Digital twin virtual atrial fibrillation dynamics predict clinical atrial arrhythmia recurrence after catheter ablation
T Hwang, D Ahn, J Huh, K Im, O Kwon, H Park, D Kim, H Yu, T Kim, J Uhm, B Joung, H PakAbstract
Background
The maximal slope of the action potential duration restitution curve (Smax) reflects electrical instability and relates to fibrillation maintenance. However, the clinical significance of digital twin–derived high-density (HD) Virtual Restitution properties and Virtual atrial fibrillation (AF) sustainability in patients undergoing AF catheter ablation (AFCA) remains unclear.
Objective
To determine whether digital twin–derived left atrial (LA) HD-Virtual Restitution patterns (>0.4 million nodes) and Virtual AF sustainability are associated with Clinical atrial arrhythmia (AA) recurrence after AFCA.
Methods
We included 323 patients undergoing AFCA (76.2% male, 60.6±9.9 years old, 78.6% persistent AF). Using bipolar electroanatomical mapping data (>1,000 points), we constructed patient-specific LA digital twin models and evaluated the relationships among low voltage area (LVA <0.5 mV) burden, Virtual AF sustainability, and quantified HD-Virtual Restitution properties. Patients with LVA ≥40% and mean Smax <1 were considered the Extremely Remodeled group (n=32) and evaluated separately in downstream analyses, given their deviation from the overall LVA–Smax relationship. Among the remaining 291 patients, Virtual Restitution patterns were classified into Overall-Low, Average-Homogeneous, Average-Heterogeneous, and Overall-High Smax, and Virtual AF sustainability was grouped into Sustained and Non-sustained groups.
Results
Virtual AF was Sustained in 79.9% and Non-sustained in 20.1%. Virtual AF sustainability was similar across the four Smax patterns (p=0.290). In multivariable Cox models using the Extremely Remodeled group as the reference, Non-sustained Virtual AF was independently associated with a significantly lower risk of clinical recurrence (aHR 0.18, 95% CI 0.06–0.55; p=0.003). The Overall-Low (aHR 0.31, 95% CI 0.12–0.85; p=0.022) and Average-Homogeneous Smax patterns (aHR 0.48, 95% CI 0.24–0.95; p=0.036) were independently associated with lower clinical AA recurrence. The Extremely Remodeled group was significantly older, more frequently female, had larger LA size, and higher E/e′. Despite significantly lower Virtual AF sustainability (15.6% vs 86.9%; p<0.001) and Smax <1, this group showed higher Clinical AA recurrence, but mostly AT recurrence (6/15, 40%) than others (Log rank p=0.003). Digital twin–derived restitution patterns and Virtual AF sustainability increased Harrell’s C-index beyond clinical covariates for Clinical AA recurrence by 0.044 (p=0.034).
Conclusion
Patient-specific digital twin–derived HD-Virtual Restitution patterns and Virtual AF sustainability were associated with Clinical AA recurrence after AFCA. However, the Extremely Remodeled subgroup with a large LVA burden exhibited discordant behavior due to a low critical mass.Figure1_ESCFigure 2