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Yamaguchi T. Atrial structural remodeling and atrial fibrillation substrate: A histopathological perspective. J Cardiol 2024:S0914-5087(24)00096-0. [PMID: 38810728 DOI: 10.1016/j.jjcc.2024.05.007] [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: 04/10/2024] [Revised: 05/16/2024] [Accepted: 05/21/2024] [Indexed: 05/31/2024]
Abstract
Atrial fibrillation (AF) substrate progresses with the advancement of atrial structural remodeling, resulting in AF perpetuation and recurrence. Although fibrosis is considered a hallmark of atrial structural remodeling, the histological background has not been fully elucidated because obtaining atrial specimens is difficult, especially in patients not undergoing open-heart surgery. Bipolar voltage reduction evaluated using electroanatomic mapping during AF ablation is considered a surrogate marker for the progression of structural remodeling; however, histological validation is lacking. We developed an intracardiac echocardiography-guided endomyocardial atrial biopsy technique to evaluate atrial structural remodeling in patients undergoing catheter ablation for nonvalvular AF. The histological factors associated with a decrease in bipolar voltage were interstitial fibrosis, as well as an increase in myocardial intercellular space preceding fibrosis, myofibrillar loss, and a decrease in cardiomyocyte nuclear density, which is a surrogate marker for cardiomyocyte density. Cardiomyocyte hypertrophy is closely associated with a decrease in cardiomyocyte nuclear density, suggesting that hypertrophic changes compensate for cardiomyocyte loss. Electron microscopy also revealed that increased intercellular spaces indicated the leakage of plasma components owing to increased vascular permeability. Additionally, amyloid deposition was observed in 4 % of biopsy cases. Only increased intercellular space and interstitial fibrosis were significantly higher for long-standing persistent AF than for paroxysmal AF and associated with recurrence after AF ablation, suggesting that this interstitial remodeling is the AF substrate. An increase in intercellular space that occurs early in AF formation is a therapeutic target for the AF substrate, which prevents irreversible interstitial degeneration due to collagen accumulation. This endomyocardial atrial biopsy technique will allow the collection of atrial tissue from a wide variety of patients and significantly facilitate the elucidation of the mechanisms of atrial cardiomyopathy, structural remodeling, and AF substrates.
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De Coster T, Teplenin AS, Feola I, Bart CI, Ramkisoensing AA, den Ouden BL, Ypey DL, Trines SA, Panfilov AV, Zeppenfeld K, de Vries AAF, Pijnappels DA. 'Trapped re-entry' as source of acute focal atrial arrhythmias. Cardiovasc Res 2024; 120:249-261. [PMID: 38048392 PMCID: PMC10939464 DOI: 10.1093/cvr/cvad179] [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: 10/03/2022] [Revised: 08/21/2023] [Accepted: 10/07/2023] [Indexed: 12/06/2023] Open
Abstract
AIMS Diseased atria are characterized by functional and structural heterogeneities, adding to abnormal impulse generation and propagation. These heterogeneities are thought to lie at the origin of fractionated electrograms recorded during sinus rhythm (SR) in atrial fibrillation (AF) patients and are assumed to be involved in the onset and perpetuation (e.g. by re-entry) of this disorder. The underlying mechanisms, however, remain incompletely understood. Here, we tested whether regions of dense fibrosis could create an electrically isolated conduction pathway (EICP) in which re-entry could be established via ectopy and local block to become 'trapped'. We also investigated whether this could generate local fractionated electrograms and whether the re-entrant wave could 'escape' and cause a global tachyarrhythmia due to dynamic changes at a connecting isthmus. METHODS AND RESULTS To precisely control and explore the geometrical properties of EICPs, we used light-gated depolarizing ion channels and patterned illumination for creating specific non-conducting regions in silico and in vitro. Insight from these studies was used for complementary investigations in virtual human atria with localized fibrosis. We demonstrated that a re-entrant tachyarrhythmia can exist locally within an EICP with SR prevailing in the surrounding tissue and identified conditions under which re-entry could escape from the EICP, thereby converting a local latent arrhythmic source into an active driver with global impact on the heart. In a realistic three-dimensional model of human atria, unipolar epicardial pseudo-electrograms showed fractionation at the site of 'trapped re-entry' in coexistence with regular SR electrograms elsewhere in the atria. Upon escape of the re-entrant wave, acute arrhythmia onset was observed. CONCLUSIONS Trapped re-entry as a latent source of arrhythmogenesis can explain the sudden onset of focal arrhythmias, which are able to transgress into AF. Our study might help to improve the effectiveness of ablation of aberrant cardiac electrical signals in clinical practice.
