scholarly journals Left atrial filling index in prediction of exercise induced pulmonary hypertension in patients with asymptomatic primary mitral regurgitation

2021 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
R Zvirblyte ◽  
A Montvilaite ◽  
E Tamulenaite ◽  
A Saniukaite ◽  
JJ Vaskelyte
Keyword(s):  
Pulmonary Hypertension ◽  
Mitral Regurgitation ◽  
Left Atrium ◽  
Peak Stress ◽  
Recovery Phase ◽  
Left Ventricular ◽  
P Value ◽  
Systolic Pulmonary Artery Pressure ◽  
Bicycle Ergometry ◽  
Exercise Induced

Abstract Funding Acknowledgements Type of funding sources: None. Introduction. In patients with chronic mitral regurgitation (MR), left atrium (LA) is one of the first cardiac structures, that are affected by progressive volume overload. Previous studies have shown that higher LA filling index (FI) could be a potential negative prognostic marker and it may provide additional information in cases where surgical valve correction is considered. Purpose. The aim of this study was to evaluate the connection between the LA FI and exercise–induced pulmonary hypertension (EIPH) in patients with asymptomatic primary moderate to severe MR. Methods. The study sample consisted of 50 patients (age 61.88 ± 12.88 years) with asymptomatic primary moderate to severe MR and preserved left ventricular (LV) ejection fraction (EF) (>60%). All of the patients underwent resting and stress (bicycle–ergometry as per protocol 25 + 25W every 3 minutes) echocardiography. The ratio of the early–diastolic mitral inflow peak velocity (E) and LA reservoir strain was calculated as the LA FI. EIPH was considered as systolic pulmonary artery pressure (SPAP) ≥60 mmHg during peak stress. Results. EIPH was identified in 13 (26%) patients with primary asymptomatic MR. LA FI at rest, during initial and peak stress was higher in patients with EIPH (p = 0.041, p = 0.023 and p = 0.036, respectively). LA FI at rest (r = 0.334; p = 0.044), during initial (25W) stress (r = 0.371; p = 0.037) and during recovery phase (r = 0.408; p = 0.023), weakly correlated with SPAP during maximal achieved workload. In univariate logistic regression analysis, LA FI during initial and peak stress was significantly related to EIPH (Table 1). According to ROC analysis, LA FI >6.46 during initial stress could predict EIPH with 70.0% sensitivity and 75.0% specificity (p = 0.023). LA FI >9.59 during peak stress could distinguish the possibility of underlying EIPH with 60.0% sensitivity and 94.3% specificity (p = 0.036). Conclusions. Resting and exercise LA FI was higher in subjects with EIPH. LA FI during stress could be the potential predictor of EIPH in patients with asymptomatic primary MR and preserved LV EF. Table 1 Parameter β Chi-Square Odds ratio Standard error 95% CI p value LA FI at rest 1.21 3.549 3.271 0.106 0.984 - 1.489 0.071 LA FI during initial (25 W) stress 1.535 6.056 4.812 0.195 1.047 - 2.250 0.028 LA FI during peak stress 1.662 7.364 4.646 0.236 1.047 - 2.638 0.031 LA FI during recovery phase 1.257 3.998 3.139 0.129 0.976 - 1.619 0.076 LA - left atrium FI - filling index Abstract Figure. Picture 1

Echocardiographic predictors of exercise induced pulmonary hypertension in patients with asymptomatic moderate to severe mitral regurgitation and preserved left ventricular ejection fraction

Perfusion ◽  
2021 ◽  
pp. 026765912098754
Author(s):  
Rūta Žvirblytė ◽  
Aistė Montvilaitė ◽  
Eglė Tamulėnaitė ◽  
Agnė Saniukaitė ◽  
Eglė Ereminienė ◽  
...  
Keyword(s):  
Pulmonary Hypertension ◽  
Regression Analysis ◽  
Left Ventricular Ejection Fraction ◽  
Mitral Regurgitation ◽  
Peak Stress ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction ◽  
Exercise Induced ◽  
Lv Diastolic Function

