https://doi.org/10.1007/s00392-025-02625-4
1Universitätsklinikum Schleswig-Holstein Innere Medizin III mit den Schwerpunkten Kardiologie und internistische Intensivmedizin Kiel, Deutschland; 2Universitätsklinikum Schleswig-Holstein Innere Medizin III mit den Schwerpunkten Kardiologie, Angiologie und internistische Intensivmedizin Kiel, Deutschland; 3Universitätsklinik Schleswig-Holstein, Campus Kiel Klinik für Kardiologie und internistische Intenisvmedizin Kiel, Deutschland
Background and Aims
Ventricular pace mapping (PM) is an established tool to identify the origin of non-inducible arrhythmias by analyzing the paced QRS morphology of the surface electrocardiogram (ECG). Using the same approach for atrial pacemapping (APM) was shown to be suboptimal, as accurate assessment of P wave morphology can be limited. A novel approach using intracardiac unipolar signals for APM was described recently. We present new technique for APM using an automatic ECG pattern-matching algorithm with intracardiac unipolar signals (aICPM).
Methods
Forty-four consecutive patients undergoing redo ablation for atrial fibrillation were prospectively included. Induction of non-sustained atrial tachycardia (nsAT) or non pulmonary vein (PV) triggers was performed in every procedure. Six unipolar signals served as a reference to create a score map by using the automatic ECG pattern-matching algorithm. Ablation targeted sites with the best IC pattern similarity. The primary endpoint was defined as non-inducibility of the arrhythmia. Secondary endpoint was defined as freedom from AF/AT during follow-up.
Results
Non-sustained atrial tachycardia (nsAT) or non pulmonary vein (PV) triggers were reproducibly induced in 24 patients at time of redo ablation.
APM with aICPM successfully identified specific areas with high intracardiac pattern similarity (median of 81%; median top 10% IC pattern matching area: 0.5 cm²) in all patients. The median time required to create a score map was 4.7 (IQR 3.3; 6.3) minutes, with 100 (IQR 77; 153) points per map. Radiofrequency ablation was performed successfully in all but two patients, with a median ablation time of 139 (IQR 82; 182) seconds and an ablation area of 2.0 (IQR 1.1; 2.3) cm². Two patients underwent ethanol ablation of the vein of Marshall. All cases achieved non-inducibility of nsAT or AF triggers. During a follow-up of 5.9±1.87 months, 5 patients experienced AF recurrence.
Conclusion
This novel approach rapidly and accurately identifies the origin of atrial arrhythmias by automatically creating atrial pacemaps with intracardiac signals using an automated ECG pattern-matching algorithm.