{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,27]],"date-time":"2026-06-27T04:48:13Z","timestamp":1782535693019,"version":"3.54.5"},"reference-count":20,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2026,6,22]],"date-time":"2026-06-22T00:00:00Z","timestamp":1782086400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCDD"],"abstract":"<jats:p>Background: The presence of left atrial fibrosis is a marker of advanced remodeling and is associated with a worse outcome after pulmonary vein isolation (PVI). Conventional fluoroscopy-only cryoballoon ablation (CBA) lacks this prognostic information. The addition of electroanatomical mapping (EAM) using the inner lumen spiral catheter allows accurate voltage assessment of the left atrial posterior wall. However, the value of the finding of posterior wall low-voltage zones (pwLVZs) is unknown. Purpose: To study the value of left atrial voltage maps during CBA by comparing clinical and procedural characteristics and clinical outcome between patients with and without pwLVZs. Methods: A cohort of 250 consecutive patients who underwent index CBA for atrial fibrillation was analyzed. All patients underwent pre- and post-procedural EAM using the AchieveTM catheter and EnSiteTM mapping system. The presence of LVZs was evaluated at the postprocedural voltage map of the posterior wall. Clinical success was defined as freedom from documented AF or atrial tachycardia (AT) &gt;30 s after 1 year. Results: PwLVZs were found in 41\/250 (16.4%) of patients. Patients with pwLVZs were older (69.3 \u00b1 8.5 vs. 64.2 \u00b1 10.4; p = 0.003), more frequently female (63.4% vs. 32.5%; p &lt; 0.001) and had higher CHA2DS2-VASc scores (3.0 \u00b1 1.6 vs. 2.0 \u00b1 1.5; p &lt; 0.001). The incidence of obesity (31.7% vs. 25.8%; p = 0.048), structural heart disease (35.5% vs. 17.4%; p = 0.021) and persistent AF (68.3% vs. 43.8%; p = 0.004) was higher in the pwLVZs group. Kaplan\u2013Meier analysis of clinical outcome showed a higher recurrence rate in the pwLVZs group. The finding of pwLVZs was a predictor of atrial arrhythmia recurrence during follow-up (HR 2.583; 95%CI: 1.334\u20135.002; p = 0.005). Conclusions: In CBA facilitated by integrated EAM, pwLVZ was associated with older age, female sex, higher CHADS-VASc scores, obesity, structural heart disease and persistent AF. The finding of pwLVZs is predictive of a worse clinical outcome.<\/jats:p>","DOI":"10.3390\/jcdd13060287","type":"journal-article","created":{"date-parts":[[2026,6,23]],"date-time":"2026-06-23T18:35:05Z","timestamp":1782239705000},"page":"287","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["The Finding of Posterior Wall Low-Voltage Zones During Cryoballoon Pulmonary Vein Isolation Facilitated by Periprocedural Electroanatomical Mapping Is Associated with a Worse Ablation Outcome"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2700-2543","authenticated-orcid":false,"given":"Maxime","family":"Tijskens","sequence":"first","affiliation":[{"name":"Department of Cardiology, ZAS Heart Centre Middelheim, 2020 Antwerp, Belgium"},{"name":"Department of Cardiology, AZ Rivierenland Hospital, 2880 Bornem, Belgium"},{"name":"Heart Rhythm Management Centre, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel Heart Rhythm Research Brussels, Postgraduate Program in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, 1090 Brussels, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1839-3693","authenticated-orcid":false,"given":"Benjamin","family":"De Becker","sequence":"additional","affiliation":[{"name":"Department of Cardiology, ZAS Heart Centre Middelheim, 2020 Antwerp, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael","family":"Wolf","sequence":"additional","affiliation":[{"name":"Department of Cardiology, ZAS Heart Centre Middelheim, 2020 Antwerp, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bruno","family":"Schwagten","sequence":"additional","affiliation":[{"name":"Department of Cardiology, ZAS Heart Centre Middelheim, 2020 Antwerp, Belgium"},{"name":"Heart Rhythm Management Centre, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel Heart Rhythm Research Brussels, Postgraduate Program in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, 1090 Brussels, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1367-4867","authenticated-orcid":false,"given":"Yves","family":"De Greef","sequence":"additional","affiliation":[{"name":"Department of Cardiology, ZAS Heart Centre Middelheim, 2020 Antwerp, Belgium"},{"name":"Heart Rhythm Management Centre, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel Heart Rhythm Research Brussels, Postgraduate Program in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, 1090 Brussels, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,6,22]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","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":"ref_2","doi-asserted-by":"crossref","first-page":"e027795","DOI":"10.1161\/JAHA.122.027795","article-title":"Characterization of Atrial Substrate to Predict the Success of Pulmonary Vein Isolation: The Prospective, Multicenter MASH-AF II (Multipolar Atrial Substrate High Density Mapping in Atrial Fibrillation) Study","volume":"12","author":"Bergonti","year":"2023","journal-title":"J. Am. Heart Assoc."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"97","DOI":"10.1016\/j.ijcard.2017.12.089","article-title":"Left atrial low-voltage areas predict atrial fibrillation recurrence after catheter ablation in patients with paroxysmal atrial fibrillation","volume":"257","author":"Masuda","year":"2018","journal-title":"Int. J. Cardiol."