Biatrial volume ratio predicts low voltage areas in atrial fibrillation

Abstract Background Low-voltage zone (LVZ) in the left atrium (LA) seems to represent fibrosis. LA longitudinal strain assessed by speckle tracking method is known to correlate with the extent of fibrosis in patients with mitral valve disease. Purpose We sought to identify the relationship between LA longitudinal strain and LA bipolar voltage in patients with atrial fibrillation (AF). We tested the hypothesis that LA strain can predict LA bipolar voltage. Methods A total of 96 consecutive patients undergoing initial AF ablation were analyzed. All patients underwent transthoracic echocardiography including 2D speckle tracking measurement on the day before ablation during sinus rhythm (SR group, N=54) or during AF (AF group, N=42). LA longitudinal strain was measured at basal, mid, and roof level of septal, lateral, anterior, and inferior wall in apical 4- and 2-chamber view. Global longitudinal strain (GLS) was defined as an average value of the 12 segments. LA voltage map was created using EnSite system, and global mean voltage was defined as a mean of bipolar voltage of the whole LA excluding pulmonary veins and left atrial appendage. LVZ was defined as less than 1.0 mV. Results There was a significantly positive correlation between GLS and global mean voltage (r=0.708, p<0.001). Multivariate regression analysis showed that GLS and age were independent predictors of global mean voltage. There was a significant negative correlation between global mean voltage and LVZ areas. Conclusions There was a strong correlation between LA longitudinal strain and LA mean voltage. GLS can independently predict LA mean voltage, subsequently LVZ areas in patients with AF. Funding Acknowledgement Type of funding source: None

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Association of low-voltage areas with the regional wall deformation and the left atrial shape in patients with atrial fibrillation: A proof of concept study

IJC Heart & Vasculature ◽

10.1016/j.ijcha.2021.100730 ◽

2021 ◽

Vol 33 ◽

pp. 100730

Author(s):

Sotirios Nedios ◽

Soroosh Sanatkhani ◽

Michael Oladosu ◽

Timm Seewöster ◽

Sergio Richter ◽

...

Keyword(s):

Atrial Fibrillation ◽

Left Atrial ◽

Low Voltage ◽

Proof Of Concept ◽

Regional Wall ◽

Concept Study ◽

Wall Deformation

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P613Cardiac magnetic resonance imaging derived left ventricular mechanical function in patients with atrial fibrillation and left atrial low voltage zones

European Heart Journal ◽

10.1093/eurheartj/ehz747.0222 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

S Ulbrich ◽

R S Schoenbauer ◽

B Kirstein ◽

J Tomala ◽

Y Huo ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Atrial Fibrillation ◽

Magnetic Resonance ◽

Stroke Volume ◽

Left Atrial ◽

Low Voltage ◽

Left Ventricular ◽

Left Ventricular Stroke Volume ◽

Resonance Imaging ◽

Ventricular Filling

Abstract Background The relation of left atrial low voltage zones (LVZ) to left ventricular function in patients undergoing pulmonary vein isolation (PVI) is not known. Objective To explore the relationship of left atrial low voltage zones (LVZ) on left ventricular function in patients with atrial fibrillation. Methods From June to Nov. 2018, 107 (mean age 67y, 70 men, 73 persistent AF) consecutive patients with symptomatic AF underwent a PVI with LVZ mapping. Before PVI the left ventricular ejection fraction (EF) and stroke volume (SV) were measured by cardiac magnetic resonance imaging (CMR). From feature-tracking of CMR-cine images left ventricular global, systolic and diastolic longitudinal strains (GLS), circumferential strains (GCS) and radial strains (GRS) were calculated. Results Of 59 patients CMR scanning in sinus rhythm was performed, LVZ were present in 24 patients. LVEF was significantly lower in patients with left atrial LVZ (62±9% vs. 55±15%) (p=0,03). Left ventricular stroke volume was significantly decreased by the extent of LVZ (94±23 vs. 72±21ml), (p=0,03). The left ventricular diastolic strains during ventricular filling (caused by atrial contraction) of GLS (r=−0,52), GCS (r=−0,65) and GRS (r=−0,65) were highly signifcantly correlated to the occurence and extent of LVZ (each p<0,001 respectively). The only systolic ventricular strain was GLS, which decreased (r=−0,3, p=0,03) by the occurance of atrial low voltage. Conclusion The active, atrial part of diastolic left ventricular filling properties is impaired by the occurrence and extent of left atrial LVZ. In patients with left atrial LVZ the left ventricular stroke volume and ejection fraction is decreased already in sinus rhythm. It seems possible that atrial mechanical dysfunction and presence of atrial low voltage maybe predicted by LV diastolic strain analysis.

