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Left atrial voltage mapping: defining and targeting the atrial fibrillation substrate.

Authors
  • Sim, Iain1
  • Bishop, Martin1
  • O'Neill, Mark1
  • Williams, Steven E2
  • 1 Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor North Wing, St. Thomas' Hospital, 249 Westminster Bridge Road, London, SE1 7EH, UK.
  • 2 Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor North Wing, St. Thomas' Hospital, 249 Westminster Bridge Road, London, SE1 7EH, UK. [email protected]
Type
Published Article
Journal
Journal of Interventional Cardiac Electrophysiology
Publisher
Springer-Verlag
Publication Date
Dec 01, 2019
Volume
56
Issue
3
Pages
213–227
Identifiers
DOI: 10.1007/s10840-019-00537-8
PMID: 31076965
Source
Medline
Keywords
Language
English
License
Unknown

Abstract

Low atrial endocardial bipolar voltage, measured during catheter ablation for atrial fibrillation (AF), is a commonly used surrogate marker for the presence of atrial fibrosis. Low voltage shows many useful associations with clinical outcomes, comorbidities and has links to trigger sites for AF. Several contemporary trials have shown promise in targeting low voltage areas as the substrate for AF ablation; however, the results have been mixed. In order to understand these results, a thorough understanding of voltage mapping techniques, the relationship between low voltage and the pathophysiology of AF, as well as the inherent limitations in voltage measurement are needed. Two key questions must be answered in order to optimally apply voltage mapping as the road map for ablation. First, are the inherent limitations of voltage mapping small enough as to be ignored when targeting specific tissue based on voltage? Second, can conventional criteria, using a binary threshold for voltage amplitude, truly define the extent of the atrial fibrotic substrate? Here, we review the latest clinical evidence with regard to voltage-based ablation procedures before analysing the utility and limitations of voltage mapping. Finally, we discuss omnipole mapping and dynamic voltage attenuation as two possible approaches to resolving these issues.

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