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Affiliation(s)
- Tim De Coster
- Laboratory of Experimental Cardiology, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, PO 9600, 2333 ZA Leiden, The Netherlands
| | - Alexander S Teplenin
- Laboratory of Experimental Cardiology, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, PO 9600, 2333 ZA Leiden, The Netherlands
| | - Iolanda Feola
- Laboratory of Experimental Cardiology, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, PO 9600, 2333 ZA Leiden, The Netherlands
| | - Cindy I Bart
- Laboratory of Experimental Cardiology, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, PO 9600, 2333 ZA Leiden, The Netherlands
| | - Arti A Ramkisoensing
- Laboratory of Experimental Cardiology, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, PO 9600, 2333 ZA Leiden, The Netherlands
| | - Bram L den Ouden
- Laboratory of Experimental Cardiology, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, PO 9600, 2333 ZA Leiden, The Netherlands
| | - Dirk L Ypey
- Laboratory of Experimental Cardiology, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, PO 9600, 2333 ZA Leiden, The Netherlands
| | - Serge A Trines
- Laboratory of Experimental Cardiology, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, PO 9600, 2333 ZA Leiden, The Netherlands
| | - Alexander V Panfilov
- Laboratory of Experimental Cardiology, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, PO 9600, 2333 ZA Leiden, The Netherlands
- Department of Physics and Astronomy, Ghent University, 9000 Ghent, Belgium
- Biomed Laboratory, Ural Federal University, 620002 Ekaterinburg, Russia
- World-Class Research Center ‘Digital Biodesign and Personalized Healthcare’, I. M. Sechenov First Moscow State Medical University, 119146 Moscow, Russia
| | - Katja Zeppenfeld
- Laboratory of Experimental Cardiology, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, PO 9600, 2333 ZA Leiden, The Netherlands
| | - Antoine A F de Vries
- Laboratory of Experimental Cardiology, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, PO 9600, 2333 ZA Leiden, The Netherlands
| | - Daniël A Pijnappels
- Laboratory of Experimental Cardiology, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, PO 9600, 2333 ZA Leiden, The Netherlands
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Saguner AM, Lunk D, Mohsen M, Knecht S, Akdis D, Costa S, Gasperetti A, Duru F, Rossi VA, Brunckhorst CB. Electroanatomical voltage mapping with contact force sensing for diagnosis of arrhythmogenic right ventricular cardiomyopathy. Int J Cardiol 2023; 392:131289. [PMID: 37619879 DOI: 10.1016/j.ijcard.2023.131289] [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: 04/21/2023] [Revised: 08/17/2023] [Accepted: 08/20/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Three-dimensional electroanatomical mapping (EAM) can be helpful to diagnose arrhythmogenic right ventricular cardiomyopathy (ARVC). Yet, previous studies utilizing EAM have not systematically used contact-force sensing catheters (CFSC) to characterize the substrate in ARVC, which is the current gold standard to assure adequate tissue contact. OBJECTIVE To investigate reference values for endocardial right ventricular (RV) EAM as well as substrate characterization in patients with ARVC by using CFSC. METHODS Endocardial RV EAM during sinus rhythm was performed with CFSC in 12 patients with definite ARVC and 5 matched controls without structural heart disease. A subanalysis for the RV outflow tract (RVOT), septum, free-wall, subtricuspid region, and apex was performed. Endocardial bipolar and unipolar voltage amplitudes (BVA, UVA), signal characteristics and duration as well as the impact of catheter orientation on endocardial signals were also investigated. RESULTS ARVC patients showed lower BVA vs. controls (p = 0.018), particularly in the subtricuspid region (1.4, IQR:0.5-3.1 vs. 3.8, IQR:2.5-5 mV, p = 0.037) and RV apex (2.5, IQR:1.5-4 vs. 4.3,IQR:2.9-6.1 mV, p = 0.019). BVA in all RV regions yielded a high sensitivity and specificity for ARVC diagnosis (AUC 59-78%, p < 0.05 for all), with the highest performance for the subtricuspid region (AUC 78%, 95% CI:0.75-0.81, p < 0.001, negative predictive value 100%). A positive correlation between BVA and an orthogonal catheter orientation (46°-90°:r = 0.106, p < 0.001), and a negative correlation between BVA and EGM duration (r = -0.370, p < 0.001) was found. CONCLUSIONS EAM using CFSC validates previous bipolar cut-off values for normal endocardial RV voltage amplitudes. RV voltages are generally lower in ARVC as compared to controls, with the subtricuspid area being commonly affected and having the highest discriminatory power to differentiate between ARVC and healthy controls. Therefore, EAM using CFSC constitutes a promising tool for diagnosis of ARVC.
