Atrial Fibrosis Helps Select the Appropriate Patient and Strategy in Catheter Ablation of Atrial Fibrillation: A DE‐MRI Guided Approach

MRI for AF Patient Selection and Ablation Approach. Introduction: Left atrial (LA) fibrosis and ablation related scarring are major predictors of success in rhythm control of atrial fibrillation (AF). We used delayed enhancement MRI (DE‐MRI) to stratify AF patients based on pre‐ablation fibrosis and also to evaluate ablation‐induced scarring in order to identify predictors of a successful ablation. Methods and Results: One hundred and forty‐four patients were staged by percent of fibrosis quantified with DE‐MRI, relative to the LA wall volume: minimal or Utah stage 1; <5%, mild or Utah stage 2; 5–20%, moderate or Utah stage 3; 20–35%, and extensive or Utah stage 4; >35%. All patients underwent pulmonary vein (PV) isolation and posterior wall and septal debulking. Overall, LA scarring was quantified and PV antra were evaluated for circumferential scarring 3 months post ablation. LA scarring post ablation was comparable across the 4 stages. Most patients had either no (36.8%) or 1 PV (32.6%) antrum circumferentially scarred. Forty‐two patients (29%) had recurrent AF over 283 ± 167 days. No recurrences were noted in Utah stage 1. Recurrence was 28% in Utah stage 2, 35% in Utah stage 3, and 56% in Utah stage 4. Recurrence was predicted by circumferential PV scarring in Utah stage 2 and by overall LA wall scarring in Utah stage 3. No recurrence predictors were identified in Utah stage 4. Conclusions: Circumferential PV antral scarring predicts ablation success in mild LA fibrosis, while posterior wall and septal scarring is needed for moderate fibrosis. This may help select the proper candidate and strategy in catheter ablation of AF. (J Cardiovasc Electrophysiol, Vol. 22, pp. 16‐22, January 2011)