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Yorgun H, Coteli C, Kılıç GS, Aytemir K. Functional substrate mapping of atrium in patients with atrial scar: A novel method to predict critical isthmus of atrial tachycardia. Pacing Clin Electrophysiol 2024; 47:653-660. [PMID: 38583088 DOI: 10.1111/pace.14981] [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: 12/26/2023] [Revised: 03/04/2024] [Accepted: 03/22/2024] [Indexed: 04/08/2024]
Abstract
Atrial tachycardia (AT) is a common rhythm disorder, especially in patients with atrial structural abnormalities. Although voltage mapping can provide a general picture of structural alterations which are mainly secondary to prior ablations, surgery or pressure/volume overload, data is scarce regarding the functional characteristics of low voltage regions in the atrium to predict critical isthmus of ATs. Recently, functional substrate mapping (FSM) emerged as a potential tool to evaluate the functionality of structurally altered regions in the atrium to predict critical sites of reentry. Current evidence suggested a clear association between deceleration zones of isochronal late activation mapping (ILAM) during sinus/paced rhythm and critical isthmus of reentry in patients with left AT. Therefore, these areas seem to be potential ablation targets even not detected during AT. Furthermore, abnormal conduction detected by ILAM may also have a role to identify the potential substrate and predict atrial fibrillation outcome after pulmonary vein isolation. Despite these promising findings, the utility of such an approach needs to be evaluated in large-scale comparative studies. In this review, we aimed to share our experience and review the current literature regarding the use of FSM during sinus/paced rhythm in the prediction of re-entrant ATs and discuss future implications and potential use in patients with atrial low-voltage areas.
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Affiliation(s)
- Hikmet Yorgun
- Faculty of Medicine, Department of Cardiology, Hacettepe University, Ankara, Turkey
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Cem Coteli
- Faculty of Medicine, Department of Cardiology, Hacettepe University, Ankara, Turkey
| | - Gül Sinem Kılıç
- Faculty of Medicine, Department of Cardiology, Hacettepe University, Ankara, Turkey
| | - Kudret Aytemir
- Faculty of Medicine, Department of Cardiology, Hacettepe University, Ankara, Turkey
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2
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Flanders WH, Moïse NS, Otani NF. Use of machine learning and Poincaré density grid in the diagnosis of sinus node dysfunction caused by sinoatrial conduction block in dogs. J Vet Intern Med 2024; 38:1305-1324. [PMID: 38682817 PMCID: PMC11099791 DOI: 10.1111/jvim.17071] [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: 10/12/2023] [Accepted: 03/27/2024] [Indexed: 05/01/2024] Open
Abstract
BACKGROUND Sinus node dysfunction because of abnormal impulse generation or sinoatrial conduction block causes bradycardia that can be difficult to differentiate from high parasympathetic/low sympathetic modulation (HP/LSM). HYPOTHESIS Beat-to-beat relationships of sinus node dysfunction are quantifiably distinguishable by Poincaré plots, machine learning, and 3-dimensional density grid analysis. Moreover, computer modeling establishes sinoatrial conduction block as a mechanism. ANIMALS Three groups of dogs were studied with a diagnosis of: (1) balanced autonomic modulation (n = 26), (2) HP/LSM (n = 26), and (3) sinus node dysfunction (n = 21). METHODS Heart rate parameters and Poincaré plot data were determined [median (25%-75%)]. Recordings were randomly assigned to training or testing. Supervised machine learning of the training data was evaluated with the testing data. The computer model included impulse rate, exit block probability, and HP/LSM. RESULTS Confusion matrices illustrated the effectiveness in diagnosing by both machine learning and Poincaré density grid. Sinus pauses >2 s differentiated (P < .0001) HP/LSM (2340; 583-3947 s) from sinus node dysfunction (8503; 7078-10 050 s), but average heart rate did not. The shortest linear intervals were longer with sinus node dysfunction (315; 278-323 ms) vs HP/LSM (260; 251-292 ms; P = .008), but the longest linear intervals were shorter with sinus node dysfunction (620; 565-698 ms) vs HP/LSM (843; 799-888 ms; P < .0001). CONCLUSIONS Number and duration of pauses, not heart rate, differentiated sinus node dysfunction from HP/LSM. Machine learning and Poincaré density grid can accurately identify sinus node dysfunction. Computer modeling supports sinoatrial conduction block as a mechanism of sinus node dysfunction.
