title: Tailored atrial substrate modification based on low-voltage areas in catheter ablation of atrial fibrillation.
abstract: BACKGROUND
  Reduced electrogram amplitude has been shown to correlate with diseased myocardium. We describe a novel individualized approach for catheter ablation of atrial fibrillation (AF) based on low-voltage areas (LVAs) in the left atrium (LA). We sought to assess (1) the incidence of LVAs in patients undergoing AF catheter ablation, (2) the distribution of LVAs within the LA, and (3) the effect of an individualized ablation strategy on long-term rhythm outcomes.
  
  
  RESULTS
  In 178 patients with paroxysmal or persistent AF, LA voltage maps were created during sinus rhythm after circumferential pulmonary vein isolation. Subsequent substrate modification was confined to the presence of LVA (<0.5 mV) and inducible regular atrial tachycardias. LVAs were identified in 35% and 10% of patients with persistent and paroxysmal AF, respectively. The LA roof and the anterior, septal, and posterior wall LA were most often affected. The 12-month atrial tachycardias/AF-free survival was 62% for patients without LVAs and 70% for patients with LVAs and tailored substrate modification (P=0.3). Success rate in a comparison group of 26 LVA patients without further substrate modification was 27%.
  
  
  CONCLUSIONS
  LVAs can be found at preferred sites in 10% of patients with paroxysmal AF and in 35% of patients with persistent AF. This is the first clinical report describing a consistent voltage-based approach for substrate modification in addition to circumferential pulmonary vein isolation irrespective of AF type. Application of this limited individualized approach may have the potential to compensate for the impaired 12-month outcome of patients with endocardial structural defects.
authors.affiliation: From the Department of Electrophysiology, University of Leipzig-Heart Center, Leipzig, Germany (S.R., S.K., A.A., C.E., P.S., S.R., A.B., C.P., G.H.); Department of Electrophysiology, University of Dresden-Heart Center, Dresden, Germany (T.G., C.P.); and Department of Cardiology, Kantonsspital St. Gallen, St. Gallen, Switzerland (D.A.). sascha.rolf@web.de.
authors.forename: Sascha
authors.initials: S
authors.lastname: Rolf
authors.affiliation: From the Department of Electrophysiology, University of Leipzig-Heart Center, Leipzig, Germany (S.R., S.K., A.A., C.E., P.S., S.R., A.B., C.P., G.H.); Department of Electrophysiology, University of Dresden-Heart Center, Dresden, Germany (T.G., C.P.); and Department of Cardiology, Kantonsspital St. Gallen, St. Gallen, Switzerland (D.A.).
authors.forename: Simon
authors.initials: S
authors.lastname: Kircher
authors.affiliation: From the Department of Electrophysiology, University of Leipzig-Heart Center, Leipzig, Germany (S.R., S.K., A.A., C.E., P.S., S.R., A.B., C.P., G.H.); Department of Electrophysiology, University of Dresden-Heart Center, Dresden, Germany (T.G., C.P.); and Department of Cardiology, Kantonsspital St. Gallen, St. Gallen, Switzerland (D.A.).
authors.forename: Arash
authors.initials: A
authors.lastname: Arya
authors.affiliation: From the Department of Electrophysiology, University of Leipzig-Heart Center, Leipzig, Germany (S.R., S.K., A.A., C.E., P.S., S.R., A.B., C.P., G.H.); Department of Electrophysiology, University of Dresden-Heart Center, Dresden, Germany (T.G., C.P.); and Department of Cardiology, Kantonsspital St. Gallen, St. Gallen, Switzerland (D.A.).
authors.forename: Charlotte
authors.initials: C
authors.lastname: Eitel
authors.affiliation: From the Department of Electrophysiology, University of Leipzig-Heart Center, Leipzig, Germany (S.R., S.K., A.A., C.E., P.S., S.R., A.B., C.P., G.H.); Department of Electrophysiology, University of Dresden-Heart Center, Dresden, Germany (T.G., C.P.); and Department of Cardiology, Kantonsspital St. Gallen, St. Gallen, Switzerland (D.A.).
