Background: Gender-related differences have been reported in atrial fibrotic remodeling and prognosis of atrial fibrillation (AF) patients after ablation. We assessed in persistent AF the regional distribution of left atrial (LA) bipolar voltage and the extent of low-voltage zones (LVZ) according to gender as well as the results of a voltage-guided substrate ablation.Methods: Consecutive patients who underwent a voltage-guided AF ablation were enrolled. LA endocardial voltage maps were obtained using a 3D electro-anatomical mapping system in sinus rhythm. LVZ was defined as <0.5 mV.Results: A total of 115 patients were enrolled (74 men, 41 women). The LA bipolar voltage amplitude was twice lower in the whole LA (p < 0.01) and in each atrial region in women compared with men, whereas the LA indexed volume was similar. LVZ were found in 56.1% of women and 16.2% of men (p < 0.01). LVZ were also more extensive in women (p = 0.01), especially in the anterior LA. Atrial voltage alteration occurred earlier in women than in men. In a multivariate analysis, the female sex (OR 12.99; 95% CI, 3.23–51.63, p = 0.0001) and LA indexed volume (OR 1.09; 95% CI, 1.04–1.16, p = 0.001) were predictive of LVZ. Atrial arrhythmia-free survival was similar in men and women 36 months after a single ablation procedure.Conclusion: The study reports a strong relationship between the female gender and atrial substrate remodeling. The female gender was significantly associated with higher incidence, earlier occurrence, and greater extent of LVZ compared with men. Despite the female-specific characteristics in atrial remodeling, LVZ-guided ablation may improve the AF ablation outcome in women.

Background: Persistent atrial fibrillation (AF) patients with tachycardia-induced cardiomyopathy (TIC) undergoing catheter ablation have similar or even better outcomes than patients without TIC. Data regarding atrial substrate remodeling are scarce in cases of TIC. We assessed regional distribution of left atrial (LA) bipolar voltage, the extent of low-voltage zones (LVZs), and outcomes of voltage-guided ablation in AF patients with and without TIC.Methods and Results: In all, 139 patients with persistent AF presenting for a first voltage-guided catheter ablation were enrolled, 61 with TIC and 78 with structurally normal hearts. LA voltage maps were obtained using a 3-dimensional electroanatomical mapping system in sinus rhythm. LVZ was defined as <0.5 mV. Compared with non-TIC patients, TIC patients had a lower indexed LA volume (median [interquartile range] 58.6 [50.6–68.7] vs. 63.4 [60.1–76.1] mL/m2; P<0.01) and higher LA voltage (2.3 [1.5–2.8] vs. 1.7 [1–2.6] mV; P=0.02). LVZs were less frequently found in patients with than without TIC (8 [13.1%] vs. 30 [39%]; P<0.01). There was no significant difference in atrial tachyarrhythmia (AT)-free survival rate over a 36-month follow-up between the 2 groups (log-rank test, P=0.176). No predictor of AT recurrence was identified.Conclusions: TIC patients exhibit less LA substrate remodeling with a smaller LA volume, higher bipolar voltage, and fewer LVZs than non-TIC patients. They have a similar favorable outcome after a single procedure.

Left atrial (LA) dilation is implicated in atrial fibrillation (AF) recurrence after catheter ablation (CA),^1,2 but there are limited data considering LA volume (LAV) in relation to low-voltage zones (LVZs). Some studies on AF ablation have noted an interesting association between large LA size and the presence of LVZs on LA voltage maps.^3–5 However, in the cohort of Bergonti et al.,⁵ 30% of paroxysmal and persistent AF patients showed significantly increased LA volume index (LAVI) without any LVZs. We assessed LA bipolar voltage and the outcome of pulmonary vein isolation (PVI) alone in a cohort of persistent AF patients with normal voltage map in relation to LAVI. Additionally, we also evaluated the predictors of LA enlargement in the same population. This single-centre retrospective study included 214 consecutive persistent AF patients who underwent a PVI alone in our institution between January 2019 and February 2023 (Ethics Committee approval no. CE-2024-26). Patients enrolled in the study had a normal LA voltage map without LVZ and no underlying structural heart disease. The cohort was divided into two groups of LAVI: <48 mL/m² (n = 36) and ≥48 mL/m² (n = 178). We chose this threshold based on ultrasound data. Normal LAVI was considered <34 mL/m² while a severe LA dilation is ≥48 mL/m² in transthoracic echography.⁶ High-density LA voltage maps were obtained with a multipolar mapping catheter PentaRay® (Biosense Webster, Diamond Bar, CA, USA) using 3D mapping system in sinus rhythm. Low-voltage zone was defined as 30 s. Antiarrhythmic drugs (AADs) were gradually discontinued between 3 and 6 months post-ablation in the absence of recurrence at physician’s discretion.

