{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,9,17]],"date-time":"2025-09-17T06:09:46Z","timestamp":1758089386596,"version":"3.44.0"},"reference-count":33,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2025,9,16]],"date-time":"2025-09-16T00:00:00Z","timestamp":1757980800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Cardiovasc. Med."],"abstract":"<jats:sec><jats:title>Background<\/jats:title><jats:p>The optimal voltage threshold for determining low voltage areas (LVA) in non-paroxysmal atrial fibrillation (<jats:italic>N<\/jats:italic>PAF) is unclear. This study aims to evaluate a patient-specific voltage measurement using the left atrial appendage (LAA) as a benchmark to establish a normalized threshold for detecting LVA in NPAF.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Bipolar LA and LAA voltage in 40 NPAF and 42 patients with no AF (control group) were studied in sinus rhythm (SR) and AF (NPAF group) and SR only in the control group. Bipolar LA and LAA voltage distribution were compared between the NPAF and control groups. Fibrotic regions identified by late gadolinium-enhanced magnetic resonance imaging (LGE-MRI) was used as the reference standard comparison in the NPAF group.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>The median, 5th percentile (V<jats:sub>LA5%<\/jats:sub>), and the 95th percentile of bipolar voltage in the LA were significantly lower in NPAF patients than controls. No significant LAA voltage differences between groups [median\u2009=\u20093.303 (1.796) vs. 3.100 (1.045); V<jats:sub>LAA95%<\/jats:sub>\u2009=\u20098.089 (3.571) vs. 7.604 (3.404), all <jats:italic>p<\/jats:italic>\u2009&amp;gt;\u20090.05]. A strong linear correlation between V<jats:sub>LA5%<\/jats:sub> and V<jats:sub>LAA95%<\/jats:sub> was observed in the control group. The standardized relative voltage index (RVI) factor of 0.1324 was identified as the threshold for defining LVA and calculated as V<jats:sub>LA5%<\/jats:sub>\u2009=\u20090.1324\u2009\u00d7\u2009V<jats:sub>LAA95%<\/jats:sub>. The correlation between LVA guided by RVI was superior to the universal threshold for detecting LVA in sinus and AF rhythms using LGE-MRI as the gold standard.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>A patient-tailored low voltage threshold can be obtained using a simplified equation and provides more accurate representation of LVA in NPAF than universal thresholds.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fcvm.2025.1656983","type":"journal-article","created":{"date-parts":[[2025,9,16]],"date-time":"2025-09-16T05:34:27Z","timestamp":1758000867000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["The relative voltage index: a novel tailored method to identify left atrial low voltage areas in non-paroxysmal AF"],"prefix":"10.3389","volume":"12","author":[{"given":"Guoshu","family":"Yang","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Shiqiang","family":"Xiong","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yan","family":"Luo","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Duan","family":"Luo","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Michael","family":"Shehata","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Zhen","family":"Zhang","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lin","family":"Cai","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Xunzhang","family":"Wang","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ashkan","family":"Ehdaie","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hanxiong","family":"Liu","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2025,9,16]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"359","DOI":"10.1016\/S0002-9343(02)01236-6","article-title":"A population-based study of the long-term risks associated with atrial fibrillation: 20-year follow-up of the renfrew\/paisley study","volume":"113","author":"Stewart","year":"2002","journal-title":"Am J Med"},{"key":"B2","doi-asserted-by":"publisher","first-page":"1042","DOI":"10.1161\/01.CIR.0000140263.20897.42","article-title":"Lifetime risk for development of atrial fibrillation: the framingham heart study","volume":"110","author":"Lloyd-Jones","year":"2004","journal-title":"Circulation"},{"key":"B3","doi-asserted-by":"publisher","first-page":"943","DOI":"10.1016\/j.jacc.2015.06.1313","article-title":"Cardiac fibrosis in patients with atrial fibrillation: mechanisms and clinical implications","volume":"66","author":"Dzeshka","year":"2015","journal-title":"J Am Coll Cardiol"},{"key":"B4","doi-asserted-by":"publisher","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":"B5","doi-asserted-by":"publisher","first-page":"1475","DOI":"10.1016\/j.hrthm.2010.06.030","article-title":"Evaluation of the left atrial substrate in patients with lone atrial fibrillation using delayed-enhanced MRI: implications for disease progression and response to catheter ablation","volume":"7","author":"Mahnkopf","year":"2010","journal-title":"Heart