Right atrial diameter and outcome of catheter ablation of atrial fibrillation

  • Song -Nan Wen
  • Nian Liu
  • Rong Bai
  • Ri-Bo Tang
  • Rong-Hui Yu
  • De-Yong Long
  • Cai-Hua Sang
  • Chen-Xi Jiang
  • Song-Nan Li
  • Jia-Hui Wu
  • Yan-Fei Ruan
  • Rong Hu
  • Xin Du
  • Xiao-Hui Liu
  • Jian-Zeng Dong
  • Chang-Sheng Ma



While AF is considered more like a left atrial (LA) disease, to what extent the right atrium contributes to the pathogenesis and ablation outcome of AF remains unclear. This study aimed to identify if right atrial diameter (RAD) could predict arrhythmia recurrence after catheter ablation of atrial fibrillation (AF).


Four hundred and seventy patients with drug-resistant AF [paroxysmal AF (PAF) 196; non-PAF 274] who underwent primary catheter ablation were enrolled. Ablation strategy included complete bilateral pulmonary vein isolation (PVI) in all patients and additional linear ablation across mitral isthmus, LA roof, and tricuspid isthmus in non-PAF cases. Risk factors associated with recurrence were determined by a Cox regression model, and the predictive power was evaluated by using receiver operating characteristic curve.


After 24.3 ± 18.0 months, 284 patients (60.6%) experienced atrial tachyarrhythmia recurrence (111 in PAF, 173 in non-PAF). RAD was moderately associated with LA diameter (r = 0.371, P < 0.001), left ventricular ejection fraction (r = −0.205, P < 0.001), and left ventricular end-diastolic diameter (r = 0.319, P < 0.001). Multivariate Cox regression analysis demonstrated that RAD was an independent predictor for recurrence only in PAF patients with LAD ≥35 mm (HR 1.044, 95% CI 1.007–1.082, P = 0.021). The RAD cutoff value of 35.5 mm predicts atrial tachyarrhythmia recurrence with 85.4% sensitivity and 29.2% specificity. Kaplan-Meier analysis indicated that RAD over 35.5 mm is associated with more recurrence after PAF ablation (log-rank P = 0.034), comparing to those with RAD <35.5 mm.


RAD predicts outcome of ablation only in patients with PAF and concurrent LA enlargement. Under this condition, RAD <35.5 mm is associated with a more favorable recurrence-free survival at over 2-year follow-up.


Atrial fibrillation Catheter ablation Recurrence Left atrium Right atrium 



Antiarrhythmic drugs


Atrial fibrillation


Atrial tachycardia




Left atrium


Left atrial appendage


Left atrium diameter


Left ventricular end-diastolic dimension


Left ventricular end-systolic dimension


Left ventricular ejection fraction


Paroxysmal AF


Pulmonary vein


Right atrium


Right atrial diameter


Sinus rhythm


Transesophagic echocardiography


Transthoracic echocardiography


Coronary sinus


Pulmonary vein isolation


Cavo-tricuspid isthmus


Authors’ contributions

Study was designed by Song-Nan Wen, Nian Liu, Rong Bai, and Chang-Sheng Ma. Data collection was done by Song-Nan Wen, Nian Liu, Ri-Bo Tang, Rong-Hui Yu, De-Yong Long, Cai-Hua Sang, Jia-Hui Wu, Chen-Xi Jiang, Yan-Fei Ruan, Song-Nan Li, Rong Hu, and Jian-Zeng Dong. Data were analyzed by Song-Nan Wen and Xin Du. Manuscript was prepared by Song-Nan Wen, Nian Liu, and Rong Bai. Critical revision to the manuscript was done by Rong Bai, Nian Liu, Xiao-Hui Liu, and Chang-Sheng Ma. All authors read and approved the manuscript.

Compliance with ethical standards

Informed consent

Informed consent for the AF ablation procedure was obtained from each patient.


This work was supported by the “National Natural Science Foundation of China” (81370290, 81500254), the “Excellent Talent of Beijing” (2015000021469G195), the “Beijing Natural Science Foundation” (7161003), and the “Capital Health Research and Development of Special” (2016-2-2062).

Conflict of interest

The authors declare that they have no conflict of interest.


Part of results of this study has been accepted for an abstract presentation in 2016 Annual Session of European Society of Cardiology (Rome, Italy).