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Affiliation(s)
- Wyatt Hutson Flanders
- Department of Clinical Sciences, College of Veterinary MedicineCornell UniversityIthacaNew YorkUSA
| | - N. Sydney Moïse
- Section of Cardiology, Department of Clinical Sciences, College of Veterinary MedicineCornell UniversityIthacaNew YorkUSA
| | - Niels F. Otani
- School of Mathematical SciencesRochester Institute of TechnologyRochesterNew YorkUSA
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Yamashita S, Oseto H, Morita T, Tokutake K, Yoshimura M, Yamane T. A rare case of modified superior vena cava isolation by using the ultra-high-resolution mapping system. Pacing Clin Electrophysiol 2024; 47:437-439. [PMID: 37260106 DOI: 10.1111/pace.14748] [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: 01/05/2023] [Revised: 04/11/2023] [Accepted: 05/18/2023] [Indexed: 06/02/2023]
Abstract
We report a case of atrial fibrillation (AF) recurrence after pulmonary vein isolation, which patient had AF trigger in the superior vena cava (SVC) near the sinus node (SN). The ultra-high-resolution mapping revealed that SN located within the SVC and the atrial activation from the SN to SVC propagated in both septal and lateral direction, then upward with circumventing the spontaneous conduction block identified just above and lateral SN (upper hemisphere). We successfully isolated SVC including the ectopic origin at the same level as the SN by utilizing the spontaneous conduction block line around the SN without any complication.
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Affiliation(s)
- Seigo Yamashita
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Hirotsuna Oseto
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Tetsuro Morita
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Kenichi Tokutake
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Michihiro Yoshimura
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Teiichi Yamane
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
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Cronin EM, Vedage N, Israel CW. Alternative atrial pacing site to improve cardiac function: focus on Bachmann's bundle pacing. Eur Heart J Suppl 2023; 25:G44-G55. [PMID: 37970517 PMCID: PMC10637835 DOI: 10.1093/eurheartjsupp/suad118] [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] [Indexed: 11/17/2023]
Abstract
Pacing from the right atrial appendage (RAA) prolongs the P wave duration and can induce interatrial and especially left-sided atrio-ventricular dyssynchrony. Pacing from Bachmann's bundle closely reproduces normal physiology and has the potential to avoid the electromechanical dysfunction associated with conventional RAA pacing. Interatrial conduction delay is associated with an increased risk of stroke, heart failure, and death. In addition to a reduction in atrial fibrillation, Bachmann's bundle pacing has emerging applications as a hemodynamic pacing modality. This review outlines the pathophysiology of atrial conduction disturbances and their potential remedies and provides the reader with a practical guide to implementing Bachmann's bundle pacing with an emphasis on the recapitulation of normal electrical and mechanical function.
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Affiliation(s)
- Edmond M Cronin
- Section of Cardiology, Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, USA
| | - Natasha Vedage
- Section of Cardiology, Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, USA
| | - Carsten W Israel
- Department of Medicine—Cardiology, Diabetology, and Nephrology, Bethel-Clinic, Bielefeld, Germany
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Nakatani Y, Takigawa M, Ramirez FD, Nakashima T, André C, Goujeau C, Carapezzi A, Anzai T, Krisai P, Takagi T, Kamakura T, Konstantinos V, Cheniti G, Tixier R, Welte N, Chauvel R, Duchateau J, Pambrun T, Derval N, Sacher F, Hocini M, Haïssaguerre M, Jaïs P. Electrophysiologic Determinants of Isoelectric Intervals on Surface Electrocardiograms During Atrial Tachycardia: Insights From High-Density Mapping. JACC Clin Electrophysiol 2023; 9:2054-2066. [PMID: 37715740 DOI: 10.1016/j.jacep.2023.06.018] [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: 01/03/2023] [Revised: 06/14/2023] [Accepted: 06/25/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND Substrate abnormalities can alter atrial activation during atrial tachycardias (ATs) thereby influencing AT-wave morphology on the surface electrocardiogram. OBJECTIVES This study sought to identify determinants of isoelectric intervals during ATs with complex atrial activation patterns. METHODS High-density activation maps of 126 ATs were studied. To assess the impact of the activated atrial surface on the presence of isoelectric intervals, this study measured the minimum activated area throughout the AT cycle, defined as the smallest activated area within a 50-millisecond period, by using signal processing algorithms (LUMIPOINT). RESULTS ATs with isoelectric intervals (P-wave ATs) included 23 macro-re-entrant ATs (40%), 26 localized-re-entrant ATs (46%), and 8 focal ATs (14%), whereas those without included 46 macro-re-entrant ATs (67%), 21 localized-re-entrant ATs (30%), and 2 focal ATs (3%). Multivariable regression identified smaller minimum activated area and larger very low voltage area as independent predictors of P-wave ATs (OR: 0.732; 95% CI: 0.644-0.831; P < 0.001; and OR: 1.042; 95% CI: 1.006-1.080; P = 0.023, respectively). The minimum activated area with the cutoff value of 10 cm2 provided the highest predictive accuracy for P-wave ATs with sensitivity, specificity, and positive and negative predictive values of 96%, 97%, 97%, and 95%, respectively. In re-entrant ATs, smaller minimum activated area was associated with lower minimum conduction velocity within the circuit and fewer areas of delayed conduction outside of the circuit (standardized β: 0.524; 95% CI: 0.373-0.675; P < 0.001; and standardized β: 0.353; 95% CI: 0.198-0.508; P < 0.001, respectively). CONCLUSIONS Reduced atrial activation area and voltage were associated with isoelectric intervals during ATs.
