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Introduction:Increasingly, catheter ablation for atrial fibrillation (AF) has been utilized for rhythm control and to improve quality of life (QoL). Data are limited on patient-centered ablation outcomes in individuals with chronic kidney disease (CKD).Objective:To examine clinical outcomes and QoL following AF ablation in CKD patients from a large patient-reported outcomes (PRO) database.Methods:All patients undergoing AF ablation (2013-2016) at our center were enrolled and assessed for outcomes using automated PRO surveys (baseline, 3 and 6 months after ablation, every 6 months thereafter). This analysis captured data at 1- and 3-year follow-up. CKD was defined as estimated glomerular filtration rate (eGFR) <60 ml/min using the 2021 CKD-EPI equation. The atrial fibrillation symptom severity scale (AFSSS) was used as the main measure for QoL assessment. In addition, data were collected on clinical improvement by patient report, AF burden, and healthcare utilization.Results:A total of 488 patients were identified (66% male, mean age 68.5, 56.2% persistent AF). QoL was significantly improved from baseline median (IQR) AFSSS of 14 (6-19.5) to 3 (0-9) at 1-year and 4 (0-9.5) at 3-year; P≤0.0001 for both. About 90% of patients reported improvement in their overall AF-related symptoms both at 1- and 3-year follow up. The proportion of patients in AF at the time of completion of the baseline survey was 51.2%, and this decreased to 6.2% at 1-year and 9.7% at 3-year follow up (P<0.0001 for both). AF burden was significantly reduced at 1-year and 3-year including frequency and duration of episodes (P<0.05 for both), with associated decrease in ER visits and hospitalizations; P<0.0001 for all comparisons. The proportion of patients on antiarrhythmics decreased from 61.8% at baseline to 35.6% and 22.7% at 1-year and 3-year, respectively (P<0.0001 for both).Conclusions:In a large AF-specific PRO system, catheter ablation for AF was associated with a significant improvement of QoL in most patients with CKD; with a decrease in AF burden and healthcare utilization.

Background:The prognostic significance of cardiac magnetic resonance (CMR) based left atrial ejection fraction (LAEF) is not well defined in the ischemic cardiomyopathy (ICM) cohort.We assess the additive effect of LAEF in a model to predict outcomes in patients with ICM.Methods:Patients with ICM, who underwent CMR between April 2001 and March 2019 were retrospectively included.Clinical characteristics and CMR parameters were collected and analyzed and LAEF was calculated in addition to myocardial infarct size (MIS) using late gadolinium enhancement (LGE) and CMR based mitral regurgitant fraction (MRF). The primary clinical endpoint was a composite of all-cause mortality and cardiac transplant. A multiple-variable Cox proportional hazards regression model which included established predictors of outcome was constructed, followed by the addition of LAEF. Four pre-specified interactions of LAEF with left ventricular end systolic volume index (LVESVi), MIS and mitral regurgitant fraction (MRF) were tested at a significance level of 0.05.RESULTS:LA functional data was measured in 718 patients. There were 416 deaths and/or transplants, with a median duration of follow up of 1763 days (4.8 years) The mean LA EF was 36 [2 ,74]. In univariate analysis, lower LAEF and higher LAVI were significant predictors of worse outcome, HR= 0.12, 95% CI [0.06, 0.25], p<0.001; HR 1.008, (1.003-1.014) p = 0.003. After addition to the multivariable model, a normal LAEF was highly predictive of reduced risk, HR 0.24, (0.12, 0.48), p<0.001. In the interaction between LAEF and MIS with MR Fraction, the highest risk was observed in patients with an LAEF < 20% and an MIS of > 30%, with MR Fraction of >35%, HR of 3.2 (1.73-5.93), p= 0.009. The lowest risk was in patients with an LAEF of >50% with an MIS of <15 and MR Fraction of <35%, HR 1.07 (0.81-1.42), p=0.009. Figure 1.CONCLUSION:Reduced LAEF is an important predictor of increased mortality in patients with ICM and additive to MIS and MR Fraction.

