Graphical Abstract.

This study presents a comparison between reentrant driver (RD)-harboring regions identified by electrocardiographic imaging (ECGI), conducted prior to catheter ablation in persistent atrial fibrillation (PsAF) patients, and via simulations conducted in patient-specific computational models reconstructed from late gadolinium-enhanced magnetic resonance imaging (LGE-MRI) scans. The finding of atrial regions in which both ECGI and simulations detected RDs (purple) suggests that PsAF is at least partially driven by fibrosis-mediated mechanisms. Simulations also identify “latent” RDs (red)—regions within the fibrotic substrate where an RD could persist, but never manifested during clinical mapping. Conversely, RD-harboring regions identified by ECGI but not in simulations (blue) indicate that some clinically mapped AF episodes were perpetuated by mechanisms other than the fibrotic substrate. Our retrospective analysis suggests that substrate-based ablation combining simulations with ECGI could improve outcomes.