Supplementary material

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  1. 1.
    Braunwald E. Shattuck lecture-cardiovascular medicine at the turn of the millennium: triumphs, concerns, and opportunities. N Engl J Med. 1997;337:1360–9.CrossRefPubMedGoogle Scholar
  2. 2.
    Sacco RL, Benjamin EJ, Broderick JP, Dyken M, Easton JD, Feinberg WM, et al. American Heart Association Prevention Conference. IV. Prevention and Rehabilitation of Stroke. Risk factors. Stroke. 1997;28:1507–17.Google Scholar
  3. 3.
    Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH, Hindricks G, Kirchhof P; ESC Committee for Practice Guidelines-CPG; Document Reviewers (2012). 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation—developed with the special contribution of the European Heart Rhythm Association. Europace, 14, 1385–1413.Google Scholar
  4. 4.
    Haïssaguerre M, Jaïs P, Shah DC, Takahashi A, Hocini M, Quiniou G, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998;339:659–66.CrossRefPubMedGoogle Scholar
  5. 5.
    Moon J, Hong YJ, Shim J, Hwang HJ, Kim JY, Pak HN, et al. Right atrial anatomical remodeling affects early outcomes of nonvalvular atrial fibrillation after radiofrequency ablation. Circ J. 2012;76:860–7.CrossRefPubMedGoogle Scholar
  6. 6.
    Luong C, Thompson DJ, Bennett M, Gin K, Jue J, Barnes ME, et al. Right atrial volume is superior to left atrial volume for prediction of atrial fibrillation recurrence after direct current cardioversion. Can J Cardiol. 2015;31:29–35.CrossRefPubMedGoogle Scholar
  7. 7.
    Houltz B, Johansson B, Berglin E, Karlsson T, Edvardsson N, Wandt B. Left ventricular diastolic function and right atrial size are important rhythm outcome predictors after intraoperative ablation for atrial fibrillation. Echocardiography. 2010;27:961–8.CrossRefPubMedGoogle Scholar
  8. 8.
    The consensus statements endorsed by the Beijing Task Force on echocardiography. [Standard techniques and normal value of echocardiography measurements in the Chinese population]. 1st ed. Beijing, Scientific and Technical Documentation Press; 2005.Google Scholar
  9. 9.
    Dong JZ, Sang CH, Yu RH, Long DY, Tang RB, Jiang CX, et al. Prospective randomized comparison between a fixed ‘2C3L’ approach vs. stepwise approach for catheter ablation of persistent atrial fibrillation. Europace. 2015;17:1798–806.CrossRefPubMedGoogle Scholar
  10. 10.
    Frick M, Frykman V, Jensen-Urstad M, Ostergren J, Rosenqvist M. Factors predicting success rate and recurrence of atrial fibrillation after first electrical cardioversion in patients with persistent atrial fibrillation. Clin Cardiol. 2001;24:238–44.CrossRefPubMedGoogle Scholar
  11. 11.
    Ausma J, Wijffels M, Thone F, Wouters L, Allessie M, Borgers M. Structural changes of atrial myocardium due to sustained atrial fibrillation in the goat. Circulation. 1997;96:3157–63.CrossRefPubMedGoogle Scholar
  12. 12.
    Guo Y, Lip GY, Apostolakis S. Inflammation in atrial fibrillation. J Am Coll Cardiol. 2012;60:2263–70.CrossRefPubMedGoogle Scholar
  13. 13.
    Schoonderwoerd BA, Ausma J, Crijns HJ, Van Veldhuisen DJ, Blaauw EH, Van Gelder IC. Atrial ultrastructural changes during experimental atrial tachycardia depend on high ventricular rate. J Cardiovasc Electrophysiol. 2004;15:1167–74.CrossRefPubMedGoogle Scholar
  14. 14.
    Avitall B, Bi J, Mykytsey A, Chicos A. Atrial and ventricular fibrosis induced by atrial fibrillation: evidence to support early rhythm control. Heart Rhythm. 2008;5:839–45.CrossRefPubMedGoogle Scholar
  15. 15.
    Li D, Fareh S, Leung TK, Nattel S. Promotion of atrial fibrillation by heart failure in dogs: atrial remodeling of a different sort. Circulation. 1999;100:87–95.CrossRefPubMedGoogle Scholar
  16. 16.
    Therkelsen SK, Groenning BA, Svendsen JH, Jensen GB. Atrial and ventricular volume and function evaluated by magnetic resonance imaging in patients with persistent atrial fibrillation before and after cardioversion. Am J Cardiol. 2006;97:1213–9.CrossRefPubMedGoogle Scholar
  17. 17.
    de Groot NM, Houben RP, Smeets JL, Boersma E, Schotten U, Schalij MJ, et al. Electropathological substrate of longstanding persistent atrial fibrillation in patients with structural heart disease: epicardial breakthrough. Circulation. 2010;122:1674–82.CrossRefPubMedGoogle Scholar
  18. 18.
    Allessie MA, de Groot NM, Houben RP, Schotten U, Boersma E, Smeets JL, et al. Electropathological substrate of long-standing persistent atrial fibrillation in patients with structural heart disease: longitudinal dissociation. Circ Arrhythm Electrophysiol. 2010;3:606–15.CrossRefPubMedGoogle Scholar
  19. 19.
    Hsu J, Hanna P, Van Wagoner DR, Barnard J, Serre D, Chung MK, et al. Whole genome expression differences in human left and right atria ascertained by RNA sequencing. Circ Cardiovasc Genet. 2012;5:327–35.CrossRefPubMedGoogle Scholar
  20. 20.
    Lin H, Dolmatova EV, Morley MP, Lunetta KL, McManus DD, Magnani JW, et al. Gene expression and genetic variation in human atria. Heart Rhythm. 2014;11:266–71.CrossRefPubMedGoogle Scholar
  21. 21.
    Platonov PG, Mitrofanova LB, Orshanskaya V, Ho SY. Structural abnormalities in atrial walls are associated with presence and persistency of atrial fibrillation but not with age. J Am Coll Cardiol. 2011;58:2225–32.CrossRefPubMedGoogle Scholar
  22. 22.
    Maury P, Thomson E, Rollin A, Berry M, Cognet T, Duparc A, et al. Lack of correlations between electrophysiological and anatomical-mechanical atrial remodeling in patients with atrial fibrillation. Pacing Clin Electrophysiol. 2015;38:617–24.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  • Song -Nan Wen
    • 1
  • Nian Liu
    • 1
  • Rong Bai
    • 1
  • Ri-Bo Tang
    • 1
  • Rong-Hui Yu
    • 1
  • De-Yong Long
    • 1
  • Cai-Hua Sang
    • 1
  • Chen-Xi Jiang
    • 1
  • Song-Nan Li
    • 1
  • Jia-Hui Wu
    • 1
  • Yan-Fei Ruan
    • 1
  • Rong Hu
    • 1
  • Xin Du
    • 1
  • Xiao-Hui Liu
    • 1
  • Jian-Zeng Dong
    • 1
  • Chang-Sheng Ma
    • 1
  1. 1.Department of Cardiology, Beijing Anzhen HospitalCapital Medical UniversityBeijingPeople’s Republic of China

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