The interplay between total and left atrial pericardial fat and atrial fibrillation: a systematic review and meta-analysis of their associations with AF onset, duration, recurrence, and postoperative
W Kociemba, M GawalkoAbstract
Introduction
Pericardial adipose tissue (PAT) has been implicated as a significant substrate for atrial fibrillation (AF) pathogenesis, maintenance, recurrence, and new-onset. Nonetheless, the evidence remains inconclusive. PAT promotes atrial remodelling through inflammation, oxidative stress, fat infiltration and fibrosis. Measuring it may aid in predicting AF onset and recurrence as well as serve as a potential therapeutic strategy.
Purpose
This study aimed to perform a meta-analysis assessing the relationship between total and left atrial (LA) PAT volume, measured by computed tomography (CT) in cm³ and indexed to body surface area (cm³/m²) and AF onset, duration, post-ablation recurrence and postoperative risk.
Methods
A systematic search of electronic databases PubMed, Web of Science, and EMBASE was conducted for articles published up to July 2025 that evaluated the association between total and LA PAT volume assessed by CT. Eligible studies included original research and observational studies.
Results
A total of 60 studies were eligible for inclusion, comprising 16,764 patients (40% female; mean age 61.4 years). The new-onset AF group included three studies with 4,485 patients (52% female; mean age 60.5 years), all of which reported total PAT volume measured by CT in cm³. New-onset AF occurred in 126 patients, and the fixed-effects model showed a statistically significant mean difference of +13.33 cm³ (95% CI 3.20–23.46; p = 0.010) (Fig. 1A). The AF versus sinus rhythm (SR) group included 16 studies assessing total PAT volume (cm³), comprising 7,819 participants (47% female; mean age 60.0 years), with 1,461 AF patients and 6,358 SR controls, revealing a significant mean difference of +12.22 cm³ favouring AF (95% CI 11.19–13.25; p < 0.00001) (Fig. 1B). For left atrial (LA) PAT, six studies assessed absolute volume (cm³; n = 818, 44% female; mean age 57.7 years) and three studies assessed indexed volume (cm³/m²; n = 235, 31% female; mean age 53.8 years), revealing pooled mean differences of +3.09 cm³ (95% CI 2.33–3.85; p < 0.00001) and +3.06 cm³/m² (95% CI 2.24–3.87; p < 0.00001), respectively. Comparisons of total PAT volume between paroxysmal and persistent AF and SR groups, based on seven studies (n = 1,307, 36% female; mean age 58.3 years), showed mean differences of +33.18 cm³ (95% CI 28.28–38.09; p < 0.00001) (Fig. 1C) and +45.66 cm³ (95% CI 39.53–51.79; p < 0.00001) (Fig. 1D), respectively.
Conclusions
Overall, these findings support a strong and progressive relationship between increasing PAT volume and AF occurrence and persistence.