title: Voltage mapping for delineating inexcitable dense scar in patients undergoing atrial fibrillation ablation: a new end point for enhancing pulmonary vein isolation.
abstract: BACKGROUND
  Characterization of left atrial scar using bipolar voltage (BiV) mapping is not well defined. We have previously shown that the BiV range of 0.2-0.45 mV can identify chronic scar from prior pulmonary vein isolation (PVI).
  
  
  OBJECTIVE
  This study sought to determine a BiV range that can identify atrial inexcitable dense scar (IDS) in patients acutely and chronically after PVI.
  
  
  METHODS
  Thirty consecutive patients undergoing first time (n = 15) or redo (n = 15) PVI were included. A left atrial shell was created using electroanatomic mapping, and IDS was defined by inability to capture at an output of 10 mA and a pulse width of 2 ms in sinus rhythm, circumferentially at the edge of PVI-related scar (≤5 mm). At each pacing site, BiV amplitude and atrial capture were recorded.
  
  
  RESULTS
  Overall, 837 pacing sites were assessed. BiV predicted IDS (receiver operating characteristic curve area 0.93 for first time PVI and 0.90 for redo PVI). In first time PVI, the best BiV value to predict IDS was 0.45 mV for the left pulmonary vein-left atrial appendage (LAA-LPV) ridge (sensitivity 0.98; specificity 1.0) and 0.2 mV for other localizations (sensitivity 0.91; specificity 0.86). In redo PVI, the best BiV value to predict IDS was 0.2 mV for the LAA-LPV ridge (sensitivity 0.77; specificity 1.0) and 0.15 mV for other localizations (sensitivity 0.81; specificity 0.82).
  
  
  CONCLUSIONS
  BiV reproducibly identifies acute and chronic IDS using a cutoff value of 0.2 mV (0.45 mV for the LAA-LPV ridge) in patients undergoing first time PVI and 0.15 mV (0.2 mV for the LAA-LPV ridge) in patients undergoing redo PVI. IDS thus identified may be a rigorous tool for validating PVI.
authors: Department of Cardiology, Pasteur University Hospital, Nice, France.
authors: Fabien
authors: F
authors: Squara
authors: Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors: David S
authors: DS
authors: Frankel
authors: Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors: Robert
authors: R
authors: Schaller
authors: Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors: Suraj
authors: S
authors: Kapa
authors: Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors: William W
authors: WW
authors: Chik
authors: Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors: David J
authors: DJ
authors: Callans
authors: Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors: Francis E
authors: FE
authors: Marchlinski
authors: Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address: Sanjay.Dixit@uphs.upenn.edu.
authors: Sanjay
authors: S
authors: Dixit
mesh_terms: D001281:Atrial Fibrillation / Q000503:physiopathology* / Q000601:surgery*; D017115:Catheter Ablation / Q000379:methods*; D002921:Cicatrix / Q000503:physiopathology*; D015897:Comorbidity; D022062:Electrophysiologic Techniques, Cardiac / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011667:Pulmonary Veins / Q000503:physiopathology* / Q000601:surgery*; D012086:Reoperation; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity
keywords: Ablation; Atrial fibrillation; Electroanatomic mapping; Scar