{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,17]],"date-time":"2026-08-17T23:19:43Z","timestamp":1787008783943,"version":"build-2736575974"},"reference-count":20,"publisher":"Oxford University Press (OUP)","issue":"2","license":[{"start":{"date-parts":[[2019,11,28]],"date-time":"2019-11-28T00:00:00Z","timestamp":1574899200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/journals\/pages\/open_access\/funder_policies\/chorus\/standard_publication_model"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2020,2,1]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Aims\u2003<\/jats:title>\n                    <jats:p>Presence of arrhythmogenic left atrial (LA) low-voltage substrate (LVS) is associated with reduced arthythmia freedom rates following pulmonary vein isolation (PVI) in persistent atrial fibrillation (AF). We hypothesized that LA-LVS modifies amplified sinus-P-wave (APW) characteristics, enabling identification of patients at risk for arrhythmia recurrences following PVI.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods and results\u2003<\/jats:title>\n                    <jats:p>Ninety-five patients with persistent AF underwent high-density (&amp;gt;1200 sites) voltage mapping in sinus rhythm. Left atrial low-voltage substrate (&amp;lt;0.5 and &amp;lt;1.0\u2009mV) was quantified in a 10-segment LA model. Amplified sinus-P-wave-morphology and -duration were evaluated using digitized 12-lead electrocardiograms (40\u201380 mm\/mV, 100\u2013200 mm\/s). 12-months arrhythmia freedom following circumferential PVI was assessed in 139 patients with persistent AF. Left atrial low-voltage substrate was most frequently (84%) found at the anteroseptal LA. Characteristic changes of APW were related to the localization and extent of LA-LVS. At an early stage, LA-LVS predominantly located to the LA-anteroseptum and was associated with APW-prolongation (\u2265150\u2009ms). More extensive LA-LVS involved larger areas of LA-anteroseptum, leading to morphological changes of APW (biphasic positive\u2013negative P-waves in inferior leads). Severe LA-LVS involved the LA-anteroseptum, roof and posterior LA, but spared the inferior LA, lateral LA, and LA appendage. In this advanced stage, widespread LVS at the posterior LA abolished the negative portion of P-wave in the inferior leads. The delayed activation of the lateral LA and LA appendage produced the late positive deflections in the anterolateral leads, resulting in the \u201clate-terminal P\u201d-pattern. Structured analysis of APW-duration and -morphology stratified patients to their individual extent of LA-LVS (Grade 1: mean LA-LVS 4.9 cm2 at &amp;lt;1.0\u2009mV; Grade 2: 28.6 cm2; Grade 3: 42.3 cm2; P\u2009&amp;lt;\u20090.01). The diagnostic value of APW-duration for identification of LA-LVS was significantly superior to standard P-wave-amplification (c-statistic 0.945 vs. 0.647). Arrhythmia freedom following PVI differed significantly between APW-predicted grades of LA-LVS-severity [hazard ratio (HR) 2.38, 95% confidence interval (CI) 1.18\u20134.83; P\u2009=\u20090.015 for Grade 1 vs. Grade 2; HR 1.79, 95% CI 1.00\u20133.21, P\u2009=\u20090.049 for Grade 2 vs. Grade 3). Arrhythmia freedom 12 months after PVI was 77%, 53%, and 33% in Grades 1, 2 and 3, respectively.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion\u2003<\/jats:title>\n                    <jats:p>Localization and extent of LA-LVS modifies APW-morphology and -duration. Analysis of APW allows accurate prediction of LA-LVS and enables rapid and non-invasive estimation of arrhythmia freedom following PVI.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/europace\/euz297","type":"journal-article","created":{"date-parts":[[2019,10,18]],"date-time":"2019-10-18T07:10:49Z","timestamp":1571382649000},"page":"240-249","source":"Crossref","is-referenced-by-count":42,"title":["Amplified sinus-P-wave reveals localization and extent of left atrial low-voltage substrate: implications for arrhythmia freedom following pulmonary vein isolation"],"prefix":"10.1093","volume":"22","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8436-3591","authenticated-orcid":false,"given":"Bj\u00f6rn","family":"M\u00fcller-Edenborn","sequence":"first","affiliation":[{"name":"Department of Electrophysiology, University Heart Center Freiburg \u2013 Bad Krozingen, Bad Krozingen Campus, S\u00fcdring 15, 79189 Bad Krozingen, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Juan","family":"Chen","sequence":"additional","affiliation":[{"name":"Department of Electrophysiology, University Heart Center Freiburg \u2013 Bad Krozingen, Bad Krozingen Campus, S\u00fcdring 15, 79189 Bad Krozingen, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"J\u00fcrgen","family":"Allgeier","sequence":"additional","affiliation":[{"name":"Department of Electrophysiology, University Heart Center Freiburg \u2013 Bad Krozingen, Bad Krozingen Campus, S\u00fcdring 15, 79189 Bad Krozingen, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3966-5651","authenticated-orcid":false,"given":"Maxim","family":"Didenko","sequence":"additional","affiliation":[{"name":"Cardiovascular Surgery Department, Military Medical Academy Named After S.M. Kirov, Saint-Petersburg, Russia"},{"name":"Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zoraida","family":"Moreno-Weidmann","sequence":"additional","affiliation":[{"name":"Department of Electrophysiology, University Heart Center Freiburg \u2013 Bad Krozingen, Bad Krozingen Campus, S\u00fcdring 15, 79189 Bad Krozingen, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0921-8351","authenticated-orcid":false,"given":"Franz-Josef","family":"Neumann","sequence":"additional","affiliation":[{"name":"Department of Cardiology, University Heart Center Freiburg \u2013 Bad Krozingen, Bad Krozingen Campus, Bad Krozingen, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Heiko","family":"Lehrmann","sequence":"additional","affiliation":[{"name":"Department of Electrophysiology, University Heart Center Freiburg \u2013 Bad Krozingen, Bad Krozingen Campus, S\u00fcdring 15, 79189 Bad Krozingen, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Reinhold","family":"Weber","sequence":"additional","affiliation":[{"name":"Department of Electrophysiology, University Heart Center Freiburg \u2013 Bad Krozingen, Bad Krozingen Campus, S\u00fcdring 15, 79189 Bad Krozingen, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thomas","family":"Arentz","sequence":"additional","affiliation":[{"name":"Department of Electrophysiology, University Heart Center Freiburg \u2013 Bad Krozingen, Bad Krozingen Campus, S\u00fcdring 15, 79189 Bad Krozingen, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6402-2845","authenticated-orcid":false,"given":"Amir","family":"Jadidi","sequence":"additional","affiliation":[{"name":"Department of Electrophysiology, University Heart Center Freiburg \u2013 Bad Krozingen, Bad Krozingen Campus, S\u00fcdring 15, 79189 Bad Krozingen, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2019,11,28]]},"reference":[{"key":"2020020703530840700_euz297-B1","doi-asserted-by":"crossref","first-page":"1812","DOI":"10.1056\/NEJMoa1408288","article-title":"Approaches to catheter ablation for persistent atrial fibrillation","volume":"372","author":"Verma","year":"2015","journal-title":"N Engl J Med"},{"key":"2020020703530840700_euz297-B2","doi-asserted-by":"crossref","first-page":"825","DOI":"10.1161\/CIRCEP.113.001251","article-title":"Tailored atrial substrate modification based on low-voltage areas in catheter ablation of atrial fibrillation","volume":"7","author":"Rolf","year":"2014","journal-title":"Circ Arrhythm Electrophysiol"},{"key":"2020020703530840700_euz297-B3","doi-asserted-by":"crossref","first-page":"e002962","DOI":"10.1161\/CIRCEP.115.002962","article-title":"Ablation of persistent atrial fibrillation targeting low-voltage areas with selective activation characteristics","volume":"9","author":"Jadidi","year":"2016","journal-title":"Circ Arrhythm Electrophysiol"},{"key":"2020020703530840700_euz297-B4","doi-asserted-by":"crossref","first-page":"2387","DOI":"10.1113\/JP270617","article-title":"Intermittent drivers anchoring to structural heterogeneities as a major pathophysiological mechanism of human persistent atrial fibrillation","volume":"594","author":"Haissaguerre","year":"2016","journal-title":"J Physiol"},{"key":"2020020703530840700_euz297-B5","doi-asserted-by":"crossref","first-page":"57","DOI":"10.1007\/s10840-013-9838-y","article-title":"Comparison of left atrial electrophysiologic abnormalities during sinus rhythm in patients with different type of atrial fibrillation","volume":"39","author":"Lin","year":"2014","journal-title":"J Interv Card Electrophysiol"},{"key":"2020020703530840700_euz297-B6","doi-asserted-by":"crossref","first-page":"2225","DOI":"10.1016\/j.jacc.2011.05.061","article-title":"Structural abnormalities in atrial walls are associated with presence and persistency of atrial fibrillation but not with age","volume":"58","author":"Platonov","year":"2011","journal-title":"J Am Coll Cardiol"},{"key":"2020020703530840700_euz297-B7","doi-asserted-by":"crossref","first-page":"531","DOI":"10.1016\/j.jacep.2017.12.001","article-title":"The duration of the amplified sinus-P-wave identifies presence of left atrial low voltage substrate and predicts outcome after pulmonary vein isolation in patients with persistent atrial fibrillation","volume":"4","author":"Jadidi","year":"2018","journal-title":"JACC Clin Electrophysiol"},{"key":"2020020703530840700_euz297-B8","doi-asserted-by":"crossref","first-page":"445","DOI":"10.1016\/j.jelectrocard.2012.06.029","article-title":"Interatrial blocks. 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