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Yano M, Egami Y, Kawanami S, Ukita K, Kawamura A, Yasumoto K, Tsuda M, Okamoto N, Matsunaga-Lee Y, Nishino M. Comparison of Postprocedural P-Wave Vector Magnitude on 12-Lead Electrocardiogram Between Cryoballoon and Radiofrequency Ablation. Am J Cardiol 2024; 220:1-8. [PMID: 38522652 DOI: 10.1016/j.amjcard.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 02/14/2024] [Accepted: 03/11/2024] [Indexed: 03/26/2024]
Abstract
Pulmonary vein isolation (PVI) causes changes in P-wave parameters. However, the difference in changes in P-wave parameters including P-wave vector magnitude (Pvm) between radiofrequency catheter ablation (RFCA) and cryoballoon ablation (CBA) remains unknown. Paroxysmal atrial fibrillation (PAF) patients who underwent only PVI were enrolled. Pvm was calculated by the square root of the sum of the squared P-wave amplitude in leads II and V6 and one-half of the P-wave amplitude in V2. The patients were divided into 2 groups: RFCA and CBA. ΔPvm was calculated as ΔPvm (mV) = (Pvm at pre-PVI)-(Pvm at post-PVI). The following factors were evaluated: (1) differences in the ΔPvm between the 2 groups, (2) relation between late arrhythmia recurrence and ΔPvm in RFCA and CBA groups, and (3) the impact of relevant factors on ΔPvm. The study population included a total of 426 patients with PAF (RFCA, 167 patients; CBA, 259 patients). ΔPvm was significantly larger in CBA than in RFCA (p <0.001). Kaplan-Meier analysis showed late arrhythmia recurrence was significantly higher in patients with low ΔPvm (<0.019 mV) than high ΔPvm (≥0.019 mV) in RFCA (Log-rank p <0.001), and low ΔPvm (<0.033 mV) than high ΔPvm (≥0.033 mV) in CBA (Log-rank p <0.001). Multiple regression analysis showed that CBA and heart rate change were independently and significantly associated with ΔPvm (p <0.001 and p <0.001, respectively). In conclusion, ΔPvm was significantly larger in CBA than RFCA during procedure. Low ΔPvm had a higher risk of late arrhythmia recurrence in RFCA and CBA.
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Affiliation(s)
- Masamichi Yano
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Yasuyuki Egami
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Shodai Kawanami
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Kohei Ukita
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Akito Kawamura
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Koji Yasumoto
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Masaki Tsuda
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Naotaka Okamoto
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | | | - Masami Nishino
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan.
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Bansmann PM, Mohsen Y, Horlitz M, Stöckigt F. Optimizing fibrosis detection: a comparison of electroanatomical mapping and late enhancement gadolinium magnetic resonance imaging. J Interv Card Electrophysiol 2024; 67:571-577. [PMID: 37612562 DOI: 10.1007/s10840-023-01627-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/16/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Fibrotic atrial cardiomyopathy plays an important role in determining the outcome of ablation in patients with atrial fibrillation (AF). Two main methods are being used for the evaluation of fibrosis: voltage-based high-density (HD) electroanatomical mapping (EAM) and late gadolinium enhancement MRI (LGE-MRI). The comparability between both methods in detecting fibrosis has not been systematically investigated. METHODS LGE-MRIs of the left atrium (LA) were performed in 21 patients. LA-fibrosis was evaluated using a custom-designed software generating a 3D-model of the LA. HD-electroanatomical maps were recorded in each patient. After processing the maps and the MRI models by excluding the mitral valve, pulmonary veins, and the left atrial appendage, the LGE areas were measured and compared to the low voltage areas (LVA) in the HD maps using three different cutoff values of 0.5 mV, 0.7 mV, and 1.0 mV. RESULTS The analysis revealed significant differences between EAM and LGE-MRI in assessing LA-fibrosis at 0.5-mV (for anterior and posterior walls) and 1.0-mV cutoffs (for anterior and posterior wall and septum). However, no significant differences were found between EAM and LGE-MRI when using a 0.7-mV cutoff for all the investigated areas. CONCLUSIONS A voltage cutoff of 0.7 mV provided the best correlation between EAM and LGE MRI for detecting left atrial fibrosis. It supports the idea that a 0.5-mV cutoff may underestimate fibrosis, as areas with local signal voltages between 0.6 and 0.8 mV could also show LGE on MRI. Further research is needed to determine the ideal voltage cutoff for detecting left atrial fibrosis.
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Affiliation(s)
- P Martin Bansmann
- Department of Radiology, Krankenhaus Porz am Rhein, Cologne, Germany
| | - Yazan Mohsen
- Department of Cardiology, Electrophysiology and Rhythmology, Krankenhaus Porz am Rhein, Urbacher Weg 19, 51149, Cologne, Germany.
- Clinical Sciences Malmö, Lund University, Lund, Sweden.
| | - Marc Horlitz
- Department of Cardiology, Electrophysiology and Rhythmology, Krankenhaus Porz am Rhein, Urbacher Weg 19, 51149, Cologne, Germany
| | - Florian Stöckigt
- Department of Cardiology, Electrophysiology and Rhythmology, Krankenhaus Porz am Rhein, Urbacher Weg 19, 51149, Cologne, Germany
- Department of Internal Medicine II, University Hospital Bonn, 53125, Bonn, Germany
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Kantharia BK, Tun ZW, Shah AN. Atrial Tachycardias After "Multiple" Previous Ablations for Tachyarrhythmias: Treatment by Anti-arrhythmic Drugs or Additional Ablation? J Innov Card Rhythm Manag 2024; 15:5795-5802. [PMID: 38584751 PMCID: PMC10994163 DOI: 10.19102/icrm.2024.15037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 09/15/2023] [Indexed: 04/09/2024] Open
Abstract
Pulmonary vein (PV) isolation (PVI) ablation as the first-line therapy for atrial fibrillation (AF) and repeat PVIs for patients who had symptomatic improvement with the index PVI but who develop AF recurrence are directed by practice guidelines. How many catheter ablation (CA) procedures constitute the definition of "multiple" ablations is not known. Whether atrial tachyarrhythmias (AF, atrial tachycardia [AT], atrial flutter [AFL]) that occur post-ablation are due entirely to the proarrhythmic effects of CA or a continuum of the arrhythmia spectrum from the underlying atriopathy is debatable. Herein, we describe a case of a 65-year-old man with a CHA2DS2-VASc score of 5 points who suffered from atrial tachyarrhythmias for which seven CA procedures were performed. Because of symptomatic and drug-refractory AT/AFL that failed cardioversions, he requested another ablation procedure. During the eighth procedure, high-density three-dimensional electroanatomic mapping, including Coherent and Ripple mapping (CARTO® 3; Biosense Webster, Diamond Bar, CA, USA), of AT/AFL was performed. Small discrete areas of relatively viable tissue within an extensively scarred left atrium and a macro-re-entrant circuit with early-meets-late activation between the left atrial anterior wall and the right superior PV were found. Radiofrequency ablation performed at this site resulted in the termination of the tachycardia, and bidirectional conduction block across the line was achieved. On clinical follow-ups and rhythm monitoring by an implantable loop recorder, the patient remained in sinus rhythm with significant clinical improvement. Our case suggests that, in patients with prior multiple CAs, additional clinically indicated ablation should be performed using high-density mapping to accurately identify arrhythmia mechanisms, elucidate the disease substrate, and restore the sinus rhythm successfully.
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Affiliation(s)
- Bharat K. Kantharia
- Cardiovascular and Heart Rhythm Consultants, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mount Sinai Hospital—Morningside, New York, NY, USA
| | - Zaw Win Tun
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mount Sinai Hospital—Morningside, New York, NY, USA
| | - Arti N. Shah
- Cardiovascular and Heart Rhythm Consultants, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- NYC Health and Hospitals, Elmhurst, Queens, NY, USA
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Li DL, Hajjar AHE, Ayoub T, Zhang Y, Huang C, Kholmovski EG, Mekhael M, Noujaim C, Feng H, Lim C, Marrouche NF. Left atrial volume affects the correlation of voltage map with magnetic resonance imaging. J Interv Card Electrophysiol 2024; 67:263-271. [PMID: 36973597 DOI: 10.1007/s10840-023-01522-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/02/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND The low-voltage area detected by electroanatomic mapping (EAM) is a surrogate marker of left atrial fibrosis. However, the correlation between the EAM and late gadolinium enhancement magnetic resonance imaging (LGE-MRI) has been inconsistent among studies. This study aimed to investigate how LA size affects the correlation between EAM and LGE-MRI. METHODS High-density EAMs of the LA during sinus rhythm were collected in 22 patients undergoing AF ablation. The EAMs were co-registered with pre-ablation LGE-MRI models. Voltages in the areas with and without LGE were recorded. Left atrial volume index (LAVI) was calculated from MRI, and LAVI > 62 ml/m2 was defined as significant LA enlargement (LAE). RESULTS Atrial bipolar voltage negatively correlates with the left atrial volume index. The median voltages in areas without LGE were 1.1 mV vs 2.0 mV in patients with vs without significant LAE (p = 0.002). In areas of LGE, median voltages were 0.4 mV vs 0.8 mV in patients with vs without significant LAE (p = 0.02). A voltage threshold of 1.7 mV predicted atrial LGE in patients with normal or mildly enlarged LA (sensitivity and specificity of 74% and 59%, respectively). In contrast, areas of voltage less than 0.75 mV correlated with LGE in patients with significant LA enlargement (sensitivity 68% and specificity 66%). CONCLUSIONS LAVI affects left atrial bipolar voltage, and the correlation between low-voltage areas and LGE-MRI. Distinct voltage thresholds according to the LAVI value might be considered to identify atrial scar by EAM.
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Affiliation(s)
- Dan L Li
- Cardiac Electrophysiology Section, Department of Internal Medicine and Cardiology, Tulane University School of Medicine, New Orleans, LA, 70112, USA
- Tulane Research and Innovation for Arrhythmia Discoveries, New Orleans, LA, USA
| | | | - Tarek Ayoub
- Cardiac Electrophysiology Section, Department of Internal Medicine and Cardiology, Tulane University School of Medicine, New Orleans, LA, 70112, USA
- Tulane Research and Innovation for Arrhythmia Discoveries, New Orleans, LA, USA
| | - Yichi Zhang
- Tulane Research and Innovation for Arrhythmia Discoveries, New Orleans, LA, USA
| | - Chao Huang
- Tulane Research and Innovation for Arrhythmia Discoveries, New Orleans, LA, USA
| | - Eugene G Kholmovski
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Mario Mekhael
- Tulane Research and Innovation for Arrhythmia Discoveries, New Orleans, LA, USA
| | - Charbel Noujaim
- Tulane Research and Innovation for Arrhythmia Discoveries, New Orleans, LA, USA
| | - Han Feng
- Tulane Research and Innovation for Arrhythmia Discoveries, New Orleans, LA, USA
| | - Chanho Lim
- Tulane Research and Innovation for Arrhythmia Discoveries, New Orleans, LA, USA
| | - Nassir F Marrouche
- Cardiac Electrophysiology Section, Department of Internal Medicine and Cardiology, Tulane University School of Medicine, New Orleans, LA, 70112, USA.
- Tulane Research and Innovation for Arrhythmia Discoveries, New Orleans, LA, USA.
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Yates TA, Vijayakumar R, McGilvray M, Khiabani AJ, Razo N, Sinn L, Schill MR, Marrouche N, Zemlin C, Damiano RJ. Delayed-enhancement cardiac magnetic resonance imaging detects disease progression in patients with mitral valve disease and atrial fibrillation. JTCVS OPEN 2023; 16:292-302. [PMID: 38204711 PMCID: PMC10774962 DOI: 10.1016/j.xjon.2023.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/22/2023] [Accepted: 07/11/2023] [Indexed: 01/12/2024]
Abstract
Objectives The mechanism by which mitral valve (MV) disease leads to atrial fibrillation (AF) remains poorly understood. Delayed-enhancement cardiac magnetic resonance imaging (DE-MRI) has been used to assess left atrial (LA) fibrosis in patients with lone AF before catheter ablation; however, few studies have used DE-MRI to assess MV-induced LA fibrosis in patients with or without AF undergoing MV surgery. Methods Between March 2018 and September 2022, 38 subjects were enrolled; 15 age-matched controls, 14 patients with lone mitral regurgitation (MR), and 9 patients with MR and AF (MR + AF). Indexed LA volume, total LA wall, and regional LA posterior wall (LAPW) enhancement were defined by the DE-MRI. One-way analysis of variance was performed. Results LA volume and LA enhancement were associated (r = 0.451, P = .004). LA volume differed significantly between controls (37.1 ± 10.6 mL) and patients with lone MR (71.0 ± 35.9, P = .020 and controls and patients with MR + AF (99.3 ± 47.4, P < .001). The difference in LA enhancement was significant between MR + AF (16.7 ± 9.6%) versus controls (8.3 ± 3.9%, P = .006) and MR + AF versus lone MR (8.0 ± 4.8%, P = .004). Similarly, the was significantly more LAPW enhancement in the MR + AF (17.5 ± 8.7%) versus control (9.2 ± 5.1%, P = .011) and MR + AF versus lone MR (9.8 ± 6.0%, P = .020). Conclusions Patients with MR + AF had significantly more total and LAPW fibrosis compared with both controls and lone MR. Volume and delayed enhancement were associated, but there was no difference between MR and MR + AF.
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Affiliation(s)
- Tari-Ann Yates
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, Saint Louis, Mo
| | - Ramya Vijayakumar
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, Saint Louis, Mo
| | - Martha McGilvray
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, Saint Louis, Mo
| | - Ali J. Khiabani
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, Saint Louis, Mo
| | - Nicholas Razo
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, Saint Louis, Mo
| | - Laurie Sinn
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, Saint Louis, Mo
| | - Matthew R. Schill
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, Saint Louis, Mo
| | - Nassir Marrouche
- Department of Cardiology, Tulane University School of Medicine, New Orleans, La
| | - Christian Zemlin
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, Saint Louis, Mo
| | - Ralph J. Damiano
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, Saint Louis, Mo
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Fink T, Sciacca V, Neven K, Didenko M, Sommer P, Sohns C. Pulsed field ablation for atrial fibrillation - Lessons from magnetic resonance imaging. Pacing Clin Electrophysiol 2023; 46:1586-1594. [PMID: 37943015 DOI: 10.1111/pace.14864] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 09/19/2023] [Accepted: 10/21/2023] [Indexed: 11/10/2023]
Abstract
Pulsed field ablation (PFA) is a promising technology for the treatment of atrial fibrillation (AF). Due to its unique tissue selectivity, PFA potentially bears superior characteristics as compared to established thermal energy sources in AF ablation procedures. Cardiovascular magnetic resonance imaging (CMR) using late gadolinium enhancement (LGE) is an established tool in the analysis of myocardial fibrosis representing atrial cardiomyopathy as well as ablation-induced atrial scar formation following catheter ablation with thermal energy. Mechanisms of atrial lesion formation differ between thermal ablation and electroporation and its impact on results of CMR imaging are not fully understood until now. In this review article, the potential of CMR imaging for PFA lesion assessment and available data are discussed. Further, additional needs to adopt imaging approaches to the cellular mechanisms of electroporation are considered.
