title: Prospective, multicenter validation of a clinical risk score for left atrial arrhythmogenic substrate based on voltage analysis: DR-FLASH score.
abstract: BACKGROUND
  Left atrial (LA) low-voltage areas (LVAs) are frequently observed in patients with atrial fibrillation (AF) and may predict AF recurrence after catheter ablation.
  
  
  OBJECTIVE
  The aim of this study was to develop and validate a clinical tool to identify LVAs that are associated with AF recurrence after pulmonary vein isolation (PVI).
  
  
  METHODS
  In a cohort of 238 patients, voltage maps were created during LA procedures. LVAs were defined as areas with electrogram amplitudes <0.5 mV. On the basis of regression analysis, predictors of LA substrate were identified. These parameters were used to establish a dedicated risk score (DR-FLASH score, based on diabetes mellitus, renal dysfunction, persistent form of AF, LA diameter >45 mm, age >65 years, female sex, and hypertension). This risk score was then prospectively validated in a multicenter cohort of 180 patients. The association of the score with long-term recurrence of atrial arrhythmias after circumferential PVI was tested in a retrospective cohort of 484 patients.
  
  
  RESULTS
  The DR-FLASH score effectively identified LVA substrate (C statistic = 0.801, P < .001). In the prospective multicenter validation cohort, the predictive value of the DR-FLASH score was confirmed (C statistic = 0.767, P < .001). The probability for the presence of LA substrate increased by a factor of 2.2 (95% confidence interval [CI] 1.6-2.9, P < .001) with each point scored. Furthermore, the risk of AF recurrence after PVI increased by a factor of 1.3 (95% CI 1.1-1.5, P < .001) with every additional point and was almost 2 times higher in patients with a DR-FLASH score >3 (odds ratio 1.7, 95% CI 1.1-2.8, P = .026).
  
  
  CONCLUSIONS
  The DR-FLASH score may be useful to identify patients who may require extensive substrate modification instead of PVI alone.
authors.affiliation: Department of Electrophysiology, Heart Center Leipzig, Leipzig, Germany. Electronic address: jedrzejkosiuk@hotmail.com.
authors.forename: Jedrzej
authors.initials: J
authors.lastname: Kosiuk
authors.affiliation: Department of Electrophysiology, Heart Center Leipzig, Leipzig, Germany.
authors.forename: Borislav
authors.initials: B
authors.lastname: Dinov
authors.affiliation: Department of Electrophysiology, Heart Center Leipzig, Leipzig, Germany.
authors.forename: Jelena
authors.initials: J
authors.lastname: Kornej
authors.affiliation: Department of Cardiology, AZ Delta, Roeselare, Belgium.
authors.forename: Willem-Jan
authors.initials: WJ
authors.lastname: Acou
authors.affiliation: Department of Internal Medicine, Mödling, Austria.
authors.forename: Robert
authors.initials: R
authors.lastname: Schönbauer
authors.affiliation: Department of Internal Medicine, Mödling, Austria.
authors.forename: Lukas
authors.initials: L
authors.lastname: Fiedler
authors.affiliation: 3rd Department of Cardiology, Department of Cardiovascular Diseases, Silesian Center for Heart Diseases, Zabrze, Poland.
authors.forename: Piotr
authors.initials: P
authors.lastname: Buchta
authors.affiliation: 3rd Department of Cardiology, Department of Cardiovascular Diseases, Silesian Center for Heart Diseases, Zabrze, Poland.
authors.forename: Krzysztof
authors.initials: K
authors.lastname: Myrda
authors.affiliation: 3rd Department of Cardiology, Department of Cardiovascular Diseases, Silesian Center for Heart Diseases, Zabrze, Poland.
authors.forename: Mariusz
authors.initials: M
authors.lastname: Gąsior
authors.affiliation: 3rd Department of Cardiology, Department of Cardiovascular Diseases, Silesian Center for Heart Diseases, Zabrze, Poland.
authors.forename: Lech
authors.initials: L
authors.lastname: Poloński
authors.affiliation: Department of Electrophysiology, Heart Center Leipzig, Leipzig, Germany.
authors.forename: Simon
authors.initials: S
authors.lastname: Kircher
authors.affiliation: Department of Electrophysiology, Heart Center Leipzig, Leipzig, Germany.
authors.forename: Arash
authors.initials: A
authors.lastname: Arya
authors.affiliation: Department of Electrophysiology, Heart Center Leipzig, Leipzig, Germany.
authors.forename: Philipp
authors.initials: P
authors.lastname: Sommer
authors.affiliation: Department of Electrophysiology, Heart Center Leipzig, Leipzig, Germany.
authors.forename: Andreas
authors.initials: A
authors.lastname: Bollmann
authors.affiliation: Department of Electrophysiology, Heart Center Leipzig, Leipzig, Germany.
authors.forename: Gerhard
authors.initials: G
authors.lastname: Hindricks
authors.affiliation: Department of Electrophysiology, Heart Center Leipzig, Leipzig, Germany.
authors.forename: Sascha
authors.initials: S
authors.lastname: Rolf
mesh_terms: D000200:Action Potentials; D000368:Aged; D001281:Atrial Fibrillation / Q000175:diagnosis* / Q000401:mortality / Q000601:surgery*; D018780:Body Surface Potential Mapping / Q000379:methods*; D053840:Brugada Syndrome / Q000175:diagnosis* / Q000601:surgery; D000075224:Cardiac Conduction System Disease; D017115:Catheter Ablation / Q000379:methods* / Q000401:mortality; D015331:Cohort Studies; D022062:Electrophysiologic Techniques, Cardiac; D005260:Female; D005500:Follow-Up Studies; D006325:Heart Atria / Q000503:physiopathology; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012372:ROC Curve; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D018709:Statistics, Nonparametric; D015996:Survival Rate; D016896:Treatment Outcome
keywords: Ablation; Atrial fibrillation; Fibrosis; Outcome; Score