Substrate mapping of the left atrium in persistent atrial fibrillation: spatial correlation of localized complex conduction patterns in global charge-density maps to low-voltage areas in 3D contact bipolar voltage maps

Gian‐Battista Chierchia; Juan Sieira; Annelies Vanderper; Thiago Guimarães Osório; Gezim Bala; Erwin Ströker; Pedro Brugada; Maysam Al Houssari; Federico Cecchini; Joerelle Mojica; Ingrid Overeinder; Antonio Bisignani; Vincenzo Mitraglia; Serge Bovéda; Gaetano Paparella; Carlo de Asmundis

doi:10.1007/s10840-020-00926-4

January 8, 2021Journal of Interventional Cardiac ElectrophysiologyOpen Access

Substrate mapping of the left atrium in persistent atrial fibrillation: spatial correlation of localized complex conduction patterns in global charge-density maps to low-voltage areas in 3D contact bipolar voltage maps

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Why the study?

The spatial relationship between low-voltage areas in bipolar voltage mapping and localized complex conduction-cores identified by global charge-density mapping was unknown.

Does localized complex conduction (LCC) mapping correlate spatially with low-voltage areas (LVAs) identified by bipolar voltage mapping in patients with persistent atrial fibrillation?

Structured PICO

Does localized complex conduction (LCC) mapping correlate spatially with low-voltage areas (LVAs) identified by bipolar voltage mapping in patients with persistent atrial fibrillation?

P

Population

10 patients with a history of index pulmonary vein isolation (PVI) for persistent atrial fibrillation (PsAF) scheduled for a repeat ablation procedure for recurrence, mean age 67.4, 80% male, based in Belgium.

I

Intervention

Global, non-contact, charge-density-based imaging and mapping system (AcQMap) to identify localized complex conduction (LCC) patterns during PsAF.

C

Comparator

3D contact bipolar voltage mapping (BVM) using CARTO 3D mapping system to identify low-voltage areas (LVAs) in sinus rhythm and during coronary sinus pacing.

O

Outcome

Spatial relationship and percentage of overlap between low-voltage areas (LVAs) in bipolar voltage mapping and localized complex conduction (LCC)-cores in charge-density mapping.surrogate

Low-voltage areas identified by bipolar voltage mapping only partially overlap with localized complex conduction cores during persistent AF, suggesting bipolar voltage mapping may be insufficient as a sole surrogate for identifying arrhythmogenic substrates.

Limitations

Small patient population
No mapping with the 3D CARTO mapping system was performed in AF

Implication

Bipolar voltage mapping may miss key substrates in persistent AF; leaves open whether LCC mapping improves ablation targeting.

Abstract

PURPOSE: This study aimed to investigate the spatial relationship between low-voltage areas (LVAs) in bipolar voltage mapping (BVM) and localized complex conduction (LCC)-cores in a global, non-contact, charge-density-based imaging, and mapping system (AcM). METHODS: Patients with history of index PVI for PsAF and scheduled for a repeat ablation procedure for recurrence of the same arrhythmia were enrolled between August 2018 and February 2020. All patients underwent both substrate mappings of the left atrium (LA) with the CARTO 3D map-ping system and with AcM. RESULTS: Ten patients where included in our analysis. All presented with persistency of PVI in all veins at the moment of repeat procedure. There was no linear relationship in BVM maps between SR and CSd (correlation coefficient 0.31 ± 0.15), SR and CSp (0.36 ± 0.12) and CSd and CSp (0.43 ± 0.10). The % overlap of localized irregular activation (LIA), localized rotational activation (LRA) and Focal (F) regions with LVA was lower at 0.2 mV compared to 0.5 mV (4.97 ± 7.39%, 3.27 ± 5.25%, 1.09 ± 1.92% and 12.59 ± 11.81%, 7.8 ± 9.20%, 4.62 ± 5.27%). Sensitivity and specificity are not significantly different when comparing composite maps with different LVA cut-offs. AURC was 0.46, 0.48, and 0.39 for LIA, LRA, and Focal, respectively. CONCLUSION: Due to wave front direction dependency, LVAs mapped with BVM in sinus rhythm and during coronary sinus pacing only partially overlap in patients with PsAF. LCC-cores mapped during PsAF partially co-localize with LVAs.