimentation. This study was granted an exemption from requiring ethics approval by Osaka Rosai Hospital Ethics Committee because this study was a retrospective observational study and the permission for using the clinical data was obtained from all study patients on admission.
Definitions of electrocardiogram alternations
The baseline electrocardiogram (ECG) was provided at the time of admission (1 day before the ablation) and diagnosed by investigated cardiologists in accordance with the American Heart Association/American College of Cardiology/Heart Rhythm Society recommendations.12,13 ST-segment depression was defined as that >0.05 mV in at least two contiguous leads.14
Echocardiography study
All patients underwent TTE before CA. The TTE was performed with a 5 MHz multiplane probe, and live images were interpreted by experienced physicians who were blinded to the outcome of the CA. Comprehensive echocardiographic examinations were performed by trained cardiac sonographers according to the American Society of Echocardiography guidelines.15 LVEF was measured by the modified Simpson method. Echocardiographic parameters during AF rhythm were acquired where the two preceding cardiac cycles had similar R-R intervals and preferably where the average heart rate was <100 b.p.m. Transesophageal echocardiography prior to the CA was performed to exclude any left atrium (LA) or LA appendage thrombi.
Ablation procedure
All antiarrhythmic drugs were discontinued for at least five half-lives before the CA. Anticoagulation therapy was started at least 3 weeks before the CA. All PerAF patients underwent radiofrequency CA. One circular mapping catheter was deployed in the superior and inferior pulmonary veins, and the left-sided then right-sided ipsilateral pulmonary veins (PVs) were circumferentially ablated guided by three-dimensional left atrium mapping (CARTO3, Biosense-Webster, Diamond Bar, CA, USA). The PVI was performed with a 3.5 mm ablation catheter with an externally irrigated tip (ThermoCool® SmartTouch® Catheter, Biosense-Webster, Diamond Bar, CA, USA). The ablation procedures performed between January 2016 and July 2018 were contact force-guided, whereas those between August 2018 and July 2022 were ablation index-guided. After the PV isolation, the induction of non-PV triggers was performed using isoproterenol and/or adenosine triphosphate. Reproducible non-PV triggers were ablated. Additional ablation, including left atrial posterior wall isolation or superior vena cava isolation, was performed at the operator's discretion. At the end of the procedure, dormant conduction of the PVs was examined with a rapid injection of 40 mg of adenosine triphosphate. Additional ablation at the dormant conduction site was performed if necessary.
Follow-up and clinical outcomes
The patients underwent continuous ECG monitoring for approximately 3 days (until discharge) after the CA. They visited private clinics or our cardiology clinic every 2–4 weeks after the ablation. The patients were encouraged to have smartphone or tablet applications and check their pulse rate and rhythm every day and to visit our hospital if they experienced any palpitations or other symptoms. The follow-up visits included a clinical interview, ECG, blood examination, 24 h Holter monitoring or portable ECG (2 week cardiac event recording), and TTE. Patients with palpitations or other chest symptoms underwent a portable ECG. Late recurrence of AF/atrial tachycardia (LRAF, 3 months after the ablation) was defined as AF/AT documented on the ECG or AF/AT continuing longer than 30 s on the Holter or portable ECG.
The enrolled patients were classified into two groups; ST-segment depression (+) and ST-segment depression (−). The following factors were investigated. (1) The difference in the percentage of improvement in the LVEF 1 year after CA. According to the previous report, improvement in the LVEF was defined as absolute improvement in the LVEF of ≥10%.16 To exclude the effect of echocardiographic measurement error as much as possible and more reliably select cases with improved LVEF, we defined improvement in the LVEF as absolute improvement in the LVEF of ≥15% in the present study. (2) Relationship between ST-segment depression before CA during AF rhythm and HF hospitalization/major adverse cardiovascular events (MACE), which are defined as a composite of HF hospitalization, cardiovascular death, hospitalization due to coronary artery disease, ventricular arrhythmia requiring hospitalization, and stroke.
