Digital Twins for Atrial Fibrillation Including Fibrosis Infiltration Characterized from Voltage Measurements

Marí­a Termenón Rivas1, Giada Sira Romitti1, Duna De Luis Moura2, Nicasio Pérez Castellano3, David Calvo Cuervo4, Alejandro Liberos5, Miguel Rodrigo6
1CoMMLab, Universitat de València, 2CoMMLab, Universidad de Valencia, 3Arrhythmia Unit at Hospital Clínico San Carlos, 4Arrhythmia Unit, Hospital Clínico San Carlos, Madrid, CiberCV, Spain, 5Universitat de València, 6Universitat de València


Abstract

Atrial fibrillation (AF) catheter ablation is associated with high recurrence rates. Personalized computational models, or digital twins (DTs), offer a framework to optimize these procedures through patient-specific ablation plan-ning. Given its key role in arrhythmia maintenance, fibrosis characterization is essential for the predictive fidelity of these models. We propose a methodology to estimate fibrotic distribution from intracavi-tary electrical recordings. Simulations of atrial tissue across varying fibrosis levels (0-35%) were conducted to generate endocardial bipolar electrograms and quantify the peak-to-peak voltage (Vpp). From these, a calibration func-tion (R²=0.94) was established to correlate Vpp with fibrotic burden. This function was applied to clinical data from three patients to generate personalized substrate maps, differentiating healthy tissue (>0.25 mV), scar (<0.1 mV), and interstitial fibrosis. This methodology was integrated into our established workflow for electrophysiologically informed DTs, which are an-atomically and functionally characterized to patient-specific biomarkers (cycle length and conduction velocity). These models would enable the development of model-guided ablation strategies tailored to the individual structural characteristics of each patient.