Posterior Pulmonary Vein Isolation Lesion Spacing and Left Atrial Posterior Wall Narrowing During Pulsed Field Ablation

Figures

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  FIGURE 1. Representative LAPW voltage maps after PVI. Bright purple indicates high voltage (≥ 0.5 mV), and red indicates low voltage (< 0.1 mV). (A) Wide bands in all segments. (B) LAPW narrowing at the roof, carina, and bottom. (C) LAPW narrowing at the carina. (D) LAPW narrowing at the carina and bottom. LAPW; left atrial posterior wall, PVI; pulmonary vein isolation.

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  FIGURE 2. Distribution of LAPW narrowing and residual LAPW band width. (A) Schematic representation of LAPW segmentation (roof, carina, and bottom) and the distribution of LAPW narrowing (residual LAPW band width < 10 mm; red circles) after PVI. (B) Comparison of the residual LAPW band widths across segments. Data are presented as mean ± standard deviation. p values were derived from a linear mixed‐effects model accounting for within‐patient correlations, followed by Tukey‐adjusted pairwise comparisons. The maximum and minimum widths in each segment are shown below the corresponding bars. LAPW; left atrial posterior wall, PVI; pulmonary vein isolation.

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  FIGURE 3. Association between inter‐tag distance and residual LAPW Band width. (A) Correlation between the TPI‐positive‐tag ITD and residual LAPW band width. (B) Correlation between all‐tag ITD and residual LAPW band width. (C) Receiver operating characteristic curves of all‐tag ITD and TPI‐positive‐tag ITD for discriminating LAPW narrowing (< 10 mm). LAPW; left atrial posterior wall, AUC, area under the curve, ITD, inter‐tag distance, TPI; tissue proximity indication.

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  FIGURE 4. All‐tag ITD guided workflow for LAPW preservation. Retrospective analysis identified an all‐tag ITD cutoff of 16.5 mm for predicting LAPW narrowing. In the prospective phase, ablation was performed targeting an all‐tag ITD ≥ 16.5 mm on the pre‐ablation geometry, followed by assessment of residual LAPW band width on post‐ablation mapping. ITD, inter‐tag distance; LAPW, left atrial posterior wall.

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  FIGURE 5. Impact of the ITD‐guided workflow on LAPW preservation. (A) Residual LAPW band widths at the roof, carina, and bottom in the retrospective and prospective phases. Data are presented as mean ± standard deviation. (B) Association between achieved all‐tag ITD and residual LAPW band width in the prospective phase. Dashed lines indicate the 16.5‐mm ITD target and 10‐mm narrowing threshold. LAPW, left atrial posterior wall; ITD, inter‐tag distance.

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  FIGURE 6. Kaplan–Meier curve of event‐free survival after the index procedure in the retrospective cohort.

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  FIGURE 7. Changes in residual LAPW band width at repeat procedures. (A) Representative voltage maps after ablation at the index procedure and before ablation at the repeat procedure, showing widening of the residual LAPW band at the roof, carina, and bottom. (B) Comparison of residual LAPW band width between the index and repeat procedures in 12 corresponding lines from 4 patients. Data are presented as mean ± standard deviation, and the p value was derived from a paired Student's t test. LAPW, left atrial posterior wall; PV, pulmonary vein; TPI, tissue proximity indication.