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Heart, Lung and Circulation

What is the Relationship Between Epicardial Adipose Tissue, Left Atrial Low Voltage Zones and Atrial Fibrillation?

      The pathophysiology of atrial fibrillation (AF) is complex and remains incompletely understood. Structural and electrophysiological remodelling of the left atrium have shown to create substrates leading to the development of AF, with atrial fibrotic changes demonstrated to be both present [
      • Gould P.A.
      • Yii M.
      • Esler M.D.
      • Power J.M.
      • Kaye D.M.
      Atrial fibrillation impairs cardiac sympathetic response to baroreceptor unloading in congestive heart failure.
      ] and pathological [
      • Dzeshka M.S.
      • Lip G.Y.
      • Snezhitskiy V.
      • Shantsila E.
      Cardiac fibrosis in patients with atrial fibrillation: mechanisms and clinical implications.
      ]. Catheter ablation, primarily as pulmonary vein isolation (PVI), has become the core part of the ablation therapy for AF. However, persistent pulmonary vein electrical isolation remains difficult to achieve, and early recurrence of AF post ablation remains a major limiting factor [
      • Hindricks G.
      • Potpara T.
      • Dagres N.
      • Arbelo E.
      • Bax J.J.
      • Blomström-Lundqvist C.
      • et al.
      ESC Scientific Document Group
      2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC.
      ]. Predictors of late recurrence include overweight/obesity and metabolic syndrome [
      • Cai L.
      • Yin Y.
      • Ling Z.
      • Su L.
      • Liu Z.
      • Wu J.
      • et al.
      Predictors of late recurrence of atrial fibrillation after catheter ablation.
      ].