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Affiliation(s)
- A M Saguner
- Arrhythmia Division, Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland; Center for Translational and Experimental Cardiology (CTEC), Department of Cardiology, Zurich University Hospital, University of Zurich, 8952 Schlieren, Switzerland.
| | - D Lunk
- Arrhythmia Division, Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - M Mohsen
- Arrhythmia Division, Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland; Department of Cardiology, Qatar Heart Hospital 7GR5+RW4, Doha, Qatar
| | - Sven Knecht
- Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Deniz Akdis
- Arrhythmia Division, Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - S Costa
- Arrhythmia Division, Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - A Gasperetti
- Arrhythmia Division, Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland; Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Carnegie 568D, 600 N. Wolfe St., Baltimore, MD 21287, USA
| | - F Duru
- Arrhythmia Division, Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland; Center for Translational and Experimental Cardiology (CTEC), Department of Cardiology, Zurich University Hospital, University of Zurich, 8952 Schlieren, Switzerland
| | - V A Rossi
- Arrhythmia Division, Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - C B Brunckhorst
- Arrhythmia Division, Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland
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Ye Z, van Schie MS, Pool L, Heida A, Knops P, Taverne YJHJ, Brundel BJJM, de Groot NMS. Characterization of unipolar electrogram morphology: a novel tool for quantifying conduction inhomogeneity. Europace 2023; 25:euad324. [PMID: 37931071 PMCID: PMC10657215 DOI: 10.1093/europace/euad324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 10/15/2023] [Accepted: 10/21/2023] [Indexed: 11/08/2023] Open
Abstract
AIMS Areas of conduction inhomogeneity (CI) during sinus rhythm may facilitate the initiation and perpetuation of atrial fibrillation (AF). Currently, no tool is available to quantify the severity of CI. Our aim is to develop and validate a novel tool using unipolar electrograms (EGMs) only to quantify the severity of CI in the atria. METHODS AND RESULTS Epicardial mapping of the right atrium (RA) and left atrium, including Bachmann's bundle, was performed in 235 patients undergoing coronary artery bypass grafting surgery. Conduction inhomogeneity was defined as the amount of conduction block. Electrograms were classified as single, short, long double (LDP), and fractionated potentials (FPs), and the fractionation duration of non-single potentials was measured. The proportion of low-voltage areas (LVAs, <1 mV) was calculated. Increased CI was associated with decreased potential voltages and increased LVAs, LDPs, and FPs. The Electrical Fingerprint Score consisting of RA EGM features, including LVAs and LDPs, was most accurate in predicting CI severity. The RA Electrical Fingerprint Score demonstrated the highest correlation with the amount of CI in both atria (r = 0.70, P < 0.001). CONCLUSION The Electrical Fingerprint Score is a novel tool to quantify the severity of CI using only unipolar EGM characteristics recorded. This tool can be used to stage the degree of conduction abnormalities without constructing spatial activation patterns, potentially enabling early identification of patients at high risk of post-operative AF or selection of the appropriate ablation approach in addition to pulmonary vein isolation at the electrophysiology laboratory.
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Affiliation(s)
- Ziliang Ye
- Department of Cardiology, Erasmus Medical Center, Dr Molewaterplein 40, Rotterdam 3015GD, The Netherlands
| | - Mathijs S van Schie
- Department of Cardiology, Erasmus Medical Center, Dr Molewaterplein 40, Rotterdam 3015GD, The Netherlands
| | - Lisa Pool
- Department of Cardiology, Erasmus Medical Center, Dr Molewaterplein 40, Rotterdam 3015GD, The Netherlands
| | - Annejet Heida
- Department of Cardiology, Erasmus Medical Center, Dr Molewaterplein 40, Rotterdam 3015GD, The Netherlands
| | - Paul Knops
- Department of Cardiology, Erasmus Medical Center, Dr Molewaterplein 40, Rotterdam 3015GD, The Netherlands
| | - Yannick J H J Taverne
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Natasja M S de Groot
- Department of Cardiology, Erasmus Medical Center, Dr Molewaterplein 40, Rotterdam 3015GD, The Netherlands
- Department of Microelectronics, Delft University of Technology, Mekelweg 5, 2628CD Delft, The Netherlands
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Kharbanda RK, Ramdat Misier NL, van Schie MS, Zwijnenburg RD, Amesz JH, Knops P, Bogers AJJC, Taverne YJHJ, de Groot NMS. Insights Into the Effects of Low-Level Vagus Nerve Stimulation on Atrial Electrophysiology: Towards Patient-Tailored Cardiac Neuromodulation. JACC Clin Electrophysiol 2023; 9:1843-1853. [PMID: 37480858 DOI: 10.1016/j.jacep.2023.05.011] [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: 01/18/2023] [Revised: 05/10/2023] [Accepted: 05/10/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Low-level vagus nerve stimulation through the tragus (tLLVNS) is increasingly acknowledged as a therapeutic strategy to prevent and treat atrial fibrillation. However, a lack in understanding of the exact antiarrhythmic properties of tLLVNS has hampered clinical implementation. OBJECTIVES In this study, the authors aimed to study the effects of tLLVNS on atrial electrophysiology by performing intraoperative epicardial mapping during acute and chronic tLLVNS. METHODS Epicardial mapping of the superior right atrium was performed before and after arterial graft harvesting in patients undergoing coronary artery bypass grafting without a history of atrial fibrillation. The time needed for arterial graft harvesting was used to perform chronic tLLVNS. Electrophysiological properties were compared before and during chronic tLLVNS. RESULTS A total of 10 patients (median age 74 years [IQR: 69-78 years]) underwent tLLVNS for a duration of 56 minutes (IQR: 43-73 minutes). During acute and chronic tLLVNS, a shift of the sinoatrial node exit site toward a more cranial direction was observed in 5 (50%) patients. Unipolar potential voltage increased significantly during acute and chronic tLLVNS (3.9 mV [IQR: 3.1-4.8 mV] vs 4.7 mV [IQR: 4.0-5.3 mV] vs 5.2 mV [IQR: 4.8-7.0 mV]; P = 0.027, P = 0.02, respectively). Total activation time, slope of unipolar potentials, amount of fractionation, low-voltage areas and conduction velocity did not differ significantly between baseline measurements and tLLVNS. Two patients showed consistent "improvement" of all electrophysiological properties during tLLVNS, while 1 patient appeared to have no beneficial effect. CONCLUSIONS We demonstrated that tLLVNS resulted in a significant increase in unipolar potential voltage. In addition, we observed the following in selective patients: 1) reduction in total activation time; 2) steeper slope of unipolar potentials; 3) decrease in the amount of fractionation; and 4) change in sinoatrial node exit sites.
