1 Electroanatomic Mapping to determine Scar Regions in patients with Atrial Fibrillation

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Electroanatomic Mapping to determine Scar

Regions in patients with Atrial Fibrillation

Jiyue He,1∗Kuk Jin Jang,1∗Katie Walsh, M.D.,2Jackson Liang, M.D.,2Sanjay Dixit, M.D.,2Rahul Mangharam1

Abstract—Left atrial voltage maps are routinely acquired dur-

ing electroanatomic mapping in patients undergoing catheter ab-

lation for atrial ﬁbrillation. For patients, who have prior catheter

ablation when they are in sinus rhythm, the voltage map can be

used to identify low voltage areas using a threshold of 0.2 - 0.45

mV. However, such a voltage threshold for maps acquired during

atrial ﬁbrillation has not been well established. A prerequisite

for deﬁning a voltage threshold is to maximize the topologically

matched low voltage areas between the electroanatomic mapping

acquired during atrial ﬁbrillation and sinus rhythm. This paper

demonstrates a new technique to improve the sensitivity and

speciﬁcity of the matched low voltage areas. This is achieved

by computing omni-directional bipolar voltages and applying

Gaussian Process Regression based interpolation to derive the

AF map. The proposed method is evaluated on a test cohort of

7 male patients, and a total of 46,589 data points were included

in analysis. The low voltage areas in the posterior left atrium

and pulmonary vein junction are determined using the standard

method and the proposed method. Overall, the proposed method

showed patient-speciﬁc sensitivity and speciﬁcity in matching low

voltage areas of 75.70% and 65.55% for a geometric mean of

70.69%. On average, there was an improvement of 3.00% in

the geometric mean, 7.88% improvement in sensitivity, 0.30%

improvement in speciﬁcity compared to the standard method.

The results show that the proposed method is an improvement

in matching low voltage areas. This may help develop the voltage

threshold to better identify low voltage areas in the left atrium

for patients in atrial ﬁbrillation.

I. INTRODUCTION

The voltage map is one form of data provided by

electroanatomic mapping (EAM) and is often used to demar-

cate low voltage areas (LVAs) and preserved voltage areas

during catheter ablation therapy to treat atrial ﬁbrillation (AF).

LVAs correspond to areas of diseased atrium (ﬁbrosis) or

dense scars from prior ablations. Identifying LVA can help

in planning ablation strategies especially in patients requiring

repeat ablation procedures for arrhythmia recurrences, for

example, AF and atypical atrial ﬂutter.

The cutoff threshold voltage for a voltage map that deter-

mines LVAs has been established for maps obtained while the

patient is in sinus rhythm (SR) [1][2]. However, this same

threshold is not applicable to maps collected during AF.

For example, Fig. 1(a) depicts the SR map with a cutoff

threshold of 0.45 mV. The regions below the threshold are

clearly delineated from the healthy regions (magenta). How-

ever, in (b), applying the same threshold to the AF map for

1University of Pennsylvania, School of Engineering and Applied Science,

Department of Electrical and Systems Engineering. 2Hospital of the Uni-

versity of Pennsylvania, Department of Cardiac Electrophysiology. ∗Both

authors contributed equally to this work.

July 23, 2019

the same patient distorts the LVAs distribution. After adjusting

to a lower threshold, as in (c), the LVAs on the AF map are

restored to match the SR map.

Fig. 1. Example of need for a threshold to be used on voltage maps obtained

during AF. Magenta area is healthy tissue, other colors are scar tissue. (a)

The SR cutoff threshold of 0.45 mV is applied to the SR map. (b) Applying

the same threshold to the AF map distorts LVAs in the AF map. (c) Adjusting

the threshold to 0.16 mV restores the LVAs.

Several studies have shown that the local atrial signal

acquired during AF is lower than in SR. Thus, identifying

LVA during EAM in AF should require a lower cutoff voltage

[3]. However, determining a consistent threshold that can be

applied to all patients remains challenging. A prerequisite is

determining the best match of LVAs that can be obtained

between the SR map and the AF map and thereby ﬁnding

the best threshold to be applied on a patient-by-patient basis.

Problem Statement: Given a set of measurements during

SR and AF for a patient, maximize the topologically matched

LVAs between the derived SR and AF map and determine the

best patient-speciﬁc cutoff voltage threshold.

In this paper, we demonstrate a method of deriving the AF

map which is robust to noise and error in the measurements

and improves the patient-speciﬁc sensitivity and speciﬁcity of

matched LVAs in comparison to the standard method through

the following the contributions:

•Compute omni-directional bipolar voltages which are

invariant to the orientation of the catheter, thus improving

signal strength during AF.

•Apply Gaussian process regression (GPR) interpolation

which improves the accuracy of LVA detection in regions

of the atrium with lower measurement density.

II. BACKGROUND: STANDARD VOLTAGE MAP

Fig. 2 depicts the steps of deriving the current standard

left atrial (LA) voltage map during catheter ablation of AF.

Initially, as in (1), a 3D anatomical mesh is generated by

manipulating a multi-electrode mapping catheter (Lasso or

Pentaray) to different parts of the LA [4]. As the mesh is being

created, recordings of 2.5 seconds of electrogram are collected

at various locations around the endocardium. (2) shows the

arXiv:2210.12772v2 [physics.med-ph] 8 Nov 2022

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1ElectroanatomicMappingtodetermineScarRegionsinpatientswithAtrialFibrillationJiyueHe,1KukJinJang,1KatieWalsh,M.D.,2JacksonLiang,M.D.,2SanjayDixit,M.D.,2RahulMangharam1AbstractLeftatrialvoltagemapsareroutinelyacquireddur-ingelectroanatomicmappinginpatientsundergoingcatheterab-lationforatrialbrill...

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1 Electroanatomic Mapping to determine Scar Regions in patients with Atrial Fibrillation

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