title: Left atrial strain as predictor of successful outcomes in catheter ablation for atrial fibrillation: a two-dimensional myocardial imaging study Normal values and clinical relevance of left atrial myocardial function analysed by speckle-tracking echocardiography: multicentre study. Left atrial deformation imaging with ultrasound based two-dimensional speckle-tracking predicts the rate of recurrence of paroxysmal and persistent atrial fibrillation after successful ablation procedures. Left atrial deformation analysis by speckle tracking echocardiography for prediction of cardiovascular outcomes. The usefulness of global left atrial strain for predicting atrial fibrillation recurrence after catheter ablation in patients with persistent and paroxysmal atrial fibrillation. Left atrial mechanics predict the success of pulmonary vein isolation in patients with atrial fibrillation 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation
abstract: Background The objective of this study was to investigate atrial myocardial properties through two-dimensional ( 2D ) myocardial imaging in patients with atrial fibrillation ( AF ) and its predictive role for recurrence after catheter ablation . Methods and results Echocardiographic examinations were performed in 40 patients with paroxysmal AF before catheter ablation and 40 age- and gender-matched healthy control subjects . Using a software package , bidimensional acquisitions were analyzed to measure longitudinal strain and strain rate for the left atrium ( LA ) . Systolic strain and strain rate in all eight segments , and its average values , were significantly reduced in AF patients compared to controls . During 9 months of follow-up after catheter ablation for AF , 11 of 40 AF patients had AF recurrence . AF recurrence was associated with gender , LA volume index , and average values of systolic strain and strain rate . By multivariate analysis , only average strain was an independent predictor of AF recurrence ( OR = 0.88 , 95 % CI 0.79 - 0.98 , p = 0.018 ) . Conclusions Lower systolic strain of LA was strongly associated with recurrence after catheter ablation . Thus , diverse adjunctive ablation strategies should be considered to reduce recurrence in patients with lower systolic strain AIMS The aim of this multicentre study was to determine the normal range and the clinical relevance of the myocardial function of the left atrium ( LA ) analysed by 2D speckle-tracking echocardiography ( 2DSTE ) . METHODS AND RESULTS We analysed 329 healthy adult subjects prospect ively included in 10 centres and a validation group of 377 patients with left ventricular diastolic dysfunction ( LVDD ) . LA myocardial function was analysed by LA strain rate peak during LA contraction ( LA-SRa ) and LA strain peak during LA relaxation ( LA-Strain ) . The range of values of LA myocardial function in healthy subjects was LA-SRa -2.11 ± 0.61 s(-1 ) and LA-Strain 45.5 ± 11.4 % , and the lowest expected values of these LA analyses ( calculated as -1.96 SD from the mean of healthy subjects ) were LA-SRa -0.91 s(-1 ) and LA-Strain 23.1 % . Concerning the clinical relevance of these LA myocardial analyses , LA-SRa and LA-Strain detected subtle LA dysfunction in patients with LVDD , even though LA volumetric measurements were normal . In addition , in these patients we found that the functional class ( dyspnoea-NYHA classification ) was inversely related to both LA-Strain and LA-SRa . CONCLUSION In the present multicentre study analysing a large cohort of healthy subjects and patients with LVDD , the normal range and the clinical relevance of the myocardial function of the LA using 2DSTE have been determined OBJECTIVE Since predictors of recurrence of atrial fibrillation ( AF ) after ablation procedures are poorly defined , this prospect i ve study was conducted to assess the value of left atrial ( LA ) deformation imaging with two-dimensional speckle-tracking ( 2D-ST ) to predict AF recurrences after successful ablation procedures . METHODS AND RESULTS One hundred and three consecutive patients ( age 58.1 ± 16.6 years , 72.8 % male ) with AF ( 76 paroxysmal , 27 persistent ) and 30 matched controls underwent transthoracic echocardiography and 2D-ST-LA-deformation analysis with assessment of LA-radial and LA-longitudinal strain ( Sr , Sl ) , and velocities derived from the apical 4- and 2-chamber views ( 4CV , 2CV ) . AF recurrence was assessed during 6 months of follow-up . For determination of AF-related LA changes , AF patients were compared to controls and patients with AF recurrences after ablation procedures ( n = 30 , 29.1 % ) were compared with patients who maintained sinus rhythm ( n = 73 , 70.9 % ) . Atrial deformation capabilities were significantly reduced ( P < 0.0005 ) in patients with AF ( 4CVSl 17.8 ± 13.5 % ; 4CVSr 22.3 ± 14.9 % ; 4CV-velocities 2.53 ± 0.97 seconds ) when compared with controls ( 4CVSl 31.3 ± 12.4 % ; 4CVSr 30.3 ± 9.1 % ; 4CV-velocities 3.48 ± 1.01 cm/s ) . Independent