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Affiliation(s)
- Rohit K Kharbanda
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands; Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Mathijs S van Schie
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Roxanne D Zwijnenburg
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands; Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Jorik H Amesz
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Paul Knops
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Yannick J H J Taverne
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
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Tourni M, Han SJ, Weber R, Kucinski M, Wan EY, Biviano AB, Konofagou EE. Electromechanical Cycle Length Mapping for atrial arrhythmia detection and cardioversion success assessment. Comput Biol Med 2023; 163:107084. [PMID: 37302374 PMCID: PMC10527498 DOI: 10.1016/j.compbiomed.2023.107084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 04/26/2023] [Accepted: 05/27/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Direct current cardioversion (DCCV) is an established treatment to acutely convert atrial fibrillation (AF) to normal sinus rhythm. Yet, more than 70% of patients revert to AF shortly thereafter. Electromechanical Cycle Length Mapping (ECLM) is a high framerate, spectral analysis technique shown to non-invasively characterize electromechanical activation in paced canines and re-entrant flutter patients. This study assesses ECLM feasibility to map and quantify atrial arrhythmic electromechanical activation rates and inform on 1-day and 1-month DCCV response. METHODS Forty-five subjects (30 AF; 15 healthy sinus rhythm (SR) controls) underwent transthoracic ECLM in four standard apical 2D echocardiographic views. AF patients were imaged within 1 h pre- and post-DCCV. 3D-rendered atrial ECLM cycle length (CL) maps and spatial CL histograms were generated. CL dispersion and percentage of arrhythmic CLs≤333ms across the entire atrial myocardium were computed transmurally. ECLM results were subsequently used as indicators of DCCV success. RESULTS ECLM successfully confirmed the electrical atrial activation rates in 100% of healthy subjects (R2=0.96). In AF, ECLM maps localized the irregular activation rates pre-DCCV and confirmed successful post-DCCV with immediate reduction or elimination. ECLM metrics successfully distinguished DCCV 1-day and 1-month responders from non-responders, while pre-DCCV ECLM values independently predicted AF recurrence within 1-month post-DCCV. CONCLUSIONS ECLM can characterize electromechanical activation rates in AF, quantify their extent, and identify and predict short- and long-term AF recurrence. ELCM constitutes thus a noninvasive arrhythmia imaging modality that can aid clinicians in simultaneous AF severity quantification, prediction of AF DCCV response, and personalized treatment planning.
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Affiliation(s)
- Melina Tourni
- Depatrment of Biomedical Engineering, Columbia University, 630 W 168th Street, New York, 10032, NY, USA.
| | - Seungyeon Julia Han
- Depatrment of Biomedical Engineering, Columbia University, 630 W 168th Street, New York, 10032, NY, USA
| | - Rachel Weber
- Depatrment of Biomedical Engineering, Columbia University, 630 W 168th Street, New York, 10032, NY, USA
| | - Mary Kucinski
- Depatrment of Biomedical Engineering, Columbia University, 630 W 168th Street, New York, 10032, NY, USA
| | - Elaine Y Wan
- Department of Medicine and Vagelos College of Physicians and Surgeons, Columbia University, 630 W 168th Street, New York, 10032, NY, USA
| | - Angelo B Biviano
- Department of Medicine and Vagelos College of Physicians and Surgeons, Columbia University, 630 W 168th Street, New York, 10032, NY, USA
| | - Elisa E Konofagou
- Depatrment of Biomedical Engineering, Columbia University, 630 W 168th Street, New York, 10032, NY, USA; Department of Radiology, Columbia University, 630 W 168th Street, New York, 10032, NY, USA.
