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\begin{document}

\title{Does Merged three-dimensional mapping Improve Contact foRce and
long-term procedure Outcome in Atrial Fibrillation ablation? (MICRO-AF
study): A prospective randomized controlled study}



\author[1]{Dong Geum Shin}%
\author[2]{Seung-Young Roh}%
\author[3]{Jinhee Ahn}%
\author[4]{Sang-Weon Park}%
\author[5]{Dong-Hyeok Kim}%
\author[6]{Sang-Jin Han}%
\author[6]{Hong Euy Lim}%
\affil[1]{Hallym University Medical Center}%
\affil[2]{Korea University Guro Hospital}%
\affil[3]{Pusan National University Hospital}%
\affil[4]{Sejong General Hospital}%
\affil[5]{Ewha Womans University}%
\affil[6]{Hallym University Sacred Heart Hospital}%


\vspace{-1em}



  
  \date{June 15, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Introduction: Integration of electroanatomical map (EAM) with
preacquired three-dimensional (3D) cardiac images provides detailed
appreciation of the complex anatomy of the left atrium (LA) and
pulmonary vein (PV). High-density (HD) multi-electrode mapping catheters
have enabled creating more accurate EAM reflecting real-time
volume-rendered LA-PV geometry during atrial fibrillation (AF) ablation.
However, no study has compared the outcomes of AF ablation using HD-EAM
versus 3D-merged map. We aimed to investigate the procedural and
clinical outcomes of AF ablation with HD-EAM (HD-EAM group) versus
3D-merged map (Merge group). Methods: One hundred patients
(59.5\selectlanguage{ngerman}±11.5years, 53\% with paroxysmal AF {[}PAF{]}) were randomly
assigned (1:1) to HD-EAM or Merged group. HD multi-electrode mapping and
contact force (CF)-sensing catheters were used to create virtual LA-PV
chamber and to perform wide antral circumferential ablation (WACA),
respectively. Results: The two groups showed no significant differences
in baseline characteristics and procedural data including ablation time,
fluoroscopy time, LA voltage, and CF. PV isolation with a single WACA
line was achieved in 21 (42\%) and 27 (54\%) patients in the Merge and
HD-EAM groups, respectively (P=NS). CF was significantly lower in
lesions with gap than lesions without gap after a single WACA (7.3±7.3 g
vs. 16.0±8.3, respectively, P\textless{}0.001). During the 12-month
follow-up, no significant difference in AF recurrence was observed
between two groups, irrespective of AF type. In multivariate analysis,
non-PAF was an independent risk factor for AF recurrence. Conclusion:
Integration of 3D cardiac imaging did not improve procedural and
clinical outcomes. HD-EAM provides an accurate real-time LA geometry.%
\end{abstract}\selectlanguage{ngerman}%



\sloppy


Does \textbf{M} erged three-dimensional mapping \textbf{I}
mprove\textbf{C} ontact fo\textbf{R} ce and long-term procedure
\textbf{O} utcome in \textbf{A} trial \textbf{F} ibrillation ablation?
(\textbf{MICRO-AF}study): A prospective randomized controlled study

Dong Geum Shin, MD\textsuperscript{a}; Seung Young Roh,
MD\textsuperscript{b}; Jinhee Ahn, MD\textsuperscript{c}; Sang Weon
Park, MD, PhD\textsuperscript{d}; Dong-Hyeok Kim, MD,
PhD\textsuperscript{e}; Sang-Jin Han, MD, PhD\textsuperscript{f}; Hong
Euy Lim, MD, PhD\textsuperscript{f}

\textsuperscript{a}Division of Cardiology, Hallym University Kangnam
Sacred Heart Hospital, Seoul, Republic of
Korea;\textsuperscript{b}Division of Cardiology, Korea University Guro
Hospital, Seoul, Republic of Korea; \textsuperscript{c}Division of
Cardiology, Department of Internal Medicine, Pusan National University
Hospital, Busan, Republic of Korea; \textsuperscript{d}Division of
Cardiology, Department of Internal Medicine, Sejong General Hospital,
Bucheon, Republic of Korea; \textsuperscript{e}Division of Cardiology,
Ewha Womans University Medical Center, Ehwa Womans University College of
Medicine, Seoul, Republic of Korea; \textsuperscript{f}Division of
Cardiology, , Hallym University College of Medicine, Anyang, Republic of
Korea

\textbf{Acknowledgement}

We would like to give special thanks to Mr. Seok Man Moon and Mrs. Yuri
Choi for collecting data from CARTO\selectlanguage{ngerman}® 3 EAM system.

