Dynamic Atrial Substrate During High-Density Mapping of Paroxysmal and Persistent AF: Implications for Substrate Ablation

Geoffrey R. Wong, Chrishan J. Nalliah, Geoffrey Lee, Aleksandr Voskoboinik, Sandeep Prabhu, Ramanathan Parameswaran, Hariharan Sugumar, Robert D. Anderson, Alex McLellan, Liang Han Ling, Joseph B. Morton, Prashanthan Sanders, Peter M. Kistler, Jonathan M. Kalman

Research output: Contribution to journalArticle

4 Citations (Scopus)

Abstract

Objectives: This study sought to determine the impact of rate and direction on left atrial (LA) substrate. Background: The extent to which substrate mapped in sinus rhythm varies according to cycle length and direction of wave front propagation is unknown. Methods: A total of 73 consecutive patients with atrial fibrillation (AF) underwent electroanatomic LA mapping before pulmonary vein isolation using multipolar catheter during distal coronary sinus (CS) pacing at 600 ms and 300 ms. Additional maps were created during left superior pulmonary vein pacing at 300 ms. Bipolar voltage, conduction velocity (CV), and complex signals were determined. Results: Mean age was 61 ± 9 years, 67% were men, and 53% had persistent AF. Global mean voltage was lower with CS pacing at 300 ms compared with 600 ms (1.56 ± 0.47 mV vs. 1.74 ± 0.48 mV; p < 0.001). This was seen in all LA segments. Global CV was reduced (30.4 ± 13.0 cm/s vs. 38.6 ± 14.0 cm/s; p < 0.001) with greater complex signals at 300 ms (8.9% vs. 5.3%; p < 0.005). Compared with CS pacing, left superior pulmonary vein pacing demonstrated highly regional changes with decreased voltage (1.04 ± 0.43 mV vs. 1.47 ± 0.53 mV; p = 0.01) and CV (24.4 ± 13.0 cm/s vs. 39.9 ± 16.6 cm/s; p = 0.008), and greater complex signals posteriorly. Longer AF duration in paroxysmal AF (p = 0.02) and shorter duration in persistent AF (p = 0.015) and left ventricular ejection fraction (p = 0.016) were independent predictors of voltage change. Conclusions: In patients with AF, variation in cycle length and direction of wave front activation produce both generalized and regional changes in voltage, CV, and complex fractionation, resulting in significant changes in substrate maps. This study highlights the potential limitations of static low-voltage maps to identify the AF ablation target zone.

Original languageEnglish
Pages (from-to)1265-1277
Number of pages13
JournalJACC: Clinical Electrophysiology
Volume5
Issue number11
DOIs
Publication statusPublished - 1 Nov 2019

Keywords

  • atrial fibrillation
  • atrial substrate
  • conduction velocity
  • cycle length
  • direction-dependent conduction
  • electroanatomic mapping
  • left atrium
  • low-voltage zone
  • voltage

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

Cite this

Wong, G. R., Nalliah, C. J., Lee, G., Voskoboinik, A., Prabhu, S., Parameswaran, R., ... Kalman, J. M. (2019). Dynamic Atrial Substrate During High-Density Mapping of Paroxysmal and Persistent AF: Implications for Substrate Ablation. JACC: Clinical Electrophysiology, 5(11), 1265-1277. https://doi.org/10.1016/j.jacep.2019.06.002