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Langmuur SJJ, Taverne YJHJ, van Schie MS, Bogers AJJC, de Groot NMS. Optimization of intra-operative electrophysiological localization of the ligament of Marshall. Front Cardiovasc Med 2022; 9:1030064. [PMID: 36407441 PMCID: PMC9669368 DOI: 10.3389/fcvm.2022.1030064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022] Open
Abstract
Background The ligament of Marshall (LOM) may play a role in the pathophysiology of several tachyarrhythmias and accurate electrophysiological localization of this structure is crucial for effective ablation therapy. This study therefore quantifies electrophysiological properties of the LOM, and identifies which electrogram (EGM) recording (uni- or bipolar) and processing technologies [local activation time (LAT) and/or voltage mapping] are most suitable for accurate localization of the LOM. Methods The LOM was electrophysiologically identified in 19 patients (mean age 66 ± 14 years; 12 male) undergoing elective cardiac surgery using intra-operative high-density epicardial mapping, to quantify and visualize EGM features during sinus rhythm. Results Only a third of LOM potentials that were visualized using unipolar EGMs, were still visible in bipolar activation maps. Unipolar LOM potentials had lower voltages (P50: LOM: 1.51 (0.42–4.29) mV vs. left atrium (LA): 8.34 (1.50–17.91) mV, p < 0.001), less steep slopes (P50: LOM: –0.48 (–1.96 to –0.17) V/s vs. LA: –1.24 (–2.59 to –0.21) V/s, p < 0.001), and prolonged activation duration (LOM: 20 (7.5–30.5) ms vs. LA: 16.5 (6–28) ms, p = 0.008) compared to LA potentials. Likewise, bipolar LOM voltages were also smaller (P50: LOM: 1.54 (0.48–3.28) mV vs. LA: 3.12 (0.50–7.19) mV, p < 0.001). Conclusion The LOM was most accurately localized in activation and voltage maps by using unipolar EGMs with annotation of primary deflections in case of single potentials and secondary deflections in case of double or fractionated potentials.
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Affiliation(s)
- Sanne J. J. Langmuur
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, Netherlands
| | | | | | - Ad J. J. C. Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, Netherlands
| | - Natasja M. S. de Groot
- Department of Cardiology, Erasmus Medical Center, Rotterdam, Netherlands
- *Correspondence: Natasja M. S. de Groot,
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Huang T, Chen J, Müller-Edenborn B, Mayer L, Eichenlaub M, Moreno Weidmann Z, Allgeier J, Bohnen M, Lehrmann H, Trenk D, Schoechlin S, Westermann D, Arentz T, Jadidi A. Validating left atrial fractionation and low-voltage substrate during atrial fibrillation and sinus rhythm-A high-density mapping study in persistent atrial fibrillation. Front Cardiovasc Med 2022; 9:1000027. [PMID: 36330001 PMCID: PMC9622778 DOI: 10.3389/fcvm.2022.1000027] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/26/2022] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Low-voltage-substrate (LVS)-guided ablation for persistent atrial fibrillation (AF) has been described either in sinus rhythm (SR) or AF. Prolonged fractionated potentials (PFPs) may represent arrhythmogenic slow conduction substrate and potentially co-localize with LVS. We assess the spatial correlation of PFP identified in AF (PFP-AF) to those mapped in SR (PFP-SR). We further report the relationship between LVS and PFPs when mapped in AF or SR. MATERIALS AND METHODS Thirty-eight patients with ablation naïve persistent AF underwent left atrial (LA) high-density mapping in AF and SR prior to catheter ablation. Areas presenting PFP-AF and PFP-SR were annotated during mapping on the LA geometry. Low-voltage areas (LVA) were quantified using a bipolar threshold of 0.5 mV during both AF and SR mapping. Concordance of fractionated potentials (CFP) (defined as the presence of PFPs in both rhythms within a radius of 6 mm) was quantified. Spatial distribution and correlation of PFP and CFP with LVA were assessed. The predictors for CFP were determined. RESULTS PFPs displayed low voltages both during AF (median 0.30 mV (Q1-Q3: 0.20-0.50 mV) and SR (median 0.35 mV (Q1-Q3: 0.20-0.56 mV). The duration of PFP-SR was measured at 61 ms (Q1-Q3: 51-76 ms). During SR, most PFP-SRs (89.4 and 97.2%) were located within LVA (<0.5 mV and <1.0 mV, respectively). Areas presenting PFP occurred more frequently in AF than in SR (median: 9.5 vs. 8.0, p = 0.005). Both PFP-AF and PFP-SR were predominantly located at anterior LA (>40%), followed by posterior LA (>20%) and septal LA (>15%). The extent of LVA < 0.5 mV was more extensive in AF (median: 25.2% of LA surface, Q1-Q3:16.6-50.5%) than in SR (median: 12.3%, Q1-Q3: 4.7-29.4%, p = 0.001). CFP in both rhythms occurred in 80% of PFP-SR and 59% of PFP-AF (p = 0.008). Notably, CFP was positively correlated to the extent of LVA in SR (p = 0.004), but not with LVA in AF (p = 0.226). Additionally, the extent of LVA < 0.5 mV in SR was the only significant predictor for CFP, with an optimal threshold of 16% predicting high (>80%) fractionation concordance in AF and SR. CONCLUSION Substrate mapping in SR vs. AF reveals smaller areas of low voltage and fewer sites with PFP. PFP-SR are located within low-voltage areas in SR. There is a high degree of spatial agreement (80%) between PFP-AF and PFP-SR in patients with moderate LVA in SR (>16% of LA surface). These findings should be considered when substrate-based ablation strategies are applied in patients with the left atrial low-voltage substrate with recurrent persistent AF.