\textbf{Sources of Funding}

This research was conducted with~financial support from the
Investigator-Initiated Study Program of Biosense Webster, Inc. (IIS446)

\textbf{Disclosures}

All authors have no conflict of interest to declare.

\textbf{Corresponding author:} Hong Euy Lim, MD, PhD

\textbf{Address for correspondence:}

Division of Cardiology, Hallym University Sacred Heart Hospital, Hallym
University College of Medicine, 22, Gwanpyeong-ro 170beon-gil,
Dongan-gu, Anyang-si, Gyeonggi-do 14068, Republic of Korea

\textbf{Tel.:} 82-31-380-3889

\textbf{E-mail:}\emph{hongeuy1046@gmail.com}

\textbf{Abstract}

\textbf{Introduction:} Integration of electroanatomical map (EAM) with
preacquired three-dimensional (3D) cardiac images provides detailed
appreciation of the complex anatomy of the left atrium (LA) and
pulmonary vein (PV). High-density (HD) multi-electrode mapping catheters
have enabled creating more accurate EAM reflecting real-time
volume-rendered LA-PV geometry during atrial fibrillation (AF) ablation.
However, no study has compared the outcomes of AF ablation using HD-EAM
versus 3D-merged map. We aimed to investigate the procedural and
clinical outcomes of AF ablation with HD-EAM (HD-EAM group) versus
3D-merged map (Merge group).

\textbf{Methods:} One hundred patients (59.5±11.5years, 53\% with
paroxysmal AF {[}PAF{]}) were randomly assigned (1:1) to HD-EAM or
Merged group. HD multi-electrode mapping and contact force (CF)-sensing
catheters were used to create virtual LA-PV chamber and to perform wide
antral circumferential ablation (WACA), respectively.

\textbf{Results:} The two groups showed no significant differences in
baseline characteristics and procedural data including ablation time,
fluoroscopy time, LA voltage, and CF. PV isolation with a single WACA
line was achieved in 21 (42\%) and 27 (54\%) patients in the Merge and
HD-EAM groups, respectively (P=NS). CF was significantly lower in
lesions with gap than lesions without gap after a single WACA (7.3±7.3
g\emph{vs.} 16.0±8.3, respectively, P\textless{}0.001). During the
12-month follow-up, no significant difference in AF recurrence was
observed between two groups, irrespective of AF type. In multivariate
analysis, non-PAF was an independent risk factor for AF recurrence.

\textbf{Conclusion:} Integration of 3D cardiac imaging did not improve
procedural and clinical outcomes. HD-EAM provides an accurate real-time
LA geometry.

\emph{\textbf{Keywords:} Atrial fibrillation; Catheter ablation;
Geometry; High density mapping; Image integration,}

\textbf{Introduction}

Atrial fibrillation (AF) is the most common cardiac arrhythmia and
radiofrequency catheter ablation (RFCA) has been recognized as an
effective treatment modality for a drug refractory
AF.\textsuperscript{1,2} Because AF ablation is a complex procedure that
requires delicate manipulation in the left atrium (LA) for pulmonary
vein (PV) isolation, accurate and real-time reconstruction of the LA and
PV geometry is essential to create durable lesions by increasing
catheter stability and preventing procedure-related
complications.\textsuperscript{3}

Various techniques have been developed to facilitate better virtual
visualization of the LA and PV anatomy. An electroanatomical map (EAM)
system can provide real-time three-dimensional (3D) virtual images of
the LA and PV. Previous studies have clearly demonstrated that the use
of EAM significantly reduces procedure time and fluoroscopy time, and
improves procedure outcome.\textsuperscript{4-6} Since the introduction
of special software for the integration of preacquired computed
tomography (CT) scan or magnetic resonance (MR) image with EAM, merged
3D image reconstruction has been widely used for AF ablation procedures.
Theoretically, the integration of volume-rendered cardiac images with
EAM can provide a more detailed appreciation of the complex anatomy of
the LA.\textsuperscript{7-9} However, merged image can lead to a less
accurate reflection of the real-time LA geometry because the component
images are obtained at different times and under different
conditions\textsuperscript{10-12}. Therefore, the use of merged 3D
mapping is still controversial with respect to its clinical benefits in
AF ablation.\textsuperscript{13-18}

Recently, a high density (HD) multi-electrode mapping catheters have
been commonly used, and it is known that HD multipolar mapping catheters
can enable faster and more accurate creation of real-time
EAM.\textsuperscript{19} However, many electrophysiologists still use
merged 3D map because there have been no randomized clinical trials on
the efficacy of using HD-EAM alone versus using merged 3D map during AF
ablation. In the present study, we investigated the procedural and
clinical outcomes of AF ablation with HD-EAM compared with AF ablation
with merged map from the integration of 3D cardiac images.