Background: The significant role of mitral regurgitation (MR) in development of pulmonary hypertension (PH) has been proved in previous studies. Experts suggest systolic pulmonary arterial pressure (SPAP) ⩾60 mmHg during exercise as a significant threshold of negative prognostic value in patients with MR. Purpose: The aim of this study was to evaluate the changes of SPAP and to ascertain the determinants of exercise induced pulmonary hypertension (EIPH) in patients with asymptomatic primary MR. Methods: We performed a prospective study that included 50 patients with asymptomatic primary moderate to severe MR with preserved left ventricular ejection fraction (LV EF ⩾60%) at rest. They were divided into two groups according to the presence (PH group; n = 13) or absence (non-PH group; n = 37) of EIPH. Rest and stress (bicycle ergometry) echocardiography and speckle-tracking offline analysis were performed. Results: An increment of SPAP from rest to peak stress was higher in PH group ( p < 0.001). Multivariate regression analysis showed that MR effective regurgitation orifice area (EROA; p = 0.008) and regurgitant volume (RVol; p = 0.006) contributed significantly to SPAP at rest. Higher increment of MR EROA during stress and worse parameters of LV diastolic function at rest (E, A, E/e’) correlated significantly with higher SPAP during peak stress and they had a major role in predicting EIPH according to univariate logistic regression analysis. In ROC analysis SPAP >33.1 mmHg at rest could predict EIPH with 84.6% sensitivity and 87.1% specificity (95%CI 0.849–1.000; p < 0.001). Conclusions: Parameters of MR severity (EROA and RVol) were significant determinants of SPAP at rest, while the increment of MR EROA during stress and parameters of resting LV diastolic function were the best predictors of significant EIPH.

412 Prevalence of pulmonary hypertension in patients referred for sleep apnea diagnostics

SLEEP ◽  
2021 ◽  
Vol 44 (Supplement_2) ◽  
pp. A163-A164
Author(s):  
Eugeniya Elfimova ◽  
Oxana Mikhailova ◽  
Nikolai Danilov ◽  
Alexander Litvin ◽  
Alexander Pevzner ◽  
...  
Keyword(s):  
Pulmonary Hypertension ◽  
Sleep Apnea ◽  
Left Atrium ◽  
Interventricular Septum ◽  
Posterior Wall ◽  
Severe Form ◽  
Left Ventricular ◽  
Chronic Obstructive ◽  
Systolic Pulmonary Artery Pressure ◽  
Sleep Laboratory

Abstract Introduction The aim to evaluate the prevalence of pulmonary hypertension according to echocardiography in patients referred for sleep apnea diagnostics. Methods We included 145 patients referred to Sleep laboratory for sleep apnea diagnostics. Mean age 63,8 ± 10,4 years, BMI 34,0 ± 5,7 kg/m2, AHI 31,3 ± 20,3/h, ODI 3% 28,2 ± 19,5/h, min SpO2 77,4 ± 9,8%, systolic pulmonary artery pressure (systolic PAP) 25,9 ± 16,4 mmHg. All patients underwent cardiorespiratory and respiratory diagnostics for sleep apnea and echocardiography. Results From the random sample of patients referred to Sleep laboratory 14,5% (21) had systolic PAP &gt; 40 mmHg (by echocardiography). Patients with higher levels of systolic PAP (Systolic PAP, mmHg 49,9 [43,6; 56,2] vs 20,7 [19,9; 23,5],p=0.000) had more severe OSA (AHI 35,7 [27,1; 44,3] vs 26,6 [22,6; 30,6], p = 0.029, ODI 3%, /h 35,8 [25,1; 46,4] vs 23,8 [19,8; 27,8], p= 0.017) and were more obese (BMI 37,1 [33,8; 40,4] vs 33,4 [32,4; 34,5], p=0.024). Prevalence of AHI &gt; 30 /h was 62% in group with systolic PAP &gt; 40 mmHg vs 23% in the group with systolic PAP &lt; 40 mmHg. We observed differences in echocardiography, in group with systolic PAP &gt; 40 mmHg: left atrium (4.6 ± 0,5 vs 4,2 ± 0,4 cm, p=0.012), left atrium volume (94.0 ± 23.6 vs 71.7 ± 16.5 ml, p=0.001) and right atrium area (24.5 ± 4.9 vs 18.4 ± 3.8cm2, p=0.000) were higher. Though ejection fraction (58.2 ± 3.8 vs 59.0 ± 3.8%, p=0.268), interventricular septum thickness (1,13 ± 0,2 vs 1,06 ± 0,3 cm, p=0,654) and left ventricular posterior wall thickness (1,05 ± 0,08 vs 1,00 ± 0,13 cm, p=0,117) didn’t differ. In terms of excessive daytime sleepiness, snoring and nocturia groups didn’t differ, as well as for the prevalence of arterial hypertension, coronary artery disease, chronic heart failure, diabetes mellitus and chronic obstructive pulmonary disease. Conclusion Pulmonary hypertension is frequently observed in patients with OSA and appears to be related to the severity of sleep apnea and obesity. PH should be considered in the regular clinical assessment of all patients with sleep apnea, especially with severe form. Support (if any):

