Is the abnormal conduction zone of the left atrium a precursor to a low voltage area in patients with atrial fibrillation?

Background The abnormal conduction zone (ACZ) in the left atrium (LA) has attracted attention as an arrhythmia source in atrial fibrillation (AF). We investigated the hypothesis that the ACZ is related to the low voltage area (LVA) or the LA anatomical contact areas (CoAs) with other organs. Methods and Results We studied 100 patients (49 non-paroxysmal AF, 66 males, and 67.9 +/- 9.9 years) who received catheter ablation for AF. High-density LA mapping during high right atrial pacing was constructed. Isochronal activation maps were created at 5-ms interval setting, and the ACZ was identified on the activation map by locating a site with isochronal crowding of >= 3 isochrones, which are calculated as <= 27 cm/s. The LVA was defined as the following; mild ( < 1.3 mV), moderate (<1.0 mV), and severe LVA (<0.5 mV). The CoAs (ascending aorta-anterior LA, descending aorta-posterior LA, and vertebrae-posterior LA) were assessed using computed tomography. The ACZ was linearly distributed, and observed in 95 patients (95%). The ACZ was most frequently observed in the anterior wall region (77%). A longer ACZ was significantly associated with a larger LA size and a prevalence of non-PAF. The 51.2 +/- 36.2% of ACZ overlapped with mild LVA, 32.9 +/- 32.8% of ACZ with moderate LVA, and 14.6 +/- 22.0% of ACZ with severe LVA. In contrast, only 25.6 +/- 28.0% of ACZ matched with the CoAs. Conclusion The ACZ reflects LA electrical remodeling and may be a precursor finding of the low voltage zone and not the LA CoAs in patients with atrial fibrillation.