Statistical analysis
JMP 17 statistical software (SAS Institute Inc., Cary, North Carolina, USA) was used for the statistical analysis. Continuous variables were expressed as median [interquartile range]. Normality test was done for continuous variables by Shapiro–Wilk W test. Normal distribution was not confirmed for all variables. Two-group comparisons were analysed by Mann–Whitney U test for continuous variables. Categorical data were expressed as the number (percentage) and were compared using the chi-square test for categorical variables. Kaplan–Meier curves were used for the incidence of the LRAF, HF hospitalization, and MACE, and the statistical significance was determined using the log rank test. A multiple regression model to find the relevant parameters for improvement in the LVEF was performed using the factors found significant in the univariable analysis. A multivariable Cox proportional hazards analysis was performed to compare the hazard ratio of HF hospitalization and MACE between the two groups, using the factors found significant in the univariable analysis. Adjusted hazard ratios (HR) and 95% confidence intervals (CI) were calculated. A value of P < 0.05 was considered to be statistically significant in the present study.
Results
Patient and procedural characteristics
From January 2016 to July 2022, 2168 patients underwent CA and 1238 patients were excluded due to paroxysmal AF, 207 patients were excluded due to repeated ablation. Among 723 persistent AF patients who underwent an initial CA, 581 patients due to LVEF≥50%, 16 patients due to AF rhythm during follow-up TTE, and 4 patients due to a lack of echocardiographic data (Figure 1). The patients who underwent percutaneous coronary intervention or coronary artery bypass grafting within the past 1 month were not included in the enrolled patients. This study population included a total of 122 PerAF patients who had LVEF < 50% and underwent an initial ablation (Figure 1). The clinical characteristics of the enrolled patients are shown in Table 1. Significant differences in CHADS2-VASc score, the percentage of dyslipidaemia, history of ischaemic heart disease, and statin use were observed between the two groups. ECG findings and echocardiographic parameters are shown in Table 1. Left bundle branch block and right bundle branch block were found only in the patients with ST-segment depression. The ratio of inverted T wave was significantly higher in the patients with ST-segment depression than in those without (P < 0.001). Regarding the echocardiographic parameters, left ventricular end-systolic diameter (LVDs) and LA diameter were significantly larger, and LVEF was significantly smaller in the patients with ST-segment depression than in those without. The procedural characteristics of the patients are shown in Table 1. There were no significant differences in procedure time, application numbers and duration, any additional ablation, and complications.
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Table 1 Clinical characteristics, electrocardiographic/echocardiographic findings and details of procedure
| Overall population ( |
ST-segment depression (+) ( |
ST-segment depression (−) ( |
||
| Clinical data | ||||
| Age (years) | 69 [56, 76] | 71 [59, 78] | 67 [56, 74] | 0.136 |
| Male | 98 (80.3) | 44 (75.9) | 54 (84.4) | 0.238 |
| Body mass index (kg/m2) | 24.2 [21.4, 27.2] | 24.1 [20.9, 27.3] | 24.2 [21.4, 27.2] | 0.992 |
| Hypertension | 67 (54.9) | 32 (55.2) | 35 (54.7) | 0.957 |
| Diabetes | 23 (18.9) | 13 (22.4) | 10 (15.6) | 0.338 |
| Chronic heart failure | 89 (73.0) | 44 (75.9) | 45 (70.3) | 0.491 |
| Stroke | 6 (4.9) | 3 (5.2) | 3 (4.7) | 0.902 |