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Affiliation(s)
- Yosuke Nakatani
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Masateru Takigawa
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France.
| | - F Daniel Ramirez
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France; Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Takashi Nakashima
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Clémentine André
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Cyril Goujeau
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | | | - Tatsuhiko Anzai
- Department of Biostatistics, M and D Data Science Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Philipp Krisai
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Takamitsu Takagi
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Tsukasa Kamakura
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Vlachos Konstantinos
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Ghassen Cheniti
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Romain Tixier
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Nicolas Welte
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Remi Chauvel
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Josselin Duchateau
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Thomas Pambrun
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Nicolas Derval
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Frédéric Sacher
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Meleze Hocini
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Michel Haïssaguerre
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Pierre Jaïs
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
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Moore BM, Al-Kaisy A, Joshi SB, Lui E, Grigg LE, Kalman JM. Noninvasive ECG imaging of the intrinsic atrial pacemaker and atrial activation in surgically repaired or palliated congenital heart disease. J Cardiovasc Electrophysiol 2023; 34:1859-1868. [PMID: 37526234 DOI: 10.1111/jce.16027] [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: 04/15/2023] [Revised: 07/19/2023] [Accepted: 07/22/2023] [Indexed: 08/02/2023]
Abstract
INTRODUCTION Sinus node location, function, and atrial activation are often abnormal in patients with congenital heart disease (CHD), due to anatomical, surgical, and acquired factors. We aimed to perform noninvasive electrocardiographic imaging (ECGI) of the intrinsic atrial pacemaker and atrial activation in patients with surgically repaired or palliated CHD, compared with control patients with structurally normal hearts. METHODS AND RESULTS Atrial ECGI was performed in eight CHD patients with prespecified diagnoses (Fontan circulation, dextro transposition of the great arteries post Mustard/Senning, tetralogy of Fallot), and three controls. Activation and propagation maps were constructed in presenting rhythm. Wavefront propagation was analyzed to identify (1) intrinsic atrial pacemaker breakout site, (2) morphological right atrial (RA) activation pattern, (3) morphological left atrial (LA) breakout sites (i.e., interatrial connections), (4) LA activation pattern, and (5) putative lines of block. Physiologically appropriate atrial activation and propagation maps were able to be constructed. In the majority of patients, atrial breakouts were in keeping with the sinus node, observed in a crescent-shaped distribution from the anterior superior vena cava to the posterior RA. Ectopic atrial pacemaker sites were demonstrated in the atriopulmonary (AP) Fontan patient (very diffuse posterolateral RA) and Mustard patient (very posterior RA competing with a low RA focus). RA propagation was laminar in controls, but suggested either a line of block or conduction slowing consistent with an atriotomy scar in the tetralogy of Fallot (TOF) patients. Putative lines of block were more complex and RA propagation more abnormal in the atrial switch and AP Fontan patients, compared with the TOF patients. RA activation in the extracardiac Fontan patients was relatively laminar. Earliest LA breakout was most commonly observed in the region of Bachmann's Bundle in both controls and CHD patients, except for posterior LA breakouts in two patients. LA activation was typically more homogeneous than RA activation in CHD patients. CONCLUSION ECGI can be utilized to create a noninvasive mapping model of atrial activation in postsurgical CHD, demonstrating atrial pacemaker location, putative lines of block and interatrial connections. Once validated invasively, this may have clinical implications in predicting risk of sinus node dysfunction and atrial arrhythmias, or in guiding catheter ablation.