\textbf{Methods}

Study population

This was a prospective, randomized, multicenter trial. Between November
2017 and August 2018, 100 patients who underwent first-time RFCA for AF
(paroxysmal AF {[}PAF{]} and non-PAF) were enrolled. PAF was defined as
a history of one or more episodes of self-terminating AF that lasted \selectlanguage{english}[?]7
days. The exclusion criteria were age \textless{}18 years, a history of
AF ablation or cardiac surgery, acute bleeding at the time of
presentation, chronic kidney disease with a creatinine clearance rate of
\textless{}30 mL/min or requiring dialysis, acute stroke within 6
months, and refusal to take oral anticoagulants (OACs) in the long term.
All antiarrhythmic drugs were withheld for more than five half-lives
before the procedure. All patients received OACs for \selectlanguage{english}[?]3 weeks before the
procedure, and these drugs were not discontinued for RFCA. The patients
were randomly assigned to AF ablation with HD-EAM alone (HD-EAM group)
or AF ablation with merged map from the integration of 3D cardiac images
(Merge group). Central randomization at a 1:1 ratio was performed using
computer-generated random permutation sequences. Before ablation, all
patients in the Merge group underwent 128-channel cardiac multi-detector
CT scan. The study protocol was approved by the institutional review
board of each hospital and complied with the Declaration of
Helsinki\textbf{(ClinicalTrials.gov: NCT03350581)} . Written informed
consent was obtained from all enrolled patients.

Multislice Computed Tomography

CT examination was performed in the morning of procedure day after
overnight fast in the Merge group. Imaging was performed during a single
inspiratory breath hold in the cranio\selectlanguage{english}-caudal direction on helical mode
with retrospective electrocardiographic (ECG) gating. An intravenous
iodinated contrast agent (80 mL, Ultravist 370 mg/mL; Schering, Berlin,
Germany) was administrated, followed by 40 mL of a mixture of normal
saline and contrast agent (ratio of 7:3), both at a rate of 5 mL/s. To
obtain adequate gating and minimize motion artifacts, subjects with a
heart rate \textgreater{}80 beats per minute received a beta\selectlanguage{english}-blocker.
Axial multiphase images were reconstructed (slice thickness, 0.8 mm;
increment, 0.5 mm) using retrospective ECG gating.

Electrophysiological mapping

Electrophysiological studies and RFCA were performed with the patients
under deep sedation with a continuous infusion of propofol and fentanyl.
We used the CARTO(r) 3 EAM system (Biosense Webster Inc., Irvine, CA,
USA). EAM and voltage map of the LA and PV were simultaneously obtained
during sinus rhythm using an HD multi-electrode mapping catheter
(PENTARAY(r); Biosense Webster Inc., Irvine, CA, USA). Cardioversion with
direct current was performed if the baseline rhythm was AF, and voltage
mapping was performed during sinus rhythm. After the completion of the
EAM, the 3D volume-rendered LA image was superimposed on the real-time
HD-EAM of the LA using the software system of CARTO(r) (Cartomerge(r)) in
the Merge group.

Catheter ablation

After the completion of the virtual LA-PV geometry according to the
method in each group (Figure 1), wide antral circumferential ablation
(WACA) of the ipsilateral PVs was performed using an irrigated contact
force (CF)-sensing catheter (THERMOCOOL SMARTTOUCH(r) SF; Biosense Webster
Inc.,Irvine, CA, USA) in all patients. If there were remnant PV
potentials after a single WACA, we performed a touch-up ablation within
the initial WACA line for PV isolation (PVI). Cavotricuspid isthmus
(CTI) ablation was performed in patients with a history of typical
atrial flutter (AFL) or induced CTI-dependent AFL. In addition, CTI
ablation was performed according to the physician's judgment.
Voltage-guided ablation was performed in non-PAF patients. If the
low-voltage area (\textless{}0.5 mV) occupied \textgreater{}10\% of the
total LA surface area in the baseline voltage mapping, we created a box
lesion through linear ablation on the roof and posterior-inferior lines
between each PV to isolate the posterior wall of the LA. If organized LA
tachycardia was induced, activation mapping and additional linear
ablation at the lateral perimitral isthmus were conducted.
Radiofrequency energy of 30 W was delivered to the anterior, roof, and
inferior segments of the PV antra and the roof line between each upper
PV for a maximum duration of 40 s to achieve voltage abatement in each
ablation lesion. We applied 25 W for a maximum of 20 s to the posterior
segments of the PV antra and the posterior-inferior line between each
lower PV. The irrigation rate was 10 mL/min at 25--30 W, and the maximum
temperature was 40degC for safety reasons. In addition, the same protocol
was applied for linear ablation on the CTI and lateral perimitral
isthmus. A fisherman's knot suture closure without protamine injection
was performed to achieve femoral venous hemostasis after sheath removal.
After 6--8 h of immobilization, the puncture sites were inspected. The
patients took OACs at the scheduled time on the day of the procedure,
after confirming complete hemostasis or the absence of bleeding
complications. In order to compare the accuracy of virtual geometry
according to the method of each group, the ablation lesion parameters
including CF were not displayed to the operator during RFCA, but were
collected in all patients. Data were independently managed and analyzed
by two independent investigators who were blinded to clinical
information.

