Three-dimensional Left Atrial Volume assessed by CT predicts atrial fibrillation recurrence after re-do catheter ablation

Three-dimensional Left Atrial Volume assessed by CT predicts atrial fibrillation recurrence after re-do catheter ablation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Three-dimensional Left Atrial Volume assessed by CT predicts atrial fibrillation recurrence after re-do catheter ablation Benjamin Alos, Maxime Pin, Rodrigue Garcia, Elsa Beard, Bruno Degand, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8195625/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose atrial fibrillation (AF) is the most frequent arrhythmia worldwide. Catheter ablation is the most effective therapy, but 20% of patients still experience recurrences after two procedures. Cardiac computed tomography angiography (CCTA) is a highly efficient imaging technique to assess left atrial anatomy but is still not mandatory before ablation procedure. We sought to evaluate the prognostic value of CCTA left atrial (LA) parameters for the risk of AF recurrence after redo procedure. Methods we included retrospectively adults who underwent a second procedure of AF catheter ablation (AFCA) to measure 3D maximal indexed LA volume (LAV) on pre-procedural CCTA. Primary endpoint was the recurrence of AF after redo AFCA. Results between 2009 and 2019, 136 consecutive patients underwent a second AFCA at our institution, with 20% women. After a mean follow-up of 7 years, 62% of patients experienced AF recurrence. In multivariate analysis, a higher indexed LAV and female sex were the only independent variables associated with recurrence. An indexed LAV threshold of 84 ml/m² had the best performances to predict the risk of recurrent AF, with relatively low AUC (0.62). Conclusion this study is the first to evaluate the prognostic role of CT-LAVmax on the risk of recurrence after two ablation procedures. Despite suboptimal performances, it was the only imaging parameter associated with recurrent AF, with a threshold of 84 ml/m². Cut-off values for LAV could help physicians refining the selection of patients suitable for AFCA, to avoid futile interventions. CT left atrial volume atrial fibrillation recurrence Figures Figure 1 Figure 2 Figure 3 Figure 4 Capsule Summary In 136 patients undergoing a second atrial fibrillation (AF) catheter ablation, the maximal indexed left atrial volume measured by CT was the only imaging predictor of AF new recurrence, with an optimal threshold of 84 mL/m². This simple metric may help refine patient selection before repeating futile ablation procedures. Introduction Atrial fibrillation (AF) is the most prevalent arrhythmia worldwide: 0.4% of the general population and its incidence increases with aging, up to 10% in those > 80 years ( 1 – 3 ). AF has been associated with significant morbidity and mortality, leading to major healthcare costs ( 4 , 5 ). The latest guidelines of the European Society of Cardiology (ESC) established AF catheter ablation (AFCA) as a first-line therapeutic option, resulting in a significant improvement in quality of life, irrespective of age. Success rate at 5 years reaches 50% after the first procedure and up to 80% after at least 2 procedures ( 6 ). After 10 years, reported success rates were 30% and 50%, respectively ( 7 ). A significant number of patients will thus still present AF, despite repeated interventional therapy and important healthcare costs. Therefore, it is crucial to identify predictive factors for AF recurrence post-ablation, to avoid futile interventions. Most series focused on recurrence after a first ablation procedure, while repeated procedures are frequent, and selection of patients remains central ( 8 ). In a recent korean study about 4248 patients treated for a first AFCA, left atrial volume (LAV) assessed by CT was a predictive factor of AF recurrence ( 9 ). LAV measured by echocardiography (TTE) or cardiac computed tomography angiography (CCTA), pulmonary vein (PV) anatomy, and left atrial appendage (LAA) volume have been reported as predictive factors for AF recurrence after catheter ablation ( 10 – 15 ). Currently, there are no strong recommendations regarding standard cardiac imaging methods before AFCA, but increasing evidence suggests the utility of CCTA due to its spatial resolution and volumetric acquisition, giving information that are closer to real anatomical dimensions ( 9 , 16 – 18 ). However, in a recent clinical consensus statement, it was only advised that CCTA or CMR may be appropriate to assess LA and PV anatomy prior to ablation ( 19 ). Moreover, image acquisition methods for LAV using CCTA vary across studies ( 10 , 13 ). Since 2009, CCTA is routinely performed in a standardized fashion at our institution before a procedure of AFCA. The main objective of our study was to identify pre-procedural CCTA predictive factors for arrhythmia recurrence after a second AF ablation. Patients and methods This is a retrospective, single center study including adult patients who underwent a redo catheter ablation procedure for recurrent, paroxysmal or persistent atrial fibrillation by either cryotherapy or radiofrequency, with CCTA performed before the first intervention, between January 2009 and December 2019. Exclusion criteria was the absence of analyzable CT images. Cardiac computed tomography angiography (CCTA) Patients not already on beta-blockers did not receive additional therapy intravenously or orally. Nitroglycerin was not administered prior to image acquisition. Each patient underwent a heart-rate-synchronized CT scan without and with iodinated contrast injection prior to first catheter ablation, as part of routine care, to evaluate the presence of coronary and valvular calcifications. From 2009 to 2016, the examination was performed on a 64-bar scanner (LightSpeed ​​VCT. GE Healthcare®, Milwaukee, WI, USA). Tube rotation for each acquisition was 0.350 seconds and collimation was 64 x 0.625 mm. From 2017 to 2019, the examination was performed on a Toshiba Aquilion One GENESIS® scanner. Tube rotation for each acquisition was 0.275 seconds, collimation was 0.5 mm every 0.25 mm on the heart. Tube voltage was 100 to 120 kV with a tube current of 600 to 750 mA depending on patient size, and automatic tube current modulation between 90% and 30% of the RR cycle duration. The average scan time was 5 to 8 seconds. Each scan began with a rhythm-synchronized injection-free volume acquisition centered on the heart for coronary and valvular calcium score calculation. This was followed by a cardiac-centered CT scan using prospective acquisition synchronized to the patient's heart rate, performed in a single breath-hold, craniocaudal direction, with injection of intravenous iodinated contrast medium (iomeprol 400 mg/ml, Iomeron 400, Bracco), during arterial time at a 3.5 mL/s rate (ie 70 mL) followed by a saline flush. In the event of allergy to this iodinated contrast medium, Ultravist 370 was used. CCTA was performed preferably at 40% of the cardiac cycle (systolic phase), to evaluate LAV at its maximum. In patients with AF during the exam, an automated mode selected the most stable RR interval automatically, to reduce motion artifacts. Finally, another prospective volume acquisition centered on the heart was performed 50 seconds after injection, to assess the presence of LAA thrombus. DICOM data were recorded on McKesson® PACS for morphological analysis, then exported to a semi-automated pot-processing software (Vitrea®, Canon Medical Systems, Suresnes, France) for morphological and functional analysis using three-dimensional segmentation technique to detect endocardial borders of the left atrium (LA) and quantifying LA maximal (systolic) volume in 3D, being the most reproducible technique according to previous work ( 20 ). In patients with diastolic acquisition (70–80% of RR cycle), we extrapolated