authors.forename: Philipp
authors.initials: P
authors.lastname: Sommer
authors.affiliation: From the Department of Electrophysiology, University of Leipzig-Heart Center, Leipzig, Germany (S.R., S.K., A.A., C.E., P.S., S.R., A.B., C.P., G.H.); Department of Electrophysiology, University of Dresden-Heart Center, Dresden, Germany (T.G., C.P.); and Department of Cardiology, Kantonsspital St. Gallen, St. Gallen, Switzerland (D.A.).
authors.forename: Sergio
authors.initials: S
authors.lastname: Richter
authors.affiliation: From the Department of Electrophysiology, University of Leipzig-Heart Center, Leipzig, Germany (S.R., S.K., A.A., C.E., P.S., S.R., A.B., C.P., G.H.); Department of Electrophysiology, University of Dresden-Heart Center, Dresden, Germany (T.G., C.P.); and Department of Cardiology, Kantonsspital St. Gallen, St. Gallen, Switzerland (D.A.).
authors.forename: Thomas
authors.initials: T
authors.lastname: Gaspar
authors.affiliation: From the Department of Electrophysiology, University of Leipzig-Heart Center, Leipzig, Germany (S.R., S.K., A.A., C.E., P.S., S.R., A.B., C.P., G.H.); Department of Electrophysiology, University of Dresden-Heart Center, Dresden, Germany (T.G., C.P.); and Department of Cardiology, Kantonsspital St. Gallen, St. Gallen, Switzerland (D.A.).
authors.forename: Andreas
authors.initials: A
authors.lastname: Bollmann
authors.affiliation: From the Department of Electrophysiology, University of Leipzig-Heart Center, Leipzig, Germany (S.R., S.K., A.A., C.E., P.S., S.R., A.B., C.P., G.H.); Department of Electrophysiology, University of Dresden-Heart Center, Dresden, Germany (T.G., C.P.); and Department of Cardiology, Kantonsspital St. Gallen, St. Gallen, Switzerland (D.A.).
authors.forename: David
authors.initials: D
authors.lastname: Altmann
authors.affiliation: From the Department of Electrophysiology, University of Leipzig-Heart Center, Leipzig, Germany (S.R., S.K., A.A., C.E., P.S., S.R., A.B., C.P., G.H.); Department of Electrophysiology, University of Dresden-Heart Center, Dresden, Germany (T.G., C.P.); and Department of Cardiology, Kantonsspital St. Gallen, St. Gallen, Switzerland (D.A.).
authors.forename: Carlos
authors.initials: C
authors.lastname: Piedra
authors.affiliation: From the Department of Electrophysiology, University of Leipzig-Heart Center, Leipzig, Germany (S.R., S.K., A.A., C.E., P.S., S.R., A.B., C.P., G.H.); Department of Electrophysiology, University of Dresden-Heart Center, Dresden, Germany (T.G., C.P.); and Department of Cardiology, Kantonsspital St. Gallen, St. Gallen, Switzerland (D.A.).
authors.forename: Gerhard
authors.initials: G
authors.lastname: Hindricks
authors.affiliation: From the Department of Electrophysiology, University of Leipzig-Heart Center, Leipzig, Germany (S.R., S.K., A.A., C.E., P.S., S.R., A.B., C.P., G.H.); Department of Electrophysiology, University of Dresden-Heart Center, Dresden, Germany (T.G., C.P.); and Department of Cardiology, Kantonsspital St. Gallen, St. Gallen, Switzerland (D.A.).
authors.forename: Christopher
authors.initials: C
authors.lastname: Piorkowski
mesh_terms: D000200:Action Potentials; D000368:Aged; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D016279:Atrial Function, Left; D002304:Cardiac Pacing, Artificial; D017115:Catheter Ablation / Q000009:adverse effects; D018572:Disease-Free Survival; D022062:Electrophysiologic Techniques, Cardiac; D005260:Female; D006325:Heart Atria / Q000503:physiopathology / Q000601:surgery; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D011237:Predictive Value of Tests; D011667:Pulmonary Veins / Q000503:physiopathology / Q000601:surgery*; D012008:Recurrence; D013617:Tachycardia, Supraventricular / Q000209:etiology; D013997:Time Factors; D016896:Treatment Outcome
keywords: arrhythmias, cardiac; atrial fibrillation; catheter ablation; fibrosis