Heterogeneity of Low Voltage Areas Spatial Distribution in Sinus Rhythm during Electroanatomic Mapping of Persistent Atrial Fibrillation

Author(s): Antoine Lepillier, Xavier Copie, William Escande, Marjorie Niro, Olivier Paziaud, Olivier Piot

Background: Current ablation strategies for persistent AF have shown a limited success rate with frequent arrhythmia recurrences. Several studies suggest PVI and complementary ablation of low voltage area (LVA) may represent an efficient strategy.

Aim: Distribution of (LVA) in sinus rhythm in patients undergoing persistent AF ablation may represent a marker of AF recurrence during follow-up.

Methods: We prospectively included patients with persistent AF (age: 63 +/- 8.7 years, men 69.3%). The ablation strategy consisted in circumferential PVI followed by a electro-anatomic mapping in sinus rhythm. Complementary radiofrequency (RF) ablation was guided by LVA < 0.5 mV. Success was defined as freedom from AF/ atrial flutter or atrial arrhythmia (AT) for a period ranging from 3 months to 18 months or more.

Results: 101 patients with persistent AF were included. LVA were identified in 48 patients (47%). Two or more different sites of LVA were found in 40 patients. The distribution of the 108 different LVA was: 33 anterior wall (32.3%), 26 septum (25.4%), 8 posterior (7.8%), 3 lateral (2.9%), 12 left appendage (11.7%), 23 roof (22.5%), 3 inferior (2.9%). RF ablation was performed in all low voltage areas. At the end of procedure, 76 patients (75.2%) were non inducible. At the end of FU of 18 months, and after a single procedure, 72.3% of patients were free of symptomatic AF (n=73 patients) and 65.3% of patients (n=66) were free of AF/AT recurrence. LVA distribution was not associated with AF/AT recurrence at 18 months.

Conclusion: Patients with persistent AF have an heterogeneity of LVA distribution in SR, a tailored ablation in SR can be an efficient strategy in addition to PVI to maintain SR.