Combined Unipolar and Bipolar Voltage Mapping at Redo Ablation After Cryoballoon Pulmonary Vein Isolation: Associations With Subsequent Arrhythmia Recurrence

Q: What are the key findings of this study?

Each 0.5-unit increase in total LVA-Disc was independently associated with a higher hazard of post-blanking arrhythmia recurrence in patients undergoing redo ablation.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Paroxysmal or persistent atrial fibrillation (n=160). Intervention: Normalized unipolar-bipolar LVA extent-difference index (LVA-Disc). Primary outcome: Post-blanking arrhythmia recurrence (AR) (HR 2.100, 95% CI 1.637-2.695, p=<0.001).

Q: What does this research mean for the field?

Combined unipolar and bipolar voltage mapping findings during redo ablation after cryoballoon pulmonary vein isolation are associated with the risk of subsequent arrhythmia recurrence. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Q: What question did this study set out to answer?

To evaluate the associations of unipolar low-voltage areas, bipolar low-voltage areas, and a normalized extent-difference index with post-blanking arrhythmia recurrence after redo catheter ablation.

Yazan Mohsen; Syed Yusuf Ali; Shreeram Sabareesan; Kensuke Sakata; Moritz Knitter; Johanna Hain; Henning Horlitz; Lucas Steffens; Ibrahim Antoun; Marc Horlitz; Florian Stöckigt; Natalia A. Trayanova

doi:10.1093/europace/euag237

September 3, 2026EP EuropaceOpen Access

Combined Unipolar and Bipolar Voltage Mapping at Redo Ablation After Cryoballoon Pulmonary Vein Isolation: Associations With Subsequent Arrhythmia Recurrence

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Key result

Higher LVA-Disc linked to ~110% increased arrhythmia recurrence risk per 0.5-unit rise after redo ablation.

HR 2.100
95% CI 1.637-2.695
P<0.001
n=160

Figures

Why the study?

Voltage-defined low-voltage areas provide an electrical phenotype of atrial cardiomyopathy, but the relationship between unipolar and bipolar LVA extent and arrhythmia recurrence after redo ablation is unclear.

Key Points

To evaluate the associations of unipolar low-voltage areas, bipolar low-voltage areas, and a normalized extent-difference index with post-blanking arrhythmia recurrence after redo catheter ablation.
Retrospectively analyzed 160 consecutive adults (median age 71.0 years, 57.5% male, 58.8% persistent AF) undergoing repeat radiofrequency ablation after cryoballoon pulmonary vein isolation at a single center.
Acquired high-density left atrial maps in sinus rhythm, defining low-voltage areas (LVA) as unipolar < 2.5 mV and bipolar < 0.5 mV outside a 10-mm peri-pulmonary vein perimeter, and calculated an extent-difference index (LVA-Disc).
Monitored patients with 72-hour to 7-day Holter and symptom-triggered electrocardiograms for a minimum of 15 months to assess post-blanking arrhythmia recurrence.
Arrhythmia recurrence occurred in 103 patients (64.4%); each 0.5-unit increase in total LVA-Disc was independently associated with recurrence (HR 2.100, 95% CI 1.637–2.695; P < 0.001).
Atrial tachycardia was documented in 76 patients (47.5%), but after full adjustment, no whole-atrial voltage measure was significantly associated with it (all P ≥ 0.289).

Study Design

Type

Cohort (n=160)

Multicenter

No

Structured PICO

P

Population

160 adults (median age 71.0, 42.5% female) with paroxysmal or persistent atrial fibrillation undergoing repeat radiofrequency ablation after cryoballoon PVI, followed for a minimum of 15 months.

E

Exposure

Combined unipolar and bipolar voltage mapping to calculate a normalized unipolar-bipolar low-voltage area extent-difference index (LVA-Disc)

O

Outcome

Arrhythmia recurrence (AF, AT, or flutter lasting ≥30 s after a 90-day blanking period)

Main Result

Hazard Ratio: 2.1 (95% CI 1.637–2.695)

p-value: p=<0.001

Limitations

Retrospective single-centre design
Intermittent surveillance
Restriction to redo ablation
Prior cryoballoon lesions may have influenced voltage
Operator-selected adjunctive ablation introduced treatment heterogeneity and potential confounding by indication
Retrospective single-centre design, intermittent surveillance, and restriction to redo ablation limit generalizability
Prior cryoballoon lesions may have influenced voltage despite the 10-mm peri-PV exclusion
Atrial tachycardia combined pre-procedural and intra-procedural events without systematic mechanism classification
Machine learning estimates came from a 32-patient internal holdout

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Implication

In patients undergoing redo AF ablation, a higher unipolar-bipolar LVA-Disc was independently associated with post-blanking arrhythmia recurrence, suggesting combined mapping improves atrial substrate assessment over absolute LVA burden alone.

Abstract

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Cite This Study

Mohsen et al. (2026) conducted a cohort in Paroxysmal or persistent atrial fibrillation (n=160). Normalized unipolar-bipolar LVA extent-difference index (LVA-Disc) was evaluated on Post-blanking arrhythmia recurrence (AR) (HR 2.100, 95% CI 1.637-2.695, p=<0.001). Each 0.5-unit increase in total LVA-Disc was independently associated with a higher hazard of post-blanking arrhythmia recurrence in patients undergoing redo ablation.

synapsesocial.com/papers/6a9bd4606b95aff0620ebfab https://doi.org/10.1093/europace/euag237

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Combined Unipolar and Bipolar Voltage Mapping at Redo Ablation After Cryoballoon Pulmonary Vein Isolation: Associations With Subsequent Arrhythmia Recurrence

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Combined Unipolar and Bipolar Voltage Mapping at Redo Ablation After Cryoballoon Pulmonary Vein Isolation: Associations With Subsequent Arrhythmia Recurrence

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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