The impact of atrial voltage and conduction velocity phenotypes on atrial fibrillation recurrence

Introduction: Low atrial voltage and slow conduction velocity (CV) have been associated with atrial fibrillation (AF); however, their interaction and relative importance as early disease markers remain incompletely understood. We aimed to elucidate the relationship between atrial voltage and CV using high-density electroanatomic (HDE) maps of patients with AF. Methods: HDE maps obtained during sinus rhythm in 52 patients with AF and five healthy controls were analysed. Atrial voltage and CV maps were generated, and their correlations were assessed. Subgroup analyses were performed based on clinically relevant factors such as AF type, CV, and voltage levels. Finally, cluster analysis was conducted to identify distinct phenotypes within the population, reflecting different patterns of conduction and voltage. Results: A moderate positive correlation was found between the mean atrial voltage and CV (r = 0.570). Subgroup analysis revealed differences in voltage (p = 0.0044) but not in global CV (p = 0.42), with no significant differences between AF types. Three distinct phenotypes emerged: normal voltage/normal CV, normal voltage/low CV, and low voltage/low CV, with distinct recurrence rates, suggesting different disease progression paths. Slower atrial CV was identified as a significant predictor of arrhythmia recurrence at 12 and 24 months after AF ablation, surpassing the predictive potential of atrial voltage. Conclusion: Atrial voltage and CV analyses revealed distinct phenotypes. Lower atrial CV emerged as a significant predictor of AF recurrence, exceeding the predictive significance of atrial voltage. These findings emphasise the importance of considering CV and voltage in managing AF and offer potential insights for personalised strategies.