Key result
Prolonged fractionated potentials in sinus rhythm show ~80% concordance with AF potentials, beating the reverse.
Why the study?
Low-voltage-substrate-guided ablation for persistent AF has been described in sinus rhythm or AF, but the spatial correlation of prolonged fractionated potentials and low-voltage substrate mapped between these rhythms needed evaluation.
Does left atrial high-density mapping show spatial concordance of fractionated potentials and low-voltage areas between atrial fibrillation and sinus rhythm in patients with persistent AF?
Observational (n=38)
No
Does left atrial high-density mapping show spatial concordance of fractionated potentials and low-voltage areas between atrial fibrillation and sinus rhythm in patients with persistent AF?
Absolute Event Rate: 80% vs 59%
p-value: p=0.008
High-density mapping demonstrates significant spatial agreement of fractionated potentials between sinus rhythm and atrial fibrillation, particularly in patients with moderate low-voltage areas in sinus rhythm.
High-density mapping may identify consistent ablation targets across rhythms in persistent AF; leaves open prospective outcome validation.
Background Low-voltage-substrate (LVS)-guided ablation for persistent atrial fibrillation (AF) has been described either in sinus rhythm (SR) or AF. Prolonged fractionated potentials (PFPs) may represent arrhythmogenic slow conduction substrate and potentially co-localize with LVS. We assess the spatial correlation of PFP identified in AF (PFP-AF) to those mapped in SR (PFP-SR). We further report the relationship between LVS and PFPs when mapped in AF or SR. Materials and methods Thirty-eight patients with ablation naïve persistent AF underwent left atrial (LA) high—density mapping in AF and SR prior to catheter ablation. Areas presenting PFP-AF and PFP-SR were annotated during mapping on the LA geometry. Low-voltage areas (LVA) were quantified using a bipolar threshold of 0.5 mV during both AF and SR mapping. Concordance of fractionated potentials (CFP) (defined as the presence of PFPs in both rhythms within a radius of 6 mm) was quantified. Spatial distribution and correlation of PFP and CFP with LVA were assessed. The predictors for CFP were determined. Results PFPs displayed low voltages both during AF (median 0.30 mV (Q1–Q3: 0.20–0.50 mV) and SR (median 0.35 mV (Q1–Q3: 0.20–0.56 mV). The duration of PFP-SR was measured at 61 ms (Q1–Q3: 51–76 ms). During SR, most PFP-SRs (89.4 and 97.2%) were located within LVA (<0.5 mV and <1.0 mV, respectively). Areas presenting PFP occurred more frequently in AF than in SR (median: 9.5 vs. 8.0, p = 0.005). Both PFP-AF and PFP-SR were predominantly located at anterior LA (>40%), followed by posterior LA (>20%) and septal LA (>15%). The extent of LVA < 0.5 mV was more extensive in AF (median: 25.2% of LA surface, Q1–Q3:16.6–50.5%) than in SR (median: 12.3%, Q1–Q3: 4.7–29.4%, p = 0.001). CFP in both rhythms occurred in 80% of PFP-SR and 59% of PFP-AF ( p = 0.008). Notably, CFP was positively correlated to the extent of LVA in SR ( p = 0.004), but not with LVA in AF ( p = 0.226). Additionally, the extent of LVA < 0.5 mV in SR was the only significant predictor for CFP, with an optimal threshold of 16% predicting high (>80%) fractionation concordance in AF and SR. Conclusion Substrate mapping in SR vs. AF reveals smaller areas of low voltage and fewer sites with PFP. PFP-SR are located within low-voltage areas in SR. There is a high degree of spatial agreement (80%) between PFP-AF and PFP-SR in patients with moderate LVA in SR (>16% of LA surface). These findings should be considered when substrate-based ablation strategies are applied in patients with the left atrial low-voltage substrate with recurrent persistent AF.
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Huang et al. (2022) conducted an observational in Persistent atrial fibrillation (n=38). High-density mapping in sinus rhythm vs. High-density mapping in atrial fibrillation was evaluated on Concordance of fractionated potentials (CFP) (p=0.008). Prolonged fractionated potentials identified during sinus rhythm showed a significantly higher spatial concordance with those in atrial fibrillation compared to the reverse (80% vs 59%, p=0.008).
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