Fibrosis and electrophysiological characteristics of the atrial appendage in patients with atrial fibrillation and structural heart disease

This study was conducted to investigate the degree of fibrosis in atrial appendages of patients with and without atrial fibrillation (AF) undergoing cardiac surgery. In addition, we hypothesized that areas of atrial fibrosis can be identified by electrogram fractionation and low voltage for potential ablation therapy. Interstitial fibrosis from right (RAA) and/or left atrial appendages (LAA) was studied in patients with sinus rhythm (SR, n = 8), paroxysmal (n = 21), and persistent AF (n = 20) undergoing coronary artery bypass and/or aortic or mitral valve surgery. Atrial fibrosis quantification was performed with Masson trichrome staining. Intraoperative bipolar epicardial electrophysiological measurements were performed to correlate fibrosis to electrogram fractionation, voltage, and AF cycle length. The average degree of fibrosis was 11.2 +/- 7.2 % in the LAA and 22.8 +/- 7.6 % in the RAA (p < 0.001). Fibrosis was not significantly higher in paroxysmal AF patients compared to SR subjects (18.2 +/- 8.7 versus 20.7 +/- 5.3 %). Persistent AF patients had a higher degree of LAA and RAA fibrosis compared to paroxysmal AF patients (LAA 14.6 +/- 8.7 versus 8.6 +/- 4.7 %, p = 0.02, and RAA 28.2 +/- 7.9 versus 18.2 +/- 8.7 %, respectively, p = 0.04). The left atrial end diastolic volume index was higher in persistent AF patients compared to SR controls (38.3 +/- 16.4 and 28 +/- 11 ml/m(2), respectively, p = 0.04). No correlation between atrial fibrosis and electrogram fractionation or voltage was found. Patients with structural heart disease undergoing cardiac surgery have more fibrosis in the RAA than in the LAA. Furthermore, RAA fibrosis is increased in persistent AF but not paroxysmal AF patients compared to control subjects. Electrogram fractionation and low voltage did not provide accurate identification of the fibrotic substrate.