Po-01-037 risk factors for presence of non-pulmonary vein triggers for atrial fibrillation

Targeting of non-pulmonary vein triggers (NPVTs) after pulmonary vein isolation (PVI) may reduce atrial fibrillation (AF) recurrence. Incrementally dosed isoproterenol infusion (up to 30mcg/min) and cardioversion of induced AF used to provoke NPVTs typically requires additional vasopressor support and increases procedure time. We aimed to identify risk factors for the presence of NPVTs in order to identify patient profiles in which NPVT provocation would have greatest yield. Using the Hospital of the University of Pennsylvania AF ablation registry, we compared patients in whom NPVTs were observed to patients in whom NPVTs were not observed using a standard provocation protocol. NPVTs were defined as a single or sequence of non-pulmonary vein atrial ectopic beats triggering non-sustained or sustained AF or focal atrial tachycardia. Continuous variables were compared using unpaired t-Test and categorical variables were compared using Fisher exact test. In a total of 1,306 AF ablation patients between January 2021 and August 2022, 87% underwent NPVT standard provocation testing and 10% of all patients had NPVTs observed. Compared to those without NPVTs, patients who had NPVTs were more likely to be female (41% vs 30%, OR 1.62 [1.12-2.35], p=0.01), and to have sinus node dysfunction (17% vs 7%, OR 2.83 [1.72-4.65], p=0.0002), prior AF ablation (68% vs 34%, OR 4.16 [2.82-6.19], p=<0.0001), and left atrial scar (>2cm2) (71% vs 36%, OR 4.28 [2.78-6.53], p=<0.0001) identified during voltage mapping (defined as peak to peak bipolar voltage <0.5mV of at least three abnormal contiguous electrograms outside pulmonary veins, Table 1). In this patient cohort, the absence of these four risk factors yielded NPVT provocation rate of 0.02%, while the presence of three or four risk factors led to NPVT provocation rate of 30-50% (Figure 1). Incremental presence of the NPVT associated risk factors allows prediction of the likelihood that provocation testing will lead to the induction of NPVTs and may influence decision making to undertake NPVT provocation testing during AF ablation.Tabled 1Table 1VariableOverall (N=1306)NPVT (N=130)No NPVT (N=1006)P ValueOdds Ratio (95% CI)Age (years)130665.89 ± 9.9965.00 ± 10.590.36BMI130629.16 ± 5.6229.95 ± 6.270.17LVEF (%)126656.42 ± 9.5755.28 ± 11.210.27LA volume index (mL/m2)62639.34 ± 17.8939.25 ± 17.180.97CHA2DS2VASc score13002.40 ± 1.452.41 ± 1.560.94Female40353 (41)350 (30)0.011.62 (1.12-2.35)Hx of CVA/TIA12314 (11)109 (9)0.53Diabetes20215 (12)187 (16)0.25Heart Failure / CM41738 (29)379 (32)0.55Hypertension1031105 (81)926 (79)0.65Obstructive Sleep Apnea42343 (33)380 (32)0.84Sinus Node Dysfunction10122 (17)79 (7)0.00022.83 (1.72-4.65)Non-Paroxysmal AF478/124151 (41)427 (38)0.63Had Previous AF Ablation48288 (68)394 (34)<0.00014.16 (2.82-6.19)Has LA scar (Any LVA)426/106978 (71)348 (36)<0.00014.28 (2.78-6.53)Values are reported as mean ± SD, or number (%). P value is comparing NPVT group vs No NPVT group. Continuous variables compared using unpaired t-Test, and categorical variables compared using Fisher exact test. BMI=body mass index; LVEF=left ventricular ejection fraction; LA=left atrium; CVA=cerebrovascular accident; TIA=transient ischemic attack, CM=cardiomyopathy; AF=atrial fibrillation; LVA=low voltage area; NPVT=non-pulmonary vein trigger Open table in a new tab