maximal systolic LAV as previously described ( 21 ). Pulmonary veins (PV) were excluded at their ostia, and the left atrial appendage (LAA) was manually removed at its base. Number of PVs and LAA anatomy were reported as recommended ( 22 ). Pictures of the CT method of LAV delineation are shown on Fig. 1 . We also evaluated the presence and measured coronary and valvular (aortic and mitral) calcifications, using the Agatston score, as recommended ( 23 ). CCTA were reviewed independently and blindly from outcomes by 2 operators, to assess inter-observer agreement. Outcomes Data collection was conducted during on-site follow-up visits, or by examining electronic medical records, directly contacting physicians, cardiologists, or patients. Also, in patients with no collectable information, the national database of deaths based on the French National Institute for Statistics and Economic Studies (INSEE) was used. The primary outcome was AF recurrence. An episode of AF lasting more than 30 seconds outside a 3-month blanking period after the procedure was considered as a recurrence according to current guidelines ( 24 ). Statistical analysis Continuous variables were summarized using means and standard deviations, while categorical variables were presented as frequencies and percentages. A univariate Cox proportional hazards regression analysis was conducted to identify factors associated with AF recurrence. Variables with a p-value less than 0.10 in univariate analysis were selected for inclusion in the multivariate Cox regression model. The multivariate model included the indexed maximum atrial volume by CCTA and was adjusted for potential confounders including CHA2DS2-VASc score, HAS-BLED score, sex, history of obesity, history of high blood pressure, and AF type before 1st ablation procedure. The hazard ratios (HR) and 95% confidence intervals (CI) were calculated for each variable in the model. To study the discrimination of the different factors associated with recurrence of AF, we created ROC (Receiver Operating Characteristic) curves and calculated the areas under the curve (AUC = Area Under the Curve). The closer the area under the curve was to 1, the greater the discrimination capacity of the factor studied. We used the ROC curve and Youden's Index to determine the optimal threshold for indexed LAVmax to predict the recurrence of atrial fibrillation (AF). Interobserver agreement for LAVI measures was assessed by the intraclass correlation coefficient (ICC), including 95% CIs, in a two-way mixed, single-measurement model with absolute agreement. Statistical significance was set at a p-value of less than 0.05. All analysis was performed using SPSS version 23.0 (IBM Corp., Armonk, NY, USA). Results Population From 2009 to 2019, 971 patients underwent their first catheter ablation for AF at our institution. Among them, 150 also underwent a second procedure because of AF recurrence. Of these, 14 patients were excluded because CCTA images were either not analyzable (n = 3) or missing (n = 11). The final population thus comprised 136 patients who underwent a redo AF catheter ablation (AFCA) with available CCTA images performed before the first procedure (Fig. 2). Among these 136 patients, 80% were men, mean age was 62 ± 10 years, 39% were overweight or obese, half had hypertension, and 93% were in NYHA class I-II. More than half of the patients suffered from persistent AF, and one in four had already undergone electrical cardioversion. Mean left atrial volume index (LAVI) measured by CCTA was 72 ± 19 ml/m². Mean number of pulmonary veins was 4.1 ± 0.5. One in five patients had aortic valve calcifications and only 7% had calcification of the mitral valve. Mean LVEF was 59.6%. The clinical characteristics, echocardiographic and CCTA data before AFCA are detailed in Table 1. After a mean follow-up of 7.3 ± 0.5 years, 85 patients (62%) experienced a recurrence of AF after redo ablation. Patients with recurrent AF had significantly more hypertension and higher CHADS-VASc score, HAS-BLED score and LAVI than patients without recurrence (all p < 0.05) (Table 1). Univariate analysis Table 2 presents the univariate and multivariate analysis of factors associated with AF recurrence after a second AFCA. In univariate analysis, there were three clinical and one imaging parameters significantly associated with AF recurrence: history of hypertension (HR 1.68; 95% CI 1.08–2.63, p = 0.02), a higher CHADS-VASc score (HR 1.19; 95% CI 1.03–1.37, p = 0.01), a higher HAS-BLED score (HR 1.4; 95% CI 1.02–1.9, p = 0.03), and higher LAVI (HR 1.02; 95% CI 1.01–1.03, p = 0.0001). Notably, the number of PVs, the presence of accessory veins, coronary and aortic valve calcium scores, were not associated with AF recurrence, even in univariate analysis. After adjustment, only two parameters were significantly and independently associated with the risk of AF recurrence: a higher LAVI measured by CCTA (HR 1.018; 95% CI 1.006–1.030, p = 0.002) and female sex (HR 1.85; 95% CI 1.07–3.2, p = 0.025). Table 2 Univariate and multivariate analysis of variables associated with AF recurrence Unadjusted HR (95% CI) p-value Adjusted HR (95% CI) p-value Age (years) 1.01 (0.99–1.03) 0.11 Female sex 1.59 (0.97–2.61) 0.06 1.85 (1.07–3.2) 0.025 CHADS VASc 1.19 (1.03–1.37) 0.01 0.91 (0.72–1.16) 0.47 HAS BLED 1.4 (1.02–1.9) 0.03 1.31 (0.81–2.12) 0.25 Prior AAD 1.27 (0.72–2.23) 0.39 NYHA 1.23 (0.85–1.77) 0.2 AF type 1.39 (0.96–2.01) 0.07 1.3 (0.85–1.97) 0.21 Obesity 1.27 (0.96–1.68) 0.08 1.24 (0.93–1.66) 0.13 Hypertension 1.68 (1.08–2.63) 0.02 1.38 (0.85–2.25) 0.18 Diabetes 0.98 (0.47–2.04) 0.97 Smoking 0.8 (0.44–1.46) 0.47 Chronic alcoholism 0.62 (0.15–2.55) 0.5 Dyslipidemia 0.9 (0.57–1.43) 0.6 OSA 1.42 (0.9–2.25) 0.12 ACS 1.03 (0.51–2.05) 0.93 PCI 0.87 (0.45–1.69) 0.68 CABG 0.83 (0.76–2.66) 0.76 Significant valvular disease 1.16 (0.16–8.33) 0.88 Stroke 0.45 (0.14–1.45) 0.18 Prior CVI ablation 0.92 (0.53–1.6) 0.79 Prior electrical CV 1.37 (0.93–2.03) 0.1 LVEF 1.003 (0.981–1.025) 0.76 LAVI 1.02 (1.01–1.03) 0.0001 1.02 (1.01–1.03) 0.002 CACS 0.99 (0.99-1) 0.3 Number of PV Right PV Left PV 1.07 (0.69–1.65) 1.29 (0.79–2.09) 0.92 (0.54–1.56) 0.75 0.3 0.7 Aortic valve calcification 0.96 (0.58–1.59) 0.89 AAD: Antiarrhythmic Drug;ACS: Acute Coronary Syndrome; AF: Atrial Fibrillation; AU: Agatston Unit;CABG: Coronary Artery Bypass Grafting;CACS: Coronary Artery Calcium Score;CV: Cardioversion;LAVI: Left Atrium Volume Index; LVEF: Left Ventricular Ejection Fraction;NYHA: New York Heart Association; OSA: Obstructive Sleep Apnoea; PCI: Percutaneous Coronary Intervention;PV: Pulmonary Vein Threshold value of LAVI for recurrence of AF ROC curves were drawn for LAVI. The optimal threshold for LAVI was 84 ml/m², with an area under the curve (AUC) of 0.62 (CI 0.52–0.71), p = 0.02. The mean recurrence-free survival was 7.3 years (95% CI 6.4–8.2) in the overall population. The 7-year recurrence-free survival rate was 52.5 ± 5.2% in the LAVI < 84 ml/m² group and 17.3 ± 8% in the LAVI ≥ 84 ml/m² group (p < 0.0001 by log-rank test) (Fig. 3). Intra-class correlation coefficient was high for LAV measurements, 0.975 [0.958;0.986] (p < 0.0001), indicating an excellent agreement between observers, as represented on the dispersion diagram (Fig. 4). Discussion To our knowledge, this is the first study about the long-term association between baseline CCTA and the recurrence risk of AF after a second ablation. The only imaging factor associated with AF recurrence was indexed LAV, with a threshold of 84 ml/m². All other imaging parameters, as well as clinical data - except for female sex - were not associated with the risk of recurrence. Left atrial volume Previous studies have shown that left atrial (LA) enlargement is as a major risk factor of AF recurrence following initial catheter ablation. Indeed, Berruezo et al. demonstrated that LA diameter