predictors for AF recurrence after ablation procedures were 2CV-LA-global-strain ( Sr , P = 0.03 ; Sl , P = 0.003 ) , 4CV-LA-gobal-strain ( Sr , P = 0.03 ; Sl , P = 0.02 ) , and regional LA-septal wall-Sl ( P = 0.008 ) . LA-global-strain parameters were superior to regional LA function analysis for the prediction of AF recurrences , with cutoff values ( cov ) , hazard ratios ( HR ) , positive and negative predictive values ( PPV , NPV ) were : 4CVSl cov , 10.79 % ( HR 27.8 , P < 0.0005 ; PPV 78.8 % , NPV 93.9 % ) , 4CVSr cov , -16.65 % ( HR 24.8 , P < 0.0005 ; PPV 69.4 % , NPV 96.6 % ) , 2CVSl cov , 12.31 % ( HR 22.7 , P < 0.0005 ; PPV 75.8 % , NPV 95.3 % ) , and 2CVSr cov , -14.9 % ( HR 12.9 , P < 0.0005 ; PPV 64.3 % , NPV 93.2 % ) . CONCLUSION Compared with controls , AF itself seems to decrease LA deformation capabilities . The assessment of global LA strain with 2D-ST identifies patients with high risk for AF recurrence after ablation procedures . This imaging technique may help to improve therapeutic guiding for patients with AF The incremental value of left atrial ( LA ) deformation analysis by speckle tracking echocardiography compared with LA volume or LA ejection fraction as a cardiovascular risk marker has not been evaluated prospect ively . We sought to compare LA function by speckle tracking echocardiography to other conventional LA parameters for prediction of adverse cardiovascular outcomes . This prospect i ve study included 312 adults ( mean age 71 ± 6 years , 56 % men ) in sinus rhythm who were followed for development of first atrial fibrillation , congestive heart failure , stroke , transient ischemic attack , myocardial infa rct ion , coronary revascularization , and cardiovascular death .  Global peak atrial longitudinal strain ( PALS ) by speckle tracking echocardiography was measured in all subjects by averaging all atrial segments . Left atrium was assessed with biplane LA volume , LA ejection fraction , 4-chamber LA area , and M-mode dimension . Of 312 subjects at baseline , 43 had 61 new events during a mean follow-up of 3.1 ± 1.4 years . All LA parameters , traditional parameters , and parameters derived by speckle tracking echocardiography were independently predictive of combined outcomes ( p < 0.0001 for all comparisons ) . Overall performance for prediction of cardiovascular events was greatest for global PALS ( area under receiver operator characteristic curve : global PALS 0.83 , indexed LA volume 0.71 , LA ejection fraction 0.69 , LA area 0.64 , LA diameter 0.59 ) . A grade d association between degree of LA enlargement and risk of cardiovascular events was evident only for global PALS and indexed LA volume . In conclusion , global PALS is a strong and independent predictor of cardiovascular events and appears to be superior to conventional parameters of LA analysis BACKGROUND Given the potential complications of atrial fibrillation ( AF ) recurrence after ablation , better predictors of the effectiveness of the procedure are necessary to guide patient selection . AIM This prospect i ve study was conducted to evaluate the clinical relevance of global left atrial longitudinal strain ( GLAS ) and AF recurrence after catheter ablation . METHODS In 115 consecutive patients with AF ( persistent , n=62 ; paroxysmal , n=53 ) ,  transthoracic echocardiography was performed before catheter ablation to assess baseline left atrial mechanical function using speckle tracking echocardiography ( STE ) . RESULTS After 12 months of follow-up , 22 ( 35.5 % ) patients in the persistent AF group and 15 ( 28.3 % ) in the paroxysmal AF group exhibited AF recurrence . In both the paroxysmal and persistent AF population s , patients with recurrence presented with significantly impaired GLAS compared with patients without recurrence . Patients with recurrence also had a significantly higher pro-B-type natriuretic peptide concentration . A receiver operator curve analysis yielded area under the curve values of 0.94 and 0.86 for paroxysmal and persistent AF , respectively . In a multivariable Cox proportional-hazards analysis , GLAS was an independent predictor of AF recurrence after catheter ablation in both the paroxysmal AF group ( hazard ratio : 0.79 , 95 % confidence interval : 0.67 - 0.96 ; P=0.01 ) and the persistent AF group ( hazard ratio : 0.81 , 95 % confidence interval : 0.71 - 0.93 ; P=0.004 ) . CONCLUSIONS In both paroxysmal and persistent AF , decreased baseline left atrial deformation capabilities assessed by two-dimensional STE can help to identify patients at high risk of AF recurrence after catheter ablation . This variable may help to guide c and i date selection and improve therapeutic strategies Background Atrial fibrillation ( AF ) is a common arrhythmia with relevant impact on mortality and morbidity .  