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Affiliation(s)
- Thomas Fink
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Vanessa Sciacca
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Kars Neven
- Department of Electrophysiology, Alfried Krupp Hospital, Essen, Germany
- Dept. of Medicine, Witten/Herdecke University, Witten, Germany
| | - Maxim Didenko
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Philipp Sommer
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Christian Sohns
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
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Chieng D, Sugumar H, Hunt A, Ling LH, Segan L, Al-Kaisey A, Hawson J, Prabhu S, Voskoboinik A, Wong G, Morton JB, Lee G, Ginks M, Sterns L, Sanders P, Kalman JM, Kistler PM. Impact of Posterior Left Atrial Voltage on Ablation Outcomes in Persistent Atrial Fibrillation: CAPLA Substudy. JACC Clin Electrophysiol 2023; 9:2291-2299. [PMID: 37715741 DOI: 10.1016/j.jacep.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND Pulmonary vein isolation (PVI) is less effective in patients with persistent atrial fibrillation (PsAF). Adjunctive ablation targeting low voltage areas (LVAs) may improve arrhythmia outcomes. OBJECTIVES This study aims to compare the outcomes of adding posterior wall isolation (PWI) to PVI, vs PVI alone in PsAF patients with posterior wall LVAs. METHODS The CAPLA (Effect of Catheter Ablation Using Pulmonary Vein Isolation With vs Without Posterior Left Atrial Wall Isolation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation) study was a multicenter, randomized trial involving PsAF patients randomized 1:1 to either PVI alone or PVI with PWI. Voltage mapping performed during pacing pre-ablation was reviewed offline, with LVA defined as bipolar voltage of <0.5 mV. The primary endpoint was freedom from any documented atrial arrhythmia of >30 seconds off antiarrhythmic medication at 12 months after a single ablation procedure in patients with posterior LVA. RESULTS A total of 210 patients (average 64.6 ± 9.2 years,73.3% males, median atrial fibrillation duration 4.5 months [IQR: 2 to 8 months]) underwent multipolar left atrial mapping during coronary sinus pacing with posterior LVA present in 69 (32.9%). Patients with posterior LVA were more likely to have LVA in other atrial regions (91.7% vs 57.1%; P < 0.01), larger left atrial diameter (4.8 cm vs 4.4 cm; P < 0.01), and significantly increased risk of atrial arrhythmia recurrence at 12 months (LVA: 56.5% vs no LVA: 41.4%; HR: 1.51; 95% CI: 1.01-2.27; P = 0.04) compared to no posterior LVA. However, the addition of PWI to PVI did not significantly improve freedom from atrial arrhythmia recurrence over PVI alone (PVI with PWI: 44.8% vs PVI: 41.9%; HR: 0.95; 95% CI: 0.51-1.79; P = 0.95). CONCLUSIONS In patients with PsAF undergoing catheter ablation, posterior LVA was associated with a significant increase in atrial arrhythmia recurrence. However, the addition of PWI in those with posterior LVA did not reduce atrial arrhythmia recurrence over PVI alone.
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Affiliation(s)
- David Chieng
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Cabrini Hospital, Melbourne, Australia
| | - Hariharan Sugumar
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Cabrini Hospital, Melbourne, Australia
| | | | - Liang-Han Ling
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Cabrini Hospital, Melbourne, Australia
| | - Louise Segan
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Cabrini Hospital, Melbourne, Australia
| | - Ahmed Al-Kaisey
- University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia
| | - Joshua Hawson
- University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia
| | - Sandeep Prabhu
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Mulgrave Private Hospital, Melbourne, Australia
| | - Aleksandr Voskoboinik
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Cabrini Hospital, Melbourne, Australia
| | - Geoffrey Wong
- University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia
| | - Joseph B Morton
- University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia
| | - Geoffrey Lee
- University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia
| | | | - Laurence Sterns
- Royal Jubilee Hospital, Vancouver Island, British Columbia, Canada
| | | | - Jonathan M Kalman
- University of Melbourne, Melbourne, Australia; Royal Melbourne Hospital, Melbourne, Australia; Monash Health, Melbourne, Australia
| | - Peter M Kistler
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia; The Alfred Hospital, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Cabrini Hospital, Melbourne, Australia; Monash Health, Melbourne, Australia; Melbourne Private Hospital, Melbourne, Australia.
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8
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Starek Z, Di Cori A, Betts TR, Clerici G, Gras D, Lyan E, Della Bella P, Li J, Hack B, Zitella Verbick L, Sommer P. Baseline left atrial low-voltage area predicts recurrence after pulmonary vein isolation: WAVE-MAP AF results. Europace 2023; 25:euad194. [PMID: 37470443 PMCID: PMC10410193 DOI: 10.1093/europace/euad194] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/04/2023] [Accepted: 05/11/2023] [Indexed: 07/21/2023] Open
Abstract
AIMS Electro-anatomical mapping may be critical to identify atrial fibrillation (AF) subjects who require substrate modification beyond pulmonary vein isolation (PVI). The objective was to determine correlations between pre-ablation mapping characteristics and 12-month outcomes after a single PVI-only catheter ablation of AF. METHODS AND RESULTS This study enrolled paroxysmal AF (PAF), early persistent AF (PsAF; 7 days-3 months), and non-early PsAF (>3-12 months) subjects undergoing de novo PVI-only radiofrequency catheter ablation. Sinus rhythm (SR) and AF voltage maps were created with the Advisor HD Grid™ Mapping Catheter, Sensor Enabled™ for each subject, and the presence of low-voltage area (LVA) (low-voltage cutoffs: 0.1-1.5 mV) was investigated. Follow-up visits were at 3, 6, and 12 months, with a 24-h Holter monitor at 12 months. A Cox proportional hazards model identified associations between mapping data and 12-month recurrence after a single PVI procedure. The study enrolled 300 subjects (113 PAF, 86 early PsAF, and 101 non-early PsAF) at 18 centres. At 12 months, 75.5% of subjects were free from AF/atrial flutter (AFL)/atrial tachycardia (AT) recurrence. Univariate analysis found that arrhythmia recurrence did not correlate with AF diagnosis, but LVA was significantly correlated. Low-voltage area (<0.5 mV) >28% of the left atrium in SR [hazard ratio (HR): 4.82, 95% confidence interval (CI): 2.08-11.18; P = 0.0003] and >72% in AF (HR: 5.66, 95% CI: 2.34-13.69; P = 0.0001) was associated with a higher risk of AF/AFL/AT recurrence at 12 months. CONCLUSION Larger extension of LVA was associated with an increased risk of arrhythmia recurrence. These subjects may benefit from substrate modification beyond PVI.
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Affiliation(s)
- Zdenek Starek
- International Clinical Research Center, St. Anne’s University Hospital Brno, Pekarska 664/53, Brno 60200, Czech Republic
- First Department of Internal Medicine/Cardioangiology, St. Anne’s Hospital, Masaryk University, Pekarska 664/53, Brno 60200, Czech Republic
| | - Andrea Di Cori
- Second Division of Cardiovascular Diseases, Cardiac-Thoracic and Vascular Department, New Santa Chiara Hospital, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Timothy R Betts
- Department of Cardiology, John Radcliffe Hospital, Oxford, UK
| | - Gael Clerici
- Cardiology Department, Rhythmology Unit, Centre Hospitalier Universitaire de La Reunion, La Reunion, France
| | - Daniel Gras
- Department of Cardiology, Hopital Prive du Confluent, Nantes, France
| | - Evgeny Lyan
- Department of Cardiology, Section of Electrophysiology, Herz-und Gefäßzentrum Bad Bevensen, Bad Bevensen, Germany
| | - Paolo Della Bella
- Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milano, Italy
| | | | | | | | - Philipp Sommer
- Department for Electrophysiology, Herz-und Diabetes Zentrum NRW, Bad Oeynhausen, Germany
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Yano M, Egami Y, Ukita K, Yasumoto K, Matsunaga-Lee Y, Nishino M, Tanouchi J. Impact of ratio of P-wave duration to P-wave amplitude on recurrent arrhythmia characteristics and low-voltage risk score in paroxysmal atrial fibrillation patients underwent catheter ablation. Europace 2023:7163079. [PMID: 37186571 DOI: 10.1093/europace/euad125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 04/20/2023] [Indexed: 05/17/2023] Open
Affiliation(s)
- Masamichi Yano
- Division of Cardiology, Osaka Rosai Hospital, 3-1179 Nagasonecho, kita-ku, Sakai, Osaka 591-8025, Japan
| | - Yasuyuki Egami
- Division of Cardiology, Osaka Rosai Hospital, 3-1179 Nagasonecho, kita-ku, Sakai, Osaka 591-8025, Japan
| | - Kohei Ukita
- Division of Cardiology, Osaka Rosai Hospital, 3-1179 Nagasonecho, kita-ku, Sakai, Osaka 591-8025, Japan
| | - Koji Yasumoto
- Division of Cardiology, Osaka Rosai Hospital, 3-1179 Nagasonecho, kita-ku, Sakai, Osaka 591-8025, Japan
| | - Yasuharu Matsunaga-Lee
- Division of Cardiology, Osaka Rosai Hospital, 3-1179 Nagasonecho, kita-ku, Sakai, Osaka 591-8025, Japan
| | - Masami Nishino
- Division of Cardiology, Osaka Rosai Hospital, 3-1179 Nagasonecho, kita-ku, Sakai, Osaka 591-8025, Japan
| | - Jun Tanouchi
- Division of Cardiology, Osaka Rosai Hospital, 3-1179 Nagasonecho, kita-ku, Sakai, Osaka 591-8025, Japan
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Watanabe R, Okumura Y, Nagashima K, Wakamatsu Y, Yamada A, Kurokawa S. Chronic Ablation Lesions after Cryoballoon and Hot Balloon Ablation of Atrial Fibrillation. J NIPPON MED SCH 2023; 90:69-78. [PMID: 36436916 DOI: 10.1272/jnms.jnms.2023_90-112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Chronological changes in ablation lesions after cryoballoon ablation (CBA) and hot balloon ablation (HBA) of atrial fibrillation (AF) remain unclear. METHODS Of 90 patients who underwent initial balloon-based catheter ablation of AF and cardiac magnetic resonance imaging (cMRI) 3 months after ablation, data from 48 propensity score-matched patients (24 per group; 34 males; age 62±10 years) were analyzed. High-density pulmonary vein-left antrum (PV-LA) voltage mapping was performed after PV isolation, and low voltage areas around the PV ostia were defined as the total acute ablation lesion area (cm2). cMRI-derived dense fibrotic tissue localized around PVs was defined as the total chronic ablation lesion area (cm2). The percentage of total ablation lesion areas to total PV-LA surface area (%ablation lesion) was calculated during each phase, and %acute ablation lesion and %chronic ablation lesion areas were compared in patients who had undergone CBA and HBA. RESULTS The %acute ablation lesion area was larger for the CBA group than for the HBA group (30.8±5.8% vs. 23.0±5.5%, p < 0.001). There was no difference in %chronic cMRI-derived ablation lesion area (24.8±10.8% vs. 21.1±11.6%, p = 0.26) between groups. The rates of chronic AF recurrence were 12.5% and 8.3%, respectively (p = 0.45; log-rank test). LA volume and LA surface area were strongly associated with AF recurrence, but %chronic ablation lesion area was not (27±8% vs. 23±12%, p = 0.39). CONCLUSION Large acute ablation lesions after CBA were smaller during the chronic phase. The size of chronic ablation lesions and the rate of AF recurrence were both similar for CBA and HBA.
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Affiliation(s)
- Ryuta Watanabe
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Koichi Nagashima
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Yuji Wakamatsu
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Akimasa Yamada
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Sayaka Kurokawa
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
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11
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Bijvoet GP, Nies HMJM, Holtackers RJ, Linz D, Adriaans BP, Nijveldt R, Wildberger JE, Vernooy K, Chaldoupi SM, Mihl C. Correlation between Cardiac MRI and Voltage Mapping in Evaluating
Atrial Fibrosis: A Systematic Review. RADIOLOGY: CARDIOTHORACIC IMAGING 2022; 4:e220061. [PMID: 36339060 PMCID: PMC9627236 DOI: 10.1148/ryct.220061] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 08/31/2022] [Accepted: 09/13/2022] [Indexed: 11/07/2022]
Abstract
Purpose To provide an overview of existing literature on the association between
late gadolinium enhancement (LGE) cardiac MRI and low voltage areas
(LVA) obtained with electroanatomic mapping (EAM) or histopathology when
assessing atrial fibrosis. Materials and Methods A systematic literature search was conducted in the PubMed, Embase, and
Cochrane Library databases to identify all studies published until June
7, 2022, comparing LGE cardiac MRI to LVA EAM and/or histopathology for
evaluation of atrial fibrosis. The study protocol was registered at
PROSPERO (registration no. CRD42022338243). Two reviewers independently
evaluated the studies for inclusion. Risk of bias and applicability for
each included study were assessed using Quality Assessment of Diagnostic
Accuracy Studies–2 (QUADAS-2) criteria. Data regarding
demographics, electrophysiology, LGE cardiac MRI, and study outcomes
were extracted. Results The search yielded 1048 total results, of which 22 studies were included.