Rhythm"},{"key":"B6","doi-asserted-by":"publisher","first-page":"1758","DOI":"10.1161\/CIRCULATIONAHA.108.811877","article-title":"Detection and quantification of left atrial structural remodeling with delayed-enhancement magnetic resonance imaging in patients with atrial fibrillation","volume":"119","author":"Oakes","year":"2009","journal-title":"Circulation"},{"key":"B7","doi-asserted-by":"publisher","first-page":"e220061","DOI":"10.1148\/ryct.220061","article-title":"Correlation between cardiac MRI and voltage mapping in evaluating atrial fibrosis: a systematic review","volume":"4","author":"Bijvoet","year":"2022","journal-title":"Radiol Cardiothorac Imaging"},{"key":"B8","doi-asserted-by":"publisher","first-page":"1585","DOI":"10.1093\/europace\/euac089","article-title":"Low-voltage area substrate modification for atrial fibrillation ablation: a systematic review and meta-analysis of clinical trials","volume":"24","author":"Junarta","year":"2022","journal-title":"Europace"},{"key":"B9","doi-asserted-by":"publisher","first-page":"791","DOI":"10.1016\/j.jacep.2017.07.004","article-title":"Assessment of left atrial fibrosis by late gadolinium enhancement magnetic resonance imaging: methodology and clinical implications","volume":"3","author":"Siebermair","year":"2017","journal-title":"JACC Clin Electrophysiol"},{"key":"B10","doi-asserted-by":"publisher","first-page":"919873","DOI":"10.3389\/fcvm.2022.919873","article-title":"It is necessary to re-understand the low-voltage area in atrial fibrillation patients","volume":"9","author":"Liu","year":"2022","journal-title":"Front Cardiovasc Med"},{"key":"B11","doi-asserted-by":"publisher","first-page":"e024521","DOI":"10.1161\/JAHA.121.024521","article-title":"Atrial structural remodeling in patients with atrial fibrillation is a diffuse fibrotic process: evidence from high-density voltage mapping and atrial biopsy","volume":"11","author":"Yamaguchi","year":"2022","journal-title":"J Am Heart Assoc"},{"key":"B12","doi-asserted-by":"publisher","first-page":"380","DOI":"10.1093\/europace\/euaa313","article-title":"Accuracy of left atrial fibrosis detection with cardiac magnetic resonance: correlation of late gadolinium enhancement with endocardial voltage and conduction velocity","volume":"23","author":"Caixal","year":"2021","journal-title":"Europace"},{"key":"B13","doi-asserted-by":"publisher","first-page":"285","DOI":"10.1016\/j.jacc.2004.10.035","article-title":"Pre-existent left atrial scarring in patients undergoing pulmonary vein antrum isolation: an independent predictor of procedural failure","volume":"45","author":"Verma","year":"2005","journal-title":"J Am Coll Cardiol"},{"key":"B14","doi-asserted-by":"publisher","first-page":"455","DOI":"10.1111\/jce.15764","article-title":"Low voltage area guided substrate modification in nonparoxysmal atrial fibrillation: a systematic review and meta-analysis","volume":"34","author":"Moustafa","year":"2023","journal-title":"J Cardiovasc Electrophysiol"},{"key":"B15","doi-asserted-by":"publisher","first-page":"1272","DOI":"10.1093\/europace\/euw219","article-title":"Left atrial fibrosis quantification by late gadolinium-enhanced magnetic resonance: a new method to standardize the thresholds for reproducibility","volume":"19","author":"Benito","year":"2017","journal-title":"Europace"},{"key":"B16","doi-asserted-by":"publisher","first-page":"354","DOI":"10.1186\/s40001-024-01952-y","article-title":"Sex-related differences in left atrial substrate among patients with atrial fibrillation: evidence from high-density voltage mapping","volume":"29","author":"Huang","year":"2024","journal-title":"Eur J Med Res"},{"key":"B17","doi-asserted-by":"publisher","first-page":"181","DOI":"10.1016\/j.hrthm.2011.09.062","article-title":"Is there a relationship between complex fractionated atrial electrograms recorded during atrial fibrillation and sinus rhythm fractionation?","volume":"9","author":"Saghy","year":"2012","journal-title":"Heart Rhythm"},{"key":"B18","doi-asserted-by":"publisher","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":"B19","doi-asserted-by":"publisher","first-page":"230","DOI":"10.1016\/S0008-6363(02)00258-4","article-title":"Electrical, contractile and structural remodeling during atrial fibrillation","volume":"54","author":"Allessie","year":"2002","journal-title":"Cardiovasc Res"},{"key":"B20","doi-asserted-by":"publisher","first-page":"498","DOI":"10.1001\/jama.2014.3","article-title":"Association of atrial tissue fibrosis identified by delayed enhancement MRI and atrial fibrillation catheter ablation: the DECAAF study","volume":"311","author":"Marrouche","year":"2014","journal-title":"Jama"},{"key":"B21","doi-asserted-by":"publisher","first-page":"268","DOI":"10.14740\/cr1503","article-title":"Comparing left atrial low voltage areas in sinus rhythm and atrial fibrillation using novel automated voltage analysis: a pilot study","volume":"14","author":"Mannion","year":"2023","journal-title":"Cardiol