Prognostic Value of Inferior Shift of P wave Axis after Catheter Ablation for Longstanding Persistent Atrial Fibrillation based on Dallas Lesion Set Including Anterior Line

ABSTRACT

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 for bidirectional block (BDB) is only about 60% at repeat procedure. We hypothesized that changes in electrocardiogram (ECG) may predict an anterior line block state and the 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 and post-procedural P wave axes, and one 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 (β=10.4, 95% confidence interval [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 one-year (n=205, p=0.923), potentially due to conduction recovery of an anterior line. However, among 160 patients without clinical recurrence within one-year, P wave axis at one-year ECG was independently associated with very late recurrence of AF after one-year (n=160, hazard ratio [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 procedures, P wave axis shift was more significant in patients with maintained BDB of an anterior line than in those without (p=0.015). CONCLUSION: An inferior shift of P wave axis reflects the achievement and the maintenance of an anterior line BDB, and is associated with better long-term clinical outcome after catheter ablation for L-PeAF based on Dallas lesion set.