Ciaccio EJ, Hsia HH, Yarmohammadi H, MD EYW, Peters NS, Saluja D, Biviano AB. Atrial fibrillation substrate mapping with emphasis on voltage-based guidance. World J Cardiol 2025; 17(11): 109739 [DOI: 10.4330/wjc.v17.i11.109739]
Corresponding Author of This Article
Edward J Ciaccio, PhD, Senior Researcher, Division of Cardiology, Department of Medicine, Columbia University Medical Center, Room 9-934, 180 Fort Washington Avenue, New York, NY 10032, United States. ejc6@columbia.edu
Research Domain of This Article
Cardiac & Cardiovascular Systems
Article-Type of This Article
Review
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Cardiol. Nov 26, 2025; 17(11): 109739 Published online Nov 26, 2025. doi: 10.4330/wjc.v17.i11.109739
Atrial fibrillation substrate mapping with emphasis on voltage-based guidance
Edward J Ciaccio, Henry H Hsia, Hirad Yarmohammadi, Elaine Y Wan MD, Nicholas S Peters, Deepak Saluja, Angelo B Biviano
Edward J Ciaccio, Hirad Yarmohammadi, Deepak Saluja, Angelo B Biviano, Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, NY 10032, United States
Henry H Hsia, Cardiac Electrophysiology and Arrhythmia Service, University of California San Francisco, San Francisco, CA 94143, United States
Elaine Y Wan MD, Division of Cardiology, Columbia University, New York, NY 10032, United States
Nicholas S Peters, Imperial Centre for Cardiac Engineering, Imperial College London, London SW7 2AZ, United Kingdom
Author contributions: Ciaccio EJ wrote the manuscript; all co-authors reviewed the manuscript and provided helpful comments and suggestions; all of the authors read and approved the final version of the manuscript to be published.
Conflict-of-interest statement: Angelo B Biviano is a medical Advisory Board member for AltaThera pharmaceuticals. The other authors have no conflicts of interest.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Edward J Ciaccio, PhD, Senior Researcher, Division of Cardiology, Department of Medicine, Columbia University Medical Center, Room 9-934, 180 Fort Washington Avenue, New York, NY 10032, United States. ejc6@columbia.edu
Received: May 20, 2025 Revised: June 16, 2025 Accepted: September 16, 2025 Published online: November 26, 2025 Processing time: 185 Days and 11.8 Hours
Abstract
Voltage substrate mapping is a promising tool for the treatment of atrial fibrillation (AF). It is helpful to detect atrial fibrosis, which includes areas with low bipolar voltage, heterogeneous conduction properties, and shortened effective refractory period. The voltage amplitude is typically defined as the maximal peak-to-peak level within a specified time window of interest. Contemporary electroanatomic mapping platforms now enable many thousands of data points to be mapped, so that a geometric model of the atrial endocardium is constructable over a short period of time. This mapping procedure is often done with bipolar electrodes to cancel the far-field signal. The recording site coordinates are projected onto an atrial shell, with interpolation of the voltage data across the shell surface. The amplitude of the recorded bipolar electrogram depicted on the three-dimensional shell provides detailed information for substrate mapping. Wherever there are areas of low peak-to-peak voltage, it is thought to mark the presence of abnormal tissue properties and conduction. However, uncontrolled variables and environmental factors affecting voltage level include the oncoming electrical activation wavefront direction, the catheter incidence angle, the force applied to the catheter, and the region-variable shape and structure of atrial tissue. Techniques and settings to acquire atrial voltage data for AF analysis have not been standardized. Methods to characterize atrial electrograms are also presently limited. These factors affect quality and reproducibility of the mapping results. Herein, voltage substrate mapping and its variables pertaining to AF and radiofrequency ablation are described and discussed, with suggestions for future work efforts.
Core Tip: Voltage mapping is commonly used during substrate mapping to detect target areas for ablation in patients with atrial fibrillation (AF). Analysis of the substrate may take the form of detecting low voltage areas or the average voltage over an entire region. Often, areas which are targets for ablation are located where the voltage level is lower than normal, indicating disease and damage to the substrate. Furthermore, as AF progresses from paroxysmal to persistent type, the voltage level of the left atrium tends to diminish. This is often associated with atrial remodeling, in which structural and electrical changes occur during arrhythmia. Protocols for finding target areas using voltage mapping are described, and future research efforts to improve mapping and outcome are discussed.
