Exploring LGE areas in the atria: Insights from electroanatomical voltage mapping in AF patients

Abstract Introduction Late gadolinium enhancement MRI (LGE MRI) is a common method for the evaluation of the atrial substrate in atrial fibrillation (AF) patients. The extent of LGE is associated with atrial cardiomyopathy and ablation outcomes. However, previous studies have yielded inconsistent results in detecting low voltage areas (LVA) using bipolar electroanatomical mapping (EAM) in LGE regions. Objective Conduct a thorough analysis of the bipolar and unipolar voltage in LGE areas and its relationship with the voltage in non-LGE areas, utilizing high-density (HD) EAM generated by a multipolar HD-mapping catheter. Methods In this study, 20 patients undergoing AF ablation were examined using LGE-MRI. A 3D mesh integrating LGE data was generated. HD-EAM (> 4000 points) was performed in sinus rhythm. The EAM map and MRI mesh underwent manual alignment and registration. Using a nearest neighbor algorithm, EAM points nearest to LGE areas were identified, and the corresponding unipolar and bipolar voltage values, along with LGE voxel intensity, were exported for analysis. Results LGE areas exhibited a median bipolar voltage amplitude of 0.93 mV, median unipolar voltage of 1.73 mV. In contrast, areas without enhancement displayed median bipolar voltage of 2.33 mV, unipolar voltage of 3.58 mV. We observed a variation in voltage amplitudes across the different LGE areas: bipolar voltage ranged from 0.04 to 2.51 mV and unipolar voltage from 0.22 to 3.75 mV. This variation strongly correlated with voxel intensity in LGE areas (correlation coefficient r = -0.86 [p <0.001]). Irrespective of the voltage amplitude in the examined LGE areas, a significant voltage drop was observed, with an average reduction of 54% in bipolar and 51% in unipolar voltages, compared to the amplitudes in non-LGE areas within the same atria. Conclusion Variations in bipolar and unipolar voltage within LGE areas are significantly correlated with local voxel intensity. Despite the inconsistent overlap with the predefined bipolar threshold for LVA, LGE regions exhibit a pronounced and consistent reduction in both bipolar and unipolar voltage compared to non-LGE areas. This pattern suggests notable electrophysiological changes in these areas. These insights underscore the need for further investigation to better understand the implications and mechanisms underlying these alterations in LGE regions.