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Affiliation(s)
- Benjamin M Moore
- Department of Cardiology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Ahmed Al-Kaisy
- Department of Cardiology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Subodh B Joshi
- Department of Cardiology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Elaine Lui
- Department of Medical Imaging, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Radiology, University of Melbourne, Melbourne, Victoria, Australia
| | - Leanne E Grigg
- Department of Cardiology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Jonathan M Kalman
- Department of Cardiology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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Lai Y, Ge W, Sang C, Macle L, Tang R, Long D, Dong J, Ma C. Epicardial connections and bi-atrial tachycardias: From anatomy to clinical practice. Pacing Clin Electrophysiol 2023; 46:895-903. [PMID: 37433176 DOI: 10.1111/pace.14778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/14/2023] [Accepted: 06/24/2023] [Indexed: 07/13/2023]
Abstract
Bi-atrial tachycardia (BiAT) is not rare after extensive atrial ablation or cardiac surgery. The complexity of bi-atrial reentrant circuits poses a great challenge for clinical practice. With recent advances in mapping technologies, we are now able to characterize atrial activation in detail. However, given the involvement of both atria and multiple epicardial conductions, endocardial mapping for BiATs is not easy to understand. Knowledge of the atrial myocardial architecture is the foundation for the clinical management of BiATs; as it is required to understand the possible mechanism of the tachycardia and identify the optimal target of ablation. In this review we summarize current knowledge about the anatomy of interatrial connections as well as other epicardial fibers and discuss the interpretation of electrophysiological findings and ablation strategies for BiATs.
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Affiliation(s)
- Yiwei Lai
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Canada
| | - Weili Ge
- Department of Cardiology, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Zhejiang, China
| | - Caihua Sang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Laurent Macle
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Canada
| | - Ribo Tang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Deyong Long
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Jianzeng Dong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
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8
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Bergonti M, Spera FR, Ferrero TG, Nsahlai M, Bonomi A, Boris W, Saenen J, Huybrechts W, Miljoen H, Vandaele L, Wittock A, Heidbuchel H, Valderrábano M, Rodríguez-Mañero M, Sarkozy A. Anterior mitral line in patients with persistent atrial fibrillation and anterior scar: A multicenter matched comparison-The MiLine study. Heart Rhythm 2023; 20:658-665. [PMID: 36640853 DOI: 10.1016/j.hrthm.2023.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/21/2022] [Accepted: 01/06/2023] [Indexed: 01/13/2023]
Abstract
BACKGROUND The benefit of an anterior mitral line (AML) in patients with persistent atrial fibrillation (AF) and anterior atrial scar undergoing ablation has never been investigated. OBJECTIVE The purpose of this study was to evaluate the outcomes of AML in addition to standard treatment compared to standard treatment alone (no AML) in this subset of patients. METHODS Patients with persistent AF and anterior low-voltage zone (LVZ) treated with AML in 3 centers were retrospectively enrolled. The patients were matched in 1:1 fashion with patients having persistent AF and anterior LVZ who underwent conventional ablation in the same centers. Matching parameters were age, LVZ burden, and repeated ablation. Primary endpoint was AF/atrial tachycardia (AT) recurrence. RESULTS One hundred eight-six patients (age 66 ± 9 years; 34% women) were selected and divided into 2 matched groups. Bidirectional conduction block was achieved in 95% of AML. After median follow-up of 2 years, AF/AT recurrence occurred in 29% of the patients in the AML group vs 48% in the no AML group (log-rank P = .024). On Cox regression multivariate analysis, left atrial volume (hazard ratio [HR] 1.03; P = .006) and AML (HR 0.46; P = .003) were significantly associated with the primary endpoint. On univariate logistic regression, lower body mass index, older age, extensive anterior LVZ, and position of the left atrial activation breakthrough away from the AML were associated with first-pass AML block. CONCLUSION In this retrospective matched analysis of patients with persistent AF and anterior scar, AML in addition to standard treatment was associated with improved AF/AT-free survival compared to standard treatment alone.
