title: Stiff left atrial syndrome after catheter ablation for atrial fibrillation: clinical characterization, prevalence, and predictors.
abstract: BACKGROUND
  There have been no studies of atrial diastolic function after catheter ablation of atrial fibrillation (AF). We encountered a few patients with symptomatic left atrial (LA) diastolic dysfunction and associated pulmonary hypertension (PH) that developed after catheter ablation for atrial fibrillation. Similar findings were described in patients after cardiac surgery and were referred to as the "stiff left atrial syndrome."
  
  
  OBJECTIVE
  The purpose of this study was to prospectively quantify the incidence of patients developing PH associated with diastolic hemodynamic abnormalities of the LA after radiofrequency ablation of AF and to identify the possible predictors.
  
  
  METHODS
  Between January 2009 and July 2010, data on 1,380 consecutive patients were prospectively collected. Before ablation and at follow-up, all patients had an echocardiogram to assess for the presence of PH. Patients with no echocardiographic evidence of PH but complaining of unexplained dyspnea with LA diastolic abnormalities were evaluated with right heart catheterization (RHC). Patients were included in the analysis if they developed new or worsening PH postablation with evidence of LA diastolic dysfunction by RHC or direct LA pressure measurement. All patients were evaluated for pulmonary vein stenosis and excluded if this condition was identified.
  
  
  RESULTS
  The mean age was 62 ± 11 (75% male), and nonparoxysmal AF was the predominant arrhythmia (71%). New or worsening PH with associated LA diastolic abnormalities was detected in 19 (1.4%) patients after ablation. The prevalence of PH did not differ between AF types (P = .612). Compared with patients who did not develop PH, LA scarring (P <.001), diabetes (P = .026), and obstructive sleep apnea (OSA; P = .006) were more frequently observed among those who developed PH. In a multivariable logistic model, preprocedure LA size ≤45 mm (odds ratio [OR] = 6.13; P = .033), mean LA pressure (OR 1.14; P = .025), severe LA scarring (OR = 4.4; P = .046), diabetes mellitus (OR = 9.5; P = .004), and OSA (OR = 6.2; P = .009) were independently associated with the development of PH postablation.
  
  
  CONCLUSIONS
  After radiofrequency catheter ablation of atrial fibrillation (RFCAF), PH with LA diastolic dysfunction or the so-called stiff LA syndrome is a rare but potentially significant complication of AF ablation. Severe LA scarring, LA ≤45 mm, diabetes mellitus, OSA, and high LA pressure are clinical variables that predict the development of this syndrome. The main clinical findings include dyspnea, congestive heart failure, PH, and large V waves on pulmonary capillary wedge pressure (PCWP) or LA pressure tracings in the absence of mitral regurgitation.
authors.affiliation: Department of Cardiovascular Diseases and Interventional Electrophysiology Scripps Clinic, San Diego, California, USA.
authors.forename: Douglas N
authors.initials: DN
authors.lastname: Gibson
authors.forename: Luigi
authors.initials: L
authors.lastname: Di Biase
authors.forename: Prasant
authors.initials: P
authors.lastname: Mohanty
authors.forename: Jigar D
authors.initials: JD
authors.lastname: Patel
authors.forename: Rong
authors.initials: R
authors.lastname: Bai
authors.forename: Javier
authors.initials: J
authors.lastname: Sanchez
authors.forename: J David
authors.initials: JD
authors.lastname: Burkhardt
authors.forename: J Thomas
authors.initials: JT
authors.lastname: Heywood
authors.forename: Allen D
authors.initials: AD
authors.lastname: Johnson
authors.forename: David S
authors.initials: DS
authors.lastname: Rubenson
authors.forename: Rodney
authors.initials: R
authors.lastname: Horton
authors.forename: G Joseph
authors.initials: GJ
authors.lastname: Gallinghouse
authors.forename: Salwa
authors.initials: S
authors.lastname: Beheiry
authors.forename: Guy P
authors.initials: GP
authors.lastname: Curtis
authors.forename: David N
authors.initials: DN
authors.lastname: Cohen
authors.forename: Mark Y
authors.initials: MY
authors.lastname: Lee
authors.forename: Michael R
authors.initials: MR
authors.lastname: Smith
authors.forename: Devi
authors.initials: D
authors.lastname: Gopinath
authors.forename: William R
authors.initials: WR
authors.lastname: Lewis
authors.forename: Andrea
authors.initials: A
authors.lastname: Natale
mesh_terms: D001281:Atrial Fibrillation / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D002140:California / Q000453:epidemiology; D017115:Catheter Ablation / Q000009:adverse effects*; D005260:Female; D006325:Heart Atria; D006801:Humans; D006976:Hypertension, Pulmonary / Q000453:epidemiology* / Q000209:etiology; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology* / Q000209:etiology; D015995:Prevalence; D011446:Prospective Studies; D013577:Syndrome; D014463:Ultrasonography