Follow-up

All patients took OACs for at least 3 months after RFCA. Thereafter,
only patients with a CHA\textsubscript{2}DS\textsubscript{2}-VASc score
of \selectlanguage{english}[?]2 continued taking OACs. Antiarrhythmic drugs were not used after
the procedure, but were allowed if any atrial tachyarrhythmia recurred
for \textgreater{}30 s during the blanking period. Clinical follow-up
was performed at 1, 3, 6, 9, and 12 months. The patients underwent
12-lead ECG at each visit and 24-h Holter recording at 3, 6, and 12
months. An ECG was also performed whenever a patient presented with
palpitations. Any ECG-documented atrial tachyarrhythmia (AF, AFL, or
atrial tachycardia) lasting for \textgreater{}30 s after the initial
3-month blanking period was defined as clinical recurrence.

Statistical analysis

All normally distributed continuous variables are expressed as mean and
standard deviation. Continuous variables were analyzed using an
independent t-test. Categorical variables are reported as counts and
proportions, and were analyzed using Pearson's chi-square test or
Fisher's exact test, as appropriate. Variables found to be statistically
significant in univariate analysis were further analyzed using
multivariate Cox regression to evaluate the independent predictors of
the clinical recurrence of AF. Kaplan-Meier analysis with a log-rank
test was performed to compare AF recurrence free survival between
groups. Statistical significance was set at p\textless{}0.05. All
statistical analyses were performed using SPSS Statistics for Windows
(version 21.0; IBM Corp., Armonk, NY, USA).

\textbf{Results}

Baseline characteristics

The clinical characteristics of the enrolled patients are shown in Table
1. The mean age was 59.5+-11.5 years, and 53 (53\%) patients had PAF. The
mean CHA\textsubscript{2}DS\textsubscript{2}-VASc score was 1.9+-1.5. No
significant differences were observed in the baseline characteristics
between the two groups except for body mass index.

Procedural outcomes

The procedural data are presented in Table 2. The total procedure,
ablation, and fluoroscopy times were not significantly different between
two groups. The average number of mapping points in the LA for baseline
voltage map was 697.6+-285.8, and was not significantly different between
two groups. The mean CF was 15.8+-4.5 g. There were no statistical
differences in CF, power, impedance, and force time integral (FTI)
between two groups. Additional ablation including the CTI and box lesion
was performed in 71 patients and was not significantly different between
two groups.

Successful PVI was accomplished in all enrolled patients. PVI through a
single WACA line was achieved in 21 (42\%) patients in the Merge group
and in 27 (54\%) patients in the HD-EAM group, with no statistical
difference between two groups. Figure 2 shows the distribution of
lesions with a residual conduction gap within four segments of each PV
after a single-line ablation of ipsilateral PVs. Total of 90 gaps that
required touch-up ablation were detected in 44 lesions in the right PVs
and in 46 lesions in the left PVs. The most prevalent gap site was the
anterior carina of the left PVs (32.2\%), followed by the posterior
carina of the right PVs (17.7\%), with no statistical difference between
two groups. The mean CF value in initial ablation lesions related with
gap was significantly lower than that in lesions without gap (7.3+-7.3 g
vs. 16.0+-8.3, respectively, p \textless{} 0.001). No serious
procedure-related complications occurred, except for groin hematoma in
three patients (one in the HD-EAM group and two in the Merge group).

Clinical outcomes

The clinical outcomes are listed in Table 3. During the 12-month
follow-up period, 1 patient in each group dropped out, leaving 98
patients who completed the study. Twenty patients experienced clinical
recurrence after the 3-month blanking period. The two groups showed no
statistically significant differences in the early and clinical
recurrence rates. Figure 3 shows the Kaplan-Meier curves for atrial
tachyarrhythmia-free survival rate, which revealed comparable outcomes
between the two groups in the overall (log-rank p=0.304), PAF (log-rank
p=0.333), and non-PAF (log-rank p=0.341) patients.