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Affiliation(s)
- Marco Bergonti
- Department of Cardiology, University Hospital Antwerp, Antwerp, Belgium.
| | | | - Teba Gonzalez Ferrero
- Complexo Hospitalario Universitario de Santiago de Compostela (CHUS) SERGAS, Santiago de Compostela, Spain
| | - Michelle Nsahlai
- Department of Cardiology, DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Alice Bonomi
- Department of Clinical Science and Community Health, University of Milan at Centro Cardiologico Monzino, Milano, Italy
| | - Wim Boris
- Department of Cardiology, University Hospital Antwerp, Antwerp, Belgium
| | - Johan Saenen
- Department of Cardiology, University Hospital Antwerp, Antwerp, Belgium
| | - Wim Huybrechts
- Department of Cardiology, University Hospital Antwerp, Antwerp, Belgium
| | - Hielko Miljoen
- Department of Cardiology, University Hospital Antwerp, Antwerp, Belgium
| | - Lien Vandaele
- Department of Cardiology, University Hospital Antwerp, Antwerp, Belgium
| | - Anouk Wittock
- Department of Anesthesiology, University Hospital Antwerp, Antwerp, Belgium
| | - Hein Heidbuchel
- Department of Cardiology, University Hospital Antwerp, Antwerp, Belgium; Department GENCOR, University of Antwerp, Antwerp, Belgium
| | - Miguel Valderrábano
- Department of Cardiology, DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Moises Rodríguez-Mañero
- Complexo Hospitalario Universitario de Santiago de Compostela (CHUS) SERGAS, Santiago de Compostela, Spain
| | - Andrea Sarkozy
- Department of Cardiology, University Hospital Antwerp, Antwerp, Belgium; Department GENCOR, University of Antwerp, Antwerp, Belgium
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Takagi T, Derval N, Duchateau J, Chauvel R, Tixier R, Marchand H, Bouyer B, André C, Kamakura T, Krisai P, Ascione C, Balbo C, Cheniti G, Denis A, Sacher F, Hocini M, Jaïs P, Haïssaguerre M, Pambrun T. Gaps after linear ablation of persistent atrial fibrillation (Marshall-PLAN): Clinical implication. Heart Rhythm 2023; 20:14-21. [PMID: 36115541 DOI: 10.1016/j.hrthm.2022.09.009] [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: 07/31/2022] [Revised: 08/30/2022] [Accepted: 09/09/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Beyond pulmonary vein (PV) isolation, anatomic isthmus transection is an adjunctive strategy for persistent atrial fibrillation. Data on the durability of multiple lines of block remain scarce. OBJECTIVE The purpose of this study was to evaluate the impact of gaps within such a lesion set. METHODS We followed 291 consecutive patients who underwent (1) vein of Marshall ethanol infusion, (2) PV isolation, and (3) mitral, cavotricuspid, and dome isthmus transection. Dome transection relied on 2 distinct strategies over time: a single roof line with touch-ups applied in case of gap demonstrated by conventional maneuvers (first leg), and an alternative floor line if the roof line exhibited a gap during high-density mapping with careful electrogram reannotation (second leg). RESULTS Twelve-month sinus rhythm maintenance was 70% after 1 procedure and 94% after 1 or 2 procedures. Event-free survival after the first procedure was lower in case of residual gaps within the lesion set (log-rank, P = .004). Delayed gaps were found in 94% of a second procedure performed in the 69 patients relapsing despite a complete lesion set with PV gaps increasing the risk of recurrence of atrial fibrillation (67% vs 34%; P = .02) and anatomic isthmus gaps supporting a majority of atrial tachycardias (60%). Between the first leg and the second leg, a significant decrease was found in roof lines considered blocked during the first procedure (99% vs 78%; P < .001) and in delayed dome gaps observed during a second procedure (68% vs 43%; P = .05). CONCLUSION Gaps are arrhythmogenic and can be reduced by optimized ablation and assessment of lines of block. Closing these gaps improves sinus rhythm maintenance.
