Fixed Complex Electrograms During Sinus Rhythm and Local Pacing: Potential Ablation Targets for Persistent Atrial Fibrillation

In atrial fibrillation (AF) patients, complex electrograms during sinus rhythm (C-EGMs) could be pathological or not. We aimed to demonstrate whether local pacing was helpful to discern pathological C-EGMs. 126 persistent AF patients and 27 patients with left-side accessory pathway (LAP) underwent left atrial mapping during sinus rhythm. If C-EGMs were detected, local pacing was performed. If the electrograms turned normal, we defined them as non-fixed C-EGMs, otherwise as fixed C-EGMs. No difference was detected in the incidence and proportion of non-fixed C-EGMs between AF patients and LAP patients (101/126 vs. 19/27, P = 0.26; 9.1 ± 6.0% vs. 7.7 ± 5.7%, P = 0.28). However, the incidence and proportion of fixed C-EGMs were higher in persistent AF patients (87/126 vs. 1/27, P < 0.01; 4.3 ± 3.4% vs. 0.1 ± 0.5%, P < 0.01). Compared with non-fixed C-EGMs, fixed C-EGMs had lower amplitudes, longer electrogram durations and longer Stimuli-P wave internals. All AF patients received circumferential pulmonary vein isolation. Among AF patients with fixed C-EGMs, 45 patients received fixed C-EGMs ablation and 42 patients underwent linear ablation. Compared with linear ablation, fixed C-EGMs ablation reduced recurrence (HR: 0.43; 95% CI 0.21‐0.81; P = 0.011). Among patients without fixed C-EGMs ablation, the proportion of fixed C-EGMs was an independent predictor of ablation outcomes (HR for per percent: 1.13, 95% CI 1.01–1.28, P = 0.038). C-EGMs could be classified into fixed and non-fixed C-EGMs through local pacing. Fixed rather than non-fixed C-EGMs might indicate abnormal atrial substrates and fixed C-EGMs ablation improve outcomes of persistent AF ablation.