ExTRa mapping-derived non-passive activation predicts atrial fibrillation recurrence following pulmonary vein isolation in persistent atrial fibrillation.

BACKGROUND

Pulmonary vein (PV) isolation is the cornerstone of catheter ablation for atrial fibrillation (AF), yet its efficacy remains suboptimal in persistent AF, partly due to non-PV drivers. ExTRa Mapping, a real-time phase mapping system, enables visualization of spatiotemporal AF dynamics and identification of non-PV drivers. This study investigated whether ExTRa Mapping parameters predict AF recurrence after PV isolation in persistent AF.

METHODS

Forty consecutive patients with symptomatic persistent AF were enrolled. All underwent extensive PV isolation followed by adjunctive ablation targeting non-PV driver regions identified by ExTRa Mapping.

RESULTS

Mean AF duration was 1.3 ± 2.1 years, and mean follow-up was 2.3 ± 1.8 years. AF recurred in 20 patients. The ExTRa score, defined as the mean of the five highest non-passive activation (%NP) values, was significantly associated with AF recurrence (p = 0.0040). An ExTRa score ≥ 55.8% predicted recurrence with an area under the curve of 0.767 (log-rank p = 0.0012). Patients with the highest %NP localized to the peri-left atrial appendage region had higher recurrence rates than those with non-peri-LAA localization (p = 0.0384). The ExTRa score was significantly associated with recurrence in univariate Cox analysis (HR 4.99, p = 0.0012) and remained an independent predictor in multivariate analysis (HR 7.86, p < 0.0001). Adjunctive ablation of the top five regions did not ensure durable rhythm control.

CONCLUSIONS

The ExTRa score independently predicts AF recurrence after PV isolation in persistent AF and may aid in identifying high-risk patients and optimizing individualized ablation strategies.