Author + information
- Received July 19, 2017
- Revision received November 27, 2017
- Accepted December 4, 2017
- Published online April 16, 2018.
- Amir Jadidi, MDa,b,∗ (, )
- Björn Müller-Edenborn, MDa,
- Juan Chen, MDb,c,
- Cornelius Keyl, MDd,
- Reinhold Weber, MDa,b,
- Jürgen Allgeier, MDa,b,
- Zoraida Moreno-Weidmann, MDb,
- Dietmar Trenk, PhDe,
- Franz-Josef Neumann, MDa,
- Heiko Lehrmann, MDa,b and
- Thomas Arentz, MDa,b
- aDepartment of Cardiology, University Heart Center Freiburg–Bad Krozingen, Bad Krozingen, Germany
- bDepartment of Electrophysiology, University Heart Center Freiburg–Bad Krozingen, Bad Krozingen, Germany
- cCardiovascular Department, The First People’s Hospital of Jingmen, Hubei, China
- dDepartment of Anesthesiology, University Heart Center Freiburg–Bad Krozingen, Bad Krozingen, Germany
- eDepartment of Pharmacology, University Heart Center Freiburg–Bad Krozingen, Bad Krozingen, Germany
- ↵∗Address for correspondence:
Dr. Amir Jadidi, Department of Rhythmology, University Heart Center Freiburg–Bad Krozingen, Südring 15, 79189 Bad Krozingen, Germany.
Objectives Left atrial (LA) low-voltage substrate (LVS) potentially slows intra-atrial conduction, which might identify patients at risk for arrhythmia recurrence following pulmonary vein isolation (PVI).
Background Up to 50% of patients with persistent atrial fibrillation (AF) have arrhythmia recurrence following PVI, mostly due to arrhythmogenic LA LVS.
Methods Seventy-two patients with persistent AF underwent electrocardioversion to sinus rhythm and high-density voltage mapping of the left atrium. Invasively measured LA activation time and P-wave duration (PWD; total PWD and LA PWD [measured from −dV/dt in leads V1 and V2 until the end of the P-wave]) on amplified (40 to 50 mm/mV, 100 to 200 mm/s) digitized 12-lead electrocardiography (ECG) were compared with the extent of LA LVS (<0.5 and <1. 0mV). Freedom from arrhythmia following PVI was evaluated in 143 patients with persistent AF stratified according to amplified PWD before ablation.
Results LA LVS resulted in regional conduction delay, which increased LA activation time (r = 0.79). LA PWD strongly correlated with LA activation time (r = 0.96) and LA LVS (r = 0.80). As the first (right atrial) portion of the P-wave (from P-wave beginning until −dV/dt in leads V1 and V2) was not affected by LA LVS, total PWD correlated with LA LVS (r = 0.84). PWD ≥150 ms identified advanced LA LVS with 94.3% sensitivity and 91.7% specificity. One-year arrhythmia freedom following PVI-only was significantly higher in patients with PWD <150 ms (n = 73) compared with those with prolonged PWD ≥150 ms (n = 70) (72.0% vs. 40.8%; p = 0.003).
Conclusions Advanced arrhythmogenic LVS is associated with significant intra-atrial conduction delay, which is accurately measurable by prolongation of PWD on amplified 12-lead ECG. PWD ≥150 ms during sinus rhythm measured prior to ablation identifies patients with persistent AF who are at increased risk for arrhythmia recurrence following PVI.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Jadidi and Müller-Edenborn contributed equally to this work and are joint first authors. Drs. Lehrmann and Arentz contributed equally to this work and are joint senior authors.
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 July 19, 2017.
- Revision received November 27, 2017.
- Accepted December 4, 2017.
- 2018 The Authors