Nineteen of the 22 included studies reported a significant correlation
between high signal intensity at LGE cardiac MRI and LVA EAM or
histopathology. However, there was great heterogeneity between included
studies regarding study design, patient samples, cardiac MRI performance
and postprocessing, and EAM performance. Conclusion Current literature suggests a correlation between LGE cardiac MRI and LVA
EAM or histopathology when evaluating atrial fibrosis but high
heterogeneity between studies, demonstrating the need for uniform
choices regarding cardiac MRI and EAM acquisition in future studies. Keywords: Cardiac, MR Imaging, Left Atrium Supplemental material is available for this
article. © RSNA, 2022
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12
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Hopman LHGA, Bhagirath P, Mulder MJ, Eggink IN, van Rossum AC, Allaart CP, Götte MJW. Quantification of left atrial fibrosis by 3D late gadolinium-enhanced cardiac magnetic resonance imaging in patients with atrial fibrillation: impact of different analysis methods. Eur Heart J Cardiovasc Imaging 2022; 23:1182-1190. [PMID: 35947873 PMCID: PMC9365307 DOI: 10.1093/ehjci/jeab245] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Indexed: 11/13/2022] Open
Abstract
Abstract
Aims
Various methods and post-processing software packages have been developed to quantify left atrial (LA) fibrosis using 3D late gadolinium-enhancement cardiac magnetic resonance (LGE-CMR) images. Currently, it remains unclear how the results of these methods and software packages interrelate.
Methods and results
Forty-seven atrial fibrillation (AF) patients underwent 3D-LGE-CMR imaging prior to their AF ablation. LA fibrotic burden was derived from the images using open-source CEMRG software and commercially available ADAS 3D-LA software. Both packages were used to calculate fibrosis based on the image intensity ratio (IIR)-method. Additionally, CEMRG was used to quantify LA fibrosis using three standard deviations (3SD) above the mean blood pool signal intensity. Intraclass correlation coefficients were calculated to compare LA fibrosis quantification methods and different post-processing software outputs. The percentage of LA fibrosis assessed using IIR threshold 1.2 was significantly different from the 3SD-method (29.80 ± 14.15% vs. 8.43 ± 5.42%; P < 0.001). Correlation between the IIR-and SD-method was good (r = 0.85, P < 0.001) although agreement was poor [intraclass correlation coefficient (ICC) = 0.19; P < 0.001]. One-third of the patients were allocated to a different fibrosis category dependent on the used quantification method. Fibrosis assessment using CEMRG and ADAS 3D-LA showed good agreement for the IIR-method (ICC = 0.93; P < 0.001).
Conclusions
Both, the IIR1.2 and 3SD-method quantify atrial fibrotic burden based on atrial wall signal intensity differences. The discrepancy in the amount of LA fibrosis between these methods may have clinical implications when patients are classified according to their fibrotic burden. There was no difference in results between post-processing software packages to quantify LA fibrosis if an identical quantification method including the threshold was used.
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Affiliation(s)
- Luuk H G A Hopman
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences , De Boelelaan 1118, 1081 HV Amsterdam , The Netherlands
| | - Pranav Bhagirath
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences , De Boelelaan 1118, 1081 HV Amsterdam , The Netherlands
| | - Mark J Mulder
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences , De Boelelaan 1118, 1081 HV Amsterdam , The Netherlands
| | - Iris N Eggink
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences , De Boelelaan 1118, 1081 HV Amsterdam , The Netherlands
| | - Albert C van Rossum
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences , De Boelelaan 1118, 1081 HV Amsterdam , The Netherlands
| | - Cornelis P Allaart
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences , De Boelelaan 1118, 1081 HV Amsterdam , The Netherlands
| | - Marco J W Götte
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences , De Boelelaan 1118, 1081 HV Amsterdam , The Netherlands
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13
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Cunha PS, Laranjo S, Heijman J, Oliveira MM. The Atrium in Atrial Fibrillation - A Clinical Review on How to Manage Atrial Fibrotic Substrates. Front Cardiovasc Med 2022; 9:879984. [PMID: 35859594 PMCID: PMC9289204 DOI: 10.3389/fcvm.2022.879984] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 06/03/2022] [Indexed: 12/27/2022] Open
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia in the population and is associated with a significant clinical and economic burden. Rigorous assessment of the presence and degree of an atrial arrhythmic substrate is essential for determining treatment options, predicting long-term success after catheter ablation, and as a substrate critical in the pathophysiology of atrial thrombogenesis. Catheter ablation of AF has developed into an essential rhythm-control strategy. Nowadays is one of the most common cardiac ablation procedures performed worldwide, with its success inversely related to the extent of atrial structural disease. Although atrial substrate evaluation remains complex, several diagnostic resources allow for a more comprehensive assessment and quantification of the extent of left atrial structural remodeling and the presence of atrial fibrosis. In this review, we summarize the current knowledge on the pathophysiology, etiology, and electrophysiological aspects of atrial substrates promoting the development of AF. We also describe the risk factors for its development and how to diagnose its presence using imaging, electrocardiograms, and electroanatomic voltage mapping. Finally, we discuss recent data regarding fibrosis biomarkers that could help diagnose atrial fibrotic substrates.
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Affiliation(s)
- Pedro Silva Cunha
- Arrhythmology, Pacing and Electrophysiology Unit, Cardiology Service, Santa Marta Hospital, Central Lisbon Hospital University Center, Lisbon, Portugal
- Lisbon School of Medicine, Universidade de Lisboa, Lisbon, Portugal
- Comprehensive Health Research Center, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Sérgio Laranjo
- Arrhythmology, Pacing and Electrophysiology Unit, Cardiology Service, Santa Marta Hospital, Central Lisbon Hospital University Center, Lisbon, Portugal
- Lisbon School of Medicine, Universidade de Lisboa, Lisbon, Portugal
- Comprehensive Health Research Center, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Jordi Heijman
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Mário Martins Oliveira
- Arrhythmology, Pacing and Electrophysiology Unit, Cardiology Service, Santa Marta Hospital, Central Lisbon Hospital University Center, Lisbon, Portugal
- Lisbon School of Medicine, Universidade de Lisboa, Lisbon, Portugal
- Comprehensive Health Research Center, Universidade NOVA de Lisboa, Lisbon, Portugal
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14
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Ezzeddine FM, DeSimone CV. Left atrial appendage emptying velocity as a predictor of recurrence of atrial fibrillation post-ablation. J Cardiovasc Electrophysiol 2022; 33:1712-1713. [PMID: 35652824 DOI: 10.1111/jce.15583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 05/27/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Fatima M Ezzeddine
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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15
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Efficacy of electrical isolation of the left atrial posterior wall depends on the existence of left atrial low-voltage zone in patients with persistent atrial fibrillation. Heart Vessels 2022; 37:1757-1768. [PMID: 35441869 DOI: 10.1007/s00380-022-02069-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 03/31/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Modification of the low-voltage zone in the left atrium (LA-LVZ) in addition to pulmonary vein isolation (PVI) has not shown sufficient improvement in arrhythmia-free survival in patients with persistent atrial fibrillation (PerAF). Further, the effect of electrical posterior wall isolation (PWI) is controversial. We investigated the impact of existence of LA-LVZ on the outcome of patients undergoing additional PWI for PerAF. METHODS A total of 347 patients with PerAF who underwent primary catheter ablation with LA-LVZ based strategy were retrospectively analyzed. Voltage mapping in the left atrium (LA) was performed during sinus rhythm. Additional LVZ ablation was performed in patients with LA-LVZ. The operators decided whether additional PWIs were to be performed. RESULTS Of 347 patients, 108 had LA-LVZ. In the LVZ group, patients with additional PWI (N = 70) had higher rates of freedom from tachyarrhythmia recurrence than those without (77.1% vs. 42.1%, p < 0.001). Furthermore, even when patients were limited to those with LA-LVZ in areas other than the posterior wall (N = 85), PWI had higher success rates (80.9% vs. 42.1%, p < 0.001). In contrast, in patients without LVZ (N = 239), there was no significant difference in the rate of successful outcome between those with and without PWI (81.3% vs. 88.1%, p = 0.112). On the other hand, the patients with PWI had greater atrial tachycardia (AT) recurrence rate than those without PWI (10.0% vs. 2.5%, p = 0.003). CONCLUSIONS PWI, in addition to PVI and LVZ modification, may improve single procedural outcomes in patients with PerAF who have LVZ, regardless of the distribution in the LA. A combination of voltage-guided ablation and PWI may be a simple, tailored, and effective ablation strategy.
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16
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Li L, Zimmer VA, Schnabel JA, Zhuang X. Medical image analysis on left atrial LGE MRI for atrial fibrillation studies: A review. Med Image Anal 2022; 77:102360. [PMID: 35124370 PMCID: PMC7614005 DOI: 10.1016/j.media.2022.102360] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 11/04/2021] [Accepted: 01/10/2022] [Indexed: 02/08/2023]
Abstract
Late gadolinium enhancement magnetic resonance imaging (LGE MRI) is commonly used to visualize and quantify left atrial (LA) scars. The position and extent of LA scars provide important information on the pathophysiology and progression of atrial fibrillation (AF). Hence, LA LGE MRI computing and analysis are essential for computer-assisted diagnosis and treatment stratification of AF patients. Since manual delineations can be time-consuming and subject to intra- and inter-expert variability, automating this computing is highly desired, which nevertheless is still challenging and under-researched. This paper aims to provide a systematic review on computing methods for LA cavity, wall, scar, and ablation gap segmentation and quantification from LGE MRI, and the related literature for AF studies. Specifically, we first summarize AF-related imaging techniques, particularly LGE MRI. Then, we review the methodologies of the four computing tasks in detail and summarize the validation strategies applied in each task as well as state-of-the-art results on public datasets. Finally, the possible future developments are outlined, with a brief survey on the potential clinical applications of the aforementioned methods. The review indicates that the research into this topic is still in the early stages. Although several methods have been proposed, especially for the LA cavity segmentation, there is still a large scope for further algorithmic developments due to performance issues related to the high variability of enhancement appearance and differences in image acquisition.
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Affiliation(s)
- Lei Li
- School of Data Science, Fudan University, Shanghai, China; School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China; School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Veronika A Zimmer
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK; Department of Informatics, Technical University of Munich, Germany
| | - Julia A Schnabel
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK; Department of Informatics, Technical University of Munich, Germany; Helmholtz Center Munich, Germany
| | - Xiahai Zhuang
- School of Data Science, Fudan University, Shanghai, China.
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17
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Aksan G, Yanık A, Yontar OC, Boyacı F, Uçar M, Şahin MK, Soylu K. The predictive value of galectin‐3 levels on left atrial low voltage areas assessed by high‐density mapping in patients with paroxysmal atrial fibrillation. J Arrhythm 2022; 38:353-362. [PMID: 35785368 PMCID: PMC9237302 DOI: 10.1002/joa3.12703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 02/20/2022] [Accepted: 03/13/2022] [Indexed: 11/12/2022] Open
Affiliation(s)
- Gökhan Aksan
- Department of Cardiology Samsun Education and Research Hospital Samsun Turkey
| | - Ahmet Yanık
- Department of Cardiology Samsun Education and Research Hospital Samsun Turkey
| | - Osman Can Yontar
- Department of Cardiology Samsun Education and Research Hospital Samsun Turkey
| | - Faruk Boyacı
- Department of Cardiology Samsun Education and Research Hospital Samsun Turkey
| | - Melisa Uçar
- Department of Cardiology Samsun Education and Research Hospital Samsun Turkey
| | - Mustafa Kürşat Şahin
- Department of Family Medicine Faculty of Medicine Ondokuz Mayıs University Samsun Turkey
| | - Korhan Soylu
- Department of Cardiology, Faculty of Medicine Ondokuz Mayis University Samsun Turkey
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18
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Masuda M, Sekiya K, Asai M, Iida O, Okamoto S, Ishihara T, Nanto K, Kanda T, Tsujimura T, Matsuda Y, Hata Y, Uematsu H, Toyoshima T, Higashino N, Mano T. Influence of catheter ablation for atrial fibrillation on atrial and ventricular functional mitral regurgitation. ESC Heart Fail 2022; 9:1901-1913. [PMID: 35293159 PMCID: PMC9065851 DOI: 10.1002/ehf2.13896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 02/07/2022] [Accepted: 03/03/2022] [Indexed: 11/29/2022] Open
Abstract
Aims The purpose of this study was to compare the impact of catheter ablation on cardiac structural reverse remodelling and atrial (AFMR) and ventricular (VFMR) functional mitral regurgitation (MR), and the long‐term prognosis of patients with AFMR and VFMR. Methods and results The retrospective study included persistent AF patients who had AFMR (n = 136, left atrial (LA) volume index >30 mL/m2 and left ventricular (LV) ejection fraction ≥40%) or VFMR (n = 31, LV ejection fraction <40% or LV regional asynergy) and had undergone the initial AF ablation from April 2015 to December 2019. Baseline and 6 month follow‐up echocardiography were performed to assess MR, LA, and LV sizes. MR improvement after ablation was comparable in the AFMR (64%) and VFMR groups (52%, P = 0.20). Patients with AFMR improvement showed a greater decrease in left atrial volume after ablation than those without (amount of change: −11.4 ± 15.1 vs. −2.3 ± 21.1 mL/m2, P = 0.01). Patients with VFMR improvement showed a greater increase in LV ejection fraction than those without (amount of change: 28.5 ± 13.6% vs. 9.0 ± 14.8%, P = 0.001). The composite endpoint of all‐cause death and heart failure hospitalization during the 2 year follow‐up period was more frequently observed in the VFMR than in the AFMR group (22.6% vs. 3.7%, P < 0.0001). Patients with MR improvement after catheter ablation less frequently demonstrated the composite endpoint than those without (1.9% vs. 15.6%, P < 0.0001). Conclusions Atrial functional mitral regurgitation and VFMR improvement after ablation were associated with atrial and ventricular reverse remodelling, respectively. It is possible that long‐term prognosis is better in patients with AFMR than with VFMR, and in those with MR improvement than in those without.
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Affiliation(s)
- Masaharu Masuda
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Kimiko Sekiya
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Mitsutoshi Asai
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Osamu Iida
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Shin Okamoto
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | | | - Kiyonori Nanto
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Takashi Kanda
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | | | | | - Yosuke Hata
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | | | - Taku Toyoshima
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Naoko Higashino
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Toshiaki Mano
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
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19
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Peters DC, Lamy J, Sinusas AJ, Baldassarre LA. Left atrial evaluation by cardiovascular magnetic resonance: sensitive and unique biomarkers. Eur Heart J Cardiovasc Imaging 2021; 23:14-30. [PMID: 34718484 DOI: 10.1093/ehjci/jeab221] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/12/2021] [Indexed: 12/12/2022] Open
Abstract
Left atrial (LA) imaging is still not routinely used for diagnosis and risk stratification, although recent studies have emphasized its importance as an imaging biomarker. Cardiovascular magnetic resonance is able to evaluate LA structure and function, metrics that serve as early indicators of disease, and provide prognostic information, e.g. regarding diastolic dysfunction, and atrial fibrillation (AF). MR angiography defines atrial anatomy, useful for planning ablation procedures, and also for characterizing atrial shapes and sizes that might predict cardiovascular events, e.g. stroke. Long-axis cine images can be evaluated to define minimum, maximum, and pre-atrial contraction LA volumes, and ejection fractions (EFs). More modern feature tracking of these cine images provides longitudinal LA strain through the cardiac cycle, and strain rates. Strain may be a more sensitive marker than EF and can predict post-operative AF, AF recurrence after ablation, outcomes in hypertrophic cardiomyopathy, stratification of diastolic dysfunction, and strain correlates with atrial fibrosis. Using high-resolution late gadolinium enhancement (LGE), the extent of fibrosis in the LA can be estimated and post-ablation scar can be evaluated. The LA LGE method is widely available, its reproducibility is good, and validations with voltage-mapping exist, although further scan-rescan studies are needed, and consensus regarding atrial segmentation is lacking. Using LGE, scar patterns after ablation in AF subjects can be reproducibly defined. Evaluation of 'pre-existent' atrial fibrosis may have roles in predicting AF recurrence after ablation, predicting new-onset AF and diastolic dysfunction in patients without AF. LA imaging biomarkers are ready to enter into diagnostic clinical practice.