Table 4 shows the results of univariate and multivariate Cox regression
analyses for identifying the potential risk factors for clinical
recurrence. Multivariate analysis revealed that non-PAF (hazard ratio
5.225, 95\% confidence interval 1.240--22.015, p=0.024) was an
independent risk factor for clinical recurrence.

\textbf{Discussion}

Since HD multi-electrode mapping catheters became widely used for AF
ablation procedures, to our knowledge, this is the first prospective
randomized clinical trial to evaluate the procedural outcomes according
to different methods of virtual volume rendering of the LA geometry for
AF ablation. Our study had several noteworthy findings: (1) no
significant differences were observed in procedural data including
procedural time, ablation time, fluoroscopy time, CF, and FTI between
the HD-EAM group and the Merge group; (2) complete PVI with a single
WACA line was achieved in approximately half of the patients (48\%), and
the two groups showed no statistical difference in the rate of
single-line isolation; (3) the most common gap site was the anterior
carina of the left PVs, followed by the posterior carina of the right
PVs; (4) lower CF was significantly related to a residual conduction gap
after a single WACA of the ipsilateral PVs; and (5) no significant
difference was found in the AF recurrence rate between two groups during
the 12-month follow-up period after RFCA.

Preprocedural 3D cardiac imaging provides specific information related
to the LA, PV, and surrounding structures before the AF ablation
procedure. Theoretically, the integration of preacquired 3D cardiac
images with EAM can correct the flaws of the EAM technique and provide a
more detailed appreciation of the complex cardiac anatomy. Several
studies have been performed to define the clinical benefits of 3D image
integration with EAM for AF ablation. Della Bella et
al.\textsuperscript{13} reported the superior efficacy of image
integration for AF ablation in a prospective randomized study. Several
studies have also shown the feasibility of AF ablation guided by
integration with 3D cardiac reconstructed
images.\textsuperscript{14,15}However, other studies did not show
clinical benefits of preacquired 3D image integration. Kistler et
al.\textsuperscript{16}, in a prospective randomized study, found no
statistical difference in the single procedure success rate between
standard geometry with EAM alone and merged geometry with CT image
integration. In additional, several other investigators have
demonstrated no significant difference in clinical outcomes with respect
to the use of image integration systems involving CT or MR
image.\textsuperscript{17,18} Unlike the present study in which an HD
multipolar mapping catheter was used, other studies used a conventional
mapping catheter to create EAM, which might explain the controversial
results.

The latest technology involving the use of an HD multi-electrode mapping
catheter enables faster and more accurate creation of real-time
representations of the virtual cardiac chamber during the procedure. The
PentaRay(r) multi-electrode mapping catheter has 20 (1-mm) electrodes with
an interelectrode spacing of 4--4--4 mm and the capability of
simultaneously acquiring multiple voltage data
points.\textsuperscript{19} The main advantage of the PentaRay(r) mapping
catheter is the atraumatic splaying of all five splines against the
endocardial surface and providing an HD-EAM covering a surface of
\textgreater{}7 cm\textsuperscript{2}. Therefore, compared with
point-by-point EAM created by a conventional mapping catheter, EAM
created using an HD multi-electrode mapping catheter have important
advantages, such as less mapping time and greater spatiotemporal
resolution. However, a few operators still prefer using merged map from
3D cardiac image integration during AF ablation despite the use of an HD
multi-electrode mapping catheter to create the virtual LA geometry. In
the present study, we compared the procedural outcomes of AF ablation
with HD-EAM and AF ablation with merged 3D map, and found no clinical
benefits of the integration of 3D cardiac image with HD-EAM.
Furthermore, CT scan can be of limited use, especially in patients with
renal dysfunction, and requires larger radiation doses than traditional
radiography. Recently, MR imaging has been used; however, it has some
limitations in patients with metallic implants (e.g., cardiac devices),
contrast allergy, and claustrophobia.