scholarly journals Prognostic relevance of exercise pulmonary hypertension for new-onset atrial fibrillation in primary mitral regurgitation

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
K Teramoto ◽  
M Izumo ◽  
S Kuwata ◽  
R Kamijima ◽  
T Suzuki ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Pulmonary Hypertension ◽  
Mitral Regurgitation ◽  
Pulmonary Artery ◽  
Systolic Pulmonary Artery Pressure ◽  
Exercise Echocardiography ◽  
Primary Mitral Regurgitation ◽  
Exercise Induced ◽  
New Onset

Abstract Background/Introduction New-onset of atrial fibrillation (AF) portends poor prognosis in patients with primary mitral regurgitation (MR). However less is known about prognostic indicator for new-onset AF. Purpose The purpose of this study was to identify the prognostic relevance of exercise pulmonary hypertension for the new-onset AF in patients with primary MR. Methods Total of 114 consecutive patients with primary MR who underwent symptom-limited exercise echocardiography using supine-cycle ergometer were followed for new-onset AF over mean follow-up time of 3.6±2.6 years. Those with prevalent AF and pulmonary hypertension (estimated systolic pulmonary artery pressure ≥50mmHg) prior to exercise echocardiography were excluded from our analysis. We defined exercise-induced pulmonary hypertension (ExPHT) as those with peak estimated systolic pulmonary artery pressure (SPAP) ≥60mmHg or delta SPAP defined as differences between rest and peak SPAP ≥20mmHg. Results The mean age was 61±15 years old and 70 (61%) were male. Of those, 8 (7.8%) had mild MR, 32 (31.1%) had moderate MR, and 63 (61.2%) had severe MR. 60 (52.2%) patients had ExPHT. A total of 27 cases of new-onset AF were found during follow-up where the ExPHT group had higher prevalence of new-onset AF than the non-ExPHT group (35% vs. 11%, p=0.002). Those with ExPHT had significantly stronger association with shorter event-free survival time of new-onset AF (log-rank p&lt;0.001, Figure). When adjusted for age, sex, body surface area, the American Society of Echocardiography MR grade, left atrial dimension, peak systolic blood pressure and heart rate, the multivariable Cox regression analysis showed that those with ExPHT had a hazard risk of 3.1 ([95% CI 1.1–9.1], p=0.039) for new-onset of AF. Conclusions Exercise-induced pulmonary hypertension predicted incident of new-onset AF in those with primary MR. Exercise echocardiography is expected to play an important role in decision making with regards to the optimal timing for surgical intervention in primary MR. Figure 1 Funding Acknowledgement Type of funding source: None

scholarly journals Interventricular septal curvature as an additional echocardiographic parameter for evaluating chronic thromboembolic pulmonary hypertension: A single-center retrospective study

2021 ◽  
Author(s):  
Akane Matsumura ◽  
Ayako Shigeta ◽  
Hajime Kasai ◽  
Hajime Yokota ◽  
Jiro Terada ◽  
...  
Keyword(s):  
Pulmonary Hypertension ◽  
Pressure Gradient ◽  
Interventricular Septum ◽  
Chronic Thromboembolic Pulmonary Hypertension ◽  
Left Ventricular ◽  
Accurate Estimation ◽  
Heart Catheterization ◽  
Systolic Pulmonary Artery Pressure ◽  
Additional Tool ◽  
Thromboembolic Pulmonary Hypertension