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Affiliation(s)
- Dana C Peters
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Jérôme Lamy
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Albert J Sinusas
- Department of Cardiology, Yale School of Medicine, New Haven, CT, USA
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20
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Marrouche NF, Dagher L, Wazni O, Akoum N, Mansour M, El Hajjar AH, Bhatnagar A, Hua H. Effect of DrOnedarone on atrial fibrosis progression and atrial fibrillation recurrence postablation: Design of the EDORA randomized clinical trial. J Cardiovasc Electrophysiol 2021; 32:3203-3210. [PMID: 34664772 PMCID: PMC9298087 DOI: 10.1111/jce.15274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 09/16/2021] [Accepted: 09/29/2021] [Indexed: 01/08/2023]
Abstract
Background Atrial fibrillation (AF) recurrence after catheter ablation is associated with worse outcomes and quality of life. Left atrial (LA) structural remodeling provides the essential substrate for AF perpetuation. Baseline extent and the progression of LA fibrosis after ablation are strong predictors of postprocedural AF recurrence. Dronedarone is an antiarrhythmic drug proven to efficiently maintain sinus rhythm. Objective We sought to investigate the effect of the antiarrhythmic drug Dronedarone in decreasing LA fibrosis progression and AF recurrence after ablation of AF patients. Methods EDORA (NCT04704050) is a multicenter, prospective, randomized controlled clinical trial. Patients with persistent or paroxysmal AF undergoing AF ablation will be randomized into Dronedarone versus placebo/standard of care. The co‐primary outcomes are the recurrence of atrial arrhythmias (AA) within 13 months of follow‐up after ablation and the progression of left atrial fibrosis postablation. All patients will receive a late‐gadolinium enhancement magnetic resonance imaging at baseline, 3‐ and 12‐month follow‐up for the quantification of LA fibrosis and ablation‐related scarring. AA recurrence and burden will be assessed using a 30‐day ECG patch every 3 months with daily ECG recordings in between. Quality of life improvement is assessed using the AFEQT and AFSS questionnaires. Conclusion EDORA will be the first trial to assess the progression of LA structural remodeling after ablation and its association with Dronedarone treatment and ablation success in a randomized controlled fashion. The trial will provide insight into the pathophysiology of AF recurrence after ablation and may provide potential therapeutic targets to optimize procedural outcomes.
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Affiliation(s)
- Nassir F Marrouche
- Department of Cardiology, Tulane University School of Medicine, New Orleans, Los Angeles, USA
| | - Lilas Dagher
- Department of Cardiology, Tulane University School of Medicine, New Orleans, Los Angeles, USA
| | - Oussama Wazni
- Department of Cardiac Electrophysiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nazem Akoum
- Department of Cardiology, University of Washington Medical Center, Seattle, Washington, USA
| | - Moussa Mansour
- Department of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Abdel Hadi El Hajjar
- Department of Cardiology, Tulane University School of Medicine, New Orleans, Los Angeles, USA
| | - Arezu Bhatnagar
- Department of Cardiology, Tulane University School of Medicine, New Orleans, Los Angeles, USA
| | - He Hua
- Department of Epidemiology, Tulane University School of Public Health, New Orleans, Los Angeles, USA
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21
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Baskovski E, Altin AT, Candemir B, Akyurek O, Esenboga K, Tutar E. Relationship between left atrial scar and P wave dispersion in patients undergoing atrial fibrillation catheter ablation. Acta Cardiol 2021; 77:586-592. [PMID: 34427176 DOI: 10.1080/00015385.2021.1967613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Left atrial scar is an important entity in the atrial fibrillation substrate. P wave dispersion (PWD) is an indicator of slow and inhomogeneous conduction in the atria. In this study, we aim to investigate the relation between PWD and left atrial scars identified by electroanatomical mapping. METHODS Patients who had an electroanatomical map obtained during sinus rhythm as well as at least one electrocardiogram in sinus rhythm prior to the procedure were included in the study. Left atrial scar (defined as <0.5 mV) area was calculated on the electroanatomical map. Maximum and minimum P wave duration and PWD were compared between patients with and without left atrial scar. RESULTS A total of 224 patients were enrolled in the study. Of them, 47.9% of the patients were female. On the electroanatomical map, left atrial scar was identified in 103 patients, and no scar was present in 121 patients. PWD was significantly increased in patients with left atrial scar when compared to the no-scar group (46 ms ± 20 vs. 38 ms ± 15, respectively, p < 0.001). Similarly, PWD was significantly increased in patients with moderate-to-severe scar, when compared to patients with mild scar (50 ms ± 19 vs. 41 ms ± 19, respectively, p = 0.026). PWD was found not to be a good predictor of left atrial scar with an AUC of 0.625 for scar vs. no scar. CONCLUSION PWD is significantly increased in patients with left atrial scar identified by electroanatomical mapping, however, the receiver operating characteristic analysis showed that PWD is not a good predictor of presence of left atrial scar.
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Affiliation(s)
- Emir Baskovski
- Cardiology Department, Ankara University, Ankara, Turkey
| | | | - Basar Candemir
- Cardiology Department, Ankara University, Ankara, Turkey
| | - Omer Akyurek
- Cardiology Department, Ankara University, Ankara, Turkey
| | - Kerim Esenboga
- Cardiology Department, Ankara University, Ankara, Turkey
| | - Eralp Tutar
- Cardiology Department, Ankara University, Ankara, Turkey
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22
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Gottlieb LA, Dekker LRC, Coronel R. The Blinding Period Following Ablation Therapy for Atrial Fibrillation: Proarrhythmic and Antiarrhythmic Pathophysiological Mechanisms. JACC Clin Electrophysiol 2021; 7:416-430. [PMID: 33736761 DOI: 10.1016/j.jacep.2021.01.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/14/2021] [Accepted: 01/17/2021] [Indexed: 02/01/2023]
Abstract
Atrial fibrillation (AF) causes heart failure, ischemic strokes, and poor quality of life. The number of patients with AF is estimated to increase to 18 million in Europe in 2050. Pharmacological therapy does not cure AF in all patients. Ablative pulmonary vein isolation is recommended for patients with drug-resistant symptomatic paroxysmal AF but is successful in only about 60%. In patients in whom ablative therapy is successful on the long term, recurrence of AF may occur in the first weeks to months after pulmonary vein ablation. The early recurrence (or delayed cure) of AF is not understood but forms the basis for the generally accepted 3-month blinding (or blanking) period after ablation therapy, which is not included in the evaluation of the eventual success rate of the procedures. The underlying pathophysiological processes responsible for early recurrence and the delayed cure are unknown. The implicit assumption of the blinding period is that the AF mechanism in this period is different from the ablation-targeted AF mechanism (ectopy from the pulmonary veins). In this review, we evaluate the temporary and long-lasting pro- and antiarrhythmic effects of each of the pathophysiological processes and interventions (necrosis, ischemia, oxidative stress, edema, inflammation, autonomic nervous activity, tissue repair, mechanical remodeling, and use of antiarrhythmic drugs) occurring in the blinding period that can modulate AF mechanisms. We propose that stretch-reducing ablation scar is a permanent antiarrhythmic mechanism that develops during the blinding period and is the reason for delayed cure.
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Affiliation(s)
- Lisa A Gottlieb
- Electrophysiology and Heart Modelling Institute, University of Bordeaux, Pessac, France; Department of Experimental Cardiology, Amsterdam University Medical Centre, Academic Medical Centre, Amsterdam, the Netherlands
| | - Lukas R C Dekker
- Department of Electrical Engineering, University of Technology, Eindhoven, the Netherlands; Cardiology Department, Catharina Hospital, Eindhoven, the Netherlands.
| | - Ruben Coronel
- Electrophysiology and Heart Modelling Institute, University of Bordeaux, Pessac, France; Department of Experimental Cardiology, Amsterdam University Medical Centre, Academic Medical Centre, Amsterdam, the Netherlands
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23
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Caixal G, Alarcón F, Althoff TF, Nuñez-Garcia M, Benito EM, Borràs R, Perea RJ, Prat-González S, Garre P, Soto-Iglesias D, Gunturitz C, Cozzari J, Linhart M, Tolosana JM, Arbelo E, Roca-Luque I, Sitges M, Guasch E, Mont L. Accuracy of left atrial fibrosis detection with cardiac magnetic resonance: correlation of late gadolinium enhancement with endocardial voltage and conduction velocity. Europace 2021; 23:380-388. [PMID: 33227129 DOI: 10.1093/europace/euaa313] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 09/23/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS Myocardial fibrosis is a hallmark of atrial fibrillation (AF) and its characterization could be used to guide ablation procedures. Late gadolinium enhanced-magnetic resonance imaging (LGE-MRI) detects areas of atrial fibrosis. However, its accuracy remains controversial. We aimed to analyse the accuracy of LGE-MRI to identify left atrial (LA) arrhythmogenic substrate by analysing voltage and conduction velocity at the areas of LGE. METHODS AND RESULTS Late gadolinium enhanced-magnetic resonance imaging was performed before ablation in 16 patients. Atrial wall intensity was normalized to blood pool and classified as healthy, interstitial fibrosis, and dense scar tissue depending of the resulting image intensity ratio. Bipolar voltage and local conduction velocity were measured in LA with high-density electroanatomic maps recorded in sinus rhythm and subsequently projected into the LGE-MRI. A semi-automatic, point-by-point correlation was made between LGE-MRI and electroanatomical mapping. Mean bipolar voltage and local velocity progressively decreased from healthy to interstitial fibrosis to scar. There was a significant negative correlation between LGE with voltage (r = -0.39, P < 0.001) and conduction velocity (r = -0.25, P < 0.001). In patients showing dilated atria (LA diameter ≥45 mm) the conduction velocity predictive capacity of LGE-MRI was weaker (r = -0.40 ± 0.09 vs. -0.20 ± 0.13, P = 0.02). CONCLUSIONS Areas with higher LGE show lower voltage and slower conduction in sinus rhythm. The enhancement intensity correlates with bipolar voltage and conduction velocity in a point-by-point analysis. The performance of LGE-MRI in assessing local velocity might be reduced in patients with dilated atria (LA diameter ≥45).
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Affiliation(s)
- Gala Caixal
- Unitat de Fibril.lació Auricular (UFA), Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBABS), Barcelona, Catalonia, Spain
| | - Francisco Alarcón
- Unitat de Fibril.lació Auricular (UFA), Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBABS), Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | - Till F Althoff
- Unitat de Fibril.lació Auricular (UFA), Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain.,Department of Cardiology and Angiology, Charité-University Medicine Berlin, Charité Campus Mitte, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Marta Nuñez-Garcia
- Department of Information and Communication Technologies, Universitat Pompeu Fabra, Barcelona, Catalonia, Spain
| | - Eva Maria Benito
- Unitat de Fibril.lació Auricular (UFA), Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBABS), Barcelona, Catalonia, Spain
| | - Roger Borràs
- Unitat de Fibril.lació Auricular (UFA), Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBABS), Barcelona, Catalonia, Spain
| | - Rosario Jesus Perea
- Unitat de Fibril.lació Auricular (UFA), Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBABS), Barcelona, Catalonia, Spain
| | - Susana Prat-González
- Unitat de Fibril.lació Auricular (UFA), Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBABS), Barcelona, Catalonia, Spain
| | - Paz Garre
- Unitat de Fibril.lació Auricular (UFA), Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBABS), Barcelona, Catalonia, Spain
| | - David Soto-Iglesias
- Unitat de Fibril.lació Auricular (UFA), Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBABS), Barcelona, Catalonia, Spain
| | - Clara Gunturitz
- Unitat de Fibril.lació Auricular (UFA), Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBABS), Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | - Jennifer Cozzari
- Unitat de Fibril.lació Auricular (UFA), Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBABS), Barcelona, Catalonia, Spain
| | - Markus Linhart
- Unitat de Fibril.lació Auricular (UFA), Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBABS), Barcelona, Catalonia, Spain
| | - Jose Maria Tolosana
- Unitat de Fibril.lació Auricular (UFA), Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBABS), Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | - Elena Arbelo
- Unitat de Fibril.lació Auricular (UFA), Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBABS), Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | - Ivo Roca-Luque
- Unitat de Fibril.lació Auricular (UFA), Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBABS), Barcelona, Catalonia, Spain
| | - Marta Sitges
- Unitat de Fibril.lació Auricular (UFA), Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBABS), Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | - Eduard Guasch
- Unitat de Fibril.lació Auricular (UFA), Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBABS), Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | - Lluis Mont
- Unitat de Fibril.lació Auricular (UFA), Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBABS), Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
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24
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Hwang J, Park HS, Han S, Lee CH, Kim IC, Cho YK, Yoon HJ, Chung JW, Kim H, Nam CW, Hur SH, Kim JY, Kim YS, Jang WS. Ablation of persistent atrial fibrillation based on high density voltage mapping and complex fractionated atrial electrograms: A randomized controlled trial. Medicine (Baltimore) 2021; 100:e26702. [PMID: 34397805 PMCID: PMC8341227 DOI: 10.1097/md.0000000000026702] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 07/07/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) catheter ablation. However, a PVI alone has been considered insufficient for persistent AF. This study aimed to evaluate the efficacy of persistent AF ablation targeting complex fractionated atrial electrogram (CFAE) areas within low voltage zones identified by high-resolution mapping in addition to the PVI. METHODS We randomized 50 patients (mean age 58.4 ± 9.5 years old, 86.0% males) with persistent AF to a PVI + CFAE group and PVI only group in a 1:1 ratio. CFAE and voltage mapping was performed simultaneously using a Pentaray Catheter with the CARTO3 CONFIDENSE module (Biosense Webster, CA, USA). The PVI + CFAE group, in addition to the PVI, underwent ablation targeting low voltage areas (<0.5 mV during AF) containing CFAEs. RESULTS The mean persistent AF duration was 24.0 ± 23.1 months and mean left atrial dimension 4.9 ± 0.5 cm. In the PVI + CFAE group, AF converted to atrial tachycardia (AT) or sinus rhythm in 15 patients (60%) during the procedure. The PVI + CFAE group had a higher 1-year AF free survival (84.0% PVI + CFAE vs 44.0 PVI only, P = .006) without antiarrhythmic drugs. However, there was no difference in the AF/AT free survival (60.0% PVI + CFAE vs 40.0% PVI only, P = .329). CONCLUSION Persistent AF ablation targeting CFAE areas within low voltage zones using high-density voltage mapping had a higher AF free survival than a PVI only. Although recurrence with AT was frequent in the PVI+CFAE group, the sinus rhythm maintenance rate after redo procedures was 76%.
