Left Atrial Intramyocardial Fat at Pulmonary Vein Reconnection Sites during Atrial Fibrillation Redo Ablation

Structured Abstract Background and Aims Electrical reconnections between pulmonary veins (PVs) and the left atrium (LA) are frequently responsible for atrial fibrillation (AF) recurrences after pulmonary vein isolation (PVI). Multidetector computed tomography (MDCT)-derived images can be post-processed to detect intramyocardial fat (inFAT) by signal radiodensity thresholding. The role of inFAT on PV-LA reconnections remains unknown. The aim of this study was to analyze the relationship between inFAT localization at pre-procedural MDCT-derived inFAT maps from first AF ablation and PV-LA reconnections in patients with AF recurrence undergoing redo ablation. Methods We included 45 consecutive patients who underwent AF redo ablation presenting at least one PV-LA reconnection. First AF ablation preprocedural MDCT-derived data were post-processed with ADAS 3DTM to create 3D LA inFAT maps, that were loaded into CARTO3 navigation system and merged with the electroanatomical map for reconnection site analysis. Results In 103 out of 156 (66.0%) PV-LA reconnection points inFAT was identified in the 6mm diameter tag point depicted in the navigation system. When dividing the PVI line into standardized segments, those identified as containing PV-LA reconnection points (i.e. reconnection segments) exhibited significantly higher total inFAT volumes compared with non-reconnection segments (8.05±6.56 vs. 5.40±5.18 μL, p<0.001). Additionally, reconnection segments showed greater volumes of inFAT components, specifically dense inFAT (0.06±0.06 vs. 0.03±0.04 μL, p<0.001) and fat-myocardial admixture (7.98±6.52 vs. 5.37±5.16 μL, p<0.001). Conclusion InFAT is co-localized with two thirds of PV-LA reconnection points in patients undergoing AF redo ablation. Reconnection segments exhibit significantly higher inFAT volumes compared to non-reconnection segments. This proof-of-concept study suggests that inFAT may play a role in PV-LA electrical reconnections following PVI.