Ablation of persistent atrial fibrillation based on atrial electrogram duration map: methodology and clinical outcomes from the AEDUM pilot study

Abstract Background Catheter ablation of persistent atrial fibrillation ( Ps AF) represents a challenge for the electrophysiologist and there are still divergences regarding the best ablative approach to adopt. Create a new map of the duration of atrial bipolar electrograms (Atrial Electrogram DUration Map, AEDUM) to recognize a functional substrate during sinus rhythm and guide a patient-tailored ablative strategy for Ps AF. Methods Forty Ps AF subjects were assigned in a 1:1 ratio to either for PVI alone (Group B 1 ) or PVI+AEDUM areas ablation (Group B 2 ). A cohort of 15 patients without AF history undergoing left-sided accessory pathway ablation was used as a control group (Group A). In all patients, voltage and AEDUM maps were created during sinus rhythm. The minimum follow-up was 12 months, with rhythm monitoring via 48-h ECG Holter or by implantable cardiac device. Results Electrogram (EGM) duration was higher in Group B than in Group A (49±16.2ms vs 34.2±3.8ms; p -value<0.001). In Group B the mean cumulative AEDUM area was 21.8±8.2cm 2 ; no difference between the two subgroups was observed (22.3±9.1cm 2 vs 21.2±7.2cm 2 ; p -value=0.45). The overall bipolar voltage recorded inside the AEDUM areas was lower than in the remaining atrial areas median: 1.30mV (IQR: 0.71–2.38mV) vs 1.54mV (IQR: 0.79–2.97mV); p -value: <0.001). Low voltage areas (<0.5mV) were recorded in three (7.5%) patients in Group B. During the follow-up median 511 days (376–845days) patients who underwent PVI-only experienced more AF recurrence than those receiving a tailored approach (65% vs 35%; p -value= 0.04). Conclusions All PsAF patients exhibited AEDUM areas. An ablation approach targeting these areas resulted in a more effective strategy compared with PVI only. Graphical Abstract