using TTE was an independent predictor of AF recurrence after pulmonary vein isolation (PVI) ( 25 ). However, this study used the antero-posterior diameter measurement of the LA on the parasternal long-axis view, which does not precisely reflect actual left atrial enlargement ( 26 ). In contrast, Sohns et al. showed that LA volume measured by CCTA prior to initial PVI was a better predictor of recurrence, compared to volume measured by TTE, with a threshold of 106 mL ( 18 ). Our study suggests that a LAVI of 84 ml/m² is a relevant threshold for determining patients at higher risk of AF recurrence after redo ablation. However, as it is presented on the ROC curve, the performances are moderate (AUC = 0.62). This threshold is higher than other published series: in a recent study, Alajaji et al. found that a LAVI greater than 55 ml/m² was predictive of AF recurrence ( 16 ). However, in this study, LAV measurement was performed by the biplane area length method (LAVI = [(0.85)∗LA Area in 4 chamber view∗LA Area in 2 chamber view / LA length] / Body Surface). This method provides only a surrogate of LAV, because of geometrical assumptions, and involves a multiplanar reconstruction of 4-chamber and 2-chamber views. Subsequently, surface measurements were performed using planimetry in these two views, based on a straight line at the level of the mitral annulus. In a previous work from our institution, LAV assessment using 3D method was more reproducible than Area-Length method and provided higher values. Moreover, in the study by Alajajj et al, images were acquired during diastole (70–80% of the RR cycle), where LAV is at its minimal value ( 16 ). Both acquisition time and volume assessment method could have led to a significant underestimation of the left atrial volume and may explain part of the differences observed with our study. In a recent retrospective study involving 1417 patients (mean age: 60 years, 72% men, 58% paroxysmal atrial fibrillation), conducted by Choi et al., the objective was to explore the mechanisms of very late (> 5 years) recurrences of AF after ablation ( 9 ). The results demonstrated that a lower LAV before the initial ablation was significantly and independently associated with delayed AF recurrences. These findings support our own results, especially given the similar characteristics of the studied populations and the identical method used for left atrial volume assessment. However, all these papers focused only on the recurrence after a first ablation. According to the literature, TTE LAV has been identified as an independent predictive factor for AF recurrence after the first and second ablations ( 9 , 27 ). However, there is to our knowledge no data regarding maximal LAV index measured by CT before the first ablation as a predictive factor for AF recurrence after the second ablation, which constitutes the main finding of our research. Pulmonary veins Our study did not find a relationship between the number of pulmonary veins (PV) and long-term AF recurrence. However, when reviewing the literature, data are discordant. Isgandarova et al. suggested that variant anatomy of the PV could predict long-term recurrence of AF and an accessory vein on the right side and the presence of a common left atrial trunk were identified as independent predictive factors ( 11 ). In contrast, Mulder et al. found no association between PV anatomy and AF recurrence ( 28 ). Calcium score No association was found between aortic valvular calcium score and AF recurrence, in contrast to Liu et al., who identified valvular calcium score as an independent factor for AF recurrence after radiofrequency ablation ( 29 ). The same holds true for coronary calcium score, for which no significant association with AF recurrence was found in our study, despite one being reported in the study by Fernandes et al. ( 30 ). The divergence in results between our study and those of Liu et al. and Fernandes et al. could be attributed to the fact that those series studied only patients with a first recurrence after AFCA, while we focused on patients experiencing AF recurrence after undergoing a second AFCA. Female sex Female sex was identified as an independent predictor of AF recurrence after a second ablation. These findings are consistent with the existing literature, particularly the study by Park et al., which demonstrated that female sex was independently associated with AF recurrence following a repeat catheter ablation procedure ( 31 ). However, even though the exact relationship between sex and AF recurrence after catheter ablation remains to be elucidated, it has been described that women undergoing AFCA were older with increased comorbidities compared to men, with more advanced disease and more atrial fibrosis, and also more non-pulmonary triggered activity in women ( 32 , 33 ). All these factors may ultimately result in increased risk AF recurrence after ablation procedures ( 34 ). Study limitations First, this was a retrospective single center study: even though this guarantees homogeneity in our acquisition and evaluation methods, our results may not be applied to other populations. Moreover, caution should be made regarding the threshold of 84 ml/m² for CCTA LAVI to be associated with AF recurrence after redo ablation: our study size is limited, and the AUC of the ROC curve was low. However, it outperformed all other imaging parameters. Conclusion In this first study exploring the predictive role of CCTA parameters in AF recurrence after a second ablation procedure, increased LAVI on initial CT was the only imaging parameter associated with a higher risk of AF recurrence, with a threshold of 84 ml/m². According to these data, a refined selection of patients undergoing AFCA could be performed, to avoid futile procedures. CCTA’s fast acquisition and wide availability, combined with its prognostic value, may encourage electrophysiological centers to choose this imaging method prior to ablation procedure. Larger prospective studies are mandatory to validate these results and establish formal recommendations regarding the place of CCTA in the selection of the most suitable candidates to AF ablation. Abbreviations AF: atrial fibrillation AFCA: atrial fibrillation catheter ablation CCTA: cardiac computed tomography angiography ECG: electrocardiogram LA: left atrium LAV: left atrial volume LVEF: left ventricular ejection fraction NYHA: New York Heart Association PV: pulmonary vein TTE: transthoracic echocardiography Declarations Ethics approval This study was conducted in accordance with the principles of the Declaration of Helsinki, and with the French reference methodology MR-004, as approved by the data protection officer of our institution and registered in the Health data Hub (N°F20230717164031). Ethical approval was obtained from the local ethics committee (n°2025-04-02). Competing interests The authors declare that they have no known competing financial interests or personal relationships that could influence the work reported in this paper. Authors' contributions All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Benjamin Alos, Maxime Pin and Claire Bouleti. The first draft of the manuscript was written by Benjamin Alos and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Availability of data and material The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. References Charlemagne A, Blacher J, Cohen A, Collet JP, Dievart F, de Groote P, et al. 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Odening KE, Deiss S, Dilling-Boer D, Didenko M, Eriksson U, Nedios S, et al. Mechanisms of sex differences in atrial fibrillation: role of hormones and differences in electrophysiology, structure, function, and remodelling. Europace. 2019;21(3):366–76. Akoum N, Mahnkopf C, Kholmovski EG, Brachmann J, Marrouche NF. Age and sex differences in atrial fibrosis among patients with atrial fibrillation. Europace. 