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Affiliation(s)
- Jongmin Hwang
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Hyoung-Seob Park
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Seongwook Han
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Cheol Hyun Lee
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - In-Cheol Kim
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Yun-Kyeong Cho
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Hyuck-Jun Yoon
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Jin wook Chung
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Hyungseop Kim
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Chang-Wook Nam
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Seung-Ho Hur
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Jin Young Kim
- Department of Radiology, Keimyung University School of Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Yun Seok Kim
- Department of Thoracic and Cardiovascular surgery, Keimyung University School of Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Woo Sung Jang
- Department of Thoracic and Cardiovascular surgery, Keimyung University School of Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
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25
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Sánchez J, Luongo G, Nothstein M, Unger LA, Saiz J, Trenor B, Luik A, Dössel O, Loewe A. Using Machine Learning to Characterize Atrial Fibrotic Substrate From Intracardiac Signals With a Hybrid in silico and in vivo Dataset. Front Physiol 2021; 12:699291. [PMID: 34290623 PMCID: PMC8287829 DOI: 10.3389/fphys.2021.699291] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/08/2021] [Indexed: 11/15/2022] Open
Abstract
In patients with atrial fibrillation, intracardiac electrogram signal amplitude is known to decrease with increased structural tissue remodeling, referred to as fibrosis. In addition to the isolation of the pulmonary veins, fibrotic sites are considered a suitable target for catheter ablation. However, it remains an open challenge to find fibrotic areas and to differentiate their density and transmurality. This study aims to identify the volume fraction and transmurality of fibrosis in the atrial substrate. Simulated cardiac electrograms, combined with a generalized model of clinical noise, reproduce clinically measured signals. Our hybrid dataset approach combines in silico and clinical electrograms to train a decision tree classifier to characterize the fibrotic atrial substrate. This approach captures different in vivo dynamics of the electrical propagation reflected on healthy electrogram morphology and synergistically combines it with synthetic fibrotic electrograms from in silico experiments. The machine learning algorithm was tested on five patients and compared against clinical voltage maps as a proof of concept, distinguishing non-fibrotic from fibrotic tissue and characterizing the patient's fibrotic tissue in terms of density and transmurality. The proposed approach can be used to overcome a single voltage cut-off value to identify fibrotic tissue and guide ablation targeting fibrotic areas.
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Affiliation(s)
- Jorge Sánchez
- Institute of Biomedical Engineering, Karlsruhe Institute for Technology, Karlsruhe, Germany
- Centro de Investigación e Innovación en Bioingeniería (Ci2B), Universitàt Politècnica de València, Valencia, Spain
| | - Giorgio Luongo
- Institute of Biomedical Engineering, Karlsruhe Institute for Technology, Karlsruhe, Germany
| | - Mark Nothstein
- Institute of Biomedical Engineering, Karlsruhe Institute for Technology, Karlsruhe, Germany
| | - Laura A. Unger
- Institute of Biomedical Engineering, Karlsruhe Institute for Technology, Karlsruhe, Germany
| | - Javier Saiz
- Centro de Investigación e Innovación en Bioingeniería (Ci2B), Universitàt Politècnica de València, Valencia, Spain
| | - Beatriz Trenor
- Centro de Investigación e Innovación en Bioingeniería (Ci2B), Universitàt Politècnica de València, Valencia, Spain
| | - Armin Luik
- Medizinische Klinik IV, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - Olaf Dössel
- Institute of Biomedical Engineering, Karlsruhe Institute for Technology, Karlsruhe, Germany
| | - Axel Loewe
- Institute of Biomedical Engineering, Karlsruhe Institute for Technology, Karlsruhe, Germany
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26
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Sohns C, Marrouche NF. Atrial fibrillation and cardiac fibrosis. Eur Heart J 2021; 41:1123-1131. [PMID: 31713590 DOI: 10.1093/eurheartj/ehz786] [Citation(s) in RCA: 119] [Impact Index Per Article: 39.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 09/30/2019] [Accepted: 10/23/2019] [Indexed: 12/25/2022] Open
Abstract
The understanding of atrial fibrillation (AF) evolved from a sole rhythm disturbance towards the complex concept of a cardiomyopathy based on arrhythmia substrates. There is evidence that atrial fibrosis can be visualized using late gadolinium enhancement cardiac magnetic resonance imaging and that it is a powerful predictor for the outcome of AF interventions. However, a strategy of an individual and fibrosis guided management of AF looks promising but results from prospective multicentre trials are pending. This review gives an overview about the relationship between cardiac fibrosis and AF focusing on translational aspects, clinical observations, and fibrosis imaging to emphasize the concept of personalized paths in AF management taking into account the individual amount and distribution of fibrosis.
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Affiliation(s)
- Christian Sohns
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Nassir F Marrouche
- Cardiac Electrophysiology, Tulane University School of Medicine, 1430 Tulane Avenue, Box 8548, New Orleans, LA 70112, USA
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27
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Kantharia BK, Lip GYH, Martin DT. Alterations in atrial electrogram amplitude as steady sinus rhythm transitions to paroxysmal atrial fibrillation during continuous monitoring in patients with implantable cardiac devices: Insights from the IMPACT study. J Cardiovasc Electrophysiol 2021; 32:1357-1363. [PMID: 33709486 DOI: 10.1111/jce.14997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/04/2021] [Accepted: 02/09/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES We aimed to evaluate whether device measured amplitudes of atrial electrogram (AEGM) would change when measured in sinus rhythm (SR) transitioning to paroxysmal atrial fibrillation (AF) from previous steady SR, and significance of such change. METHODS From the IMPACT trial's database we selected two groups; (A) those who developed AF (n = 164), and (B) propensity-matched control (n = 459) who stayed in SR during continuous Home Monitoring (HM) to compare AEGMs amplitudes at baseline SR and transition phase. RESULTS During 420.0 ± 349.2 days (mean ± SD) from first postenrollment HM transmission to AF event transmission in Group A, and corresponding 515.3 ± 407.0 days in Group B, baseline and transition AEGM amplitude were 2.88 ± 1.146 and 2.74 ± 1.186 mV, respectively, for Group A (p = .1), and 2.88 ± 1.155 and 2.79 ± 1.145, respectively, for Group B (p < .005). Comparison of differences of AEGM amplitude, 0.14 ± 1.072 mV in Group A and 0.09 ± 0.893 mV in Group B were insignificant (p = .3). Age, sex, and hypertension identified as confounders had no association to AEGM changes (p = NS). CONCLUSIONS Independent of age, sex, and hypertension, AEGMs amplitudes decline over a long period of time in patients with defibrillators and substrate for AF. The significance of such change remains unclear as it occurs whether patients develop AF or not, but raises a possibility of progressive atrial myopathy that patients with substrate for AF may be predisposed to.
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Affiliation(s)
- Bharat K Kantharia
- Cardiovascular and Heart Rhythm Consultants, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gregory Y H Lip
- University of Liverpool Centre for Cardiovascular Science, Liverpool, UK
| | - David T Martin
- Brigham and Women's Hospital, Boston, Massachusetts, USA
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28
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Ho G, Lin AY, Krummen DE. Linking Electrical Drivers With Atrial Cardiomyopathy for the Targeted Treatment of Atrial Fibrillation. Front Physiol 2020; 11:570740. [PMID: 33281614 PMCID: PMC7689158 DOI: 10.3389/fphys.2020.570740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/22/2020] [Indexed: 12/19/2022] Open
Abstract
The relationship between atrial fibrillation (AF) and underlying functional and structural abnormalities has received substantial attention in the research literature over the past decade. Significant progress has been made in identifying these changes using non-invasive imaging, voltage mapping, and electrical recordings. Advances in computed tomography and cardiac magnetic resonance imaging can now provide insight regarding the presence and extent of cardiac fibrosis. Additionally, multiple technologies able to identify electrical targets during AF have emerged. However, an organized strategy to employ these resources in the targeted treatment of AF remains elusive. In this work, we will discuss the basis for mechanistic importance of atrial fibrosis and scar as potential sites promoting AF and emerging technologies to identify and target these structural and functional substrates in the electrophysiology laboratory. We also propose an approach to the use of such technologies to serve as a basis for ongoing work in the field.
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Affiliation(s)
- Gordon Ho
- Division of Cardiology, Department of Medicine, University of California, San Diego, San Diego, CA, United States
- Division of Cardiology, Veterans Affairs San Diego Medical Center, San Diego, CA, United States
| | - Andrew Y. Lin
- Division of Cardiology, Department of Medicine, University of California, San Diego, San Diego, CA, United States
- Division of Cardiology, Veterans Affairs San Diego Medical Center, San Diego, CA, United States
| | - David E. Krummen
- Division of Cardiology, Department of Medicine, University of California, San Diego, San Diego, CA, United States
- Division of Cardiology, Veterans Affairs San Diego Medical Center, San Diego, CA, United States
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29
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Borra D, Andalò A, Paci M, Fabbri C, Corsi C. A fully automated left atrium segmentation approach from late gadolinium enhanced magnetic resonance imaging based on a convolutional neural network. Quant Imaging Med Surg 2020; 10:1894-1907. [PMID: 33014723 DOI: 10.21037/qims-20-168] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Several studies suggest that the evaluation of left atrial (LA) fibrosis is a relevant information for the assessment of the appropriate strategy in catheter ablation in atrial fibrillation (AF). Late gadolinium enhanced (LGE) cardiac magnetic resonance imaging (MRI) is a non-invasive technique, which might be employed for the non-invasive quantification of LA myocardial fibrotic tissue in patients with AF. Nowadays, the analysis of LGE MRI relies on manual tracing of LA boundaries and this procedure is time-consuming and prone to high inter-observer variability given the different degrees of observers' experience, LA wall thickness and data resolution. Therefore, an automated segmentation approach of the atrial cavity for the quantification of scar tissue would be highly desirable. Methods This study focuses on the design of a fully automated LGE MRI segmentation pipeline which includes a convolutional neural network (CNN) based on the successful architecture U-Net. The CNN was trained, validated and tested end-to-end with the data available from the Statistical Atlases and Computational Modelling of the Heart 2018 Atrial Segmentation Challenge (100 cardiac data). Two different approaches were tested: using both stacks of 2-D axial slices and using 3-D data (with the appropriate changes in the baseline architecture). In the latter approach, thanks to the 3-D convolution operator, all the information underlying 3-D data can be exploited. Once the training was completed using 80 cardiac data, a post-processing step was applied on 20 predicted segmentations belonging to the test set. Results By applying the 2-D and 3-D approaches, average Dice coefficient and mean Hausdorff distances were 0.896, 0.914, and 8.98 mm, 8.34 mm, respectively. Volumes of the anatomical LA meshes from the automated analysis were highly correlated with the volumes from ground truth [2-D: r=0.978, y=0.94x+0.07, bias=3.5 ml (5.6%), SD=5.3 mL (8.5%); 3-D: r=0.982, y=0.92x+2.9, bias=2.1 mL (3.5%), SD=5.2 mL (8.4%)]. Conclusions These results suggest the proposed approach is feasible and provides accurate results. Despite the increase of the number of trainable parameters, the proposed 3-D CNN learns better features leading to higher performance, feasible for a real clinical application.
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Affiliation(s)
- Davide Borra
- Department of Electrical, Electronic and Information Engineering "Guglielmo Marconi" (DEI), University of Bologna, Bologna, Italy
| | - Alice Andalò
- Department of Electrical, Electronic and Information Engineering "Guglielmo Marconi" (DEI), University of Bologna, Bologna, Italy
| | - Michelangelo Paci
- BioMediTech, Faculty of Medicine and Health Technology, Tampere University, FI-33520 Tampere, Finland
| | - Claudio Fabbri
- Department of Electrical, Electronic and Information Engineering "Guglielmo Marconi" (DEI), University of Bologna, Bologna, Italy
| | - Cristiana Corsi
- Department of Electrical, Electronic and Information Engineering "Guglielmo Marconi" (DEI), University of Bologna, Bologna, Italy
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Gunasekaran S, Kim D. Is Otsu thresholding the answer to reproducible quantification of left atrial scar from late gadolinium-enhancement MRI? J Cardiovasc Electrophysiol 2020; 31:2833-2835. [PMID: 32931626 DOI: 10.1111/jce.14742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 09/08/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Suvai Gunasekaran
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Daniel Kim
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Department of Biomedical Engineering, Northwestern University, Evanston, Illinois, USA
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Masuda M, Asai M, Iida O, Okamoto S, Ishihara T, Nanto K, Kanda T, Tsujimura T, Matsuda Y, Okuno S, Mano T. Low-Voltage Areas as Alternative Targets for the Ablation of Unmappable Atrial Tachycardia in Patients Undergoing Atrial Fibrillation Ablation. J Atr Fibrillation 2020; 13:2165. [PMID: 34950285 DOI: 10.4022/jafib.2165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 06/16/2019] [Accepted: 07/20/2019] [Indexed: 11/10/2022]
Abstract
Aims Unmappable regular atrial tachycarrhythmias (ATs) occasionally develop during atrial fibrillation (AF) ablation, and are difficult to treat by conventional ablation. Recently, low-voltage areas (LVAs) have been reported to represent AT substrate. The purpose of this study was to elucidate the efficacy of LVA ablation for unmappable AT. Methods This observational study included 32 consecutive patients who developed unmappable ATs during and after AF ablation. Unmappable AT was defined as AT lasting for >5 s, but that terminated or changed the activation sequence over too short a time to create a sufficient activation map. We used conventional ablation to target undetermined AT circuits estimated from activation timings of electrograms recorded on the placed electrode catheter, the response to entrainment mappings, and/or diastolic potentials during AT. Subsequently, in cases without successful elimination of unmappable ATs by conventional ablation, LVA (≤ 0.5 mV) ablation was performed at the discretion of the operators. Results Conventional ablation failed to eliminate at least one unmappable AT in 29 patients. Among them, LVA ablation was performed in 16 patients. LVA ablation eliminated all the unmappable ATs in 8 of 16 patients. The LVA size did not differ between patients with and without the acute elimination of unmappable ATs (17±11 vs. 21±12 cm2, p = 0.39), and AT/AF recurrence rates were comparable between the two groups (38% vs. 63%, p = 0.62) during a mean follow-up period of 14±8 months. Conclusions LVA ablation was efficacious to some extent for the elimination of unmappable ATs refractory to conventional ablation.
