Formation of low-voltage zones on the anterior left atrial wall due to mechanical compression by the ascending aorta

Background: Although low-voltage zones (LVZs) in the left atrium (LA) are considered arrhythmogenic substrates in some patients with atrial fibrillation (AF), the pathophysiologic factors responsible for LVZ formations remain unclear.

Objective: To elucidate the anatomical relationship between the LA and ascending aorta responsible for anterior LA wall remodeling.

Methods: We assessed the relationship between existence of LVZs on the anterior LA wall and the three-dimensional computed tomography image measurements in 102 patients who underwent AF ablation.

Results: Twenty-nine patients (28%) had LVZs grearer than 1.0 cm² on the LA wall in the LA-ascending aorta contact area (LVZ group); no LVZs were seen in the other 73 patients (no-LVZ group). The LVZ group (vs. no-LVZ group) had a smaller aorta-LA angle (21.0 ± 7.7° vs. 24.9 ± 7.1°, p = .015), greater aorta-left-ventricle (LV) angle (131.3 ± 8.8° vs. 126.0 ± 7.9°; p = .005), greater diameter of the noncoronary cusp (NCC; 20.4 ± 2.2 vs. 19.3 ± 2.5 mm; p = .036), thinner LA wall-thickness adjacent to the NCC (2.3 ± 0.7 vs. 2.8 ± 0.8 mm; p = .006), and greater cardiothoracic ratio (percentage of the area in the thoracic area, 40.1 ± 7.1% vs. 35.4 ± 5.7%, p < .001). The aorta-LA angle correlated positively with the patients' body mass index (BMI), and the aorta-LV angle correlated negatively with the body weight and BMI.

Conclusion: Deviation of the ascending aorta's course and distention of the NCC appear to be related to the development of LA anterior wall LVZs in the LA-ascending aorta contact area. Mechanical pressure exerted by extracardiac structures on the LA along with the limited thoracic space may contribute to the development of LVZs associated with AF.