The Duration of the Amplified Sinus-P-Wave Identifies Presence of Left Atrial Low Voltage Substrate and Predicts Outcome After Pulmonary Vein Isolation in Patients With Persistent Atrial Fibrillation

OBJECTIVES Left atrial (LA) low-voltage substrate (LVS) potentially slows intra-atrial conduction, which might identify patients at risk for arrhythmia recurrence following pulmonary vein isolation (PVI). BACKGROUND Up to 50% of patients with persistent atrial fibrillation (AF) have arrhythmia recurrence following PVI, mostly due to arrhythmogenic LA LVS. METHODS Seventy-two patients with persistent AF underwent electrocardioversion to sinus rhythm and high-density voltagemapping of the left atrium. Invasivelymeasured LA activation time and P-wave duration (PWD; total PWD and LA PWD [measured from -dV/dt in leads V-1 and V-2 until the end of the P-wave]) on amplified (40 to 50 mm/mV, 100 to 200mm/s) digitized 12-lead electrocardiography (ECG) were compared with the extent of LA LVS (<0.5 and <1. 0mV). Freedom from arrhythmia following PVI was evaluated in 143 patientswith persistent AF stratified according to amplifiedPWDbefore ablation. RESULTS LA LVS resulted in regional conduction delay, which increased LA activation time (r = 0.79). LA PWD strongly correlated with LA activation time (r = 0.96) and LA LVS (r = 0.80). As the first (right atrial) portion of the P-wave (from P-wave beginning until -dV/dt in leads V-1 and V-2) was not affected by LA LVS, total PWD correlated with LA LVS (r = 0.84). PWD >= 150 ms identified advanced LA LVS with 94.3% sensitivity and 91.7% specificity. One-year arrhythmia freedom following PVI-only was significantly higher in patients with PWD <150 ms (n = 73) compared with those with prolonged PWD >= 150 ms (n = 70) (72.0% vs. 40.8%; p = 0.003). CONCLUSIONS Advanced arrhythmogenic LVS is associated with significant intra-atrial conduction delay, which is accurately measurable by prolongation of PWD on amplified 12-lead ECG. PWD >= 150 ms during sinus rhythm measured prior to ablation identifies patients with persistent AFwho are at increased risk for arrhythmia recurrence following PVI. (C) 2018 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation.