Identifying Driver Regions in Persistent Atrial Fibrillation: A Mosaic Pattern Within the Atrial Voltage Transition...

Area of Science:

• Cardiology
• Electrophysiology
• Medical Devices

Background:

• Identifying drivers of persistent atrial fibrillation (PsAF) is challenging but essential for effective treatment.
• Driver-targeted ablation alongside pulmonary vein isolation (PVI) shows promise but requires precise driver localization.

Purpose of the Study:

• To investigate if voltage characteristics can aid in identifying drivers of PsAF.
• To develop and validate a mapping approach using voltage thresholds for driver identification.

Main Methods:

• Analysis of voltage characteristics in 241 driver regions from a retrospective cohort of 201 PsAF patients undergoing PVI and driver ablation.
• Derivation of an optimal voltage transition zone and prospective validation in 53 patients.

Main Results:

• An optimal voltage threshold (0.16-0.61 mV) identified 78.8% of driver regions, often showing a mosaic pattern.
• This mosaic pattern approach demonstrated higher accuracy (78.8%) compared to conventional low-voltage area identification (42.3%).
• Prospective validation showed comparable acute termination rates and 12-month freedom from atrial arrhythmias, with reduced procedure times and drivers ablated.

Conclusions:

• AF driver regions in PsAF frequently exhibit a mosaic pattern under optimized voltage thresholds.
• This voltage-based mapping may serve as a feasible adjunct to electrogram-guided mapping for PsAF ablation.
• Further research is needed to confirm if this approach improves long-term clinical outcomes.