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Affiliation(s)
- Taiyuan Huang
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Juan Chen
- Department of Cardiology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Björn Müller-Edenborn
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Louisa Mayer
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Martin Eichenlaub
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Zoraida Moreno Weidmann
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
- Arrhythmia Unit, Department of Cardiology, Hospital Universitario Sant Pau, Barcelona, Spain
| | - Juergen Allgeier
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Marius Bohnen
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Heiko Lehrmann
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Dietmar Trenk
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Simon Schoechlin
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Dirk Westermann
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Thomas Arentz
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Amir Jadidi
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
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9
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van Schie MS, de Groot NMS. Clinical Relevance of Sinus Rhythm Mapping to Quantify Electropathology Related to Atrial Fibrillation. Arrhythm Electrophysiol Rev 2022; 11:e11. [PMID: 35846426 PMCID: PMC9277615 DOI: 10.15420/aer.2022.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 05/25/2022] [Indexed: 11/28/2022] Open
Abstract
Progression of AF is accompanied by structural and electrical remodelling, resulting in complex electrical conduction disorders. This is defined as electropathology and it increases with the progression of AF. The severity of electropathology, thus, defines the stage of AF and is a major determinant of effectiveness of AF therapy. As specific features of AF-related electropathology are still unknown, it is essential to first quantify the electrophysiological properties of atrial tissue and then to examine the inter- and intra-individual variation during normal sinus rhythm. Comparison of these parameters between patients with and without a history of AF unravels quantified electrophysiological features that are specific to AF patients. This can help to identify patients at risk for early onset or progression of AF. This review summarises current knowledge on quantified features of atrial electrophysiological properties during sinus rhythm and discusses its relevance in identifying AF-related electropathology.
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Affiliation(s)
- Mathijs S van Schie
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Natasja MS de Groot
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
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10
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van Schie MS, Veen D, Kharbanda RK, Heida A, Starreveld R, van Schaagen FRN, Bogers AJJC, Taverne YJHJ, de Groot NMS. Characterization of pre-existing arrhythmogenic substrate associated with de novo early and late postoperative atrial fibrillation. Int J Cardiol 2022; 363:71-79. [PMID: 35705170 DOI: 10.1016/j.ijcard.2022.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/01/2022] [Accepted: 06/10/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND PoAF is the most common complication after cardiac surgery and may occur in patients with pre-existing arrhythmogenic substrate. Characterization of this substrate could aid in identifying patients at risk for PoAF. We therefore compared intra-atrial conduction parameters and electrogram morphology between patients without and with early- (≤5 days after surgery) and late- (up to 5 years) postoperative atrial fibrillation (PoAF). METHODS AND RESULTS Epicardial mapping of the right and left atrium and Bachmann's Bundle (BB) was performed during sinus rhythm (SR) in 263 patients (207male, 67 ± 11 years). Unipolar potentials were classified as single, short or long double and fractionated potentials. Unipolar voltage, fractionation delay (time difference between the first and last deflection), conduction velocity (CV) and conduction block (CB) prevalence were measured. Comparing patients without (N = 166) and with PoAF (N = 97), PoAF was associated with lower CV and more CB at BB. Unipolar voltages were lower and more low-voltage areas were found at the left and right atrium and BB in PoAF patients. These differences were more pronounced in patients with late-PoAF (6%), which could even occur up to 5 years after surgery. Although several electrophysiological parameters were related to PoAF, age was the only independent predictor. CONCLUSIONS Patients with de novo PoAF have more extensive arrhythmogenic substrate prior to cardiac surgery compared to those who remained in SR, which is even more pronounced in late-PoAF patients. Future studies should evaluate whether intra-operative electrophysiological examination enables identification of patients at risk for developing PoAF and hence (preventive) therapy.