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Affiliation(s)
- Takamitsu Takagi
- Hôpital Cardiologique Haut-Lévêque, CHU de Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université de Bordeaux, Bordeaux-Pessac, France.
| | - Nicolas Derval
- Hôpital Cardiologique Haut-Lévêque, CHU de Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université de Bordeaux, Bordeaux-Pessac, France
| | - Josselin Duchateau
- Hôpital Cardiologique Haut-Lévêque, CHU de Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université de Bordeaux, Bordeaux-Pessac, France
| | - Rémi Chauvel
- Hôpital Cardiologique Haut-Lévêque, CHU de Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université de Bordeaux, Bordeaux-Pessac, France
| | - Romain Tixier
- Hôpital Cardiologique Haut-Lévêque, CHU de Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université de Bordeaux, Bordeaux-Pessac, France
| | - Hugo Marchand
- Hôpital Cardiologique Haut-Lévêque, CHU de Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université de Bordeaux, Bordeaux-Pessac, France
| | - Benjamin Bouyer
- Hôpital Cardiologique Haut-Lévêque, CHU de Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université de Bordeaux, Bordeaux-Pessac, France
| | - Clémentine André
- Hôpital Cardiologique Haut-Lévêque, CHU de Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université de Bordeaux, Bordeaux-Pessac, France
| | - Tsukasa Kamakura
- Hôpital Cardiologique Haut-Lévêque, CHU de Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université de Bordeaux, Bordeaux-Pessac, France
| | - Philipp Krisai
- Hôpital Cardiologique Haut-Lévêque, CHU de Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université de Bordeaux, Bordeaux-Pessac, France
| | - Ciro Ascione
- Hôpital Cardiologique Haut-Lévêque, CHU de Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université de Bordeaux, Bordeaux-Pessac, France
| | - Conrado Balbo
- Hôpital Cardiologique Haut-Lévêque, CHU de Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université de Bordeaux, Bordeaux-Pessac, France
| | - Ghassen Cheniti
- Hôpital Cardiologique Haut-Lévêque, CHU de Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université de Bordeaux, Bordeaux-Pessac, France
| | - Arnaud Denis
- Hôpital Cardiologique Haut-Lévêque, CHU de Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université de Bordeaux, Bordeaux-Pessac, France
| | - Frédéric Sacher
- Hôpital Cardiologique Haut-Lévêque, CHU de Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université de Bordeaux, Bordeaux-Pessac, France
| | - Mélèze Hocini
- Hôpital Cardiologique Haut-Lévêque, CHU de Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université de Bordeaux, Bordeaux-Pessac, France
| | - Pierre Jaïs
- Hôpital Cardiologique Haut-Lévêque, CHU de Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université de Bordeaux, Bordeaux-Pessac, France
| | - Michel Haïssaguerre
- Hôpital Cardiologique Haut-Lévêque, CHU de Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université de Bordeaux, Bordeaux-Pessac, France
| | - Thomas Pambrun
- Hôpital Cardiologique Haut-Lévêque, CHU de Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université de Bordeaux, Bordeaux-Pessac, France
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Kalyanasundaram A, Li N, Augostini RS, Weiss R, Hummel JD, Fedorov VV. Three-dimensional functional anatomy of the human sinoatrial node for epicardial and endocardial mapping and ablation. Heart Rhythm 2023; 20:122-133. [PMID: 36113768 PMCID: PMC9897959 DOI: 10.1016/j.hrthm.2022.08.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/25/2022] [Accepted: 08/30/2022] [Indexed: 02/05/2023]
Abstract
The sinoatrial node (SAN) is the primary pacemaker of the human heart. It is a single, elongated, 3-dimensional (3D) intramural fibrotic structure located at the junction of the superior vena cava intercaval region bordering the crista terminalis (CT). SAN activation originates in the intranodal pacemakers and is conducted to the atria through 1 or more discrete sinoatrial conduction pathways. The complexity of the 3D SAN pacemaker structure and intramural conduction are underappreciated during clinical multielectrode mapping and ablation procedures of SAN and atrial arrhythmias. In fact, defining and targeting SAN is extremely challenging because, even during sinus rhythm, surface-only multielectrode mapping may not define the leading pacemaker sites in intramural SAN but instead misinterpret them as epicardial or endocardial exit sites through sinoatrial conduction pathways. These SAN exit sites may be distributed up to 50 mm along the CT beyond the ∼20-mm-long anatomic SAN structure. Moreover, because SAN reentrant tachycardia beats may exit through the same sinoatrial conduction pathway as during sinus rhythm, many SAN arrhythmias are underdiagnosed. Misinterpretation of arrhythmia sources and/or mechanisms (eg, enhanced automaticity, intranodal vs CT reentry) limits diagnosis and success of catheter ablation treatments for poorly understood SAN arrhythmias. The aim of this review is to provide a state-of-the-art overview of the 3D structure and function of the human SAN complex, mechanisms of SAN arrhythmias and available approaches for electrophysiological mapping, 3D structural imaging, pharmacologic interventions, and ablation to improve diagnosis and mechanistic treatment of SAN and atrial arrhythmias.
