Unipolar voltage for better characterizing left atrium substrates: Comparing the predictive efficacy for recurrence post atrial fibrillation ablation in a post-hoc analysis of STABLE-SR-III

Abstract Background Intracardiac mapping has become a prevalent technique for assessing cardiac fibrosis. While bipolar recording is universally acknowledged as an indicator of cardiomyocyte activation, unipolar recording has emerged as an alternative technique due to its advantage of providing a wider field of view. This study aims to compare the efficacy of unipolar voltage (UV) versus bipolar voltage (BV) in predicting recurrence in elderly atrial fibrillation patients. Methods In Substrate Ablation in the Left Atrium during Sinus Rhythm Trial III, 414 patients were enrolled in the modified intention-to-treat analysis. Of them, 375 patients who completed the follow-up with preserved mapping data were included in the analysis. For each patient, the mean UV and BV was obtained from the electrograms sampled in left atrium (LA). Results Both low UV and BV of LA had significant associations with the long-term recurrence of atrial tachyarrhythmia (ATa). At the same time, only mean UV was independently associated with the outcome. The model by UV with ablation feature had higher discriminatory power to predict ATa recurrence compared with BV model (AUC: 0.858 vs 0.757, P<0.001). Decision curve analysis demonstrates that UV model provides larger net benefit across the range of reasonable threshold probabilities between 0% and 70% compared with BV model between 0% and 45%. In subgroup analysis, UV reveals more powerful predictive efficacy compared with BV, with the AUC 0.843 vs. 0.751 (P=0.0008) in CPVI alone cohort and 0.882 vs. 0.750 (P=0.0004) in CPVI plus cohort, respectively. Conclusion UV exhibits a higher efficacy for predicting long-term ATa recurrence after ablation compared with BV in elderly patients with atrial fibrillation. The superiority exists regardless of whether the patient accepts substrate modification. The outcome suggests that unipolar recording may better characterize LA fibrosis by capturing more comprehensive transmural features than bipolar signals. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial Unique Identifier: [NCT03462628][1] ### Funding Statement This study was supported by Special Foundation for Clinical Science and Technology of Jiangsu Province (BE2017754), Department of Science and Technology of Guangdong Province(2019B020230004), and the National Natural Science Foundation of China (General Program,82370322). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The STABLE-SR-III trial was approved by the Institutional Review Broad of the First Affiliated Hospital of Nanjing Medical University and each participating site. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data that support the findings of this study are available from the corresponding author, [Weizhu Ju], upon reasonable request. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT03462628&atom=%2Fmedrxiv%2Fearly%2F2024%2F02%2F08%2F2024.02.07.24302471.atom