Validating Left Atrial Low Voltage Areas During Atrial Fibrillation and Atrial Flutter Using Multielectrode Automated Electroanatomic Mapping
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Author + information
- Moisés Rodríguez-Mañero, MD, PhDa,b,∗ (moirmanero{at}gmail.com),
- Miguel Valderrábano, MDc,
- Aurora Baluja, MD, PhDd,
- Omar Kreidieh, MDe,
- Jose Luis Martínez-Sande, MD, PhDa,b,
- Javier García-Seara, MD, PhDa,b,
- Johan Saenen, MD, PhDf,
- Diego Iglesias-Álvarez, MDa,b,
- Wim Boriesf,
- Luis Miguel Villamayor-Blancoa,
- María Pereira-Vázqueza,
- Ricardo Lage, MD, PhDa,b,
- Julián Álvarez-Escudero, MD, PhDd,
- Hein Heidbuchel, MD, PhDf,
- José Ramón González-Juanatey, MD, PhDa,b and
- Andrea Sarkozy, MD, PhDf
- aCardiology Department, Hospital Universitario Santiago de Compostela, Santiago de Compostela, IDIS, Spain
- bCentro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV CB16/11/00226 - CB16/11/00420), Madrid, Spain
- cDivision of Cardiac Electrophysiology, Department of Cardiology Houston Methodist Hospital, Houston, Texas
- dCritical Patient Translational Research Group, Department of Anesthesiology, Intensive Care and Pain Management, Hospital Clínico Universitario, Santiago de Compostela, Spain
- eCardiology Department, Newark Beth Israel Medical Center, Newark, New Jersey
- fCardiology Department, Cardiac Electrophysiology Section, University Hospital of Antwerp, Antwerp, Belgium
- ↵∗Address for correspondence:
Dr. Moisés Rodríguez-Mañero, Cardiology Department, Complejo Hospital Universitario de Santiago, Santiago de Compostela, Spain, CIBERCV, Travesía da Choupana s/n, Santiago de Compostela, 15706 A Coruña, Spain.
Graphical abstract
Abstract
Objectives This study aimed: 1) to determine the voltage correlation between sinus rhythm (SR) and atrial fibrillation (AF)/atrial flutter (AFL) using multielectrode fast automated mapping; 2) to identify a bipolar voltage cutoff for scar and/or low voltage areas (LVAs); and 3) to examine the reproducibility of voltage mapping in AF.
Background It is unclear if bipolar voltage cutoffs should be adjusted depending on the rhythm and/or area being mapped.
Methods High-density mapping was performed first in SR and afterward in induced AF/AFL. In some patients, 2 maps were performed during AF. Maps were combined to create a new one. Points of <1 mm difference were analyzed. Correlation was explored with scatterplots and agreement analysis was assessed with Bland-Altman plots. The generalized additive model was also applied.
Results A total of 2,002 paired-points were obtained. A cutoff of 0.35 mV in AFL predicted a sinus voltage of 0.5 mV (95% confidence interval [CI]: 0.12 to 2.02) and of 0.24 mV in AF (95% CI: 0.11 to 2.18; specificity [SP]: 0.94 and 0.96; sensitivity [SE]: 0.85 and 0.75, respectively). When generalized additive models were used, a cutoff of 0.38 mV was used for AFL for predicting a minimum value of 0.5 mV in SR (95% CI: 0.5 to 1.6; SP: 0.94, SE: 0.88) and of 0.31 mV for AF (95% CI: 0.5 to 1.2; SP: 0.95, SE: 0.82). With regard to AF maps, there was no change in the classification of any left atrial region other than the roof.
Conclusions It is possible to establish new cutoffs for AFL and/or AF with acceptable validity in predicting a sinus voltage of <0.5 mV. Multielectrode fast automated mapping in AFL and/or AF seems to be reliable and reproducible when classifying LVAs. These observations have clinical implications for left atrial voltage distribution and in procedures in which scar distribution is used to guide pulmonary vein isolation and/or re-isolation.
Footnotes
Dr. Valderrábano has received research support from Biosense Webster. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received May 18, 2018.
- Revision received July 17, 2018.
- Accepted August 16, 2018.
- 2018 American College of Cardiology Foundation
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