Background Bipolar electrogram voltage during sinus rhythm (V SR ) has been used as a surrogate for atrial fibrosis in guiding catheter ablation of persistent atrial fibrillation (AF), but the fixed rate and wavefront characteristics present during sinus rhythm may not accurately reflect underlying functional vulnerabilities responsible for AF maintenance. Objective The purpose of this study was determine whether, given adequate temporal sampling, the spatial distribution of mean AF voltage (V mAF ) better correlates with delayed-enhancement magnetic resonance imaging (MRI-DE)–detected atrial fibrosis than V SR . Methods AF was mapped (8 seconds) during index ablation for persistent AF (20 patients) using a 20-pole catheter (660 ± 28 points/map). After cardioversion, V SR was mapped (557 ± 326 points/map). Electroanatomic and MRI-DE maps were co-registered in 14 patients. Results The time course of V mAF was assessed from 1–40 AF cycles (∼8 seconds) at 1113 locations. V mAF stabilized with sampling >4 seconds (mean voltage error 0.05 mV). Paired point analysis of V mAF from segments acquired 30 seconds apart (3667 sites; 15 patients) showed strong correlation (r = 0.95; P <.001). Delayed enhancement (DE) was assessed across the posterior left atrial (LA) wall, occupying 33% ± 13%. V mAF distributions were (median [IQR]) 0.21 [0.14–0.35] mV in DE vs 0.52 [0.34–0.77] mV in non-DE regions. V SR distributions were 1.34 [0.65–2.48] mV in DE vs 2.37 [1.27–3.97] mV in non-DE. V mAF threshold of 0.35 mV yielded sensitivity of 75% and specificity of 79% in detecting MRI-DE compared with 63% and 67%, respectively, for V SR (1.8-mV threshold) . Conclusion The correlation between low-voltage and posterior LA MRI-DE is significantly improved when acquired during AF vs sinus rhythm. With adequate sampling, mean AF voltage is a reproducible marker reflecting the functional response to the underlying persistent AF substrate.

1Background: The activation pattern of localized re-entry (LR) in atrial tachycardia (AT)

Background-Ripple mapping (RM) displays each electrogram at its 3-dimensional coordinate as a bar changing in length according to its voltage-time relationship with a fiduciary reference. We applied RM to left ventricular ischemic scar for evidence of slow-conducting channels that may act as ventricular tachycardia (VT) substrate. Methods and Results-CARTO-3© (Biosense Webster Inc, Diamond Bar, CA) maps in patient undergoing VT ablation were analyzed on an offline MatLab RM system. Scar was assessed for sequential movement of ripple bars, during sinus rhythm or pacing, which were distinct from surrounding tissue and termed RM conduction channels (RMCC). Conduction velocity was measured within RMCCs and compared with the healthy myocardium (>1.5 mV