      Keywords

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      References

        • Gould P.A.
        • Yii M.
        • Esler M.D.
        • Power J.M.
        • Kaye D.M.
        Atrial fibrillation impairs cardiac sympathetic response to baroreceptor unloading in congestive heart failure.
        Eur Heart J. 2005; 26: 2562-2567
        • Dzeshka M.S.
        • Lip G.Y.
        • Snezhitskiy V.
        • Shantsila E.
        Cardiac fibrosis in patients with atrial fibrillation: mechanisms and clinical implications.
        Am Coll Cardiol. 2015; 66: 943-959
        • Hindricks G.
        • Potpara T.
        • Dagres N.
        • Arbelo E.
        • Bax J.J.
        • Blomström-Lundqvist C.
        • et al.
        • ESC Scientific Document Group
        2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC.
        Eur Heart J. 2021; 42: 373-498
        • Cai L.
        • Yin Y.
        • Ling Z.
        • Su L.
        • Liu Z.
        • Wu J.
        • et al.
        Predictors of late recurrence of atrial fibrillation after catheter ablation.
        Int J Cardiol. 2013; 164: 82-87
        • Wang X.H.
        • Li Z.
        • Mao J.L.
        • Zang M.H.
        • Pu J.
        Low voltage areas in paroxysmal atrial fibrillation: The prevalence, risk factors and impact on the effectiveness of catheter ablation.
        Int J Cardiol. 2018; 269: 139-144
        • Liu Z.
        • Xia Y.
        • Guo C.
        • Li X.
        • Fang P.
        • Yin X.
        • Yang X.
        Low-voltage zones as the atrial fibrillation substrates: Relationship with initiation, perpetuation, and termination.
        Front Cardiovasc Med. 2021; 8705510
        • Teh A.W.
        • Kistler P.M.
        • Lee G.
        • Medi C.
        • Heck P.M.
        • Spence S.J.
        • et al.
        The relationship between complex fractionated electrograms and atrial low-voltage zones during atrial fibrillation and paced rhythm.
        Europace. 2011; 13: 1709-1716
        • Verma A.
        • Jiang C.Y.
        • Betts T.R.
        • Chen J.
        • Deisenhofer I.
        • Mantovan R.
        • et al.
        • STAR AF II Investigators
        Approaches to catheter ablation for persistent atrial fibrillation.
        N Engl J Med. 2015; 372: 1812-1822
        • Iacobellis G.
        Anatomy of the epicardial adipose tissue.
        in: Epicardial Adipose Tissue. Humana, Cham2020: 1-8
        • Mahajan R.
        • Nelson A.
        • Pathak R.K.
        • Middeldorp M.E.
        • Wong C.X.
        • Twomey D.J.
        • et al.
        Electroanatomical remodeling of the atria in obesity: Impact of adjacent epicardial fat.
        JACC: Clin Electrophysiol. 2018; 4: 1529-1540
        • Ernault A.C.
        • Meijborg V.M.
        • Coronel R.
        Modulation of cardiac arrhythmogenesis by epicardial adipose tissue: JACC State-of-the-Art Review.
        J Am Coll Cardiol. 2021; 78: 1730-1745
        • Batal O.
        • Schoenhagen P.
        • Shao M.
        • Ayyad A.E.
        • Van Wagoner D.R.
        • Halliburton S.S.
        • et al.
        Left atrial epicardial adiposity and atrial fibrillation.
        Circ: Arrhythm Electrophysiol. 2010; 3: 230-236
        • Wong C.X.
        • Abed H.S.
        • Molaee P.
        • Nelson A.J.
        • Brooks A.G.
        • Sharma G.
        • et al.
        Pericardial fat is associated with atrial fibrillation severity and ablation outcome.
        J Am Coll Cardiol. 2011; 57: 1745-1751
        • Kawasaki M.
        • Yamada T.
        • Furukawa Y.
        • Morita T.
        • Tamaki S.
        • Kida H.
        • et al.
        Are cardiac sympathetic nerve activity and epicardial adipose tissue associated with atrial fibrillation recurrence after catheter ablation in patients without heart failure?.
        Int J Cardiol. 2020; 303: 41-48
        • Thanassoulis G.
        • Massaro J.M.
        • O'Donnell C.J.
        • Hoffmann U.
        • Levy D.
        • Ellinor P.T.
        • et al.
        Pericardial fat is associated with prevalent atrial fibrillation: the Framingham Heart Study.
        Circ: Arrhythm Electrophysiol. 2010; 3: 345-350
        • Zhao L.
        • Harrop D.L.
        • Ng A.C.
        • Wang W.Y.
        Epicardial adipose tissue is associated with left atrial dysfunction in people without obstructive coronary artery disease or atrial fibrillation.
        Can J Cardiol. 2018; 34: 1019-1025
        • Mahajan R.
        • Lau D.H.
        • Brooks A.G.
        • Shipp N.J.
        • Manavis J.
        • Wood J.P.
        • et al.
        Electrophysiological, electroanatomical, and structural remodeling of the atria as consequences of sustained obesity.
        J Am Coll Cardiol. 2015; 66: 1-11
        • Haemers P.
        • Hamdi H.
        • Guedj K.
        • Suffee N.
        • Farahmand P.
        • Popovic N.
        • et al.
        Atrial fibrillation is associated with the fibrotic remodelling of adipose tissue in the subepicardium of human and sheep atria.
        Eur Heart J. 2017; 38: 53-61
        • Shao Y.
        • Chen L.
        • Chen W.
        • Sang C.
        • Xu C.
        • Zhang C.
        Left atrial epicardial adipose tissue is associated with low voltage zones in the left atrium in patients with non-valvular atrial fibrillation.
        Front Cardiovasc Med. 2022; 9924646
        • Klein C.
        • Brunereau J.
        • Lacroix D.
        • Ninni S.
        • Brigadeau F.
        • Klug D.
        • et al.
        Left atrial epicardial adipose tissue radiodensity is associated with electrophysiological properties of atrial myocardium in patients with atrial fibrillation.
        Eur Radiol. 2019; 29: 3027-3035
        • Wang J.
        • Sun X.
        • Liu W.
        • Zhu X.
        • Zhu Y.
        • Lin S.
        • et al.
        Cardiac computed tomography-based epicardial adipose tissue assessment reveals association with electroanatomical voltage mapping in patients with atrial fibrillation.
        Heart Lung Circ. 2022; 31: 1385-1392
        • Nakahara S.
        • Hori Y.
        • Nishiyama N.
        • Okumura Y.
        • Fukuda R.
        • Kobayashi S.
        • et al.
        Influence of the left atrial contact areas on fixed low-voltage zones during atrial fibrillation and sinus rhythm in persistent atrial fibrillation.
        J Cardiovasc Electrophysiol. 2017; 28: 1259-1268
        • Müller P.
        • Schiedat F.
        • Bialek A.
        • Bösche L.
        • Ewers A.
        • Kara K.
        • et al.
        Total atrial conduction time assessed by tissue doppler imaging (PA-TDI interval) to predict early recurrence of persistent atrial fibrillation after successful electrical cardioversion.
        J Cardiovasc Electrophysiol. 2014; 25: 161-167
        • Walters T.E.
        • Nisbet A.
        • Morris G.M.
        • Tan G.
        • Mearns M.
        • Teo E.
        • et al.
        Progression of atrial remodeling in patients with high-burden atrial fibrillation: Implications for early ablative intervention.
        Heart Rhythm. 2016; 13: 331-339
        • Launbo N.
        • Zobel E.H.
        • von Scholten B.J.
        • Færch K.
        • Jørgensen P.G.
        • Christensen R.H.
        Targeting epicardial adipose tissue with exercise, diet, bariatric surgery or pharmaceutical interventions: A systematic review and meta-analysis.
        Obes Rev. 2021 J; 22e13136

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