2018;20(7):1086–92. Kaiser DW, Fan J, Schmitt S, Than CT, Ullal AJ, Piccini JP, et al. Gender Differences in Clinical Outcomes after Catheter Ablation of Atrial Fibrillation. JACC Clin Electrophysiol. 2016;2(6):703–10. Table 1 Table 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files floatimage1.jpeg Central illustration Table1.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8195625","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":557877836,"identity":"c2f986eb-99cc-4b0f-83f8-9fd610ad7ac9","order_by":0,"name":"Benjamin Alos","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYDACdgYGZgYwZmxg+ABksbET0sKMpIVxBkgLM5FaIGweqAhewN/MfPhzQcUddv5ph9se2/zaJs/HzMD44WMObi0Sh9nSpGececYscTux3Ti377ZhGzMDs+TMbXisOcxjxszbdpiZ4XZim3Ruz21GoBY2Zl48WuQP8xh/5v13mFkepMWy57Y9QS0Gh3kMpHkbDjMbgLQw/ACShLQYgv1y7DCzIVCxZG/D7eQ2ZsZmvH6RO94MDLGaw8lyt9OfSfz4c9t2fnvzwQ8f8XkfCpLBJGMbmGwgrB4I7CDUH6IUj4JRMApGwQgDAGntTTQD8Wq/AAAAAElFTkSuQmCC","orcid":"","institution":"University Hospital of Poitiers","correspondingAuthor":true,"prefix":"","firstName":"Benjamin","middleName":"","lastName":"Alos","suffix":""},{"id":557877837,"identity":"f9e9c299-45a7-4d91-830a-e13bac305910","order_by":1,"name":"Maxime Pin","email":"","orcid":"","institution":"University Hospital of 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12:38:54","extension":"html","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":125281,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8195625/v1/8560d99a3b43c73c661e5fe2.html"},{"id":97979893,"identity":"c51b1ffb-ebc3-4da7-b58b-133fcae6b09b","added_by":"auto","created_at":"2025-12-11 12:38:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":76179,"visible":true,"origin":"","legend":"\u003cp\u003eAutomated reconstruction of the left atrium and pulmonary veins (posterior view) B. Axial images centered on the marked left atrium after manual delineation of its contours c) 3D reconstruction of the left atrium volume after removing pulmonary veins and left atrium appendage.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8195625/v1/8e6b75514c4ef60aff3b1616.png"},{"id":97979897,"identity":"1801426d-99ea-4687-b2e4-f5454e5398f5","added_by":"auto","created_at":"2025-12-11 12:38:47","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":57645,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of the study population\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8195625/v1/f43614eb1e1f2bcd13e64b65.png"},{"id":98423662,"identity":"0482e094-f1e3-4ae2-8740-27f4122fddf6","added_by":"auto","created_at":"2025-12-17 16:32:29","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":108005,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier curve for recurrence-free survival according to LAVI\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8195625/v1/63e4c5848cb3373268a6c9e2.png"},{"id":97979917,"identity":"791e9db3-d29d-42f3-93ba-7d65ddb978bb","added_by":"auto","created_at":"2025-12-11 12:38:52","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":53673,"visible":true,"origin":"","legend":"\u003cp\u003eDispersion diagram of LAV measurements by the two operators\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-8195625/v1/6a64e9743b8dbe5293d54081.png"},{"id":104362435,"identity":"8b11e18f-af17-444e-bcf6-8f5519a05566","added_by":"auto","created_at":"2026-03-11 01:55:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1019856,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8195625/v1/db3c2007-e9c6-481a-961d-18a0dc3eba8c.pdf"},{"id":97979887,"identity":"689c39bc-3ae4-41f4-a550-b8c5b796b103","added_by":"auto","created_at":"2025-12-11 12:38:45","extension":"jpeg","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":85125,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCentral illustration\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8195625/v1/eb850dd3fe38cf7586b4f47e.jpeg"},{"id":97979886,"identity":"ee112aa8-1fbe-45bd-b13f-80a7420a6c2e","added_by":"auto","created_at":"2025-12-11 12:38:45","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":19567,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8195625/v1/1e72afeca476ff9bc7287fd9.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Three-dimensional Left Atrial Volume assessed by CT predicts atrial fibrillation recurrence after re-do catheter ablation","fulltext":[{"header":"Capsule Summary","content":"\u003cp\u003eIn 136 patients undergoing a second atrial fibrillation (AF) catheter ablation, the maximal indexed left atrial volume measured by CT was the only imaging predictor of AF new recurrence, with an optimal threshold of 84 mL/m\u0026sup2;. This simple metric may help refine patient selection before repeating futile ablation procedures.\u003c/p\u003e\n"},{"header":"Introduction","content":"\u003cp\u003eAtrial fibrillation (AF) is the most prevalent arrhythmia worldwide: 0.4% of the general population and its incidence increases with aging, up to 10% in those\u0026thinsp;\u0026gt;\u0026thinsp;80 years (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). AF has been associated with significant morbidity and mortality, leading to major healthcare costs (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The latest guidelines of the European Society of Cardiology (ESC) established AF catheter ablation (AFCA) as a first-line therapeutic option, resulting in a significant improvement in quality of life, irrespective of age. Success rate at 5 years reaches 50% after the first procedure and up to 80% after at least 2 procedures (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). After 10 years, reported success rates were 30% and 50%, respectively (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). A significant number of patients will thus still present AF, despite repeated interventional therapy and important healthcare costs.\u003c/p\u003e\u003cp\u003eTherefore, it is crucial to identify predictive factors for AF recurrence post-ablation, to avoid futile interventions. Most series focused on recurrence after a first ablation procedure, while repeated procedures are frequent, and selection of patients remains central (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). In a recent korean study about 4248 patients treated for a first AFCA, left atrial volume (LAV) assessed by CT was a predictive factor of AF recurrence (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). LAV measured by echocardiography (TTE) or cardiac computed tomography angiography (CCTA), pulmonary vein (PV) anatomy, and left atrial appendage (LAA) volume have been reported as predictive factors for AF recurrence after catheter ablation (\u003cspan additionalcitationids=\"CR11 CR12 CR13 CR14\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eCurrently, there are no strong recommendations regarding standard cardiac imaging methods before AFCA, but increasing evidence suggests the utility of CCTA due to its spatial resolution and volumetric acquisition, giving information that are closer to real anatomical dimensions (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). However, in a recent clinical consensus statement, it was only advised that CCTA or CMR may be appropriate to assess LA and PV anatomy prior to ablation (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Moreover, image acquisition methods for LAV using CCTA vary across studies (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Since 2009, CCTA is routinely performed in a standardized fashion at our institution before a procedure of AFCA.\u003c/p\u003e\u003cp\u003eThe main objective of our study was to identify pre-procedural CCTA predictive factors for arrhythmia recurrence after a second AF ablation.