Res"},{"key":"B22","doi-asserted-by":"publisher","first-page":"559","DOI":"10.1111\/pace.13051","article-title":"Comparison of left atrial voltage between sinus rhythm and atrial fibrillation in association with electrogram waveform","volume":"40","author":"Masuda","year":"2017","journal-title":"Pacing Clin Electrophysiol"},{"key":"B23","doi-asserted-by":"publisher","first-page":"1541","DOI":"10.1016\/j.jacep.2018.08.015","article-title":"Validating left atrial low voltage areas during atrial fibrillation and atrial flutter using multielectrode automated electroanatomic mapping","volume":"4","author":"Rodr\u00edguez-Ma\u00f1ero","year":"2018","journal-title":"JACC Clin Electrophysiol"},{"key":"B24","doi-asserted-by":"publisher","first-page":"905","DOI":"10.1111\/jce.13002","article-title":"Correlation of left atrial voltage distribution between Sinus rhythm and atrial fibrillation: identifying structural remodeling by 3-D electroanatomic mapping irrespective of the rhythm","volume":"27","author":"Yagishita","year":"2016","journal-title":"J Cardiovasc Electrophysiol"},{"key":"B25","doi-asserted-by":"publisher","first-page":"1357","DOI":"10.1016\/j.hrthm.2019.05.032","article-title":"Voltage during atrial fibrillation is superior to voltage during sinus rhythm in localizing areas of delayed enhancement on magnetic resonance imaging: an assessment of the posterior left atrium in patients with persistent atrial fibrillation","volume":"16","author":"Qureshi","year":"2019","journal-title":"Heart Rhythm"},{"key":"B26","doi-asserted-by":"publisher","first-page":"1044","DOI":"10.1111\/jce.12452","article-title":"Contact electroanatomic mapping derived voltage criteria for characterizing left atrial scar in patients undergoing ablation for atrial fibrillation","volume":"25","author":"Kapa","year":"2014","journal-title":"J Cardiovasc Electrophysiol"},{"key":"B27","doi-asserted-by":"publisher","first-page":"e003382","DOI":"10.1161\/CIRCEP.115.003382","article-title":"Catheter ablation of nonparoxysmal atrial fibrillation using electrophysiologically guided substrate modification during Sinus rhythm after pulmonary vein isolation","volume":"9","author":"Yang","year":"2016","journal-title":"Circ Arrhythm Electrophysiol"},{"key":"B28","doi-asserted-by":"publisher","first-page":"147","DOI":"10.1111\/jce.13122","article-title":"Long-term outcome of left atrial voltage-guided substrate ablation during atrial fibrillation: a novel adjunctive ablation strategy","volume":"28","author":"Yagishita","year":"2017","journal-title":"J Cardiovasc Electrophysiol"},{"key":"B29","doi-asserted-by":"publisher","first-page":"258","DOI":"10.1111\/j.1540-8167.2007.00719.x","article-title":"Progressive remodeling of the atrial substrate\u2013a novel finding from consecutive voltage mapping in patients with recurrence of atrial fibrillation after catheter ablation","volume":"18","author":"Lo","year":"2007","journal-title":"J Cardiovasc Electrophysiol"},{"key":"B30","doi-asserted-by":"publisher","first-page":"403","DOI":"10.1016\/j.jacep.2016.06.006","article-title":"Left atrial appendage: embryology, anatomy, physiology, arrhythmia and therapeutic intervention","volume":"2","author":"Naksuk","year":"2016","journal-title":"JACC Clin Electrophysiol"},{"key":"B31","doi-asserted-by":"publisher","first-page":"356","DOI":"10.1161\/01.RES.58.3.356","article-title":"Relating extracellular potentials and their derivatives to anisotropic propagation at a microscopic level in human cardiac muscle. Evidence for electrical uncoupling of side-to-side fiber connections with increasing age","volume":"58","author":"Spach","year":"1986","journal-title":"Circ Res"},{"key":"B32","doi-asserted-by":"publisher","first-page":"161","DOI":"10.1161\/01.CIR.72.1.161","article-title":"Atrial fibrillation in patients with Wolff-Parkinson-White syndrome: incidence after surgical ablation of the accessory pathway","volume":"72","author":"Sharma","year":"1985","journal-title":"Circulation"},{"key":"B33","doi-asserted-by":"publisher","first-page":"493","DOI":"10.1016\/0002-9149(92)90992-8","article-title":"Frequency of recurrent atrial fibrillation after catheter ablation of overt accessory pathways","volume":"69","author":"Haissaguerre","year":"1992","journal-title":"Am J Cardiol"}],"container-title":["Frontiers in Cardiovascular Medicine"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fcvm.2025.1656983\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,9,16]],"date-time":"2025-09-16T05:34:28Z","timestamp":1758000868000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fcvm.2025.1656983\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,9,16]]},"references-count":33,"alternative-id":["10.3389\/fcvm.2025.1656983"],"URL":"https:\/\/doi.org\/10.3389\/fcvm.2025.1656983","relation":{},"ISSN":["2297-055X"],"issn-type":[{"type":"electronic","value":"2297-055X"}],"subject":[],"published":{"date-parts":[[2025,9,16]]},"article-number":"1656983"}}