AIMS: Electro-anatomical mapping may be critical to identify atrial fibrillation (AF) subjects who require substrate modification beyond pulmonary vein isolation (PVI). The objective was to determine correlations between pre-ablation mapping characteristics and 12-month outcomes after a single PVI-only catheter ablation of AF. METHODS AND RESULTS: This study enrolled paroxysmal AF (PAF), early persistent AF (PsAF; 7 days-3 months), and non-early PsAF (>3-12 months) subjects undergoing de novo PVI-only radiofrequency catheter ablation. Sinus rhythm (SR) and AF voltage maps were created with the Advisor HD Grid™ Mapping Catheter, Sensor Enabled™ for each subject, and the presence of low-voltage area (LVA) (low-voltage cutoffs: 0.1-1.5 mV) was investigated. Follow-up visits were at 3, 6, and 12 months, with a 24-h Holter monitor at 12 months. A Cox proportional hazards model identified associations between mapping data and 12-month recurrence after a single PVI procedure. The study enrolled 300 subjects (113 PAF, 86 early PsAF, and 101 non-early PsAF) at 18 centres. At 12 months, 75.5% of subjects were free from AF/atrial flutter (AFL)/atrial tachycardia (AT) recurrence. Univariate analysis found that arrhythmia recurrence did not correlate with AF diagnosis, but LVA was significantly correlated. Low-voltage area (<0.5 mV) >28% of the left atrium in SR [hazard ratio (HR): 4.82, 95% confidence interval (CI): 2.08-11.18; P = 0.0003] and >72% in AF (HR: 5.66, 95% CI: 2.34-13.69; P = 0.0001) was associated with a higher risk of AF/AFL/AT recurrence at 12 months. CONCLUSION: Larger extension of LVA was associated with an increased risk of arrhythmia recurrence. These subjects may benefit from substrate modification beyond PVI.

1st Department of Internal Medicine Cardioangiology St Anne's Hospital Masaryk University Pekarska 664 53 Brno 60200 Czech Republic

2nd Division of Cardiovascular Diseases Cardiac Thoracic and Vascular Department New Santa Chiara Hospital Azienda Ospedaliero Universitaria Pisana Pisa Italy

Abbott Saint Paul MN USA

Arrhythmia Unit and Electrophysiology Laboratories Ospedale San Raffaele Milano Italy

Cardiology Department Rhythmology Unit Centre Hospitalier Universitaire de La Reunion La Reunion France

Department for Electrophysiology Herz und Diabetes Zentrum NRW Bad Oeynhausen Germany

Department of Cardiology Hopital Prive du Confluent Nantes France

Department of Cardiology John Radcliffe Hospital Oxford UK

Department of Cardiology Section of Electrophysiology Herz und Gefäßzentrum Bad Bevensen Bad Bevensen Germany

International Clinical Research Center St Anne's University Hospital Brno Pekarska 664 53 Brno 60200 Czech Republic

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