| Dyslipidaemia | 29 (23.8) | 19 (32.8) | 10 (15.6) | 0.026 |
| History of ischaemic heart disease | 19 (15.6) | 13 (22.4) | 6 (9.4) | 0.047 |
| CHADS2 VASc score | 0.018 | |||
| 0 | 6 (4.9) | 2 (3.5) | 4 (6.3) | |
| 1 | 23 (18.9) | 14 (24.1) | 9 (14.1) | |
| 2 | 24 (19.7) | 8 (13.8) | 16 (25.0) | |
| ≥3 | 69 (56.6) | 34 (58.6) | 35 (54.7) | |
| Laboratory data | ||||
| Creatinine (mg/dL) | 0.9 [0.8, 1.1] | 1.0 [0.9, 1.3] | 0.9 [0.8, 1.1] | 0.159 |
| C reactive protein (mg/dL) | 0.12 [0.06, 0.31] | 0.13 [0.06, 0.33] | 0.12 [0.06, 0.30] | 0.639 |
| Haemoglobin (g/dL) | 14.5 [12.9, 15.9] | 14.5 [12.8, 15.9] | 14.5 [13.0, 15.9] | 0.780 |
| Brain natriuretic peptide (pg/mL) | 253.0 [125.7, 399.7] | 253.6 [149.3, 439.4] | 234.4 [113.8, 394.8] | 0.399 |
| Medications | ||||
| Anticoagulant | 120 (98.4) | 58 (100) | 62 (96.9) | 0.175 |
| AAD | 10 (9.1) | 6 (12.0) | 4 (6.7) | 0.333 |
| ACEI/ARB | 82 (67.2) | 39 (67.2) | 43 (67.2) | 0.995 |
| Beta-blocker | 94 (77.1) | 43 (74.1) | 51 (79.7) | 0.467 |
| Statin | 36 (29.5) | 23 (39.7) | 13 (20.3) | 0.019 |
| Electrocardiographic findings | ||||
| Complete right bundle branch block | 6 (4.9) | 6 (10.3) | 0 (0) | 0.008 |
| Complete left bundle branch block | 1 (0.8) | 1 (1.7) | 0 (0) | 0.292 |
| ST segment depression | ||||
| Anterior leads | 15 (12.3) | 15 (25.9) | - | |
| Inferior leads | 22 (18.0) | 22 (37.9) | - | |
| Lateral leads | 49 (40.2) | 49 (84.5) | - | |
| Inverted T wave | 56 (45.9) | 39 (67.2) | 17 (26.6) | <0.001 |
| Anterior leads | 25 (20.5%) | 18 (31.0%) | 7 (10.9%) | 0.006 |
| Inferior leads | 22 (18.0%) | 20 (34.5%) | 2 (3.1%) | <0.001 |
| Lateral leads | 39 (32.0%) | 26 (44.8%) | 13 (20.3%) | 0.004 |
| Heart rate (b.p.m.) | 96 [85, 120] | 95 [85, 117] | 96 [84, 121] | 0.957 |
| Echocardiographic parameters (before CA) | ||||
| LVDd (mm) | 55 [50, 60] | 57 [51, 61] | 55 [50, 59] | 0.317 |
| LVDs (mm) | 44 [39, 49] | 46 [39, 50] | 43 [39, 49] | 0.641 |
| LVEF (%) | 40 [31, 46] | 37 [30, 46] | 42 [31, 46] | 0.338 |
| IVSTd (mm) | 9 [8, 10] | 9 [8, 10] | 9 [8, 10] | 0.276 |
| LVPWTd (mm) | 9 [8, 10] | 9 [8, 10] | 9 [9, 10] | 0.623 |
| LA diameter (mm) | 49 [45, 53] | 49 [46, 54] | 48 [44, 53] | 0.511 |
| Mitral regurgitation ≥III | 18 (14.8) | 7 (12.1) | 11 (17.2) | 0.426 |
| Tricuspid regurgitation ≥III | 16 (13.1) | 6 (10.3) | 10 (15.6) | 0.388 |
| LAAV (m/s) | 29 [21, 38] | 28 [20, 41] | 29 [22, 36] | 0.812 |
| Echocardiographic parameters (1 year after CA) | ||||
| LVDd (mm) | 51 [49, 56] | 52 [50, 57] | 50 [47, 56] | 0.058 |
| LVDs (mm) | 34 [30, 39] | 35 [32, 42] | 33 [29, 37] | 0.019 |
| LVEF (%) | 62 [55, 67] | 60 [46, 67] | 65 [58, 67] | 0.018 |
| LA diameter (mm) | 43 [40, 48] | 45 [42, 49] | 41 [38, 47] | 0.001 |
| Mitral regurgitation ≥III | 5 (4.1) | 4 (6.9) | 1 (1.6) | 0.138 |
| Tricuspid regurgitation ≥III | 19 (15.6) | 10 (17.2) | 9 (14.1) | 0.629 |
| Procedural characteristics | ||||
| Procedure time (min) | 161 [128, 202] | 165 [140, 205] | 155 [126, 192] | 0.286 |
| Number of applications | 89 [75, 110] | 92 [77, 109] | 88 [75, 112] | 0.734 |
| Total time of the applications (min) | 35 [26, 46] | 34 [25, 43] | 35 [26, 47] | 0.491 |
| Fluoroscopy duration (min) | 20 [12, 36] | 21 [12, 33] | 18 [11, 40] | 0.729 |
| CTIB | 67 (57.3) | 28 (50.9) | 39 (62.9) | 0.191 |
| SVCI | 11 (9.4) | 5 (9.1) | 6 (9.7) | 0.914 |
| LAPWI | 23 (19.7) | 12 (21.8) | 11 (17.7) | 0.580 |
| Other non-PV foci ablation | 7 (6.0) | 4 (7.3) | 3 (4.8) | 0.580 |
| Complications | ||||
| Cardiac tamponade | 0 (0) | 0 (0) | 0 (0) | - |
| Phrenic nerve palsy | 0 (0) | 0 (0) | 0 (0) | - |
| Bleeding at the puncture site | 0 (0) | 0 (0) | 0 (0) | - |