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Affiliation(s)
- Masaharu Masuda
- Kansai Rosai Hospital Cardiovascular Center, 3-1-69 Inabaso, Amagasaki, Hyogo 660-8511, Japan
| | - Mitsutoshi Asai
- Kansai Rosai Hospital Cardiovascular Center, 3-1-69 Inabaso, Amagasaki, Hyogo 660-8511, Japan
| | - Osamu Iida
- Kansai Rosai Hospital Cardiovascular Center, 3-1-69 Inabaso, Amagasaki, Hyogo 660-8511, Japan
| | - Shin Okamoto
- Kansai Rosai Hospital Cardiovascular Center, 3-1-69 Inabaso, Amagasaki, Hyogo 660-8511, Japan
| | - Takayuki Ishihara
- Kansai Rosai Hospital Cardiovascular Center, 3-1-69 Inabaso, Amagasaki, Hyogo 660-8511, Japan
| | - Kiyonori Nanto
- Kansai Rosai Hospital Cardiovascular Center, 3-1-69 Inabaso, Amagasaki, Hyogo 660-8511, Japan
| | - Takashi Kanda
- Kansai Rosai Hospital Cardiovascular Center, 3-1-69 Inabaso, Amagasaki, Hyogo 660-8511, Japan
| | - Takuya Tsujimura
- Kansai Rosai Hospital Cardiovascular Center, 3-1-69 Inabaso, Amagasaki, Hyogo 660-8511, Japan
| | - Yasuhiro Matsuda
- Kansai Rosai Hospital Cardiovascular Center, 3-1-69 Inabaso, Amagasaki, Hyogo 660-8511, Japan
| | - Shota Okuno
- Kansai Rosai Hospital Cardiovascular Center, 3-1-69 Inabaso, Amagasaki, Hyogo 660-8511, Japan
| | - Toshiaki Mano
- Kansai Rosai Hospital Cardiovascular Center, 3-1-69 Inabaso, Amagasaki, Hyogo 660-8511, Japan
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Nattel S, Heijman J, Zhou L, Dobrev D. Molecular Basis of Atrial Fibrillation Pathophysiology and Therapy: A Translational Perspective. Circ Res 2020; 127:51-72. [PMID: 32717172 PMCID: PMC7398486 DOI: 10.1161/circresaha.120.316363] [Citation(s) in RCA: 212] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Atrial fibrillation (AF) is a highly prevalent arrhythmia, with substantial associated morbidity and mortality. There have been significant management advances over the past 2 decades, but the burden of the disease continues to increase and there is certainly plenty of room for improvement in treatment options. A potential key to therapeutic innovation is a better understanding of underlying fundamental mechanisms. This article reviews recent advances in understanding the molecular basis for AF, with a particular emphasis on relating these new insights to opportunities for clinical translation. We first review the evidence relating basic electrophysiological mechanisms to the characteristics of clinical AF. We then discuss the molecular control of factors leading to some of the principal determinants, including abnormalities in impulse conduction (such as tissue fibrosis and other extra-cardiomyocyte alterations, connexin dysregulation and Na+-channel dysfunction), electrical refractoriness, and impulse generation. We then consider the molecular drivers of AF progression, including a range of Ca2+-dependent intracellular processes, microRNA changes, and inflammatory signaling. The concept of key interactome-related nodal points is then evaluated, dealing with systems like those associated with CaMKII (Ca2+/calmodulin-dependent protein kinase-II), NLRP3 (NACHT, LRR, and PYD domains-containing protein-3), and transcription-factors like TBX5 and PitX2c. We conclude with a critical discussion of therapeutic implications, knowledge gaps and future directions, dealing with such aspects as drug repurposing, biologicals, multispecific drugs, the targeting of cardiomyocyte inflammatory signaling and potential considerations in intervening at the level of interactomes and gene-regulation. The area of molecular intervention for AF management presents exciting new opportunities, along with substantial challenges.
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Affiliation(s)
- Stanley Nattel
- Department of Medicine, Montreal Heart Institute and Université de Montréal, Montreal, Canada
- Institute of Pharmacology, West German Heart and Vascular Center, Faculty of Medicine, University Duisburg-Essen, Essen, Germany
- Department of Pharmacology and Therapeutics, McGill University, Montreal, Canada
- IHU Liryc and Fondation Bordeaux Université, Bordeaux, France
| | - Jordi Heijman
- Institute of Pharmacology, West German Heart and Vascular Center, Faculty of Medicine, University Duisburg-Essen, Essen, Germany
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Liping Zhou
- Department of Medicine, Montreal Heart Institute and Université de Montréal, Montreal, Canada
| | - Dobromir Dobrev
- Department of Medicine, Montreal Heart Institute and Université de Montréal, Montreal, Canada
- Institute of Pharmacology, West German Heart and Vascular Center, Faculty of Medicine, University Duisburg-Essen, Essen, Germany
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Habibi M, Chrispin J, Spragg DD, Zimmerman SL, Tandri H, Nazarian S, Halperin H, Trayanova N, Calkins H. Utility of Cardiac MRI in Atrial Fibrillation Management. Card Electrophysiol Clin 2020; 12:131-139. [PMID: 32451098 DOI: 10.1016/j.ccep.2020.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Advances in cardiac magnetic resonance (CMR) techniques and image acquisition have made it an excellent tool in the assessment of atrial myopathy. Remolding of the left atrium is the mainstay of atrial fibrillation (AF) development and its progression. CMR can detect phasic atrial volumes, atrial function, and atrial fibrosis using cine, and contrast-enhanced or non-contrast-enhanced images. These abilities make CMR a versatile and extraordinary tool in management of patients with AF including for risk stratification, ablation prognostication and planning, and assessment of stroke risk. We review the latest advancements in utility of CMR in management of patients with AF.
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Affiliation(s)
- Mohammadali Habibi
- Division of Cardiology, Section for Cardiac Electrophysiology, Johns Hopkins University, Baltimore, MD, USA
| | - Jonathan Chrispin
- Division of Cardiology, Section for Cardiac Electrophysiology, Johns Hopkins University, Baltimore, MD, USA
| | - David D Spragg
- Division of Cardiology, Section for Cardiac Electrophysiology, Johns Hopkins University, Baltimore, MD, USA
| | | | - Harikrishna Tandri
- Division of Cardiology, Section for Cardiac Electrophysiology, Johns Hopkins University, Baltimore, MD, USA
| | - Saman Nazarian
- Division of Cardiology, Section for Cardiac Electrophysiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Henry Halperin
- Division of Cardiology, Section for Cardiac Electrophysiology, Johns Hopkins University, Baltimore, MD, USA; Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Natalia Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Hugh Calkins
- Division of Cardiology, Section for Cardiac Electrophysiology, Johns Hopkins University, Baltimore, MD, USA.
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Gizatulina TP, Martyanova LU, Pavlov AV, Shirokov NE, Kolunin GV, Belonogov DV, Gorbatenko EA. [Predictors of Left Atrial Severe Fibrosis in Patients with Nonvalvular Atrial Fibrillation]. ACTA ACUST UNITED AC 2020; 60:47-53. [PMID: 32345198 DOI: 10.18087/cardio.2020.2.n850] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 03/05/2020] [Indexed: 11/18/2022]
Abstract
Objective The search for predictors of severe (>35 %) left atrial (LA) fibrosis in patients (pts) with nonvalvular atrial fibrillation (AF) directed for catheter ablation (CA).Materials and Methods 69 pts with nonvalvular AF (57 paroxismal and 12 persistent) aged from 32 to 69 years (mean age 57.1±8.4, 28 females) were included in the study, among them 59 pts (86 %) with arterial hypertension (AH), 24 (34.8 %) - with AH and CAD. Complete physical study, laboratory tests (including NT-proBNP level), comprehensive echocardiography were performed. As a surrogate substrate of LA fibrosis, the area of low-voltage (<0.5 mV) zones in LA was estimated in the process of voltage electroanatomic mapping, as the first stage of CA. The total square of LA fibrosis in absolute values (Sf, cm2) and in percent of total LA square (Sf%), as well as the degree of fibrosis: degree I - <5 %, II - 5-19 %, III - 20-35 %, IV - >35 % were calculated. Degree IV of fibrosis was considered as severe fibrosis.Results Extent of fibrosis didn't depend on sex, age, body weight, presence of diabetes, CHA2DS2VASc scores, duration of AF history. There was a tendency to smaller Sf in pts with spontaneous termination of AF compared to those who required cardioversion: 7.2 cm2 (4.4; 17.1) and 12.6 cm2 (4.2; 30.5), respectively (p=0.069). Although NT-proBNP level was normal in 62 % of pts (<125 pg / ml), it was higher in Sf% ≥20 % than in Sf% <5 %: 146.0 (48.0; 276.0) and 42.8 (24.2; 91.0) pg / ml, respectively (p=0.0216). The distribution of pts by left ventricular (LV) geometry types was as follows: normal geometry (t.1) - 34, concentric remodeling (t.2) - 16, concentric LV hypertrophy (t.3) - 8, eccentric LV hypertrophy (t.4) - 11. Compared to pts with t. 1 (reference level), pts with t.3 and t.4 had higher LA volume and LV myocardial mass index, and pts with t.4 had larger end-diastolic LV volume and lower LV ejection fraction. Pts with t.4 tended to have higher Sf% than t.1: 31.1 (10.2; 46.2) and 11.2 (5.1; 28.0), respectively (p=0.053). Using logistic regression 3 independent predictors of LA severe fibrosis were detected: type 4 geometry of LV - OR=8.893 (95 % CI 1.150; 68.78), NT-proBNP >128 pg / ml - OR=6.184 (1.01; 37.99), LA volume index >34 ml / m2 - OR=5.92 (1.05; 33.38). According to ROC analysis, the area of the curve AUC = 0.839 (p<0.001), model specificity - 85.1 %, sensitivity - 70.0 %, predictive accuracy - 82.5 %.Conclusion In pts with nonvalvular AF predictors of severe (>35 %) LA fibrosis were LV geometry type in the form of eccentric LV hypertrophy, LA volume index >34 ml / m2 and NT-proBNP >128 pg / ml.
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Affiliation(s)
- T P Gizatulina
- Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia
| | - L U Martyanova
- Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia
| | - A V Pavlov
- Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia
| | - N E Shirokov
- Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia
| | - G V Kolunin
- Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia
| | - D V Belonogov
- Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia
| | - E A Gorbatenko
- Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, Russia
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Aparina OP, Mironov NY, Fedorova EA, Dzaurova KM, Maikov EB, Stukalova OV, Golitsyn SP. [Cardiac magnetic resonance imaging with contrast enhancement in treatment of atrial fibrillation]. ACTA ACUST UNITED AC 2020; 60:119-125. [PMID: 32375624 DOI: 10.18087/cardio.2020.3.n582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 12/04/2019] [Accepted: 12/09/2019] [Indexed: 11/18/2022]
Abstract
Catheter ablation is presently the main method for interventional treatment of atrial fibrillation (AF). Despite improvements of the method and accumulation of personnel's experience, incidence of recurrent AF following catheter interventions remains high. This review addresses a possibility of using contrast-enhanced cardiac magnetic resonance imaging to increase the effectiveness of interventional treatment of arrhythmia.
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Affiliation(s)
- O P Aparina
- National Medical Research Center of Cardiology
| | | | | | | | - E B Maikov
- National Medical Research Center of Cardiology
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36
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Nakatani Y, Sakamoto T, Yamaguchi Y, Tsujino Y, Kataoka N, Kinugawa K. P-wave vector magnitude predicts the left atrial low-voltage area in patients with paroxysmal atrial fibrillation. J Electrocardiol 2019; 59:35-40. [PMID: 31954955 DOI: 10.1016/j.jelectrocard.2019.12.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 12/14/2019] [Accepted: 12/20/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND P-wave amplitude (PWA) parameters can be the surrogate measures of the left atrial low-voltage areas (LVAs). METHODS We measured PWAs using an automated system in 50 patients with paroxysmal atrial fibrillation (AF). We examined the relationships between left atrial LVAs and PWA parameters, including P-wave vector magnitude, calculated as the square root of the sum of lead II PWA squared, lead V6 PWA squared, and a one-half lead V2 PWA squared. RESULTS Lead I PWA was most strongly correlated with LVAs in the anterior wall and appendage (anterior wall, R = -0.391, P = 0.006; appendage, R = -0.342, P = 0.016), whereas lead II PWA was most strongly correlated with LVAs in the septum, posterior wall, and bottom wall (septum, R = -0.413, P = 0.003; posterior wall, R = -0.297, P = 0.039; bottom wall; R = -0.288, P = 0.045). Although maximum, minimum, mean, and lead I PWAs were not correlated with total LVA, P-wave vector magnitude and lead II PWA were significantly correlated with total LVA (P-wave vector magnitude, R = -0.430, P = 0.002; lead II PWA, R = -0.323, P = 0.023). P-wave vector magnitude achieved the highest accuracy for predicting significant LVA (total LVA > 10%) with an area under the curve of 0.772; sensitivity, specificity, and positive and negative predictive values were 64%, 88%, 85%, and 69%, respectively, for the cutoff value of 0.130 mV. CONCLUSION P-wave vector magnitude is a useful electrocardiographic predictor of left atrial LVAs.