We also analyzed the characteristics of the residual conduction gap
after a single WACA of ipsilateral PVs. The most frequent gap location
was the anterior carina of the left PVs, and the second common gap site
was the posterior carina of the right PVs. The CF value was
significantly lower in initial ablation lesions with gap than in lesions
without gap. This result is consistent with that of other
studies.\textsuperscript{20,21} The EFFICAS-I study demonstrated that
gap sites correlated with lower minimum CF and FTI during the initial
ablation.\textsuperscript{21} CF is mostly affected by catheter
stability, and maintenance of a CF of \textgreater{}10 g during energy
application is challenging in the ridge area between the left PVs and LA
appendage, as well as in the posterior carina of the right PVs, because
of the acute angle between the right superior PV and right inferior PV.
Interestingly, the achievement of PVI with a single WACA line did not
affect clinical outcomes, possibly because complete PVI with additional
touch-up ablations was accomplished in all PVs in the present study.

This study had several limitations. First, the number of enrolled
patients was too small and may have been insufficient to determine the
efficacy of AF ablation with HD-EAM alone. Furthermore, highly
experienced operators performed the procedure in the present study,
which could reduce the sensitivity of the results. Second, intracardiac
echocardiography (ICE) has been recently used to reconstruct the virtual
geometry of the LA and PV.\textsuperscript{22} Therefore, further
large-scale randomized studies involving the use of ICE are required.

\textbf{Conclusions}

Integration of 3D cardiac images with EAM does not improve the
procedural and clinical outcomes of AF ablation. The use of HD-EAM,
created using a multi-electrode mapping catheter, can provide accurate
real-time virtual cardiac geometry. Thus, AF ablation with HD-EAM alone
may be an efficient method.

\textbf{Data Availability}

The data underlying this article will be shared on reasonable request to
the corresponding author

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study. \emph{J Cardiovasc Electrophysiol.} 2009;20(3):258-265.

14. Bertaglia E, Bella PD, Tondo C, et al. Image integration increases
efficacy of paroxysmal atrial fibrillation catheter ablation: results
from the CartoMerge Italian Registry.
\emph{Europace.}2009;11(8):1004-1010.

15. Hunter RJ, Ginks M, Ang R, et al. Impact of variant pulmonary vein
anatomy and image integration on long-term outcome after catheter
ablation for atrial fibrillation. \emph{Europace.}2010;12(12):1691-1697.

16. Kistler PM, Rajappan K, Harris S, et al. The impact of image
integration on catheter ablation of atrial fibrillation using
electroanatomic mapping: a prospective randomized study. \emph{Eur Heart
J.} 2008;29(24):3029-3036.

17. Tang K, Ma J, Zhang S, et al. A randomized prospective comparison of
CartoMerge and CartoXP to guide circumferential pulmonary vein isolation
for the treatment of paroxysmal atrial fibrillation. \emph{Chin Med J
(Engl).} 2008;121(6):508-512.

18. Caponi D, Corleto A, Scaglione M, et al. Ablation of atrial
fibrillation: does the addition of three-dimensional magnetic resonance
imaging of the left atrium to electroanatomic mapping improve the
clinical outcome?: a randomized comparison of Carto-Merge vs. Carto-XP
three-dimensional mapping ablation in patients with paroxysmal and
persistent atrial fibrillation. \emph{Europace.} 2010;12(8):1098-1104.

19. Anter E, Tschabrunn CM, Josephson ME. High-resolution mapping of
scar-related atrial arrhythmias using smaller electrodes with closer
interelectrode spacing. \emph{Circ Arrhythm
Electrophysiol.}2015;8(3):537-545.

20. Pedrote A, Arana-Rueda E, Arce-Leon A, et al. Impact of Contact
Force Monitoring in Acute Pulmonary Vein Isolation Using an Anatomic
Approach. A Randomized Study. \emph{Pacing Clin
Electrophysiol.}2016;39(4):361-369.

21. Neuzil P, Reddy VY, Kautzner J, et al. Electrical reconnection after
pulmonary vein isolation is contingent on contact force during initial
treatment: results from the EFFICAS I study. \emph{Circ Arrhythm
Electrophysiol.} 2013;6(2):327-333.

22. Kimura M, Sasaki S, Owada S, et al. Validation of accuracy of
three-dimensional left atrial CartoSound and CT image integration:
influence of respiratory phase and cardiac cycle. \emph{J Cardiovasc
Electrophysiol.} 2013;24(9):1002-1007.