},{"key":"ref_4","doi-asserted-by":"crossref","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":"ref_5","doi-asserted-by":"crossref","first-page":"1393","DOI":"10.1111\/jce.13321","article-title":"Low-voltage areas detected by high-density electroanatomical mapping predict recurrence after ablation for paroxysmal atrial fibrillation","volume":"28","author":"Vlachos","year":"2017","journal-title":"J. Cardiovasc. Electrophysiol."},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"Tijskens, M., Abugattas, J.P., Thoen, H., Strazdas, A., Schwagten, B., Wolf, M., and De Greef, Y. (2024). Adding Electroanatomical Mapping to Cryoballoon Pulmonary Vein Isolation Improves 1-Year Clinical Outcome and Durability of Pulmonary Vein Isolation: A Propensity Score-Matched Analysis. J. Cardiovasc. Dev. Dis., 11.","DOI":"10.3390\/jcdd11020057"},{"key":"ref_7","first-page":"923","article-title":"Electroanatomical mapping improves procedural outcomes of cryoballoon pulmonary vein isolation (the Achieve Plus study)","volume":"66","author":"Tijskens","year":"2023","journal-title":"J. Interv. Card. Electrophysiol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"868","DOI":"10.1111\/pace.13709","article-title":"Over-the-needle trans-septal access using the cryoballoon delivery sheath and dilator in atrial fibrillation ablation","volume":"42","author":"Stroker","year":"2019","journal-title":"Pacing Clin. Electrophysiol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1514","DOI":"10.1161\/01.CIR.0000121734.47409.AA","article-title":"Electrophysiological and electroanatomic characterization of the atria in sinus node disease: Evidence of diffuse atrial remodeling","volume":"109","author":"Sanders","year":"2004","journal-title":"Circulation"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"euae043","DOI":"10.1093\/europace\/euae043","article-title":"2024 European Heart Rhythm Association\/Heart Rhythm Society\/Asia Pacific Heart Rhythm Society\/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation","volume":"26","author":"Tzeis","year":"2024","journal-title":"Europace"},{"key":"ref_11","first-page":"170","article-title":"Cryoballoon Pulmonary Vein Isolation Facilitated by Integrated Electroanatomical Mapping for Paroxysmal Atrial Fibrillation in a Patient with Kartagener\u2019s Syndrome","volume":"6","author":"Tijskens","year":"2026","journal-title":"Case Rep. Clin. Cardiol. J."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"EVIDoa2200141","DOI":"10.1056\/EVIDoa2200141","article-title":"Low-Voltage Myocardium-Guided Ablation Trial of Persistent Atrial Fibrillation","volume":"1","author":"Huo","year":"2022","journal-title":"NEJM Evid."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"451","DOI":"10.1016\/j.amjcard.2023.06.095","article-title":"Gender-Related Differences in Atrial Substrate in Patients with Atrial Fibrillation","volume":"203","author":"Bergonti","year":"2023","journal-title":"Am. J. Cardiol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1395","DOI":"10.1111\/jce.16651","article-title":"Recurrence of Atrial Fibrillation After Cryoballoon Ablation in Women Is Less Pulmonary Vein Mediated as Compared to Men: Lessons From Repeat Ablation Procedures","volume":"36","author":"Tijskens","year":"2025","journal-title":"J. Cardiovasc. Electrophysiol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"249","DOI":"10.1007\/s10840-020-00882-z","article-title":"Voltage-guided ablation in persistent atrial fibrillation-favorable 1-year outcome and predictors","volume":"62","author":"Schade","year":"2021","journal-title":"J. Interv. Card. Electrophysiol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"2291","DOI":"10.1016\/j.jacep.2023.08.002","article-title":"Impact of Posterior Left Atrial Voltage on Ablation Outcomes in Persistent Atrial Fibrillation: CAPLA Substudy","volume":"9","author":"Chieng","year":"2023","journal-title":"JACC Clin. Electrophysiol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"720","DOI":"10.1016\/j.hroo.2024.08.006","article-title":"Left atrial posterior wall isolation in addition to pulmonary vein isolation using a pentaspline catheter in pulsed-field ablation for atrial fibrillation: A systematic review and meta-analysis","volume":"5","author":"Pranata","year":"2024","journal-title":"Heart Rhythm O2"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1108","DOI":"10.1111\/pace.15035","article-title":"Adjunctive left atrial posterior wall isolation for atrial fibrillation: An updated systematic review and meta-analysis","volume":"47","author":"Ibrahim","year":"2024","journal-title":"Pacing Clin. Electrophysiol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"210","DOI":"10.31083\/j.rcm2506210","article-title":"The Value of Adjunctive Left Atrial Posterior Wall Isolation on Clinical Outcomes in Atrial Fibrillation Patients: A Systematic Review and Meta-Analysis","volume":"25","author":"Liu","year":"2024","journal-title":"Rev. Cardiovasc. Med."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"euae246","DOI":"10.1093\/europace\/euae246","article-title":"Multielectrode catheter-based pulsed field ablation of persistent and long-standing persistent atrial fibrillation","volume":"26","author":"Sorgente","year":"2024","journal-title":"Europace"}],"container-title":["Journal of Cardiovascular Development and Disease"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2308-3425\/13\/6\/287\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,27]],"date-time":"2026-06-27T04:37:44Z","timestamp":1782535064000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2308-3425\/13\/6\/287"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,22]]},"references-count":20,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2026,6]]}},"alternative-id":["jcdd13060287"],"URL":"https:\/\/doi.org\/10.3390\/jcdd13060287","relation":{},"ISSN":["2308-3425"],"issn-type":[{"value":"2308-3425","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,22]]}}}