Patient-Specific Atrial Simulations Reproducing Clinical Electrogram Biomarkers Under Pacing Stress Protocol

Duna De Luis Moura1, Chiara Celotto2, Saman Golmaryami3, Marí­a Termenón Rivas4, Giada Sira Romitti4, Santiago Moreno Pineda5, Etel Silva Garcia6, Juan Fernandez Armenta Pastor7, Jose F Rodriguez Matas2, Alejandro Liberos8, Miguel Rodrigo5
1CoMMLab, Universidad de Valencia, 2Politecnico di Milano, 3INIBICA, 4CoMMLab, Universitat de València, 5Universitat de València, 6Instituto de Investigación e Innovación Biomédica de Cádiz (INiBICA), Grupo GADICOR , Hospital Universitario Puerta del Mar, Universidad de Cádiz, 7Hospital Viamed Santa Ángela de la Cruz, 8Universitat de València


Abstract

Digital twins offer a framework to study atrial substrate, but their ability to reproduce intracardiac electrogram biomarkers used to guide therapy is not fully established. We analyzed five patients with persistent atrial fibrillation, projecting 1,363 clinical bipolar electrograms onto a patient-specific digital twin of the left atrium. The model was calibrated using a triple extrastimulus pacing protocol, including adjustments of conduction properties and structural remodeling. This calibrated framework was then used to generate 21,527 simulated bipolar electrograms with integrated fibrosis. Electrograms were analyzed in a 290 ms window following a triple extrastimulus pacing protocol, extracting activation duration, number of deflections, and local activation time variability. Aberrant regions consistently showed increased activation duration in both datasets (simulations: 91 to 130 ms; clinical: 134 to 193 ms), together with consistent increases in deflections (sim: 5.6 to 7.4; clinical: 11.4 to 20.9) and LAT variability (sim: 3.5 to 5.8 ms; clinical: 11.4 to 21.9 ms). These findings demonstrate that patient-specific atrial models can reproduce electrophysiological patterns and may support identification of conduction abnormalities.