Abstract Background: Noninvasive estimation of the actual systolic pulmonary artery pressure measured via right-sided heart catheterization (sPAPRHC) is important for the management of pulmonary hypertension, including chronic thromboembolic pulmonary hypertension (CTEPH). Evaluation related to the interventricular septum (IVS) is generally performed with only visual assessment and has been rarely assessed quantitatively in the field of echocardiography. Thus, this study aimed to investigate the utility of echocardiographic IVS curvature to estimate sPAPRHC in patients with CTEPH. Methods: Data of 72 patients with CTEPH were studied retrospectively. We estimated sPAPRHC using echocardiographic IVS curvature (esPAPcurv) and left ventricular eccentricity index (esPAPLVEI), and compared their ability to predict sPAPRHC with estimated sPAPRHC using tricuspid regurgitant pressure gradient (esPAPTRPG). Results: IVS curvature and LVEI were significantly correlated with sPAPRHC (r = - 0.52 and r = 0.49, respectively). Moreover, the IVS curvature was effective in estimating the sPAPRHC of patients with trivial tricuspid regurgitation (r = - 0.56) and in determining patients with sPAPRHC ≥70 mmHg with higher sensitivity (77.0%) compared to those with esPAPTRPG and esPAPLVEI. Conclusion: Our results indicate that the echocardiographic IVS curvature could be a useful additional tool for estimating sPAPRHC in CTEPH patients in whom accurate estimation of sPAPRHC using tricuspid regurgitant pressure gradient is difficult.

P4379Pathophysiology of left atrial filling in mitral regurgitation. A new volumetric flow rate index describing disturbed left atrial filling behavior in mitral regurgitation by 3D TTE

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
D Frumkin ◽  
K Stangl ◽  
A Muegge ◽  
T Buck ◽  
B Plicht
Keyword(s):  
Mitral Regurgitation ◽  
Left Atrium ◽  
Flow Rate ◽  
Left Atrial ◽  
Volume Overload ◽  
Volumetric Flow Rate ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Mean Flow ◽  
Flow Rates

Abstract Background In chronic mitral regurgitation (MR) the left atrium (LA) is one of the first cardiac structures involved in remodeling by progressive volume overload. Real-time three-dimensional echocardiography is able to monitor volumetric changes of the left atrium during the heart cycle. Purpose We hypothesized that chronic volume overload due to MR leads to detectable changes in the LA filling behavior described by mean and maximum filling flow rates and their relation called volumetric flow rate index. Methods We prospectively analyzed data of 36 patients in different stages of chronic MR and 13 patients without MR. Transthoracic echocardiography was conducted using the Epiq 7G Ultrasound System. Standard 2D- and 3D apical 4-chamber views were recorded and stored for offline analysis. We generated volume-time-curves by 3D volume analysis to derive mean and maximum volumetric flow rates during LA reservoir, conduit and pump phase. Volumetric flow rate index was calculated as the quotient of mean flow rate/maximum flow rate. Results Average MR severity, calculated with the MR Scoring system introduced from Buck et al. and implicated in the ESC Guidelines, was 6.2 points (±2.5) according to Grade I-II. We included 13 patients without MR, 18 with mild MR, 12 patients with moderate MR, 6 patients with severe MR. Left ventricular ejection fraction was similar in the different groups (51,2±12,3%). Maximum and mean flow rate showed no significant correlation with MR severity. Correlation of MR severity with LA dilation (ml/m2 BSA) was r=0.41; p<0.001. Flow rate index showed strong significant correlation with MR severity in left atrial reservoir phase (r=−0.75; p<0.001). There was no statistically relevant difference of volumetric flow rate parameters in left atrial pump and conduit phase. Line chart Conclusions We observed a significant correlation of the volumetric flow rate index to MR severity in the left atrial reservoir phase with stronger correlation than MR severity to left atrial dilation. The results of this work encourage further investigations to establish the presented volumetric flow rate index as a progression marker of MR and to evaluate its prognostic value.

scholarly journals P770 Does intraoperative transesophageal match postoperative echocardiography in mitral valve surgery?