\u003c/p\u003e"},{"header":"Patients and methods","content":"\u003cp\u003eThis is a retrospective, single center study including adult patients who underwent a redo catheter ablation procedure for recurrent, paroxysmal or persistent atrial fibrillation by either cryotherapy or radiofrequency, with CCTA performed before the first intervention, between January 2009 and December 2019. Exclusion criteria was the absence of analyzable CT images.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eCardiac computed tomography angiography (CCTA)\u003c/h2\u003e\u003cp\u003ePatients not already on beta-blockers did not receive additional therapy intravenously or orally. Nitroglycerin was not administered prior to image acquisition. Each patient underwent a heart-rate-synchronized CT scan without and with iodinated contrast injection prior to first catheter ablation, as part of routine care, to evaluate the presence of coronary and valvular calcifications.\u003c/p\u003e\u003cp\u003eFrom 2009 to 2016, the examination was performed on a 64-bar scanner (LightSpeed ​​VCT. GE Healthcare\u0026reg;, Milwaukee, WI, USA). Tube rotation for each acquisition was 0.350 seconds and collimation was 64 x 0.625 mm. From 2017 to 2019, the examination was performed on a Toshiba Aquilion One GENESIS\u0026reg; scanner. Tube rotation for each acquisition was 0.275 seconds, collimation was 0.5 mm every 0.25 mm on the heart. Tube voltage was 100 to 120 kV with a tube current of 600 to 750 mA depending on patient size, and automatic tube current modulation between 90% and 30% of the RR cycle duration. The average scan time was 5 to 8 seconds.\u003c/p\u003e\u003cp\u003eEach scan began with a rhythm-synchronized injection-free volume acquisition centered on the heart for coronary and valvular calcium score calculation. This was followed by a cardiac-centered CT scan using prospective acquisition synchronized to the patient's heart rate, performed in a single breath-hold, craniocaudal direction, with injection of intravenous iodinated contrast medium (iomeprol 400 mg/ml, Iomeron 400, Bracco), during arterial time at a 3.5 mL/s rate (ie 70 mL) followed by a saline flush. In the event of allergy to this iodinated contrast medium, Ultravist 370 was used. CCTA was performed preferably at 40% of the cardiac cycle (systolic phase), to evaluate LAV at its maximum. In patients with AF during the exam, an automated mode selected the most stable RR interval automatically, to reduce motion artifacts.\u003c/p\u003e\u003cp\u003eFinally, another prospective volume acquisition centered on the heart was performed 50 seconds after injection, to assess the presence of LAA thrombus.\u003c/p\u003e\u003cp\u003eDICOM data were recorded on McKesson\u0026reg; PACS for morphological analysis, then exported to a semi-automated pot-processing software (Vitrea\u0026reg;, Canon Medical Systems, Suresnes, France) for morphological and functional analysis using three-dimensional segmentation technique to detect endocardial borders of the left atrium (LA) and quantifying LA maximal (systolic) volume in 3D, being the most reproducible technique according to previous work (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). In patients with diastolic acquisition (70\u0026ndash;80% of RR cycle), we extrapolated maximal systolic LAV as previously described (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Pulmonary veins (PV) were excluded at their ostia, and the left atrial appendage (LAA) was manually removed at its base.\u003c/p\u003e\u003cp\u003eNumber of PVs and LAA anatomy were reported as recommended (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Pictures of the CT method of LAV delineation are shown on Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eWe also evaluated the presence and measured coronary and valvular (aortic and mitral) calcifications, using the Agatston score, as recommended (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eCCTA were reviewed independently and blindly from outcomes by 2 operators, to assess inter-observer agreement.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cp\u003eData collection was conducted during on-site follow-up visits, or by examining electronic medical records, directly contacting physicians, cardiologists, or patients. Also, in patients with no collectable information, the national database of deaths based on the French National Institute for Statistics and Economic Studies (INSEE) was used. The primary outcome was AF recurrence. An episode of AF lasting more than 30 seconds outside a 3-month blanking period after the procedure was considered as a recurrence according to current guidelines (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eContinuous variables were summarized using means and standard deviations, while categorical variables were presented as frequencies and percentages. A univariate Cox proportional hazards regression analysis was conducted to identify factors associated with AF recurrence.\u003c/p\u003e\u003cp\u003eVariables with a p-value less than 0.10 in univariate analysis were selected for inclusion in the multivariate Cox regression model. The multivariate model included the indexed maximum atrial volume by CCTA and was adjusted for potential confounders including CHA2DS2-VASc score, HAS-BLED score, sex, history of obesity, history of high blood pressure, and AF type before 1st ablation procedure.\u003c/p\u003e\u003cp\u003eThe hazard ratios (HR) and 95% confidence intervals (CI) were calculated for each variable in the model.\u003c/p\u003e\u003cp\u003eTo study the discrimination of the different factors associated with recurrence of AF, we created ROC (Receiver Operating Characteristic) curves and calculated the areas under the curve (AUC\u0026thinsp;=\u0026thinsp;Area Under the Curve). The closer the area under the curve was to 1, the greater the discrimination capacity of the factor studied.\u003c/p\u003e\u003cp\u003eWe used the ROC curve and Youden's Index to determine the optimal threshold for indexed LAVmax to predict the recurrence of atrial fibrillation (AF).\u003c/p\u003e\u003cp\u003eInterobserver agreement for LAVI measures was assessed by the intraclass correlation coefficient (ICC), including 95% CIs, in a two-way mixed, single-measurement model with absolute agreement.\u003c/p\u003e\u003cp\u003eStatistical significance was set at a p-value of less than 0.05. All analysis was performed using SPSS version 23.0 (IBM Corp., Armonk, NY, USA).\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\"\u003e\n \u003ch2\u003ePopulation\u003c/h2\u003e\n \u003cp\u003eFrom 2009 to 2019, 971 patients underwent their first catheter ablation for AF at our institution. Among them, 150 also underwent a second procedure because of AF recurrence. Of these, 14 patients were excluded because CCTA images were either not analyzable (n = 3) or missing (n = 11). The final population thus comprised 136 patients who underwent a redo AF catheter ablation (AFCA) with available CCTA images performed before the first procedure (Fig. 2).\u003c/p\u003e\n \u003cp\u003eAmong these 136 patients, 80% were men, mean age was 62 ± 10 years, 39% were overweight or obese, half had hypertension, and 93% were in NYHA class I-II. More than half of the patients suffered from persistent AF, and one in four had already undergone electrical cardioversion.\u003c/p\u003e\n \u003cp\u003eMean left atrial volume index (LAVI) measured by CCTA was 72 ± 19 ml/m². Mean number of pulmonary veins was 4.1 ± 0.5. One in five patients had aortic valve calcifications and only 7% had calcification of the mitral valve. Mean LVEF was 59.6%.\u003c/p\u003e\n \u003cp\u003eThe clinical characteristics, echocardiographic and CCTA data before AFCA are detailed in Table 1.\u003c/p\u003e\n \u003cp\u003eAfter a mean follow-up of 7.3 ± 0.5 years, 85 patients (62%) experienced a recurrence of AF after redo ablation. Patients with recurrent AF had significantly more hypertension and higher CHADS-VASc score, HAS-BLED score and LAVI than patients without recurrence (all p \u0026lt; 0.05) (Table 1).