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Affiliation(s)
- Mathijs S van Schie
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Danny Veen
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Rohit K Kharbanda
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands; Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Annejet Heida
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Roeliene Starreveld
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Frank R N van Schaagen
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Yannick J H J Taverne
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
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11
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Quah JX, Jenkins E, Dharmaprani D, Tiver K, Smith C, Hecker T, Joseph MX, Selvanayagam JB, Tung M, Stanton T, Ahmad W, Stoyanov N, Lahiri A, Chahadi F, Singleton C, Ganesan A. Role of interatrial conduction in atrial fibrillation. Mechanistic insights from renewal theory-based fibrillatory dynamic analysis. Heart Rhythm O2 2022; 3:335-343. [PMID: 36097465 PMCID: PMC9463713 DOI: 10.1016/j.hroo.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background Interatrial conduction has been postulated to play an important role in atrial fibrillation (AF). The pathways involved in interatrial conduction during AF remain incompletely defined. Objective We recently showed physiological assessment of fibrillatory dynamics could be performed using renewal theory, which determines rates of phase singularity formation (λf) and destruction (λd). Using the renewal approach, we aimed to understand the role of the interatrial septum and other electrically coupled regions during AF. Method RENEWAL-AF is a prospective multicenter observational study recruiting AF ablation patients (ACTRN 12619001172190). We studied unipolar electrograms obtained from 16 biatrial locations prior to ablation using a 16-electrode Advisor HD Grid catheter. Renewal rate constants λf and λd were calculated, and the relationships between these rate constants in regions of interatrial connectivity were examined. Results Forty-one AF patients (28.5% female) were recruited. A positive linear correlation was observed between λf and λd (1) across the interatrial septum (λf r2 = 0.5, P < .001, λd r2 = 0.45, P < .001), (2) in regions connected by the Bachmann bundle (right atrial appendage–left atrial appendage λf r2 = 0.29, P = .001; λd r2 = 0.2, P = .008), and (3) across the inferior interatrial routes (cavotricuspid isthmus–left atrial septum λf r2 = 0.67, P < .001; λd r2 = 0.55, P < .001). Persistent AF status and left atrial volume were found to be important effect modifiers of the degree of interatrial renewal rate statistical correlation. Conclusion Our findings support the role of interseptal statistically determined electrical disrelation in sustaining AF. Additionally, renewal theory identified preferential conduction through specific interatrial pathways during fibrillation. These findings may be of importance in identifying clinically significant targets for ablation in AF patients.
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Affiliation(s)
- Jing Xian Quah
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Evan Jenkins
- College of Science and Engineering, Flinders University of South Australia, Adelaide, Australia
| | - Dhani Dharmaprani
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
- College of Science and Engineering, Flinders University of South Australia, Adelaide, Australia
| | - Kathryn Tiver
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Corey Smith
- Department of Cardiology, Fiona Stanley Hospital, Perth, Australia
| | - Teresa Hecker
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Majo X. Joseph
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | | | - Matthew Tung
- Department of Cardiovascular Medicine, Sunshine Coast University Hospital, Birtinya, Australia
| | - Tony Stanton
- Department of Cardiovascular Medicine, Sunshine Coast University Hospital, Birtinya, Australia
- School of Medicine and Dentistry, Griffith University, Sunshine Coast University Hospital, Birtinya, Australia
| | - Waheed Ahmad
- Department of Cardiovascular Medicine, Princess Alexandra Hospital, Brisbane, Australia
| | - Nik Stoyanov
- Department of Cardiology, Fiona Stanley Hospital, Perth, Australia
| | - Anandaroop Lahiri
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Fahd Chahadi
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Cameron Singleton
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Anand Ganesan
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
- Address reprint requests and correspondence: Dr Anand Ganesan, College of Medicine and Public Health, Flinders University, Flinders Dr, Bedford Park SA 5042, Australia.
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12
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Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia despite substantial efforts to understand the pathophysiology of the condition and develop improved treatments. Identifying the underlying causative mechanisms of AF in individual patients is difficult and the efficacy of current therapies is suboptimal. Consequently, the incidence of AF is steadily rising and there is a pressing need for novel therapies. Research has revealed that defects in specific molecular pathways underlie AF pathogenesis, resulting in electrical conduction disorders that drive AF. The severity of this so-called electropathology correlates with the stage of AF disease progression and determines the response to AF treatment. Therefore, unravelling the molecular mechanisms underlying electropathology is expected to fuel the development of innovative personalized diagnostic tools and mechanism-based therapies. Moreover, the co-creation of AF studies with patients to implement novel diagnostic tools and therapies is a prerequisite for successful personalized AF management. Currently, various treatment modalities targeting AF-related electropathology, including lifestyle changes, pharmaceutical and nutraceutical therapy, substrate-based ablative therapy, and neuromodulation, are available to maintain sinus rhythm and might offer a novel holistic strategy to treat AF.