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
P Alves ◽  
V Marinho ◽  
C Branco ◽  
A R Ramalho ◽  
M J Maldonado ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
P Value ◽  
Systolic Pulmonary Artery Pressure ◽  
Flow Profile ◽  
Strongly Correlated ◽  
Functional Area ◽  
Global Improvement ◽  
Ventricular Ejection Fraction

Abstract BACKGROUND Intraoperative transesophageal echocardiography (iTEE) has an important role in mitral valve (MV) surgery, but may have dissimilar parameters from postoperative echocardiography (post-TTE). We aimed to evaluate iTTE Doppler flow profile and compare with the post-TTE in MV surgery. METHODS We conducted a prospective, observational study of 126 patients that underwent MVsurgery during 2 years. iTEE evaluated mean pressure gradient (MPG) and functional area. Patients were re-evaluated with TTE, 72 hours after surgery (post-TTE). iTEE and post-TTE Doppler values were compared and correlated. Preoperative TTE (pre-TTE) parameters were also determined. RESULTS The mean age was 59 ± 18 years and 55% were female. The prevalence of severe mitral regurgitation (MR) was 77.6% and severe mitral stenosis (MS) 23.7%. Globally, mitral valve repair was performed in 71%cases (83% for MR and 15% for MS) and replacement in 29% (64% for MR and 46% for MS). Left ventricular ejection fraction (LVEF), systolic pulmonary artery pressure (sPAP), tricuspid annular plane systolic excursion (TAPSE) assessed in pre-TTE and post-TTE, as also MPG and functional area in post-TTE and iTEE are depicted on table 1. There was a higher numerical difference in iTEE vs post-TTE MPG values in mechanical valves (n = 5) (3.5 ± 1.2 to 5.2 ± 1.6, difference of 1.65 ± 2.4mmHg), than in biological valves (n = 17) (3.1 ± 1.1 to 3.9 ± 1.5, difference of 0.8 ± 1.7mmHg). Globally, iTEE-derived MPG and functional area were strongly correlated with their post-TTE values (r2 0.7 and 0.8,p &lt; 0.001). CONCLUSIONS iTEE Doppler parameters were strongly correlated with postoperative TTE parameters, with minimal differences: postoperative MPG were +0.4 ± 1mmHg higher in MV repair and +1.0 ± 1.8mmHg in MV replacement. There was a global improvement in sPAP. Our study demonstrates the usefulness of iTEE and its importance in stablishing possible reference values for postoperative follow-up. MR MS pre-TTE post-TTE P value pre-TTE post-TTE P value LVEF (± SD,%) 57 ± 9 52 ± 10 &lt;0.001 58 ± 6 56 ± 7 &lt;0.001 sPAP (± SD,mmHg) 42 ± 17 33 ± 9 &lt;0.001 47 ± 18 35 ± 6 &lt;0.001 TAPSE (± SD,mm) 18 ± 2 14 ± 3 &lt;0.001 18 ± 2 14 ± 3 &lt;0.001 MV repair MV replacement iTEE post-TTE P value iTEE post-TTE P value MPG (± SD, mmHg) 2.8 ± 1.5 3.1 ± 1.4 0.084 3.2 ± 1.4 4.2 ± 1.6 0.016 Functional Area (± SD, cm2) 2.8 ± 0.6 2.8 ± 0.7 0.665 2.8 ± 0.6 2.7 ± 0.8 0.653

scholarly journals 587 Exercise induced pulmonary hypertension in hypertrophic cardiomyopathy: a combined cardiopulmonary exercise test-echocardiographic study

2021 ◽  
Vol 23 (Supplement_G) ◽  
Author(s):  
Federica Re ◽  
Geza Halasz ◽  
Francesco Moroni ◽  
Matteo Beltrami ◽  
Pasquale Baratta ◽  
...  
Keyword(s):  
Pulmonary Hypertension ◽  
Hypertrophic Cardiomyopathy ◽  
Exercise Test ◽  
Functional Limitation ◽  
Prognostic Significance ◽  
Cardiopulmonary Exercise Test ◽  
Left Ventricular ◽  
Peak Exercise ◽  
Cardiopulmonary Exercise ◽  
Exercise Induced