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Duration of Electrically Induced Atrial Fibrillation Is Augmented by High Voltage of Stimulus with Higher Blood Pressure in Hypertensive Rats

International Journal of Hypertension ◽

10.1155/2014/980505 ◽

2014 ◽

Vol 2014 ◽

pp. 1-6 ◽

Cited By ~ 1

Author(s):

Tomomi Nagayama ◽

Yoshitaka Hirooka ◽

Akiko Chishaki ◽

Masao Takemoto ◽

Yasushi Mukai ◽

...

Keyword(s):

Atrial Fibrillation ◽

Blood Pressure ◽

Arterial Pressure ◽

High Voltage ◽

Spontaneously Hypertensive Rats ◽

Low Voltage ◽

Hypertensive Rats ◽

Spontaneously Hypertensive ◽

High Stimulus ◽

Wistar Kyoto

Objective.Many previous clinical studies have suggested that atrial fibrillation (AF) is closely associated with hypertension. However, the benefits of antihypertensive therapy on AF are still inconsistent, and it is necessary to explore the factors augmenting AF in hypertensive rats. The aim of the present study was to investigate the correlation between arterial pressure or voltage stimulus and to the duration of electrically induced AF in normotensive or hypertensive rats.Methods.AF was reproducibly induced by transesophageal atrial burst pacing in spontaneously hypertensive rats (SHR) and Wistar-Kyoto rats (WKY). We did the burst pacing at high (20 V) or low (5 V) voltage.Results.Duration of AF did not correlate with systolic blood pressure (SBP) and stimulus voltage in WKY. However, only in SHR, duration of AF with high stimulus voltage significantly correlated with SBP and was significantly longer in high than in low voltage stimulus.Discussion and Conclusion.Duration of AF is augmented by high voltage stimulus with higher blood pressure in SHR.

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ATRIAL LOW VOLTAGE AREAS: A COMPARISON BETWEEN ATRIAL FIBRILLATION AND SINUS RHYTHM

10.22541/au.160430252.23780427/v1 ◽

2020 ◽

Author(s):

Ana Andres ◽

Carlos Roberto ◽

Francisco Javier Saiz ◽

Oscar Cano ◽

Laura Martínez-Mateu ◽

...

Keyword(s):

Atrial Fibrillation ◽

Sinus Rhythm ◽

Low Voltage

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Low-voltage-area ablation in paroxysmal atrial fibrillation: Extended follow-up results of the VOLCANO trial

10.22541/au.161661216.67499040/v1 ◽

2021 ◽

Author(s):

Masaharu Masuda ◽

Mitsutoshi Asai ◽

Osamu Iida ◽

Shin Okamoto ◽

Takayuki Ishihara ◽

...

Keyword(s):