Table1. Baseline characteristics in enrolled patients\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Overall (n=100)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
HD-EAM (n=50)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Merge (n=50)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
P-value\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Age, years\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
59.5\selectlanguage{ngerman}±11.5\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
60.2\selectlanguage{ngerman}±10.9\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
58.9\selectlanguage{ngerman}±12.2\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.581\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Sex, male (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
77 (77.0)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
35 (70.0)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
42 (84.0)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.096\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
BMI, kg/m\textsuperscript{2}\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
24.9\selectlanguage{ngerman}±2.7\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
24.3\selectlanguage{ngerman}±2.5\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
25.5\selectlanguage{ngerman}±2.8\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.019\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Type of AF (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.841\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Paroxysmal\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
53 (53.0)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
27 (54.0)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
26 (52.0)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Non-paroxysmal\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
47 (47.0)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
23 (46.0)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
24 (48.0)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Medical history (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Heart failure\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
17 (17.0)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
8 (16.0)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
9 (18.0)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.790\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Hypertension\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
57 (57.0)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
29 (58.0)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
28 (56.0)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.840\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Diabetes mellitus\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
20 (20.0)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
9 (18.0)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
11 (22.0)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.617\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Stroke/TIA\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
9 (9.0)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
7 (14.0)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2 (4.0)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.081\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Vascular disease\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2 (2.0)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1 (2.0)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1 (2.0)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.999\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
CHA\textsubscript{2}DS\textsubscript{2}-VASc\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.9\selectlanguage{ngerman}±1.5\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2.0\selectlanguage{ngerman}±1.7\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.7\selectlanguage{ngerman}±1.3\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.385\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Echocardiography\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
LA (AP), mm\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
41.7\selectlanguage{ngerman}±6.0\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
41.3\selectlanguage{ngerman}±6.7\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
42.1\selectlanguage{ngerman}±5.4\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.507\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
LVEF, \%\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
57.2\selectlanguage{ngerman}±8.8\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
56.9\selectlanguage{ngerman}±10.4\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
57.4\selectlanguage{ngerman}±6.9\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.788\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

AF, atrial fibrillation; BMI, body mass index;
CHA\textsubscript{2}DS\textsubscript{2}-VASc, Congestive heart failure,
Hypertension, Age [?]75 (doubled), Diabetes mellitus, and prior ischemic
Stroke, transient ischemic attack or thromboembolism (doubled), Vascular
disease, Age 65 to 74, Sex category (female); HD-EAM, high density
electroanatomical map; LA, left atrium; LVEF, left ventricle ejection
fraction; TIA, transient ischemic attack

Table2. Procedural data\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Overall (n=100)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
HD-EAM (n=50)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Merge (n=50)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
P-value\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Procedure time, min\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
150.2\selectlanguage{ngerman}±30.5\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
149.8\selectlanguage{ngerman}±25.1\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
150.6\selectlanguage{ngerman}±35.4\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.900\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Ablation time, min\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
68.6\selectlanguage{ngerman}±22.4\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
68.0\selectlanguage{ngerman}±21.8\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
69.2\selectlanguage{ngerman}±23.1\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.900\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Fluoroscopy time, min\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
22.6\selectlanguage{ngerman}±12.9\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
23.7\selectlanguage{ngerman}±13.9\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
21.5\selectlanguage{ngerman}±11.8\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.401\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
LA point, n\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
697.6\selectlanguage{ngerman}±285.8\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
700.1\selectlanguage{ngerman}±294.3\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
695.3\selectlanguage{ngerman}±280.5\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.934\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
LA voltage, mV\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.5\selectlanguage{ngerman}±0.7\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.4\selectlanguage{ngerman}±0.7\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.5\selectlanguage{ngerman}±0.7\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.562\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Contact force, g\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
15.8\selectlanguage{ngerman}±4.5\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
16.2\selectlanguage{ngerman}±4.6\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
15.4\selectlanguage{ngerman}±4.4\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.418\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Power, W\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
28.6\selectlanguage{ngerman}±1.9\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
28.3\selectlanguage{ngerman}±1.8\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
28.9\selectlanguage{ngerman}±2.0\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.132\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Impedance, ohm\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
128.4\selectlanguage{ngerman}±9.7\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
128.0\selectlanguage{ngerman}±8.6\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
128.8\selectlanguage{ngerman}±10.7\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.691\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Force time integral, gs\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
207.7\selectlanguage{ngerman}±80.2\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
205.5\selectlanguage{ngerman}±76.3\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
209.6\selectlanguage{ngerman}±84.4\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.809\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Single line isolation (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
48 (48.0)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
27 (54.0)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
21 (42.0)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.230\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Additional ablation (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Cavotricuspid isthmus\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
69 (69)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
35 (70)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
34 (68)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
0.829\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Box lesion\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
15 (15)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
8 (16)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
7 (14)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
0.779\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Perimitral isthmus\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
1 (1)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
1 (2)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
0.999\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