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Affiliation(s)
- Anuradha Kalyanasundaram
- Department of Physiology & Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio; Bob and Corrine Frick Center for Heart Failure and Arrhythmia, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ning Li
- Department of Physiology & Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio; Bob and Corrine Frick Center for Heart Failure and Arrhythmia, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ralph S Augostini
- Bob and Corrine Frick Center for Heart Failure and Arrhythmia, The Ohio State University Wexner Medical Center, Columbus, Ohio; Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Raul Weiss
- Bob and Corrine Frick Center for Heart Failure and Arrhythmia, The Ohio State University Wexner Medical Center, Columbus, Ohio; Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - John D Hummel
- Bob and Corrine Frick Center for Heart Failure and Arrhythmia, The Ohio State University Wexner Medical Center, Columbus, Ohio; Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Vadim V Fedorov
- Department of Physiology & Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio; Bob and Corrine Frick Center for Heart Failure and Arrhythmia, The Ohio State University Wexner Medical Center, Columbus, Ohio.
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11
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Amsaleg A, Sánchez J, Mikut R, Loewe A. Characterization of the pace-and-drive capacity of the human sinoatrial node: A 3D in silico study. Biophys J 2022; 121:4247-4259. [PMID: 36262044 PMCID: PMC9703096 DOI: 10.1016/j.bpj.2022.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 09/20/2022] [Accepted: 10/13/2022] [Indexed: 12/14/2022] Open
Abstract
The sinoatrial node (SAN) is a complex structure that spontaneously depolarizes rhythmically ("pacing") and excites the surrounding non-automatic cardiac cells ("drive") to initiate each heart beat. However, the mechanisms by which the SAN cells can activate the large and hyperpolarized surrounding cardiac tissue are incompletely understood. Experimental studies demonstrated the presence of an insulating border that separates the SAN from the hyperpolarizing influence of the surrounding myocardium, except at a discrete number of sinoatrial exit pathways (SEPs). We propose a highly detailed 3D model of the human SAN, including 3D SEPs to study the requirements for successful electrical activation of the primary pacemaking structure of the human heart. A total of 788 simulations investigate the ability of the SAN to pace and drive with different heterogeneous characteristics of the nodal tissue (gradient and mosaic models) and myocyte orientation. A sigmoidal distribution of the tissue conductivity combined with a mosaic model of SAN and atrial cells in the SEP was able to drive the right atrium (RA) at varying rates induced by gradual If block. Additionally, we investigated the influence of the SEPs by varying their number, length, and width. SEPs created a transition zone of transmembrane voltage and ionic currents to enable successful pace and drive. Unsuccessful simulations showed a hyperpolarized transmembrane voltage (-66 mV), which blocked the L-type channels and attenuated the sodium-calcium exchanger. The fiber direction influenced the SEPs that preferentially activated the crista terminalis (CT). The location of the leading pacemaker site (LPS) shifted toward the SEP-free areas. LPSs were located closer to the SEP-free areas (3.46 ± 1.42 mm), where the hyperpolarizing influence of the CT was reduced, compared with a larger distance from the LPS to the areas where SEPs were located (7.17± 0.98 mm). This study identified the geometrical and electrophysiological aspects of the 3D SAN-SEP-CT structure required for successful pace and drive in silico.
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Affiliation(s)
- Antoine Amsaleg
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany
| | - Jorge Sánchez
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany
| | - Ralf Mikut
- Institute for Automation and Applied Informatics, Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany
| | - Axel Loewe
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany.
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