Atrial Fibrillation ◽

Paroxysmal Atrial Fibrillation ◽

Low Voltage ◽

Recurrence Rates ◽

Group A ◽

C 32 ◽

Group B ◽

Group D

Introduction: The randomized controlled VOLCANO trial demonstrated comparable 1-year rhythm outcomes between patients with and without ablation targeting low-voltage areas (LVAs) in addition to pulmonary vein isolation among paroxysmal atrial fibrillation (AF) patients with LVAs. To compare long-term AF/atrial tachycardia (AT) recurrence rates and types of recurrent-atrial-tachyarrhythmia between treatment cohorts during a > 2-year follow-up period. Methods: An extended-follow-up study of 402 patients enrolled in the VOLCANO trial with paroxysmal AF, divided into 4 groups based on the results of voltage mapping: Group A, no LVA (n=336); group B, LVA ablation (n=30); group C, LVA presence without ablation (n=32); and group D, incomplete voltage map (n=4). Results: At 25 (23, 31) months after the initial ablation, AF/AT recurrence rates were 19% in group A, 57% in group B, 59% in group C, and 100% in group D. Recurrence rates were higher in patients with LVAs than those without (group A vs. B+C, p<0.0001), and were comparable between those with and without LVA ablation (group B vs. C, p=0.83). Among patients who underwent repeat ablation, ATs were more frequently observed in patients with LVAs (Group B+C, 50% vs. A, 14%, p<0.0001). In addition, LVA ablation increased the incidence of AT development (group B, 71% vs. C, 32%, p<0.0001), especially biatrial tachycardia (20% vs. 0%, p=0.01). Conclusion: Patients with LVAs demonstrated poor long-term rhythm outcomes irrespective of LVA ablation. ATs were frequently observed in patients with LVAs, and LVA ablation might exacerbate iatrogenic ATs.

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Mapping & Ablation19Novel global ultrasound imaging and continuous dipole density mapping: initial findings in AF patients20Low voltage functional myocardium is critical in determining the substrate of post-ablation atrial tachycardia: results from a prospective study using ripple mapping distinguishing low-voltage scar from conducting tissue21Ripple mapping of post infarct ventricular scar to identify conduction channels and guide substrate based ablation22Effect of chamber geometry and activation pattern on optimal local activation time sampling density for tachycardia diagnosis25Clinical measures of good basket placement predict successful outcome from atrial fibrillation rotor ablation26Unipolar electrogram amplitude is reduced at rotor sites critical to focal termination of human persistent AF27Cryoballoon versus point by point radiofrequency ablation or a novel combined approach: long term follow up and comparison of patterns of pulmonary vein reconnection between different ablation strategies in a randomised controlled trial28Recurrent high dominant frequency patterns in persistent atrial fibrillation29Optimisation of late gadolinium enhanced (LGE) cmr imaging of atrial ablation scar30Hyperacute and chronic changes in cerebral magnetic resonance images after PVAC, NMARQ and epicardial thoracoscopic surgical ablation for paroxysmal atrial fibrillation

EP Europace ◽

10.1093/europace/euv326 ◽

2015 ◽

Vol 17 (suppl 5) ◽

pp. v6-v9

Author(s):

P.M. Heck ◽

V. Luther ◽

S.E. Williams ◽

A.A. Schricker ◽

...

Keyword(s):

Atrial Fibrillation ◽

Low Voltage ◽

Dominant Frequency ◽

Magnetic Resonance Images ◽

Successful Outcome ◽

Surgical Ablation ◽

Density Mapping ◽

Atrial Ablation ◽

Randomised Controlled ◽

A Prospective Study

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Abstract 20107: Randomized Comparison of Personalized versus Standardized Substrate Modification During Catheter Ablation for Symptomatic Atrial Fibrillation

Circulation ◽

10.1161/circ.132.suppl_3.20107 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Simon Kircher ◽

Arash Arya ◽

David Altmann ◽

Sascha Rolf ◽

Andreas Bollmann ◽

...

Keyword(s):