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Affiliation(s)
- Yosuke Nakatani
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan.
| | - Tamotsu Sakamoto
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan
| | - Yoshiaki Yamaguchi
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan
| | - Yasushi Tsujino
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan
| | - Naoya Kataoka
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan
| | - Koichiro Kinugawa
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan
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Wijesurendra RS, Casadei B. Mechanisms of atrial fibrillation. Heart 2019; 105:1860-1867. [PMID: 31444267 DOI: 10.1136/heartjnl-2018-314267] [Citation(s) in RCA: 148] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 08/02/2019] [Accepted: 08/09/2019] [Indexed: 01/26/2023] Open
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia, currently affecting over 33 million individuals worldwide, and its prevalence is expected to more than double over the next 40 years. AF is associated with a twofold increase in premature mortality, and important major adverse cardiovascular events such as heart failure, severe stroke and myocardial infarction. Significant effort has been made over a number of years to define the underlying cellular, molecular and electrophysiological changes that predispose to the induction and maintenance of AF in patients. Progress has been limited by the realisation that AF is a complex arrhythmia that can be the end result of various different pathophysiological processes, with significant heterogeneity between individual patients (and between species). In this focused Review article, we aim to succinctly summarise for the non-specialist the current state of knowledge regarding the mechanisms of AF. We address all aspects of pathophysiology, including the basic electrophysiological and structural changes within the left atrium, the genetics of AF and the links to comorbidities and wider systemic and metabolic perturbations that may be upstream contributors to development of AF. Finally, we outline the translational implications for current and future rhythm control strategies in patients with AF.
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Affiliation(s)
| | - Barbara Casadei
- Division of Cardiovascular Medicine, University of Oxford, Oxford, UK
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Bertelsen L, Alarcón F, Andreasen L, Benito E, Olesen MS, Vejlstrup N, Mont L, Svendsen JH. Verification of threshold for image intensity ratio analyses of late gadolinium enhancement magnetic resonance imaging of left atrial fibrosis in 1.5T scans. Int J Cardiovasc Imaging 2019; 36:513-520. [PMID: 31748945 PMCID: PMC7080681 DOI: 10.1007/s10554-019-01728-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 11/03/2019] [Indexed: 11/25/2022]
Abstract
The use of cardiovascular magnetic resonance imaging left atrial late gadolinium enhancement (LA LGE) is increasing for fibrosis evaluation though the use is still limited to specialized centres due to complex image acquisition and lack of consensus on image analyses. Analysis of LA LGE with image intensity ratio (IIR) (pixel intensity of atrial wall normalized by blood pool intensity) provides an objective method to obtain quantitative data on atrial fibrosis. A threshold between healthy myocardium and fibrosis of 1.2 has previously been established in 3T scans. The aim of the study was to reaffirm this threshold in 1.5T scans. LA LGE was performed using a 1.5T magnetic resonance scanner on: 11 lone-AF patients, 11 age-matched healthy volunteers (aged 27-44) and 11 elderly patients without known history of AF but varying degrees of comorbidities. Mean values of IIR for all healthy volunteers +2SD were set as upper limit of normality and was reproduced to 1.21 and the original IIR-threshold of 1.20 was maintained. The degree of fibrosis in lone-AF patients [median 9.0% (IQR 3.9-12.0)] was higher than in healthy volunteers [2.8% (1.3-8.3)] and even higher in elderly non-AF [20.1% (10.2-35.8), p = 0.001]. The previously established IIR-threshold of 1.2 was reaffirmed in 1.5T LA LGE scans. Patients with lone AF presented with increased degrees of atrial fibrosis compared to healthy volunteers in the same age-range. Elderly patients with no history of AF showed significantly higher degrees of fibrosis compared to both groups with younger individuals.
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Affiliation(s)
- Litten Bertelsen
- Department of Cardiology, Centre for Cardiac-, Vascular-, Pulmonary and Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Francisco Alarcón
- Department of Cardiology, Unitat de Fibril.lació Auricular (UFA) Hospital Clinic, University of Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Laura Andreasen
- Department of Cardiology, Centre for Cardiac-, Vascular-, Pulmonary and Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Eva Benito
- Department of Cardiology, Unitat de Fibril.lació Auricular (UFA) Hospital Clinic, University of Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Niels Vejlstrup
- Department of Cardiology, Centre for Cardiac-, Vascular-, Pulmonary and Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Lluis Mont
- Department of Cardiology, Unitat de Fibril.lació Auricular (UFA) Hospital Clinic, University of Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Jesper Hastrup Svendsen
- Department of Cardiology, Centre for Cardiac-, Vascular-, Pulmonary and Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Nakatani Y, Sakamoto T, Yamaguchi Y, Tsujino Y, Kataoka N, Nishida K, Mizumaki K, Kinugawa K. Correlation between the left atrial low-voltage area and the cardiac function improvement after catheter ablation for paroxysmal atrial fibrillation. J Arrhythm 2019; 35:725-732. [PMID: 31624511 PMCID: PMC6787158 DOI: 10.1002/joa3.12221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 06/01/2019] [Accepted: 06/24/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The impact of the left atrial low-voltage area (LVA) on the cardiac function improvement following ablation for atrial fibrillation (AF) is unclear. METHODS In 49 patients with paroxysmal AF who underwent ablation, the left ventricular stroke volume index (SVI) was repeatedly measured using an impedance cardiography until 6 months after ablation. We defined the cardiac function improvement as a 20% increase in the SVI. The LVA (the area with the voltage amplitude of <0.5 mV) was assessed before ablation. RESULTS The reduced baseline SVI (<33 mL/m2) was observed in 18 (37%) patients. The SVI increased following ablation (from 36 ± 5 to 39 ± 6 mL/m2, P < .001). We observed the cardiac function improvement in 14 (29%) patients. The LVA was smaller in patients with the improved cardiac function than in those without (8.3% ± 5.2% vs 14.0% ± 8.5%, P = .026). The multivariate analysis revealed that only the LVA was independently associated with the cardiac function improvement (odds ratio, 0.878; 95% confidence interval: 0.778-0.991, P = .036). Furthermore, LVAs of the anterior (7.9% ± 7.6% vs 18.2% ± 15.5%, P = .022), septal (12.0 ± 7.3% vs 20.7% ± 13.8%, P = .031), and roof walls (6.9% ± 6.0% vs 16.9% ± 15.2%, P = .022) were smaller in patients with the improved cardiac function than in those without. CONCLUSIONS The LVA was related to the cardiac function improvement following ablation in patients with paroxysmal AF.
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Affiliation(s)
- Yosuke Nakatani
- Second Department of Internal MedicineUniversity of ToyamaToyamaJapan
| | - Tamotsu Sakamoto
- Second Department of Internal MedicineUniversity of ToyamaToyamaJapan
| | | | - Yasushi Tsujino
- Second Department of Internal MedicineUniversity of ToyamaToyamaJapan
| | - Naoya Kataoka
- Second Department of Internal MedicineUniversity of ToyamaToyamaJapan
| | | | | | - Koichiro Kinugawa
- Second Department of Internal MedicineUniversity of ToyamaToyamaJapan
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40
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Left atrial wall thickness is associated with the low-voltage area in patients with paroxysmal atrial fibrillation. J Interv Card Electrophysiol 2019; 58:315-321. [DOI: 10.1007/s10840-019-00611-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 08/06/2019] [Indexed: 12/23/2022]
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Mann I, Sasikaran T, Sandler B, Babalis D, Johnson N, Falaschetti E, Copley A, Tayebjee M, Todd D, Shepherd E, McCready J, Poulter N, Kanagaratnam P. Ablation versus Anti-Arrhythmic Therapy for Reducing All Hospital Episodes from Recurrent Atrial Fibrillation (AVATAR-AF): Design and rationale. Am Heart J 2019; 214:36-45. [PMID: 31152874 DOI: 10.1016/j.ahj.2019.04.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 04/25/2019] [Indexed: 12/31/2022]
Abstract
Atrial Fibrillation (AF) ablation using the cryoballoon is effective at reducing symptomatic AF episodes. The prevalence of AF is increasing with the aging population and access to such treatment would be enhanced by reducing the resource requirements. Relinquishing electrical mapping of the pulmonary veins (PV) removes the need for PV catheters, electrical recording equipment and staff trained in using this equipment. Moreover, the majority of complications are peri-procedural so overnight hospitalization maybe unnecessary. We tested this streamlined approach to AF ablation against medical therapy using the endpoint of time to all hospital episodes. METHODS: The AVATAR-AF study is a prospective, multicenter, randomized controlled trial testing the primary hypothesis that AF ablation done without PV mapping or overnight hospitalization is more effective than anti-arrhythmic drugs at reducing all hospital episodes related to recurrent atrial arrhythmias. We included a third arm to test a secondary hypothesis that confirming PV entrance block as per consensus guidelines can improve outcomes. Three hundred twenty-one patients with documented paroxysmal AF will be randomized in a 1:1:1 manner to one of three investigation arms: (1) AVATAR protocol cryoballoon ablation without assessment of acute PV isolation or overnight hospitalization; (2) medical therapy with anti-arrhythmic drugs; or (3) conventional cryoballoon ablation with assessment of acute PV isolation. The primary endpoint is defined as the time to all hospital episodes (including outpatient consultation) related to treatment for atrial arrhythmia. CONCLUSION: The AVATAR-AF study will determine whether the resource utilization for AF ablation can be reduced whilst maintaining superiority over medical therapy.
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Yamashita K, Silvernagel J, Kwan E, Kamali R, Ghafoori E, MacLeod R, Dosdall DJ, Ranjan R. Changes in atrial electrophysiological and structural substrate and their relationship to histology in a long-term chronic canine atrial fibrillation model. Pacing Clin Electrophysiol 2019; 42:930-936. [PMID: 31127633 DOI: 10.1111/pace.13730] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 05/02/2019] [Accepted: 05/20/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is related to numerous electrophysiological changes; however, the extent of structural and electrophysiological remodeling with long-term AF is not well characterized. METHODS Dogs (n = 6) were implanted with a neurostimulator in the right atrium (AF group). No implantation was done in the Control group (n = 3). Electroanatomical mapping was done prior to and following more than 6 months of AF. Magnetic resonance imaging was also done to assess structural remodeling. Animals were euthanized and tissue samples were acquired for histological analysis. RESULTS A significant increase was seen in the left atrial (LA) volume among all AF animals (22.25 ± 12.60 cm3 vs 34.00 ± 12.23 cm3 , P = .01). Also, mean bipolar amplitude in the LA significantly decreased from 5.96 ± 2.17 mV at baseline to 3.23 ± 1.51 mV (P < .01) after chronic AF. Those significant changes occurred in each anterior, lateral, posterior, septal, and roof regions as well. Additionally, the dominant frequency (DF) in the LA increased from 7.02 ± 0.37 Hz to 10.12 ± 0.28 Hz at chronic AF (P < .01). Moreover, the percentage of fibrosis in chronic AF animals was significantly larger than that of control animals in each location (P < .01). CONCLUSIONS Canine chronic AF is accompanied by a significant decrease in intracardiac bipolar amplitudes. These decreased electrogram amplitude values are still higher than traditional cut-off values used for diseased myocardial tissue. Despite these "normal" bipolar amplitudes, there is a significant increase in DF and tissue fibrosis.
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Affiliation(s)
- Kennosuke Yamashita
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah
| | - Josh Silvernagel
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah
- Department of Bioengineering, University of Utah, Salt Lake City, Utah
| | - Eugene Kwan
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah
- Department of Bioengineering, University of Utah, Salt Lake City, Utah
| | - Roya Kamali
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah
- Department of Bioengineering, University of Utah, Salt Lake City, Utah
| | - Elyar Ghafoori
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah
- Department of Bioengineering, University of Utah, Salt Lake City, Utah
| | - Robert MacLeod
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah
- Department of Bioengineering, University of Utah, Salt Lake City, Utah
| | - Derek J Dosdall
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah
- Department of Bioengineering, University of Utah, Salt Lake City, Utah
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Ravi Ranjan
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah
- Department of Bioengineering, University of Utah, Salt Lake City, Utah
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Ghannam M, Oral H. Mapping and Imaging in Non-paroxysmal AF. Arrhythm Electrophysiol Rev 2019; 8:202-209. [PMID: 31463058 PMCID: PMC6702463 DOI: 10.15420/aer.2019.18.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 04/25/2019] [Indexed: 01/22/2023] Open
Abstract
Despite intense research efforts, maintenance of sinus rhythm in patients with non-paroxysmal AF remains challenging with suboptimal outcomes. A major limitation to the success of current ablation-based treatments is that our understanding of AF pathophysiology is incomplete. Advances in imaging and mapping tools have been reported to improve ablation outcomes. However, the role of these new approaches on the clinical care of patients with AF remains to be validated and better understood before wide adoption can occur. This article reviews the current techniques of imaging and mapping that can be applied in the management of patients with non-paroxysmal AF with a focus on their relevance to catheter ablation. Future applications and opportunities for new knowledge are also discussed.
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Affiliation(s)
- Michael Ghannam
- Cardiac Arrhythmia Service, Division of Cardiovascular Medicine, University of Michigan Ann Arbor, MI, US
| | - Hakan Oral
- Cardiac Arrhythmia Service, Division of Cardiovascular Medicine, University of Michigan Ann Arbor, MI, US
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Qureshi NA, Kim SJ, Cantwell CD, Afonso VX, Bai W, Ali RL, Shun-Shin MJ, Malcolme-Lawes LC, Luther V, Leong KMW, Lim E, Wright I, Nagy S, Hayat S, Ng FS, Wing MK, Linton NWF, Lefroy DC, Whinnett ZI, Davies DW, Kanagaratnam P, Peters NS, Lim PB. Voltage during atrial fibrillation is superior to voltage during sinus rhythm in localizing areas of delayed enhancement on magnetic resonance imaging: An assessment of the posterior left atrium in patients with persistent atrial fibrillation. Heart Rhythm 2019; 16:1357-1367. [PMID: 31170484 PMCID: PMC6722483 DOI: 10.1016/j.hrthm.2019.05.032] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Indexed: 11/30/2022]
Abstract
Background Bipolar electrogram voltage during sinus rhythm (VSR) has been used as a surrogate for atrial fibrosis in guiding catheter ablation of persistent atrial fibrillation (AF), but the fixed rate and wavefront characteristics present during sinus rhythm may not accurately reflect underlying functional vulnerabilities responsible for AF maintenance. Objective The purpose of this study was determine whether, given adequate temporal sampling, the spatial distribution of mean AF voltage (VmAF) better correlates with delayed-enhancement magnetic resonance imaging (MRI-DE)–detected atrial fibrosis than VSR. Methods AF was mapped (8 seconds) during index ablation for persistent AF (20 patients) using a 20-pole catheter (660 ± 28 points/map). After cardioversion, VSR was mapped (557 ± 326 points/map). Electroanatomic and MRI-DE maps were co-registered in 14 patients. Results The time course of VmAF was assessed from 1–40 AF cycles (∼8 seconds) at 1113 locations. VmAF stabilized with sampling >4 seconds (mean voltage error 0.05 mV). Paired point analysis of VmAF from segments acquired 30 seconds apart (3667 sites; 15 patients) showed strong correlation (r = 0.95; P <.001). Delayed enhancement (DE) was assessed across the posterior left atrial (LA) wall, occupying 33% ± 13%. VmAF distributions were (median [IQR]) 0.21 [0.14–0.35] mV in DE vs 0.52 [0.34–0.77] mV in non-DE regions. VSR distributions were 1.34 [0.65–2.48] mV in DE vs 2.37 [1.27–3.97] mV in non-DE. VmAF threshold of 0.35 mV yielded sensitivity of 75% and specificity of 79% in detecting MRI-DE compared with 63% and 67%, respectively, for VSR (1.8-mV threshold). Conclusion The correlation between low-voltage and posterior LA MRI-DE is significantly improved when acquired during AF vs sinus rhythm. With adequate sampling, mean AF voltage is a reproducible marker reflecting the functional response to the underlying persistent AF substrate.
