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. 2024 Jun;67(4):773-784.
doi: 10.1007/s10840-023-01663-0. Epub 2023 Oct 16.

Incidence, distribution, and electrogram characteristics of endocardial-epicardial connections identified by ultra-high-resolution mapping during a left atrial posterior wall isolation of atrial fibrillation

Kohki Nakamura  1 , Takehito Sasaki  2 , Kentaro Minami  3 , Hideyuki Aoki  2 , Kan Kondo  2 , Shingo Yoshimura  2 , Kohki Kimura  2 , Yumiko Haraguchi  2 , Ryoya Takizawa  2 , Yosuke Nakatani  2 , Yuko Miki  2 , Koji Goto  2 , Yutaka Take  2 , Kenichi Kaseno  2 , Eiji Yamashita  2 , Shigeto Naito  2
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Incidence, distribution, and electrogram characteristics of endocardial-epicardial connections identified by ultra-high-resolution mapping during a left atrial posterior wall isolation of atrial fibrillation

Kohki Nakamura et al. J Interv Card Electrophysiol. 2024 Jun.

Abstract

Purpose: The left atrial posterior wall (LAPW) can be a target for atrial fibrillation (AF) catheter ablation but is sometimes difficult to completely isolate due to the presence of endocardial-epicardial connections. We aimed to investigate the incidence and distribution of epicardial residual connections (epi-RCs) and the electrogram characteristics at epi-RC sites during an initial LAPW isolation.

Methods: We retrospectively studied 102 AF patients who underwent LAPW mapping before and after a first-pass linear ablation along the superior and inferior LAPW (pre-ablation and post-ablation maps) using an ultra-high-resolution mapping system (Rhythmia, Boston Scientific).

Results: Epi-RCs were observed in 41 patients (40.2%) and were widely distributed in the middle LAPW area and surrounding it. The sites with epi-RCs had a higher bipolar voltage amplitude and greater number of fractionated components than those without (median, 1.09 mV vs. 0.83 mV and 3.9 vs. 3.4 on the pre-ablation map and 0.38 mV vs. 0.27 mV and 8.5 vs. 4.2 on the post-ablation map, respectively; P < 0.001). Receiver operating characteristic analyses demonstrated that the number of fractionated components on the post-ablation map had a larger area under the curve of 0.847 than the others, and the sensitivity and specificity for predicting epi-RCs were 95.4% and 62.1%, respectively, at an optimal cutoff of 5.0.

Conclusions: Among the patients with epi-RCs after a first-pass LAPW linear ablation, areas with a greater number of fractionated components (> 5.0 on the post-ablation LAPW map) may have endocardial-epicardial connections and may be potential targets for touch-up ablation to eliminate the epi-RCs.

Keywords: Atrial fibrillation; Catheter ablation; Complex activation; Epicardial connection; Left atrial posterior wall; Ultra-high-resolution mapping.

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