| Embolism | 0 (0) | 0 (0) | 0 (0) | - |
ST-segment depression and improvement in the left ventricular ejection fraction after catheter ablation
The follow-up TTE was performed at 363 [338, 425] days. The percentage of patients with improvement in the LVEF 1 year after CA was significantly lower in those with ST segment depression compared with those without it (58.6%; 34 out of 58 in patients with ST-segment depression and 79.7%; 51 out of 64 patients in patients without ST-segment depression) (Figure 2). Multiple regression analysis showed that ST-segment depression before CA during AF rhythm was independently and significantly associated with improvement in the LVEF 1 year after CA (P = 0.035), in addition to history of ischaemic heart disease, LV end-diastolic diameter and LV ejection fraction (P = 0.002, P = 0.001, and P < 0.001, respectively) (Table 2).
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Table 2 Multivariable logistic regression analysis for improvement of LVEF.
| Variables | Univariable | Multivariable | ||||
| OR | 95% CI | OR | 95% CI | |||
| Age (per 10-year increase) | 0.83 | 0.585–1.165 | 0.291 | |||
| Female | 1.07 | 0.402–2.853 | 0.890 | |||
| Hypertension | 0.77 | 0.346–1.668 | 0.506 | |||
| Diabetes mellitus | 0.31 | 0.120–0.789 | 0.014 | 0.47 | 0.148–1.486 | 0.193 |
| Dyslipidaemia | 0.43 | 0.179–1.026 | 0.055 | |||
| History of ischaemic heart disease | 0.19 | 0.063–0.515 | 0.002 | 0.12 | 0.026–0.475 | 0.002 |
| ST-segment depression | 0.36 | 0.158–0.795 | 0.013 | 0.35 | 0.129–0.928 | 0.035 |
| LV end-diastolic diameter (per 10 mm increase) | 0.49 | 0.253–0.913 | 0.028 | 0.23 | 0.087–0.530 | 0.001 |
| LV ejection fraction (per 10% increase) | 0.46 | 0.270–0.749 | 0.003 | 0.22 | 0.099–0.443 | <0.001 |
| LA diameter (per 10 mm increase) | 0.59 | 0.303–1.100 | 0.103 | |||
| ACEI/ARB | 0.98 | 0.420–2.202 | 0.956 | |||
| Beta-blocker | 0.90 | 0.338–2.213 | 0.818 | |||
| Haemoglobin | 1.08 | 0.883–1.317 | 0.467 | |||
| Brain natriuretic peptide (per 1000 pg increase) | 1.07 | 0.480–3.064 | 0.871 | |||
| No LRAF before follow-up TEE | 2.13 | 0.836–5.366 | 0.112 |
Relationship between ST-segment depression and clinical outcomes
The median follow-up duration was 736 [330, 1179] days and the LRAF occurred in 36 patients (29.5%). Kaplan–Meier analysis demonstrated that no significant difference in LRAF between the two groups was observed (Figure 3A). The number of CA sessions within 1 year after primary CA did not differ between the two groups (Figure 3B). MACE occurred in 26 patients (21.3%) and included 14 patients with HF hospitalization, 1 patient with cardiovascular death, 8 patients with hospitalization due to coronary artery disease, 2 patients with ventricular arrhythmia requiring hospitalization, and 1 patient with stroke (Table 3). The incidence of MACE was significantly elevated in patients with ST-segment depression compared with those without (P = 0.013). Notably, among them, HF hospitalization showed a pronounced increase in patients with ST-segment depression compared with those without (P = 0.013) (Table 3). Kaplan–Meier analysis showed that the patients with ST-segment depression before CA during AF rhythm significantly had higher risk of HF hospitalization than those without (P = 0.022) (Figure 4A). Kaplan–Meier analysis showed that the patients with ST-segment depression before CA during AF rhythm had a significantly higher risk of MACE than those without (P = 0.002) (Figure 4B). Multivariable Cox proportional hazards analysis showed that ST-segment depression was independently and significantly associated with a higher risk of MACE (HR: 2.82; 95% CI: 1.210–6.584, P = 0.016) (Table 4).
