Voltage mapping and pulmonary vein isolation in master athletes with atrial fibrillation

Master athletes encompass a wide range of exercise enthusiasts. At the extreme, there is an increased risk of atrial fibrillation (AF). Therapies aimed at rate or rhythm control are often limited given unfavorable side effects. Although studies suggest an increase in left atrial (LA) fibrosis in this population, minimal electrophysiologic data exist regarding the LA voltage mapping and the efficacy of AF ablation with pulmonary vein isolation (PVI).

In a retrospective single-center study, we reviewed AF ablations (pulmonary vein isolation and assessment/ablation of non-pulmonary vein triggers) performed in extreme master athletes with AF. We define "extreme" as those who have repeatedly competed in long distance endurance events for a > 10-year period. Bipolar voltage mappings obtained through PENTARAY Catheter (Biosense Webster) were reviewed using CARTO. LA scarring was defined as an area of less than 0.1 mV. All patients were monitored as outpatients for AF recurrence.

Between January 2018 and February 2022, 16 patients (11 marathon runners, four long distance cyclers, and one marathon swimmer) underwent AF ablations. All patients in the cohort were male with an average CHA2DS2-VASc score of 1.2 ± 0.8 and left atrial volume of 34.4 cc/m²  ± 9.9. A total of eight patients (50%) had persistent AF. One patient (6.3%) had LA scar on bipolar voltage mapping, whom also had a non-pulmonary vein trigger of AF. Bidirectional blocks of the four pulmonary veins were achieved by radiofrequency (RF) ablation in all patients. Freedom from documented recurrence of AF up to 24 months was 93.8%. One patient (6.3%) had recurrence of AF at 14 months and underwent successful cardioversion.

In our series of extreme master athletes with AF, the incidence of LA scarring on bipolar voltage mapping was low and the recurrence of AF following PVI by RF ablation was minimal.