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Affiliation(s)
- Norman A Qureshi
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | | | | | | | - Wenjia Bai
- Imperial College London, London, United Kingdom
| | | | - Matt J Shun-Shin
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | | | - Vishal Luther
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Kevin M W Leong
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Elaine Lim
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Ian Wright
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Szabi Nagy
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Sajad Hayat
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Fu Siong Ng
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Michael Koa Wing
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Nick W F Linton
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - David C Lefroy
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Zachary I Whinnett
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - D Wyn Davies
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Prapa Kanagaratnam
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Nicholas S Peters
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Phang Boon Lim
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom.
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Ballesteros G, Ravassa S, Bragard J, Ramos P, López B, Vives E, Neglia R, Wise B, González A, Moreno MU, Díez J, García‐Bolao I. Association of left atrium voltage amplitude and distribution with the risk of atrial fibrillation recurrence and evolution after pulmonary vein isolation: An ultrahigh‐density mapping study. J Cardiovasc Electrophysiol 2019; 30:1231-1240. [DOI: 10.1111/jce.13972] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 05/01/2019] [Accepted: 05/03/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Gabriel Ballesteros
- Department of Cardiology and Cardiac SurgeryClínica Universidad de Navarra Pamplona Spain
| | - Susana Ravassa
- Program of Cardiovascular Diseases, Center for Applied Medical Research (CIMA)Universidad de Navarra Pamplona Spain
- IdiSNANavarra Institute for Health Research Pamplona Spain
- CIBERCVCarlos III Institute of Health Madrid Spain
| | - Jean Bragard
- Department of Physics and Applied MathUniversidad de Navarra Pamplona Spain
| | - Pablo Ramos
- Department of Cardiology and Cardiac SurgeryClínica Universidad de Navarra Pamplona Spain
| | - Begoña López
- Program of Cardiovascular Diseases, Center for Applied Medical Research (CIMA)Universidad de Navarra Pamplona Spain
- IdiSNANavarra Institute for Health Research Pamplona Spain
- CIBERCVCarlos III Institute of Health Madrid Spain
| | - Enrique Vives
- Department of Cardiology and Cardiac SurgeryClínica Universidad de Navarra Pamplona Spain
| | - Renzo Neglia
- Department of Cardiology and Cardiac SurgeryClínica Universidad de Navarra Pamplona Spain
| | - Bernardo Wise
- Department of Cardiology and Cardiac SurgeryClínica Universidad de Navarra Pamplona Spain
| | - Arantxa González
- Program of Cardiovascular Diseases, Center for Applied Medical Research (CIMA)Universidad de Navarra Pamplona Spain
- IdiSNANavarra Institute for Health Research Pamplona Spain
- CIBERCVCarlos III Institute of Health Madrid Spain
| | - María U. Moreno
- Program of Cardiovascular Diseases, Center for Applied Medical Research (CIMA)Universidad de Navarra Pamplona Spain
- IdiSNANavarra Institute for Health Research Pamplona Spain
- CIBERCVCarlos III Institute of Health Madrid Spain
| | - Javier Díez
- Department of Cardiology and Cardiac SurgeryClínica Universidad de Navarra Pamplona Spain
- Program of Cardiovascular Diseases, Center for Applied Medical Research (CIMA)Universidad de Navarra Pamplona Spain
- IdiSNANavarra Institute for Health Research Pamplona Spain
- CIBERCVCarlos III Institute of Health Madrid Spain
- Department of NephrologyClínica Universidad de Navarra Pamplona Spain
| | - Ignacio García‐Bolao
- Department of Cardiology and Cardiac SurgeryClínica Universidad de Navarra Pamplona Spain
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Left atrial voltage mapping: defining and targeting the atrial fibrillation substrate. J Interv Card Electrophysiol 2019; 56:213-227. [PMID: 31076965 PMCID: PMC6900285 DOI: 10.1007/s10840-019-00537-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 03/12/2019] [Indexed: 12/23/2022]
Abstract
Low atrial endocardial bipolar voltage, measured during catheter ablation for atrial fibrillation (AF), is a commonly used surrogate marker for the presence of atrial fibrosis. Low voltage shows many useful associations with clinical outcomes, comorbidities and has links to trigger sites for AF. Several contemporary trials have shown promise in targeting low voltage areas as the substrate for AF ablation; however, the results have been mixed. In order to understand these results, a thorough understanding of voltage mapping techniques, the relationship between low voltage and the pathophysiology of AF, as well as the inherent limitations in voltage measurement are needed. Two key questions must be answered in order to optimally apply voltage mapping as the road map for ablation. First, are the inherent limitations of voltage mapping small enough as to be ignored when targeting specific tissue based on voltage? Second, can conventional criteria, using a binary threshold for voltage amplitude, truly define the extent of the atrial fibrotic substrate? Here, we review the latest clinical evidence with regard to voltage-based ablation procedures before analysing the utility and limitations of voltage mapping. Finally, we discuss omnipole mapping and dynamic voltage attenuation as two possible approaches to resolving these issues.
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Hwang M, Kim J, Lim B, Song JS, Joung B, Shim EB, Pak HN. Multiple factors influence the morphology of the bipolar electrogram: An in silico modeling study. PLoS Comput Biol 2019; 15:e1006765. [PMID: 30951529 PMCID: PMC6469793 DOI: 10.1371/journal.pcbi.1006765] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 04/17/2019] [Accepted: 01/07/2019] [Indexed: 12/04/2022] Open
Abstract
Although bipolar electrograms (Bi-egms) are commonly used for catheter mapping and ablation of cardiac arrhythmias, the accuracy and reproducibility of Bi-egms have not been evaluated. We aimed to clarify the influence of the catheter orientation (CO), catheter contact angle (CA), local conduction velocity (CV), scar size, and catheter type on the Bi-egm morphology using an in silico 3-dimensional realistic model of atrial fibrillation. We constructed a 3-dimensional, realistic, in silico left atrial model with activation wave propagation including bipolar catheter models. Bi-egms were obtained by computing the extracellular potentials from the distal and proximal electrodes. The amplitude and width were measured on virtual Bi-egms obtained under different conditions created by changing the CO according to the wave direction, catheter-atrial wall CA, local CV, size of the non-conductive area, and catheter type. Bipolar voltages were also compared between virtual and clinically acquired Bi-egms. Bi-egm amplitudes were lower for a perpendicular than parallel CO relative to the wave direction (p<0.001), lower for a 90° than 0° CA (p<0.001), and lower for a CV of 0.13m/s than 0.48m/s (p<0.001). Larger sized non-conductive areas were associated with a decreased bipolar amplitude (p<0.001) and increased bipolar width (p<0.001). Among three commercially available catheters (Orion, Pentaray, and Thermocool), those with more narrowly spaced and smaller electrodes produced higher voltages on the virtual Bi-egms (p<0.001). Multiple factors including the CO, CA, CV, and catheter design significantly influence the Bi-egm morphology. Universal voltage cut-off values may not be appropriate for bipolar voltage-guided substrate mapping. Cardiac arrhythmias are rhythm disorders of the heart leading to abnormal heart function. For the diagnosis and treatment of the arrhythmias, clinicians insert catheters into the heart and examine the electrical signal propagation in the heart. Among different type of catheters, bipolar catheters have two electrodes at the tip of the catheter with the signal being the difference between the two electrodes, which provides sharper signal than unipolar catheter. However, bipolar electrogram is dependent on many factors including catheter design and orientation, and consequently, knowledge of the determinants of the bipolar electrogram is needed for proper interpretation of the signal. In this study, we examined the effects of many factors on bipolar electrogram using computer simulation. Computer simulation is very useful in this type of study because, in clinical settings, it is not feasible to control each factor precisely. We quantitatively demonstrated the effects of catheter design and orientation, and cardiac wave propagation speed on bipolar electrogram.
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Affiliation(s)
- Minki Hwang
- Division of Cardiology, Yonsei University Health System, Seoul, Republic of Korea
| | - Jaehyuk Kim
- Division of Cardiology, Yonsei University Health System, Seoul, Republic of Korea
| | - Byounghyun Lim
- Division of Cardiology, Yonsei University Health System, Seoul, Republic of Korea
| | - Jun-Seop Song
- Division of Cardiology, Yonsei University Health System, Seoul, Republic of Korea
| | - Boyoung Joung
- Division of Cardiology, Yonsei University Health System, Seoul, Republic of Korea
| | - Eun Bo Shim
- Department of Mechanical and Biomedical Engineering, Kangwon National University, Chuncheon, Kangwon-do, Republic of Korea
| | - Hui-Nam Pak
- Division of Cardiology, Yonsei University Health System, Seoul, Republic of Korea
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Ahmed‐Jushuf F, Murgatroyd F, Dhillon P, Scott PA. The impact of the presence of left atrial low voltage areas on outcomes from pulmonary vein isolation. J Arrhythm 2019; 35:205-214. [PMID: 31007784 PMCID: PMC6457382 DOI: 10.1002/joa3.12174] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 12/31/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AF ablation (AFA) with pulmonary vein isolation (PVI) is highly successful for paroxysmal atrial fibrillation (PAF). However, success rates for persistent AF (PsAF) are significantly lower. In this study we evaluate the impact of left atrial (LA) low voltage areas (LVA) on response to AFA. METHODS Consecutive patients undergoing first-time radiofrequency AFA were included (n = 160, 53% PAF). PVI was performed followed by LA voltage mapping during sinus rhythm. Patients were categorized as having LVA based on the presence of LVA (0.2-0.5 mV) in the LA assessed visually by the operator intra-procedurally. Further adjunctive LA ablation was performed at the operators' discretion. The end-point was recurrence of any sustained atrial arrhythmia (atrial fibrillation/tachycardia/flutter) during 12 months follow-up. RESULTS All patients had PVI and 23 (14%) had adjunctive LA ablation. LVA were found in 49 (31%) patients and were an independent predictor of arrhythmia recurrence. Patients with LVA compared to those without had significantly lower 12-month arrhythmia-free survival in both PAF (38% vs 76%; P = 0.002) and PsAF (27% vs 61%; P = 0.015). PsAF patients without LVA (93% had PVI alone) had similar arrhythmia-free survival to patients with PAF (61% vs 67%, respectively; P = 0.42). Recurrence in patients with LVA compared to those without was more likely to be an organized atrial arrhythmia rather than AF (16/30 recurrences vs 2/26, P < 0.001). CONCLUSIONS The presence of LVA predicts AFA success as well as the type of arrhythmia recurrence. The absence of LVA identifies PsAF patients that respond well to a PVI-based ablation strategy.
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Affiliation(s)
- Fiyyaz Ahmed‐Jushuf
- Department of CardiologyKing's College Hospital NHS Foundation TrustLondonUK
| | - Francis Murgatroyd
- Department of CardiologyKing's College Hospital NHS Foundation TrustLondonUK
| | - Para Dhillon
- Department of CardiologyKing's College Hospital NHS Foundation TrustLondonUK
| | - Paul A. Scott
- Department of CardiologyKing's College Hospital NHS Foundation TrustLondonUK
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49
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Benito EM, Alarcon F, Mont L. LGE-MRI Characterization of Left Atrial Fibrosis: a Tool to Establish Prognosis and Guide Atrial Fibrillation Ablation. CURRENT CARDIOVASCULAR RISK REPORTS 2019. [DOI: 10.1007/s12170-019-0604-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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50
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Nakatani Y, Sakamoto T, Yamaguchi Y, Tsujino Y, Kataoka N, Kinugawa K. P-wave vector magnitude predicts recurrence of atrial fibrillation after catheter ablation in patients with persistent atrial fibrillation. Ann Noninvasive Electrocardiol 2019; 24:e12646. [PMID: 30896059 DOI: 10.1111/anec.12646] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 01/10/2019] [Accepted: 01/23/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The predictive efficacies of parameters related to P-wave amplitude (PWA) for atrial fibrillation (AF) recurrence after catheter ablation are unclear. METHODS We measured multiple PWA parameters using an automated system in 126 consecutive patients with persistent and long-standing persistent AF who underwent catheter ablation. The relationships between AF recurrence and various PWA parameters were examined, including the association with P-wave vector magnitude (calculated as the square root of the sum of lead II PWA squared, lead V6 PWA squared, and a one-half lead V2 PWA squared). RESULTS Atrial fibrillation did not recur in 87 patients (69%) during 32 ± 15 months of follow-up. The maximum PWA, mean PWA, and P-wave vector magnitude were lower in patients with AF recurrence than those without (maximum PWA, 0.14 ± 0.05 mV vs. 0.16 ± 0.05 mV, p = 0.017; mean PWA, 0.05 ± 0.02 mV vs. 0.06 ± 0.02 mV, p = 0.003; P-wave vector magnitude, 0.09 ± 0.03 mV vs. 0.13 ± 0.04 mV, p < 0.001). A multivariate Cox regression analysis revealed that the predictive ability of P-wave vector magnitude for AF recurrence was independent of other clinical properties (hazard ratio: 0.153, 95% confidence interval: 0.046-0.507, p = 0.002). Atrial fibrillation freedom rates of patients with P-wave vector magnitude higher and lower than 0.13 mV were 93% and 57%, respectively. P-wave vector magnitude weakly correlated with left atrial dimension (R = -0.280, p = 0.004). CONCLUSIONS P-wave vector magnitude can predict AF recurrence after catheter ablation in patients with persistent AF.
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Affiliation(s)
- Yosuke Nakatani
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Tamotsu Sakamoto
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Yoshiaki Yamaguchi
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Yasushi Tsujino
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Naoya Kataoka
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Koichiro Kinugawa
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
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