\u003c/p\u003e\n \u003cdiv\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\"\u003e\n \u003ch2\u003eUnivariate analysis\u003c/h2\u003e\n \u003cp\u003eTable 2 presents the univariate and multivariate analysis of factors associated with AF recurrence after a second AFCA. In univariate analysis, there were three clinical and one imaging parameters significantly associated with AF recurrence: history of hypertension (HR 1.68; 95% CI 1.08–2.63, p = 0.02), a higher CHADS-VASc score (HR 1.19; 95% CI 1.03–1.37, p = 0.01), a higher HAS-BLED score (HR 1.4; 95% CI 1.02–1.9, p = 0.03), and higher LAVI (HR 1.02; 95% CI 1.01–1.03, p = 0.0001). Notably, the number of PVs, the presence of accessory veins, coronary and aortic valve calcium scores, were not associated with AF recurrence, even in univariate analysis. After adjustment, only two parameters were significantly and independently associated with the risk of AF recurrence: a higher LAVI measured by CCTA (HR 1.018; 95% CI 1.006–1.030, p = 0.002) and female sex (HR 1.85; 95% CI 1.07–3.2, p = 0.025).\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 2\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eUnivariate and multivariate analysis of variables associated with AF recurrence\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eUnadjusted HR (95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAdjusted HR (95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.01 (0.99–1.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale sex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.59 (0.97–2.61)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.06\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.85 (1.07–3.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.025\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCHADS VASc\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.19 (1.03–1.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.91 (0.72–1.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHAS BLED\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.4 (1.02–1.9)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.03\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.31 (0.81–2.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrior AAD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.27 (0.72–2.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNYHA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.23 (0.85–1.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAF type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.39 (0.96–2.01)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.07\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.3 (0.85–1.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eObesity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.27 (0.96–1.68)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.08\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.24 (0.93–1.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHypertension\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.68 (1.08–2.63)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.02\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.38 (0.85–2.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.98 (0.47–2.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSmoking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.8 (0.44–1.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChronic alcoholism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.62 (0.15–2.55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDyslipidemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.9 (0.57–1.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.42 (0.9–2.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eACS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.03 (0.51–2.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.87 (0.45–1.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCABG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.83 (0.76–2.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSignificant valvular disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.16 (0.16–8.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStroke\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.45 (0.14–1.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrior CVI ablation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.92 (0.53–1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrior electrical CV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.37 (0.93–2.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLVEF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.003 (0.981–1.025)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLAVI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.02 (1.01–1.03)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.02 (1.01–1.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCACS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.99 (0.99-1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNumber of PV\u003c/p\u003e\n \u003cp\u003eRight PV\u003c/p\u003e\n \u003cp\u003eLeft PV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.07 (0.69–1.65)\u003c/p\u003e\n \u003cp\u003e1.29 (0.79–2.09)\u003c/p\u003e\n \u003cp\u003e0.92 (0.54–1.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAortic valve calcification\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.96 (0.58–1.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003eAAD: Antiarrhythmic Drug;ACS: Acute Coronary Syndrome; AF: Atrial Fibrillation; AU: Agatston Unit;CABG: Coronary Artery Bypass Grafting;CACS: Coronary Artery Calcium Score;CV: Cardioversion;LAVI: Left Atrium Volume Index; LVEF: Left Ventricular Ejection Fraction;NYHA: New York Heart Association; OSA: Obstructive Sleep Apnoea; PCI: Percutaneous Coronary Intervention;PV: Pulmonary Vein\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003ch3\u003eThreshold value of LAVI for recurrence of AF\u003c/h3\u003e\n\u003cp\u003eROC curves were drawn for LAVI. The optimal threshold for LAVI was 84 ml/m², with an area under the curve (AUC) of 0.62 (CI 0.52–0.71), p = 0.02.\u003c/p\u003e\n\u003cp\u003eThe mean recurrence-free survival was 7.3 years (95% CI 6.4–8.2) in the overall population.\u003c/p\u003e\n\u003cp\u003eThe 7-year recurrence-free survival rate was 52.5 ± 5.2% in the LAVI \u0026lt; 84 ml/m² group and 17.3 ± 8% in the LAVI ≥ 84 ml/m² group (p \u0026lt; 0.0001 by log-rank test) (Fig. 3).\u003c/p\u003e\n\u003cp\u003eIntra-class correlation coefficient was high for LAV measurements, 0.975 [0.958;0.986] (p \u0026lt; 0.0001), indicating an excellent agreement between observers, as represented on the dispersion diagram (Fig. 4).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo our knowledge, this is the first study about the long-term association between baseline CCTA and the recurrence risk of AF after a second ablation. The only imaging factor associated with AF recurrence was indexed LAV, with a threshold of 84 ml/m\u0026sup2;. All other imaging parameters, as well as clinical data - except for female sex - were not associated with the risk of recurrence.