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Table 3 Details of MACE in patients with and without ST-segment depression
| Overall population ( |
ST-segment depression (+) ( |
ST-segment depression (−) ( |
||
| MACE | 26 (21.3) | 18 (31.0) | 8 (12.5) | 0.013 |
| HF hospitalization | 14 (11.5) | 11 (19.0) | 3 (4.7) | 0.013 |
| Cardiovascular death | 1 (0.8) | 1 (1.7) | 0 (0) | 0.292 |
| Hospitalization due to coronary artery disease | 8 (6.6) | 5 (8.6) | 3 (4.7) | 0.381 |
| Ventricular arrhythmia requiring hospitalization | 2 (1.6) | 1 (1.7) | 1 (1.6) | 0.944 |
| Stroke | 1 (0.8) | 0 (0) | 1 (1.6) | 0.339 |
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Table 4 Cox proportional hazard analysis for MACE after CA
| MACE | Univariable | Multivariable | ||||
| Variables | OR | 95% CI | OR | 95% CI | ||
| Age (per 10-year increase) | 1.38 | 0.960–2.042 | 0.091 | |||
| Female | 1.60 | 0.669–3.834 | 0.291 | |||
| Hypertension | 0.96 | 0.440–2.080 | 0.911 | |||
| Diabetes mellitus | 1.02 | 0.385–2.711 | 0.965 | |||
| Dyslipidaemia | 1.62 | 0.696–3.754 | 0.264 | |||
| History of ischaemic heart disease | 1.44 | 0.541–3.821 | 0.467 | |||
| ST-segment depression | 3.07 | 1.328–7.078 | 0.009 | 2.82 | 1.210–6.584 | 0.016 |
| LV end-diastolic diameter (per 10 mm increase) | 1.27 | 0.717–2.200 | 0.409 | |||
| LV ejection fraction (per 10% increase) | 1.26 | 0.822–2.013 | 0.309 | |||
| LA diameter (per 10 mm increase) | 1.35 | 0.736–2.468 | 0.334 | |||
| ACEI/ARB | 0.71 | 0.320–1.556 | 0.387 | |||
| Beta-blocker | 1.24 | 0.464–3.288 | 0.672 | |||
| Haemoglobin | 0.85 | 0.696–1.034 | 0.106 | |||
| Brain natriuretic peptide (per 1000 pg increase) | 1.79 | 0.974–2.671 | 0.018 | 1.59 | 0.852–2.395 | 0.066 |
| No LRAF before follow-up TEE | 0.61 | 0.253–1.484 | 0.278 |
Discussion
Main findings
The main findings in the present study were that (1) the percentage of patients with improvement in the LVEF 1 year after CA was significantly lower in the patients with ST-segment depression during AF rhythm than in those without in PerAF patients and (2) ST-segment depression was independently and significantly associated with a higher risk of the HF hospitalization and MACE. These results suggested that ST-segment depression during AF rhythm was a simple and useful predictor of the improvement in LV systolic function and clinical outcomes after CA in PerAF patients.