Background: Lead perforation is a rare but potentially fatal complication of cardiac device implantation. Atrial lead perforations, though less common than ventricular ones, can have severe consequences, especially in elderly patients with underlying structural heart disease. Case summary: An 83-year-old male with amyloid and valvular cardiomyopathy underwent dual-chamber pacemaker implantation for third-degree atrioventricular block following transcatheter aortic valve implantation. The active-fixation atrial lead was positioned on the right atrial free wall. Six hours post-implantation, the patient developed haemodynamic instability. Echocardiography revealed a small pericardial effusion, while pacemaker interrogation showed an increased atrial pacing threshold. Chest imaging demonstrated a moderate right haemothorax. Initially, conservative management was recommended. However, the patient’s condition deteriorated, progressing to cardiac arrest requiring brief cardiopulmonary resuscitation. Emergency sternotomy revealed a large right haemothorax and laceration of the right upper pulmonary vein in contact with the atrial lead screw. The laceration was repaired, and the atrial lead was repositioned. The patient recovered well and was discharged 5 days after surgery. Discussion: Lead perforation is an uncommon but potentially severe complication of pacemaker implantation, with an incidence of 0.5–1% of cases. Several risk factors have been identified, including advanced age, low body mass index, atrial remodelling, and lateral lead placement. In this case, the atrial lead perforation extended from the atrial wall to the right superior pulmonary vein. This case underscores the potential risks associated with lateral lead positioning in geriatric patients and emphasizes the necessity for meticulous lead placement and vigilant post-implantation monitoring to mitigate complications.

Background: Obesity is a risk factor for atrial fibrillation (AF). Data regarding left atrial (LA) remodeling in obese patients are scarce. Whether obesity favors AF recurrence after catheter ablation (CA) is still controversial. We assessed the distribution of epicardial atrial fat on computed tomography (CT), LA bipolar voltage, low-voltage zone (LVZ) extent, and the outcome of voltage-guided ablation of persistent AF in obese and non-obese patients.Methods: A total of 139 patients with persistent AF undergoing a first voltage-guided ablation were enrolled and divided into two groups: 74 were non-obese and 65 were obese. Epicardial adipose tissue (EAT) was assessed on a CT scanner. LA endocardial voltage maps were obtained using a 3D mapping system in sinus rhythm. LVZ was defined as a bipolar peak-to-peak voltage amplitude <0.5 mV.Results: LA volume, voltage, and EAT amount were similar in the two groups. LVZ was less frequent in obese patients [12 (18.8%) vs. 26 (35.1%), p = 0.05], particularly on the anterior wall. The posterior and lateral EATs were correlated with posterior and lateral LVZ extent, respectively, in obese patients. After 36 months of follow-up, the AF-free survival rate was similar. Lateral EAT [odds ratio (OR) 1.21, 95% confidence interval (CI) 1–1.4, p = 0.04] and P-wave duration (OR 1.03, 95% CI 1–1.05, p = 0.03), but not body mass index (BMI), were predictors of AF recurrence after CA.Conclusion: In obese patients, LVZ was less marked than in non-obese patients with similar LA volumes, voltage, and EAT amounts. In obese patients, posterior and lateral EATs were correlated with posterior and lateral LVZ extents. Obese patients had a similar and favorable 36-month outcome after AF ablation. BMI was not predictive of AF recurrence.