Background:Functional mitral regurgitation (FMR) is associated with poor prognosis, however the determinants of FMR progression are not well understood. We aimed to determine clinical and cardiac magnetic resonance imaging (CMR) factors associated with FMR progression in patients with non-ischemic cardiomyopathy (NICM) who underwent baseline and follow-up echocardiography.Methods:NICM patients undergoing CMR between 12/2002-12/2017 with baseline (within 90 days of CMR) and follow-up echocardiography were evaluated. Progressive FMR was assessed by echocardiography based on reported FMR severity (none, mild, moderate, moderate-severe, severe). Associations between clinical and CMR parameters (left ventricular and left atrial (LA) size and function, late gadolinium enhancement, and mitral valve (MV) geometry quantification) and progressive FMR were assessed by univariable and stepwise multivariable linear regression.Results:Amongst 311 NICM patients (age 53±15.7 years, female 121 (38.9%)). A total of 17 patients (5.5%) had at least 1-grade of deterioration in FMR, while 66 patients (21.2%) had at least 1-grade of improvement. Univariable and multivariable analyses results are listed in the table. Mean baseline mitral regurgitant fraction by CMR was 14% ± 13%, while the mean of mitral regurgitation severity by echo was in the mild range (1.28 ±1). Baseline FMR grade by TTE (P<0.001), CMR-LA volume indexed (P=0.003), sphericity ratio (P=0.005), MV annular mean indexed (P=0.027), and BMI (P=0.044) were independently associated with significant change in FMR.Conclusion:CMR-derived remodeling, LA and MV geometry parameters predicted progressive vs regression in FMR. Further studies are needed to determine if CMR predictors of FMR progression vs regression can improve selection criteria for procedural intervention vs guideline-directed medical therapy.

Background:Echocardiography is the primary imaging modality for assessment of patients with non-ischemic cardiomyopathy (NICM), but it is known to underestimate cardiac magnetic resonance (CMR) measurements of LV volumes. We sought to assess the impact of increasing left ventricular end-diastolic volume index (LVEDVi) and left atrial volume index (LAVi) on the accuracy of echocardiographic measurements, when compared to CMR.Methods:NICM patients undergoing CMR between 4/4/2001-12/29/2017 with echocardiography measurements that were obtained within 90 days were retrospectively recorded. Bland Altman analysis and Pearson’s correlation were performed to compare echocardiographic and CMR assessment. Multivariable logistic regression analysis was also performed to predict Echo bias > 50cc/m2 for LVEDVi.Results:Echocardiographic and CMR measurements of LVEDVi and LAVI were obtained in 390 and 400 patients, respectively. Figure 1 illustrates the Bland Altman and Pearson’s correlation of echo vs CMR measurements of LVEDVi and LAVi. While echo and CMR LVEDVi and LAVi were significantly correlated (r=0.762 and 0.605, respectively), there was significant increase in echocardiographic underestimation as the LVEDVi and LAVi as the left ventricle and left atrium increased in size. Multivariable logistic regression analysis is presented in Figure 1. There was a trend toward increased error in women (p=0.076), but age and BME were not significantly associated with increased echo underestimation. Increasing LVEDVi was the strongest predictor of echo underestimation (p<0.0001).Conclusion:Echo underestimation of LV and LA size in patients with NICM increases as the LV and LA size increases. Increased error in echocardiographic measurements may have significant clinical impact in regards to prognosis and procedural therapeutic management strategies.

Background:The impact of cardiomyopathy on left atrial function is currently unclear. The aim of this study was to assess the predictors of left atrial function in patients with non-ischemic dilated cardiomyopathy (NICM) utilizing cardiovascular magnetic resonance (CMR) assessment.Methods:We evaluated 251 NICM patients who underwent CMR in our study, between 12/2008 - 1/2014. LA volumes were measured by the modified biplane method from 2- and 4-chamber long axis views at end-systole and end-diastole. Left atrial ejection fraction (LAEF) was calculated. Multivariable linear regression was performed to determine significant covariate associations with LA EF.Results:We studied 251consecutive patients (61 % male), mean age of 52.5 ± 15.5 years.The results of the multivariable linear regression are provided in Figure 1. Younger age, female sex, and less myocardial fibrosis were significantly associated with higher LAEF (p=0.008, p= 0.004, and p= 0.031, respectively). Additionally, increasing left ventricular end diastolic volume index (LVEDVi) and left ventricular ejection fraction (LVEF) was significantly associated with increasing LAEF (both with a significance of p<0.0001). Increased LA volume index (LAVi) was significantly associated with decreased LAEF (p<0.0001). Of note, there was a trend towards less mitral regurgitation fraction being significantly associated with higher LA EF, but did not demonstrate a significant effect on the LAEF (p=0.083). Similarly, right ventricular size and function were not significantly associated with LA EF.Conclusions:In patients with NICM, age, sex, LVEDVi, LVEF, myocardial fibrosis, and LAVi were independently associated with LAEF.Keywords:Nonischemic cardiomyopathy, left atrial ejection fraction, left atrial function, cardiovascular magnetic resonance