Improvement in the LVEF and ST-segment depression
Irregular contraction leads to adverse haemodynamic consequences that are independent of heart rate.17,18 AF-induced cardiomyopathy is triggered in part due to heart rate irregularity with calcium mishandling and loss of atrial contraction associated with sympathetic activation contributing to increased filling pressures, functional mitral regurgitation, and diastolic dysfunction.19 Regular atrial contraction contributes up to 20% of cardiac output and loss of atrial contraction adversely affects cardiac output in AF.20 In the present study, the patients with improvement in the LVEF (>15%) 1 year after CA consisted of 85 patients (69.7%). Recovery of regular atrial contraction is critical for improving LVEF, but approximately 30% of the enrolled patients showed no improvement in the LVEF. The percentage of patients with improvement in the LVEF 1 year after CA was significantly lower in the patients with ST-segment depression than in those without (Figure 2). Myocardium stressed by ischaemia, increased intraventricular pressure, and mechanical stretch exhibits changes in action potential waveforms including decreased resting membrane potential, action potential amplitude reduction, and shortening of action potential duration and those changes cause ST-segment depression and inverted-T wave. The patients with ST-segment depression may have severe and irreversible myocardial damage, and it may have contributed to the lower percentage of improvement in the LVEF despite the removal of rhythm irregularity by CA.
This study did not identify a significant correlation between LVEF improvement and LRAF following CA. Nonetheless, there was a trend indicating lower LRAF in patients with ST-segment depression (P = 0.094). The hypothesis to explain the above-mentioned result is that multiple factors are associated with LRAF other than ST-segment depression, suggesting abnormalities in the ventricular muscle. The small sample size may have precluded the detection of a significant difference, suggesting that larger future studies might produce different outcomes.
Clinical impact of ST-segment depression
Previous studies showed that ST-segment depression was significantly associated with all-cause mortality at 30 days or 1 year in acute coronary syndrome, a poor prognosis in hypertrophic cardiomyopathy patients and sudden cardiac death in men with any conventional risk factor but no previously diagnosed coronary heart disease.21–24 In the present study, MACE occurred in 26 patients (18 patients with ST-segment depression) including 15 patients with HF hospitalization, 8 patients with coronary artery disease, 2 patients with ventricular arrhythmia requiring hospitalization, and 1 patient with cerebral infarction. Multivariable Cox proportional hazards analysis showed that only ST-segment depression was independently and significantly associated with a higher risk of MACE (Table 4). A previous report has shown that the presence of coronary artery disease in AF patients with ST-segment depression is 32.5%.25 ST-segment depression suggests the presence of cardiac structural abnormalities including not only coronary artery disease but also left ventricular hypertrophy, several cardiomyopathies, and high risk of heart rhythm abnormalities (sick sinus syndrome, atrioventricular block, and ventricular arrhythmia). In the present study, 3 patients were hospitalized for HF due to AF recurrence, 2 patients were hospitalized for HF due to sick sinus syndrome, and 1 patient was hospitalized for HF due to complete atrioventricular block. ST-segment depression may suggest that there are myocardial abnormalities, and it is highly useful prognostic predictor in PerAF patients with HFrEF accompanied with ST-segment depression during AF rhythm.
The type of ST-segment depression (upsloping, horizontal, and downsloping) serves as an indicator of myocardial ischaemia severity.26 A previous study demonstrated a significant disparity in the composite of HF hospitalization and cardiac death based on the type of ST-segment depression; patients with horizontal and downsloping ST-segment depression exhibited a higher incidence of these adverse events.7 This report suggests that the type of ST-segment depression may influence the improvement in LVEF. In the present study, 58 patients with LVEF < 50% manifested ST-segment depression before undergoing CA during AF rhythm. Among them, 9 patients presented with the upsloping type, 10 patients with the horizontal type, and 39 patients with the downsloping type. Improvement in LVEF was observed in 6 patients (66.7%) with the upsloping type, 4 patients (40.0%) with the horizontal type, and 24 patients (61.5%) with the downsloping type. No significant differences in improvement in LVEF among the types of ST-segment depression were observed. Future research would be mandatory to elucidate the impact of ST-segment depression type on the improvement in LVEF after AF ablation.