Pulmonary vein isolation ( PVI ) is an established therapy in patients who remain symptomatic under optimal medical therapy . However , up to 70 % of patients present with recurrence of AF after PVI . Therefore , identifying ideal c and i date s is an unmet clinical need . Left atrial ( LA ) fibrosis is associated with reduced LA function . Analysis of LA mechanics using 2D speckle tracking echocardiography ( STE ) might give more insight into LA substrates and be therefore of predictive value . Methods This prospect i ve single-center pilot study included 31 patients ( mean age , 62.3 ± 9.1 years ; 19 males ) with AF who underwent PVI and 20 matched healthy controls ( mean age , 60.6 ± 6.6 years ; 10 males ) .  2D STE strain indices of LA reservoir ( RLA ) , conduit , and , if feasible , contractile function , were analyzed before and 6 months after PVI . Assessment of the LV diastolic function was based on st and ard indices . Responders to PVI were defined as being asymptomatic and free of AF in a 7-day Holter-ECG after 6 months . Results At baseline , all patients with AF had significantly lower reservoir and contractile function compared with controls . After 6 months , 17 patients ( 54.8 % ) were identified as responders . At baseline , the reservoir function was significantly higher in responders compared with nonresponders ( 32.7 ± 11.1 vs. 22.9 ± 10.9 % ; P = 0.019 ) . Only in responders , RLA and contractile LA function improved and reached normal values whereas LA function remained unchanged in nonresponders . In a ROC analysis , a RLA value of ≥19.5 % discriminated responders and nonresponders in patients with persistent AF with a sensitivity of 86 % and a specificity of 100 % ( P = 0.012 ; area under the curve 0.943 ; CI , 0.81–1.0 ) . Conclusions LA reservoir function helps to predict efficacy of PVI after 6 months . Only in responders , reservoir , and contractile function normalized within 6 months after PVI indicating a lower level of atrial remodeling at baseline . No deleterious effects of ablation were detected in nonresponders During the past three decades , catheter and surgical ablation of  atrial fibrillation ( AF ) have evolved from investigational procedures to their current role as effective treatment options for patients with AF .  Surgical ablation of AF , using either st and ard , minimally invasive , or hybrid techniques , is available in most major hospitals throughout the world . Catheter ablation of AF is even more widely available , and is now the most commonly performed catheter ablation procedure . In 2007 , an initial Consensus Statement on Catheter and Surgical AF Ablation was developed as a joint effort of the Heart Rhythm Society ( HRS ) , the European Heart Rhythm Association ( EHRA ) , and the European Cardiac Arrhythmia Society (ECAS).1 The 2007 document was also developed in collaboration with the Society of Thoracic Surgeons ( STS ) and the American College of Cardiology ( ACC ) . This Consensus Statement on Catheter and Surgical AF Ablation was rewritten in 2012 to reflect the many advances in AF ablation that had occurred in the interim.2 The rate of advancement in the tools , techniques , and outcomes of AF ablation continue to increase as enormous research efforts are focused on the mechanisms , outcomes , and treatment of AF . For this reason , the HRS initiated an effort to rewrite and up date this Consensus Statement . Reflecting both the worldwide importance of AF , as well as the worldwide performance of AF ablation , this document is the result of a joint partnership between the HRS , EHRA , ECAS , the Asia Pacific Heart Rhythm Society ( APHRS ) , and the Latin American Society of Cardiac Stimulation and Electrophysiology ( Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia [ SOLAECE ] ) . The purpose of this 2017 Consensus Statement is to provide a state-of-the-art review of the field of catheter and surgical ablation of AF and to report the findings of a writing group , convened by these five international societies . The writing group is charged with defining the indications , techniques , and outcomes of AF ablation procedures . Included within this document are recommendations pertinent to the design of clinical trials in the field of AF ablation and the reporting of outcomes , including definitions relevant to this topic . The writing group is composed of 60 experts representing 11 organizations : HRS , EHRA , ECAS , APHRS , SOLAECE , STS , ACC , American Heart Association ( AHA ) , Canadian Heart Rhythm Society ( CHRS ) , Japanese Heart Rhythm Society ( JHRS ) , and Brazilian Society of Cardiac Arrhythmias ( Sociedade Brasileira de Arritmias Cardiacas [ SOBRAC ] ) . All the members of the writing group , as well as peer review ers of the document , have provided disclosure statements for all relationships that might be perceived as real or potential conflicts of interest . All author and peer review er disclosure information is provided in Appendix A and Appendix B. In writing a consensus document , it is recognized that consensus does not mean that there was complete agreement among all the writing group members . Surveys of the entire writing group were