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International Journal of Arrhythmia 2017;0(0):
Prognostic value of inferior shift of P-wave axis after catheter ablation for longstanding persistent atrial fibrillation including anterior line
Dong Geum Shin 1, Tae-Hoon Kim 1, Hyunmin Jeong 1, Alexander Kim 1, Jae-Sun Uhm 1, Boyoung Joung 1, Moon-Hyoung Lee 1, Chun Hwang 2, Pak Hui-Nam 1
1Yonsei University Health System, Seoul, Korea
2Utah Valley Medical Center, Provo, UT, U.S.A., Utah, United States
Corresponding Author: Pak Hui-Nam ,Tel: 82 2 2228 8461, Fax: 82 2 2227 7732, Email: hnpak@yuhs.ac
Received: February 13, 2017.  Accepted: March 30, 2017.
Background and Objectives: Although an anterior linear ablation is an effective lesion set in radiofrequency catheter ablation (RFCA) for longstanding persistent atrial fibrillation (L-PeAF), its durability of bidirectional block (BDB) is about 60% at repeat procedure. We hypothesized that electrocardiogram (ECG) change may predict an anterior line block state and clinical outcome of L-PeAF ablation.
Subjects and Methods: We studied 304 L- PeAF patients (77% male, 60±10yrs), who consistently underwent RFCA Dallas Lesion Set (Circumferential Pulmonary vein isolation, posterior box lesion, and anterior line) protocol with subsequent comparison of pre-procedural, post-procedural P-wave axes, and 1 year follow up (n=205) sinus rhythm (SR) ECGs.
Results: 1. P-wave axis shifted inferiorly at immediate post-procedure (p<0.001), and was independently correlated with BDB of anterior line (ß=10.4, 95% CI 2.79-17.94, p=0.008). 2. The degree of post-procedural inferior shift of P-wave axis did not reflect clinical recurrence within 1-year (n=205, p=0.923) potentially due to conduction recovery of an anterior line. However, among 160 patients without clinical recurrence within 1-year, P-wave axis at 1-year ECG was independently associated with very late recurrence of AF after 1-year (n=160, HR 0.98; 95% CI 0.97–0.99, p=0.001) during 45.6±16.7 months of follow-up. 3. Among 22 patients who underwent repeat procedure, P-wave axis shift was more significant in patients with maintained BDB of an anterior line than those without (p=0.015).
Conclusion: Inferior shift of P-wave axis reflects the achievement and the maintenance of an anterior line BDB, and associated with better long-term clinical outcome after catheter ablation for L-PeAF.
Key Words: P-wave; Longstanding persistent atrial fibrillation; Catheter ablation; Anterior line; very late recurrence