Abstract
Background The burden and persistence of atrial fibrillation (AF) have been associated with the presence and extent of left atrial (LA) fibrosis. Recent reports have implicated an association between the extent of LA fibrosis and the outcome of pulmonary vein isolation (PVI). We aimed to analyse the value of an automated scar quantification method in the prediction of success following PVI. Methods One hundred and nine consecutive patients undergoing PVI for paroxysmal or persistent AF were included in our observational study with a 2-year follow-up. Prior to PVI, patients underwent high-definition LA electroanatomical mapping, and scar burden was quantified by automated software (Voltage Histogram Analysis, CARTO 3, Biosense Webster), then classified into 4 subgroups (Dublin Classes I-IV). Recurrence rates were analysed on and off antiarrhythmic drug therapy (AAD), respectively. Results The overall success rate was 74% and 67% off AAD at 1- and 2-year follow-up, respectively. Patients with Dublin Class IV had significantly lower success rates (p = 0.008, off AAD). Dublin Class IV (OR = 2.27, p = 0.022, off AAD) and the presence of arrhythmia in the blanking period (OR = 3.28, p = 0.001, off AAD) were the only significant predictors of recurrence. The use of AAD did not affect these results. Conclusions We propose a classification of low voltage areas based on automated quantification by software during 3D mapping prior to PVI. Patients with high burden of low voltage areas (>31% of <0.5 mV, Dublin Class IV) have a higher risk of recurrence following PVI. Information gathered during electroanatomical mapping may have important prognostic value.
Highlights
Despite significant technological developments in the ablation of atrial fibrillation (AF) ablation, there is still a significant percentage of arrhythmia recurrence [1]
We have investigated the efficacy of the Dublin classification in predicting recurrent AF in patients who underwent pulmonary vein isolation (PVI)
Atrial fibrosis is a significant contributor to the complex pathomechanism of atrial fibrillation, and they together act in a vicious circle, while the arrhythmia itself can lead to “structural, architectural, contractile, or electrophysiological changes” in the atria, and the fibrotic changes contribute to the manifestation of AF [10]
Summary
Despite significant technological developments in the ablation of atrial fibrillation (AF) ablation, there is still a significant percentage of arrhythmia recurrence [1]. In most of the studies to date, the extent of LA low voltage area is assessed by visual estimation only and not by automated, operator-unbiased measurements [4, 5]. This has been shown to overestimate the amount of dense scar and underestimates the extent of diseased atrial tissue [6]. Prior to PVI, patients underwent high-definition LA electroanatomical mapping, and scar burden was quantified by automated software (Voltage Histogram Analysis, CARTO 3, Biosense Webster), classified into 4 subgroups (Dublin Classes I-IV). Patients with high burden of low voltage areas (>31% of
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