Atrial asynchrony and function before and after electrical cardioversion for persistent atrial fibrillation†

The relation between left atrial (LA) electrical and mechanical activity is a challenging field of investigation. The availability of echocardiographic strain analysis techniques has enhanced our ability to non-invasively assess LA wall mechanical synchrony and performance. The aim of our study was to investigate how new strain analysis tools describe the improvement in LA mechanical function after sinus rhythm (SR) restoration as a result of electrical cardioversion (CV) and how such improvement mirrors endocrine profile changes. Seventy-three patients, with persistent atrial fibrillation (AF) who underwent successful electrical CV, were prospectively studied with transthoracic echocardiography 1 week before CV and 1 month after SR. Speckle-tracking 2D-strain evaluation and asynchrony quantification were performed according to the standard deviation of time-to-peak (TP-SD) of deformation of six segments automatically located along the perimeter of the LA cavity, as imaged in an apical four-chamber view. We also calculated classic echocardiograhic parameters such as mitral regurgitation (MR) jet area, LA volume, LV diastolic and systolic volumes, as well as E-wave velocity and deceleration time (DT) on transmitral pulsed wave Doppler. Specimens for plasmatic brain natriuretic peptide (BNP) were also obtained before and 1 month after CV. After 1 month of SR, we detected a significant reduction in TP-SD (from 17.5 +/- 7.4 to 15.2 +/- 7.5%, P = 0.022), this being the expression of improved LA asynchrony, together with a marked increase in LA deformation (peak strain from 11.4 +/- 5.2 to 17.2 +/- 7.5%, P < 0.001) and a reduction in LA volume (-4.5 +/- 36%, P = 0.012). BNP decreased by one-third (from 127 +/- 96 to 86 +/- 89 pg/mL, P = 0.01). We also noticed improved ventricular pump performance [LV ejection fraction (EF) from 53 +/- 10 to 57 +/- 8%, P = < 0.001] due to a 20 +/- 42% (P < 0.001) increase in LV diastolic volume (without variations in LV systolic volume and mass), a better diastolic profile (DT 34 +/- 64%, P = 0.003), and a reduction in MR jet area (-1.0 +/- 2.0 cm(2), P < 0.001). These findings are compatible with reverse LA remodelling secondary to SR maintenance, with a favourable effect on LV function that appears modulated by the atrium itself. A significant correlation (r = 0.40, P < 0.001) was demonstrated between TP-SD and peak strain data pre-post CV. At multivariate analysis, a significant capacity for the TP-SD/peak strain ratio to predict AF recurrence at 1-year follow-up (P = 0.013) was shown. Our novel noninvasive approach appears to be able to describe the LA mechanical behaviour during AF and how this ameliorates after 1 month of SR, together with an improved endocrine profile. LA mechanical data pre-CV can predict AF recurrence 1-year post CV.