used to identify areas of consensus concerning performance of AF ablation procedures and to develop recommendations concerning the indications for catheter and surgical AF ablation . These recommendations were systematic ally balloted by the 60 writing group members and were approved by a minimum of 80 % of these members . The recommendations were also subject to a 1-month public comment period . Each partnering and collaborating organization then officially review ed , commented on , edited , and endorsed the final document and recommendations . The grading system for indication of class of evidence level was adapted based on that used by the ACC and the AHA.3,4 It is important to state , however , that this document is not a guideline . The indications for catheter and surgical ablation of AF , as well as recommendations for procedure performance , are presented with a Class and Level of Evidence ( LOE ) to be consistent with what the reader is familiar with seeing in guideline statements . A Class I recommendation means that the benefits of the AF ablation procedure markedly exceed the risks , and that AF ablation should be performed ; a Class IIa recommendation means that the benefits of an AF ablation procedure exceed the risks , and that it is reasonable to perform AF ablation ; a Class IIb recommendation means that the benefit of AF ablation is greater or equal to the risks , and that AF ablation may be considered ; and a Class III recommendation means that AF ablation is of no proven benefit and is not recommended . The writing group review ed and ranked evidence supporting current recommendations with the weight of evidence ranked as Level A if the data were derived from high- quality evidence from more than one r and omized clinical trial , meta-analyses of high- quality r and omized clinical trials , or one or more r and omized clinical trials corroborated by high- quality registry studies . The writing group ranked available evidence as Level B-R when there was moderate- quality evidence from one or more r and omized clinical trials , or meta-analyses of moderate- quality r and omized clinical trials . Level B-NR was used to denote moderate- quality evidence from one or more well- design ed , well-executed nonr and omized studies , observational studies , or registry studies . This design ation was also used to denote moderate- quality evidence from meta-analyses of such studies . Evidence was ranked as Level C-LD when the primary source of the recommendation was r and omized or nonr and omized observational or registry studies with limitations of design or execution , meta-analyses of such studies , or physiological or mechanistic studies of human subjects . Level C-EO was defined as expert opinion based on the clinical experience of the writing group . Despite a large number of authors , the participation of several societies and professional organizations , and the attempts of the group to reflect the current knowledge in the field adequately , this document is not intended as a guideline . Rather , the group would like to refer to the current guidelines on AF management for the purpose of guiding overall AF management strategies.5,6 This consensus document is specifically focused on catheter and surgical ablation of AF , and summarizes the opinion of the writing group members based on an extensive literature review as well as their own experience . It is directed to all health care professionals who are involved in the care of patients with AF , particularly those who are caring for patients who are undergoing , or are being considered for , catheter or surgical ablation procedures for AF , and those involved in research in the field of AF ablation . This statement is not intended to recommend or promote catheter or surgical ablation of AF . Rather , the ultimate judgment regarding care of a particular patient must be made by the health care provider and the patient in light of all the circumstances presented by that patient . The main objective of this document is to improve patient care by providing a foundation of knowledge for those involved with catheter ablation of AF . A second major objective is to provide recommendations for design ing clinical trials and reporting outcomes of clinical trials of AF ablation . It is recognized that this field continues to evolve rapidly . As this document was being prepared , further clinical trials of catheter and surgical ablation of AF were under way
target: Lower values of PALS are associated with an increased risk of AF recurrence after RFA .
  PALS provides prognostic value in clinical practice
background: The usefulness of peak atrial longitudinal strain ( PALS ) in identifying patients at high risk of atrial fibrillation ( AF ) recurrence after radiofrequency ablation ( RFA )  has been investigated in several small AF population s. The aim of this systematic review and meta- analysis was to investigate whether PALS predicts recurrence of AF after RFA treatment .