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eLeft atrial volume\u003c/h2\u003e\u003cp\u003ePrevious studies have shown that left atrial (LA) enlargement is as a major risk factor of AF recurrence following initial catheter ablation. Indeed, Berruezo et al. demonstrated that LA diameter using TTE was an independent predictor of AF recurrence after pulmonary vein isolation (PVI) (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). However, this study used the antero-posterior diameter measurement of the LA on the parasternal long-axis view, which does not precisely reflect actual left atrial enlargement (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). In contrast, Sohns et al. showed that LA volume measured by CCTA prior to initial PVI was a better predictor of recurrence, compared to volume measured by TTE, with a threshold of 106 mL (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Our study suggests that a LAVI of 84 ml/m\u0026sup2; is a relevant threshold for determining patients at higher risk of AF recurrence after redo ablation. However, as it is presented on the ROC curve, the performances are moderate (AUC\u0026thinsp;=\u0026thinsp;0.62). This threshold is higher than other published series: in a recent study, Alajaji et al. found that a LAVI greater than 55 ml/m\u0026sup2; was predictive of AF recurrence (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). However, in this study, LAV measurement was performed by the biplane area length method (LAVI = [(0.85)\u0026lowast;LA Area in 4 chamber view\u0026lowast;LA Area in 2 chamber view / LA length] / Body Surface). This method provides only a surrogate of LAV, because of geometrical assumptions, and involves a multiplanar reconstruction of 4-chamber and 2-chamber views. Subsequently, surface measurements were performed using planimetry in these two views, based on a straight line at the level of the mitral annulus. In a previous work from our institution, LAV assessment using 3D method was more reproducible than Area-Length method and provided higher values. Moreover, in the study by Alajajj et al, images were acquired during diastole (70\u0026ndash;80% of the RR cycle), where LAV is at its minimal value (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Both acquisition time and volume assessment method could have led to a significant underestimation of the left atrial volume and may explain part of the differences observed with our study.\u003c/p\u003e\u003cp\u003eIn a recent retrospective study involving 1417 patients (mean age: 60 years, 72% men, 58% paroxysmal atrial fibrillation), conducted by Choi et al., the objective was to explore the mechanisms of very late (\u0026gt;\u0026thinsp;5 years) recurrences of AF after ablation (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The results demonstrated that a lower LAV before the initial ablation was significantly and independently associated with delayed AF recurrences. These findings support our own results, especially given the similar characteristics of the studied populations and the identical method used for left atrial volume assessment. However, all these papers focused only on the recurrence after a first ablation. According to the literature, TTE LAV has been identified as an independent predictive factor for AF recurrence after the first and second ablations (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). However, there is to our knowledge no data regarding maximal LAV index measured by CT before the first ablation as a predictive factor for AF recurrence after the second ablation, which constitutes the main finding of our research.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003ePulmonary veins\u003c/h2\u003e\u003cp\u003eOur study did not find a relationship between the number of pulmonary veins (PV) and long-term AF recurrence. However, when reviewing the literature, data are discordant. Isgandarova et al. suggested that variant anatomy of the PV could predict long-term recurrence of AF and an accessory vein on the right side and the presence of a common left atrial trunk were identified as independent predictive factors (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). In contrast, Mulder et al. found no association between PV anatomy and AF recurrence (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eCalcium score\u003c/h2\u003e\u003cp\u003eNo association was found between aortic valvular calcium score and AF recurrence, in contrast to Liu et al., who identified valvular calcium score as an independent factor for AF recurrence after radiofrequency ablation (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). The same holds true for coronary calcium score, for which no significant association with AF recurrence was found in our study, despite one being reported in the study by Fernandes et al. (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). The divergence in results between our study and those of Liu et al. and Fernandes et al. could be attributed to the fact that those series studied only patients with a first recurrence after AFCA, while we focused on patients experiencing AF recurrence after undergoing a second AFCA.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eFemale sex\u003c/h2\u003e\u003cp\u003eFemale sex was identified as an independent predictor of AF recurrence after a second ablation. These findings are consistent with the existing literature, particularly the study by Park et al., which demonstrated that female sex was independently associated with AF recurrence following a repeat catheter ablation procedure (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). However, even though the exact relationship between sex and AF recurrence after catheter ablation remains to be elucidated, it has been described that women undergoing AFCA were older with increased comorbidities compared to men, with more advanced disease and more atrial fibrosis, and also more non-pulmonary triggered activity in women (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). All these factors may ultimately result in increased risk AF recurrence after ablation procedures (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eStudy limitations\u003c/h2\u003e\u003cp\u003eFirst, this was a retrospective single center study: even though this guarantees homogeneity in our acquisition and evaluation methods, our results may not be applied to other populations. Moreover, caution should be made regarding the threshold of 84 ml/m\u0026sup2; for CCTA LAVI to be associated with AF recurrence after redo ablation: our study size is limited, and the AUC of the ROC curve was low. However, it outperformed all other imaging parameters.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this first study exploring the predictive role of CCTA parameters in AF recurrence after a second ablation procedure, increased LAVI on initial CT was the only imaging parameter associated with a higher risk of AF recurrence, with a threshold of 84 ml/m\u0026sup2;. According to these data, a refined selection of patients undergoing AFCA could be performed, to avoid futile procedures. CCTA\u0026rsquo;s fast acquisition and wide availability, combined with its prognostic value, may encourage electrophysiological centers to choose this imaging method prior to ablation procedure. Larger prospective studies are mandatory to validate these results and establish formal recommendations regarding the place of CCTA in the selection of the most suitable candidates to AF ablation.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAF: atrial fibrillation\u003c/p\u003e\n\u003cp\u003eAFCA: atrial fibrillation catheter ablation\u003c/p\u003e\n\u003cp\u003eCCTA: cardiac computed tomography angiography\u003c/p\u003e\n\u003cp\u003eECG: electrocardiogram\u003c/p\u003e\n\u003cp\u003eLA: left atrium\u003c/p\u003e\n\u003cp\u003eLAV: left atrial volume\u003c/p\u003e\n\u003cp\u003eLVEF: left ventricular ejection fraction\u003c/p\u003e\n\u003cp\u003eNYHA: New York Heart Association\u003c/p\u003e\n\u003cp\u003ePV: pulmonary vein\u003c/p\u003e\n\u003cp\u003eTTE: transthoracic echocardiography\u003cbr\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cu\u003eEthics approval\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the principles of the Declaration of Helsinki, and with the French reference methodology MR-004, as approved by the data protection officer of our institution and registered in the Health data Hub (N\u0026deg;F20230717164031). Ethical approval was obtained from the local ethics committee (n\u0026deg;2025-04-02).