Non pulmonary vein triggers and pulmonary pressure in atrial fibrillation ablation for cardiac amyloidosis patients

Nicola Pierucci, 0000 – Phd Candidate, Policlinico Umberto I, Roma; Carlo Gigante, 0000 – Research Fellow, texas cardiac arrhythmia institute; carola Gianni, 0000 – Research Fellow, texas cardiac arrhythmia institute; Preem Geeta Torlapati, 0000 – biostatistician, texas cardiac arrhythmia institute; Sanghamitra Mohanty, 0000 – Director of Research, texas cardiac arrhythmia institute; Luigi Di Biase, 0000 – Section Head Electrophysiology, Albert Einstein College of Medicine at Montefiore Hospital; Andrea Natale, 0000 – Executive Medical Director, texas cardiac arrhythmia institute

Purpose: The study evaluates the prevalence of non-PV triggers during catheter ablation in atrial fibrillation (AF) patients affected by cardiac amyloidosis and how restoration of sinus rhythm affects pulmonary pressures.

Material and Methods: This is a study including 74 consecutive patients with an established diagnosis of amyloidosis ATTR diagnosed with cardiac MRI or myocardial biopsy that underwent their first AF catheter ablation. All have a transthoracic echocardiogram before ablation. They underwent pulmonary vein (PV) isolation + isolation of left atrial posterior wall and superior vena cava. Additionally, extrapulmonary triggers, which are defined as ectopic triggers originating from sites other than PVs including left atrial appendage (LAA), coronary sinus (CS), interatrial septum, crista terminalis, mitral valve anulus were identified. Post procedure, patients were followed up routinely with ECG during office visits, echocardiogram, 7-day Holter monitor and event recorders during the first year followed by biannual checkups during the remaining part of the follow-up period. Student’s t-test was used to compare pulmonary pressure between the groups.

Results: Isoproterenol-challenge revealed non-PV triggers in 51 (68.9%) patients. These triggers were mostly mapped to LAA (39, 52.7%), CS (30, 40,5%), and crista terminalis (35, 47.3%). Besides, ectopic beats were seen originating from inter-atrial septum (19, 25.6%), mitral valve annulus (10, 13.5%). More than one trigger was found in (68%) patients. At 1-year after the ablation, 65 (87.8%) were arrhythmia-free off antiarrhythmic drugs.

Moreover, in patients who maintained sinus rhythm post-ablation, there was either a non progression or a reduction in pulmonary pressures (PAPm before ablation: 44.8 ± 8.9 mmHg vs PAPm after ablation 45.1 ± 11.1 mmHg, P value =0.87). Conversely, those experiencing arrhythmic recurrences demonstrated an increase in pulmonary pressures (PAPm before ablation: 41.9 ± 7.7 mmHg vs PAPm after ablation 47.8 ± 10.2 mmHg, P value =0.019). Fig.1

Conclusions: Our findings suggest that non-PV triggers are highly prevalent in cardiac amyloidosis AF patients including a high rate crista terminalis firing. Notably, restoration of sinus rhythm post-ablation was linked to stable or reduced pulmonary arterial pressures, whereas patients with arrhythmic recurrences experienced a significant increase.