Abstract Aims Pulmonary arterial hypertension (PAH) has been described in patients with hypertrophic cardiomyopathy (HCM) and it was associated with a worse prognosis. Nevertheless in most HCM patients, despite normal pulmonary pressures at rest, congestive symptoms are elicited by exercise. In the present study, combining cardiopulmonary exercise test (CPET) with echocardiography, we aimed to evaluate the presence of exercise-induced pulmonary hypertension (EiPAH) its role in functional limitation and its prognostic significance in a cohort of patients with obstructive and non-obstructive HCM. Methods and results 182 HCM patients (35% females, mean age 47.5 ± 15.9) undergoing CPET. During CPET, LVOT velocities and trans-tricuspid gradient were measured. Thirty-seven patients (20%) developed sPAP &gt; 40 mmHg at peak exercise (EiPAH). EiPAH was associated with an lower exercise performance, larger left atrial volumes, higher left ventricular gradient and higher VE/VCO2 slope .At multivariable model baseline sPAP (P &lt; 0.0001) and baseline left ventricular obstruction (LVOT) (P = 0.028) were significantly associated with EiPAH .Kaplan-Meier curve analysis showed EiPAH was a significant predictor of HCM –related morbidity (hazards ratio: 6.21, 95% CI: 1.47–26.19; P = 0.05; 4.21, 95% CI: 1.94–9.12; P &lt; 0.001) for the primary and the secondary endpoint respectively. Conclusions EiPAH was present in about one fifth of HCM patients without evidence of elevated pulmonary pressures at rest, and was associated with adverse clinical outcome. Diagnosing EiPAH by exercise echo/CPET may help physicians to detect early stage of PAH requiring a closer clinical monitoring and individualized treatment strategies.

P1037Relationship between left atrium low voltage areas and atrial fibrillation radiofrequency ablation success-rate: preliminary results of the SMOP study

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
R Rordorf ◽  
S Cornara ◽  
L Frigerio ◽  
A Sanzo ◽  
E Chieffo ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Radio Frequency ◽  
Success Rate ◽  
Left Atrium ◽  
Low Voltage ◽  
Left Ventricular ◽  
High Density ◽  
Left Ventricular Ejection ◽  
P Value ◽  
Short Term

Abstract Background radio frequency catheter ablation (CA) is an effective therapy for atrial fibrillation (AF). Some authors have described a potential relationship between the presence of areas of fibrosis in the left atrium (LA) and the success of CA, nevertheless there is a lack of multicenter studies in this field. Objective the aim of our study was to assess the relationship between the of presence of low voltage areas of the LA detected during subtrate mapping at the time of the procedure and recurrences of AF after CA. Methods we analyzed 214 patients of the SMOP-AF (Substrate Mapping as Outcome Predictor in Atrial Fibrillation Ablation), a prospective multi-centric study enrolling patients with both paroxysmal and persistent AF undergoing a first radio-frequency CA procedure. High-density mapping was performed in sinus rhythm using the CARTO system before performing pulmonary vein isolation. Areas with less than 0,5 mV on mapping were defined as low voltage zone (LVZ), while between 0,5 mV and 1,5 mV intermediate voltage zone (IVZ). IVZ and LVZ were expressed as a percentage of the LA surface. Comparisons were made by Pearson correlation, cross-tables and Chi-square test or Student T test. Results the mean age of the enrolled population was 59±9 years, left ventricular ejection fraction was 59±9%, 86.4% of the pts had tested at least one anti-arrhythmic drug. Persistent atrial fibrillation was present in 10.3% of patients. The rate of documented AF recurrence at 3 months was 15,3% (n=29). There was a statistical significant correlation between the presence of IVZ and the rate of recurrences at 3 months (r=0.16, p value 0.03). Patients with IVZ greater than 4% of the left atrium surface showed a higher risk of recurrences (19.5% vs. 8,7%, p value 0.04). No statistical difference was observed in other procedural variables (number of lesions, contact force, force-time integral) among patients with or without recurrences. Conclusion Our study showed a relationship between CA short-term success rate and the presence of areas of intermediate voltage zone detected with high-density substrate mapping at the time of the procedure. The presence of areas of intermediate voltage zone greater than 4% of the LA determines a 2.5 folds increased risk of short-term recurrence. Our data needs to be confirmed in a longer follow-up.

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