\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCompeting interests\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAuthors\u0026apos; contributions\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Benjamin Alos, Maxime Pin and Claire Bouleti. The first draft of the manuscript was written by Benjamin Alos and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eFunding\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAvailability of data and material\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCharlemagne A, Blacher J, Cohen A, Collet JP, Dievart F, de Groote P, et al. Epidemiology of atrial fibrillation in France: extrapolation of international epidemiological data to France and analysis of French hospitalization data. Arch Cardiovasc Dis. 2011;104(2):115\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHeeringa J, van der Kuip DA, Hofman A, Kors JA, van Herpen G, Stricker BH, et al. Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study. Eur Heart J. 2006;27(8):949\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGabet A, Lailler G, Fauchier L, Deharo JC, Tuppin P, Leclercq C, et al. Epidemiology of major heart rhythm and conduction disorders. Arch Cardiovasc Dis. 2024;117(12):693\u0026ndash;704.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBenjamin EJ, Wolf PA, D'Agostino RB, Silbershatz H, Kannel WB, Levy D. Impact of atrial fibrillation on the risk of death: the Framingham Heart Study. Circulation. 1998;98(10):946\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLe Heuzey JY, Paziaud O, Piot O, Said MA, Copie X, Lavergne T, et al. Cost of care distribution in atrial fibrillation patients: the COCAF study. Am Heart J. 2004;147(1):121\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGanesan AN, Shipp NJ, Brooks AG, Kuklik P, Lau DH, Lim HS, et al. Long-term outcomes of catheter ablation of atrial fibrillation: a systematic review and meta-analysis. J Am Heart Assoc. 2013;2(2):e004549.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGaita F, Scaglione M, Battaglia A, Matta M, Gallo C, Galata M, et al. Very long-term outcome following transcatheter ablation of atrial fibrillation. Are results maintained after 10 years of follow up? Europace. 2018;20(3):443\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDretzke J, Chuchu N, Agarwal R, Herd C, Chua W, Fabritz L, et al. Predicting recurrent atrial fibrillation after catheter ablation: a systematic review of prognostic models. Europace. 2020;22(5):748\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChoi SH, Yu HT, Kim D, Park JW, Kim TH, Uhm JS et al. Late recurrence of atrial fibrillation 5 years after catheter ablation: predictors and outcome. Europace. 2023;25(5).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eStraube F, Pongratz J, Hartl S, Brueck B, Tesche C, Ebersberger U, et al. Cardiac computed tomography angiography-derived analysis of left atrial appendage morphology and left atrial dimensions for the prediction of atrial fibrillation recurrence after pulmonary vein isolation. Clin Cardiol. 2021;44(11):1636\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIsgandarova K, Bergau L, El Hamriti M, Braun M, Piran M, Imnadze G, et al. Impact of pulmonary vein anatomy and ostial dimensions on long-term outcome after single-shot device-guided cryoablation for paroxysmal atrial fibrillation. J Interv Card Electrophysiol. 2023;66(9):2125\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGuckel D, Lucas P, Isgandarova K, Hamriti ME, Bergau L, Fink T, et al. Impact of pulmonary vein variant anatomy and cross-sectional orifice area on freedom from atrial fibrillation recurrence after cryothermal single-shot guided pulmonary vein isolation. J Interv Card Electrophysiol. 2022;65(1):251\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbecasis J, Dourado R, Ferreira A, Saraiva C, Cavaco D, Santos KR, et al. Left atrial volume calculated by multi-detector computed tomography may predict successful pulmonary vein isolation in catheter ablation of atrial fibrillation. Europace. 2009;11(10):1289\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSohns C, Sohns JM, Bergau L, Sossalla S, Vollmann D, Luthje L, et al. Pulmonary vein anatomy predicts freedom from atrial fibrillation using remote magnetic navigation for circumferential pulmonary vein ablation. Europace. 2013;15(8):1136\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKranert M, Shchetynska-Marinova T, Liebe V, Doesch C, Papavassiliu T, Akin I, et al. Recurrence of Atrial Fibrillation in Dependence of Left Atrial Volume Index. Vivo. 2020;34(2):889\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlajaji W, Costantini O, Taigen TL, Iler MA. Left atrial volume by cardiac CTA prior to catheter ablation: comparison to echocardiography and association with recurrent atrial fibrillation. BMC Res Notes. 2023;16(1):47.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChristiaens L, Lequeux B, Ardilouze P, Ragot S, Mergy J, Herpin D, et al. 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JACC Clin Electrophysiol. 2016;2(6):703\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Table 1","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"CT, left atrial volume, atrial fibrillation, recurrence","lastPublishedDoi":"10.21203/rs.3.rs-8195625/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8195625/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eatrial fibrillation (AF) is the most frequent arrhythmia worldwide. Catheter ablation is the most effective therapy, but 20% of patients still experience recurrences after two procedures. Cardiac computed tomography angiography (CCTA) is a highly efficient imaging technique to assess left atrial anatomy but is still not mandatory before ablation procedure. We sought to evaluate the prognostic value of CCTA left atrial (LA) parameters for the risk of AF recurrence after redo procedure.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003ewe included retrospectively adults who underwent a second procedure of AF catheter ablation (AFCA) to measure 3D maximal indexed LA volume (LAV) on pre-procedural CCTA. Primary endpoint was the recurrence of AF after redo AFCA.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003ebetween 2009 and 2019, 136 consecutive patients underwent a second AFCA at our institution, with 20% women. After a mean follow-up of 7 years, 62% of patients experienced AF recurrence. In multivariate analysis, a higher indexed LAV and female sex were the only independent variables associated with recurrence. An indexed LAV threshold of 84 ml/m\u0026sup2; had the best performances to predict the risk of recurrent AF, with relatively low AUC (0.62).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003ethis study is the first to evaluate the prognostic role of CT-LAVmax on the risk of recurrence after two ablation procedures. Despite suboptimal performances, it was the only imaging parameter associated with recurrent AF, with a threshold of 84 ml/m\u0026sup2;. Cut-off values for LAV could help physicians refining the selection of patients suitable for AFCA, to avoid futile interventions.\u003c/p\u003e","manuscriptTitle":"Three-dimensional Left Atrial Volume assessed by CT predicts atrial fibrillation recurrence after re-do catheter ablation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-11 12:38:12","doi":"10.21203/rs.3.rs-8195625/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4fd81a5e-dd54-438c-b0dc-782f65fe5ca9","owner":[],"postedDate":"December 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-11T01:55:04+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-11 12:38:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8195625","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8195625","identity":"rs-8195625","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}