Atrial Fibrillation ◽

Low Voltage ◽

Randomized Study ◽

Standard Group ◽

Linear Lesions ◽

Substrate Modification ◽

Arrhythmogenic Substrate ◽

Group 2 ◽

Group 1

Introduction: Pulmonary vein (PV) isolation forms the cornerstone of any ablation procedure for atrial fibrillation (AF). There is, however, no uniform strategy how to detect and target left atrial (LA) arrhythmogenic substrate outside the PV antra. Fibrosis that corresponds well to LA low-voltage areas (LVAs) seems to play a key role in AF arrhythmogenesis and might therefore be a suitable target for additional substrate modification (SM). Objective: The purpose of this prospective randomized study was to compare a novel technique for SM based on ablation of potentially arrhythmogenic LA LVAs with a standard approach consisting of empiric LA linear ablation. Methods: Patients (pts) with symptomatic paroxysmal or persistent AF were randomized to standard (group 1) or personalized (group 2) SM. Circumferential PV isolation was the primary step in both groups. In group 1, pre-defined linear lesions were applied at the LA roof and bottom, respectively, and at the mitral isthmus only in pts with persistent AF. In group 2, targets for SM (i.e. LVAs) were identified by detailed bipolar voltage mapping (BVM) during sinus rhythm irrespective of AF type. Peak-to-peak electrogram amplitudes were defined as “normal” (> 0.5 mV), as “low voltages” (0.2 to 0.5 mV), or as “scar” (< 0.2 mV). LVAs were targeted by tissue homogenization and / or strategic linear lesions. The primary endpoint was freedom from any atrial arrhythmia (i.e. AF, atrial flutter, or atrial tachycardia) > 30 seconds off antiarrhythmic drugs on serial 7-d-Holter ECG recordings after a follow-up period of 12 months. Results: In total, 124 ablation-naïve pts (mean age 63 ± 9 years, 62 % male, 49 % with persistent AF) were enrolled in this study. LVAs were present in 18 % of pts with paroxysmal and in 41 % of pts with persistent AF (p<0.05). At the end of the follow-up period, 25 out of 59 pts (42 %) in the conventional group were free from arrhythmia recurrence as compared to 40 out of 59 pts (68 %) in the BVM-guided group (unadjusted log rank p = 0.003). Conclusion: Personalized SM guided by endocardial BVM is associated with a higher success rate compared to a conventional approach applying empirical SM based on AF phenotype.

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Abstract 15692: Voltage Mapping in Atrial Fibrillation vs Sinus Rhythm: Results From the Mavs Study

Circulation ◽

10.1161/circ.142.suppl_3.15692 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Carola Gianni ◽

Jerri A Cunningham ◽

Sanghamitra Mohanty ◽

CHINTAN TRIVEDI ◽

Domenico G Della Rocca ◽

...

Keyword(s):

Atrial Fibrillation ◽

Sinus Rhythm ◽

Low Voltage ◽

Lateral Wall ◽

Posterior Wall ◽

Anterior Wall ◽

Inferior Wall ◽

Voltage Mapping ◽

First Time ◽

Mapping Catheter

Background: Left atrial (LA) scar can be identified with bipolar voltage mapping during sinus rhythm (SR). It is not clear whether the same voltage criteria can be applied during atrial fibrillation (AF). Objective: Aim of this study was to compare voltage maps performed in the same patient both in AF and SR. Methods: Voltage mapping was performed using a 10-pole circular mapping catheter in patients with non-paroxysmal AF undergoing first time RF ablation. For descriptive purposes, the LA was divided in 6 regions: septum, posterior wall (PW), inferior wall (IW), lateral wall, anterior wall, and roof. The threshold for low voltage was <0.5 mV (with a color range setting 0.2-0.5 mV). Mild “scar” was defined as an area low voltage 5-20%, moderate 20-35% and severe as >35%. Results: 16 patients (62% persistent AF, 38% longstanding persistent AF) were included in the study. The map density was comparable during AF and SR (mean points per map 551 vs 547, paired t test P = NS). 2 patients displayed normal voltage during both AF and SR. 14 patients showed areas of low voltage during AF, which were still present during SR in 8. All patients with mild “scarring” during AF (n = 4), showed normal voltage during SR. Of the 7 patients with moderate “scarring”, 2 patients showed normal voltage during SR, while in the remaining 5 “scarring” was only mild during SR. 3 patients showed extensive “scarring” during AF, which was only moderate during SR. During AF, areas of low voltage were more commonly observed in the PW (12/14) followed by the IW (6/14) and antero-septum (4/14); while in SR, in the antero-septum (4/8), PW (3/8) and IW (3/8). Interestingly, in all patients both the PW/IW and (less dramatically) the antero-septum showed more “scarring” during AF as compared to SR. Conclusion: Areas of low voltage are more severe and diffuse during AF when compared to SR. When areas of low voltage are detected during AF, they are more commonly seen in the PW, IW and antero-septal areas.

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