HD-EAM, high density electroanatomical map; LA, left atrium; RA, right
atrium

Table3. Clinical outcome findings after radiofrequency catheter ablation\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Overall (n=98)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
HD-EAM (n=49)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Merge (n=49)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
P-value\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Early recurrence (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
26 (26.5)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
11 (22.4)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
15 (30.6)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.360\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Clinical recurrence (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
20 (20.4)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
8 (16.3)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
12 (24.5)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.316\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
AF\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
16 (16.3)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
7 (14.3)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
9 (18.4)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Atypical AFL/AT\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
4 (4.1)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1 (2.0)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
3 (6.1)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

AF, atrial fibrillation; AFL, atrial flutter; AT, atrial tachycardia;
HD-EAM, high density electroanatomical map

Table4. Univariate and multivariate Cox regression analysis for
predictors of clinical recurrence\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
& Univariate analysis & Univariate analysis & Multivariate analysis+ &
Multivariate analysis+\tabularnewline
\midrule
\endhead
& HR (95\% CI) & P-value & HR (95\% CI) & P-value\tabularnewline
Age & 0.988 (0.953-1.024) & 0.509 & &\tabularnewline
Sex, male & 0.379 (0.167-1.946) & 0.370 & &\tabularnewline
BMI, kg/m\textsuperscript{2} & 1.075 (0.914-1.266) & 0.382 &
&\tabularnewline
Non-paroxysmal AF & 5.784 (1.931-17.325) & 0.002 & 5.225 (1.240-22.015)
& 0.024\tabularnewline
Medical history & & & &\tabularnewline
Heart failure & 1.555 (0.520-4.652) & 0.430 & &\tabularnewline
Hypertension & 0.721 (0.353-2.056) & 0.245 & &\tabularnewline
Diabetes mellitus & 1.683 (0.646-4.381) & 0.286 & &\tabularnewline
Stroke/TIA & 1.824 (0.534-6.226) & 0.338 & &\tabularnewline
Echocardiography & & & &\tabularnewline
LA diameter (AP), mm & 1.088 (1.018-1.163) & 0.013 & 1.003 (0.904-1.113)
& 0.995\tabularnewline
LVEF, \% & 0.966 (0.935-0.999) & 0.044 & 0.964 (0.908-1.023) &
0.230\tabularnewline
Procedural data & & & &\tabularnewline
Avg. LA voltage & 0.868 (0.444-1.695) & 0.677 & &\tabularnewline
Procedure time, min & 0.998 (0.983-1.014) & 0.832 & &\tabularnewline
Ablation time, min & 0.984 (0.963-1.006) & 0.149 & &\tabularnewline
Avg. Contact force, g & 0.888 (0.783-1.007) & 0.064 & 0.965
(0.765-1.216) & 0.760\tabularnewline
Avg. Powder, W & 0.797 (0.598-1.064) & 0.124 & &\tabularnewline
Force time integral, gs & 0.992 (0.985-1.000) & 0.051 & 1.001
(0.983-1.020) & 0.899\tabularnewline
Single line isolation & 0.532 (0.212-1.334) & 0.178 & &\tabularnewline
HD-EAM & 0.645 (0.264-1.579) & 0.337 & &\tabularnewline
\bottomrule
\end{longtable}

+Age, sex and BMI adjusted

AF, atrial fibrillation; BMI, body mass index; HD-EAM, high density
electroanatomical map; LA, left atrium; LVEF, left ventricle ejection
fraction; TIA, transient ischemic attack

\textbf{Figure Legends.}

\textbf{Figure 1.} Representative images of ablation lesions on the left
atrium in the HD-EAM (A) and merged three-dimensional map (B). The red
dot indicates an ablation lesion at 30 W; green dot indicates an
ablation lesion at 25 W; and blue dot indicates a touch-up ablation
lesion.

HD-EAM, high-density electroanatomic map

\textbf{Figure 2.} Division of the antrum of each pulmonary vein into
four segments and distribution of residual conduction gaps after a
single wide antral circumferential ablation of ipsilateral pulmonary
veins.

PV, pulmonary vein; LI, left inferior; LS, left superior; RI, right
inferior; RS, right superior

\textbf{Figure 3.} Kaplan-Meier survival curves for atrial
tachyarrhythmia recurrence free survival during the 12-month follow-up
after radiofrequency catheter ablation in the overall (A), paroxysmal AF
(B), and non-paroxysmal AF (C) patients.

AF, atrial fibrillation; HD-EAM, high-density electroanatomic map\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/MICRO-AF-Figure-1/MICRO-AF-Figure-1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/MICRO-AF-Figure-2/MICRO-AF-Figure-2}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/MICRO-AF-Figure-3/MICRO-AF-Figure-3}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

