Identifying Extra Pulmonary Vein Targets for Persistent Atrial Fibrillation Ablation: Bridging Advanced and Conventional Mapping Techniques.

Background And Aims: Advanced technologies such as charge density mapping (CDM) show promise in guiding adjuvant ablation in patients with persistent atrial fibrillation (AF); however, their limited availability restricts widespread adoption. We sought to determine whether regions of the left atrium containing CDM-identified pivoting and rotational propagation patterns during AF could also be reliably identified using more conventional contact mapping techniques.

Methods: Twenty-two patients undergoing de novo ablation of persistent AF underwent both CDM and electroanatomic voltage mapping during AF and sinus rhythm with multiple pacing protocols. Though the use of a left atrium statistical shape model, the location of distinctive propagation patterns identified by CDM were compared with low-voltage areas (LVAs) and regions of slow conduction velocity (CV).

Results: Neither LVA nor CV mapping during paced rhythms reliably identified regions containing CDM propagation patterns. CV mapping during AF did correlate with these regions (ρ = -0.63, p < 0.0001 for pivoting patterns; ρ = -0.54, p < 0.0001 for rotational patterns). These propagation patterns consistently occurred in two specific anatomical regions across patients: the anteroseptal and inferoposterior walls of the left atrium.

Conclusion: Mapping techniques during paced rhythms do not reliably correspond with regions of CDM-identified propagation patterns in persistent AF. However, these propagation patterns are consistently observed in two specific anatomical regions, suggesting a predisposition to abnormal electrophysiological properties. While further research is needed, these regions may serve as promising targets for empirical ablation, potentially reducing the reliance on complex mapping techniques.