Evaluation of atrial substrate using COHERENT mapping in atrial fibrillation: correlation with clinical profiles and structural remodeling

Atrial fibrillation is the most commonly encountered arrhythmia in a clinical setting. At its core, the mechanism of atrial fibrillation is associated with two primary substrates: the triggering substrate and the sustaining substrate. Additionally, when fibrosis occurs in the myocardium, it heightens the risk of evolving into chronic atrial fibrillation. These processes are known as "electrical remodeling" and "structural remodeling." Moreover, these myocardial remodeling changes influence the propagation patterns of myocardial electrical conduction. The COHERENT mapping module on CARTO system (COHERENT-MAP) offers detailed visualization of the direction and speed of these electrical propagation patterns, facilitating an accurate assessment of myocardial pathology. The purpose of this study is to investigate the relationship between abnormalities observed in COHERENT-MAP and the clinical background. Furthermore, the study aims to identify guidelines used in determining the ablation treatment strategies and decision-making for postoperative anticoagulant management based on these findings.

We acquired atrial potentials using the Coherent mapping module on the CARTO system and visualized the flow patterns. Atrial potentials were measured at over 2,000 points in both atria using a 1 mm multi-electrode mapping catheter (PENTARAY-NAV). We identified five propagation patterns: Normal conduction pattern, Conduction delay pattern, Congested flow pattern, Disrupted flow pattern, and Multi-bachmann’s bundle pattern.

We enrolled 107 patients with atrial fibrillation who underwent catheter ablation therapy. The conduction delay pattern was more pronounced in patients with persistent atrial fibrillation than in those with paroxysmal atrial fibrillation (p<0.01). Additionally, significant differences were observed in left atrial measurements (p=0.01). The congested flow pattern correlated with increased left atrial measurements (LAVI: p<0.01), diastolic dysfunction (E/E': p<0.01), and elevated NT-proBNP levels (p=0.03). Notably, the disrupted flow pattern was associated with a history of stroke (p<0.01), heart failure, and cardiomyopathy (p=0.04), among other metrics. The multi-bachmann’s bundle pattern strongly correlated with risk factors for cardiogenic cerebral embolism.

The COHERENT-MAP serves as a crucial tool for evaluating myocardial changes. Notably, bachmann's bundle split pattern is linked to cerebral embolism, underscoring the ongoing need for anticoagulants. Additionally, the disrupted flow pattern is associated with heart failure and cardiomyopathy, emphasizing the importance of pharmacological interventions in cases of atrial cardiomyopathy.

Coherent pattern