Clinical implications
In the PerAF patients with HFrEF, maintenance of sinus rhythm even if multiple sessions of CA were required was important for improvement in the LVEF. However, ST-segment depression during AF rhythm had a high risk of no-improvement in the LVEF and poor clinical outcomes after CA. In the patients with ST-segment depression, detailed follow-up after CA, and accurate diagnosis and optimal treatment of underlying cardiac diseases should be required, in addition to CA.
Study limitations
Several limitations of the study need to be acknowledged. First, the present study was a single-center, non-randomized registry-based study. Second, the follow-up TTE was performed at a variety of times, which might have underestimated the improvement in the LVEF. Third, the follow-up TTE was performed during sinus rhythm, but AF burden after primary CA was not evaluated in the present study. Fourth, a detailed investigation into adverse baseline characteristics associated with ST-segment depression was not fully investigated (serum troponin levels the presence of late gadolinium enhancement on cardiac magnetic resonance imaging). Fifth, there is a disparity in LVEF measurement between sinus rhythm and AF rhythm, but all patients demonstrated AF rhythm before undergoing CA, and sinus rhythm was observed during the follow-up TTE. Echocardiographic parameters during AF rhythm were collected when the two preceding cardiac cycles had similar R-R intervals, preferably with an average heart rate below 100 b.p.m.
Conclusions
ST-segment depression before CA during AF rhythm was useful prognostic predictor of improvement in the LVEF and clinical outcomes in the PerAF patients with HFrEF.
Acknowledgements
The authors thank Mr. John Martin for his linguistic assistance with this manuscript.
Conflict of interest
The authors have no conflicts of interest to declare.
Funding
None.
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Abstract
Aims
Catheter ablation (CA) of atrial fibrillation (AF) improves left ventricular ejection fraction (LVEF) in patients with heart failure with reduced ejection fraction (HFrEF). The impact of ST‐segment depression before CA on LVEF recovery and clinical outcomes remains unknown. In the present study, we aimed to investigate the relationship between ST‐segment depression during AF rhythm before CA and improvement in the LVEF and clinical outcomes in persistent atrial fibrillation (PerAF) patients with HFrEF.
Methods and results
The present study included 122 PerAF patients (male; 98 patients, 80%, mean age: 69 [56, 76] years) from the Osaka Rosai Atrial Fibrillation ablation (ORAF) registry who had LVEF < 50% and underwent an initial ablation. The patients who underwent percutaneous coronary intervention or coronary artery bypass grafting within the past 1 month were not included in the enrolled patients. We assigned the patients based on the presence of ST‐segment depression before CA during AF rhythm and evaluated improvement in the LVEF (LVEF ≥ 15%) 1 year after CA and the relationship between ST‐segment depression and heart failure (HF) hospitalization/major adverse cardiovascular events (MACE), which are defined as a composite of HF hospitalization, cardiovascular death, hospitalization due to coronary artery disease, ventricular arrhythmia requiring hospitalization and stroke. The percentage of patients with improvement in the LVEF 1 year after CA was significantly lower in the patients with ST‐segment depression than those without (58.6% vs. 79.7%, P = 0.012). Multiple regression analysis showed ST‐segment depression was independently and significantly associated with improvement in the LVEF 1 year after CA (HR: 0.35; 95% CI: 0.129–0.928, P = 0.035). Kaplan–Meier analysis showed that the patients with ST‐segment depression significantly had higher risk of HF hospitalization and MACE than those without (log rank P = 0.022 and log rank P = 0.002, respectively). Multivariable Cox proportional hazards analysis showed that ST‐segment depression was independently and significantly associated with a higher risk of MACE (HR: 2.82; 95% CI: 1.210–6.584, P = 0.016).
Conclusions
ST‐segment depression before CA during AF rhythm was useful prognostic predictor of improvement in the LVEF and clinical outcomes including HF hospitalization and MACE in PerAF patients with HFrEF.
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Details
1 Division of Cardiology, Osaka Rosai Hospital, Osaka, Japan