Predictors of sinus rhythm restoration during radiofrequency ablation in patients with persistent atrial fibrillation

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Abstract
Aim . To identify predictors of sinus rhythm restoration during radiofrequency ablation (RFA) in patients with persistent atrial fibrillation (AF). Methods . The study included 51 patients with persistent AF who underwent primary RFA. All patients underwent left atrial (LA) voltage mapping. The percentage of low-voltage areas (LVA%) was calculated, with a low-voltage threshold 0.5 mV. After pulmonary vein isolation (PVI), if AF persist, posterior wall isolation and mitral isthmus ablation were performed. In cases of persistent AF, LA electrophysiological mapping was performed using a multielectrode catheter to identify areas of fractionated signals and local re-entry, followed by ablation of these areas. If AF transformed into atrial flutter, activation mapping was performed to verify the arrhythmia mechanism and ablate the critical isthmus. If the AF rhythm persisted, electrical cardioversion was performed. Results . Sinus rhythm was restored during RFA in 29 patients (56.8%) and by electrical cardioversion in 22 patients (43.2%). Statistically significant differences between rhythm restoration types were found in AF duration (p=0.013; AUC=0.705) and LA appendage flow velocity (p=0.021; AUC=0.697). Patients who achieved rhythm restoration at the PVI stage had significantly smaller LA volume (p=0.004; AUC=0.796) and LVA% (p=0.002; AUC=0.792). In the group of patients in whom AF was eliminated by direct restoration to sinus rhythm during RFA, LVA% was significantly lower (p=0.039; AUC=0.738) compared with those in whom AF was eliminated via transformation into atrial flutter. Conclusions . AF duration and LA appendage flow velocity are predictors of rhythm restoration during RFA. Among patients who achieved sinus rhythm restoration during ablation, those who converted at the PVI stage had smaller LA volume and LVA%. An LVA% greater than 28.5% was identified as a predictor of AF transformation into atypical atrial flutter during RFA of persistent AF.

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