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Affiliation(s)
- Bianca J J M Brundel
- Department of Physiology, Amsterdam University Medical Centers, VU Universiteit, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands.
| | - Xun Ai
- Department of Physiology and Cell Biology, College of Medicine/Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | | | - Myrthe F Kuipers
- AFIPonline.org, Atrial Fibrillation Innovation Platform, Amsterdam, Netherlands
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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13
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Identification of high priority focal activations in persistent atrial fibrillation using a novel mapping strategy. Heart Vessels 2021; 37:840-853. [PMID: 34708268 DOI: 10.1007/s00380-021-01977-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 10/22/2021] [Indexed: 10/20/2022]
Abstract
Focal activation is believed to be an atrial fibrillation (AF) driver; however, little is known about whether all focal activations are necessary for AF persistence. The purpose of this study was to assess the electrical nature of focal activation and identify high-priority focal activations using a novel mapping system (CARTOFINDER). Thirty-five patients with persistent AF who underwent catheter ablation were assessed. Cycle length (CL) and CL standard deviation (CLSD) on unipolar recordings and voltage amplitude and electrogram morphologies on bipolar recordings were evaluated at all points of interest. The most frequent CL at each mapping site was defined as the dominant CL. We identified dominant focal activations (DFAs) that had a shorter dominant CL on the integrated CARTOFINDER map. The effect of elimination of DFAs on AF maintenance was assessed by the composite endpoint (termination to sinus rhythm, organization of the rhythm to atrial tachycardia, and AF CL slowing). In all, 450 focal activations were identified among 10,868 points, and 50.4% of focal activations were DFAs. Focal activations showed relatively long CL and regularity with short CLSD. Most focal activations showed an isoelectric baseline and were located outside of the fractionated electrogram area. Both DFAs and non-DFAs were typically observed in the normal voltage range. Elimination of DFAs was achieved in 19 (54.3%) patients, with a remarkable impact on AF maintenance (68.4% vs. 25.0%, p = 0.018). In conclusion, DFAs may play an important role in AF maintenance and could be an attractive therapeutic target for AF.
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14
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van Schie MS, Starreveld R, Bogers AJJC, de Groot NMS. Sinus rhythm voltage fingerprinting in patients with mitral valve disease using a high-density epicardial mapping approach. Europace 2021; 23:469-478. [PMID: 33432326 PMCID: PMC7947572 DOI: 10.1093/europace/euaa336] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 10/06/2020] [Indexed: 12/03/2022] Open
Abstract
Aims Unipolar voltage (UV) mapping is increasingly used for guiding ablative therapy of atrial fibrillation (AF) as unipolar electrograms (U-EGMs) are independent of electrode orientation and atrial wavefront direction. This study was aimed at constructing individual, high-resolution sinus rhythm (SR) UV fingerprints to identify low-voltage areas and study the effect of AF episodes in patients with mitral valve disease (MVD). Methods and results Intra-operative epicardial mapping (interelectrode distance 2 mm) of the right and left atrium, Bachmann’s bundle (BB), and pulmonary vein area was performed in 67 patients (27 male, 67 ± 11 years) with or without a history of paroxysmal AF (PAF). In all patients, there were considerable regional variations in voltages. UVs at BB were lower in patients with PAF compared with those without [no AF: 4.94 (3.56–5.98) mV, PAF: 3.30 (2.25–4.57) mV, P = 0.006]. A larger number of low-voltage potentials were recorded at BB in the PAF group [no AF: 2.13 (0.52–7.68) %, PAF: 12.86 (3.18–23.59) %, P = 0.001]. In addition, areas with low-voltage potentials were present in all patients, yet we did not find any predilection sites for low-voltage potentials to occur. Conclusion Even in SR, advanced atrial remodelling in MVD patients shows marked inter-individual and regional variation. Low UVs are even present during SR in patients without a history of AF indicating that low UVs should carefully be used as target sites for ablative therapy.
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Affiliation(s)
- Mathijs S van Schie
- Department of Cardiology, Erasmus Medical Center, Dr Molewaterplein 40, 3015GD Rotterdam, The Netherlands
| | - Roeliene Starreveld
- Department of Cardiology, Erasmus Medical Center, Dr Molewaterplein 40, 3015GD Rotterdam, The Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, 3015GD Rotterdam, The Netherlands
| | - Natasja M S de Groot
- Department of Cardiology, Erasmus Medical Center, Dr Molewaterplein 40, 3015GD Rotterdam, The Netherlands
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15
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van der Does LJME, Starreveld R, Kharbanda RK, Knops P, Kik C, Bogers AJJC, de Groot NMS. Detection of Endo-epicardial Asynchrony in the Atrial Wall Using One-Sided Unipolar and Bipolar Electrograms. J Cardiovasc Transl Res 2021; 14:902-911. [PMID: 33782858 PMCID: PMC8575733 DOI: 10.1007/s12265-021-10111-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 02/16/2021] [Indexed: 11/26/2022]
Abstract
Endo-epicardial asynchrony (EEA) is a new mechanism possibly maintaining atrial fibrillation. We aimed to determine the sensitivity and best recording modus to detect EEA on electrograms recorded from one atrial side using electrogram fractionation. Simultaneously obtained right atrial endo- and epicardial electrograms from 22 patients demonstrating EEA were selected. Unipolar and (converted) bipolar electrograms were analyzed for presence and characteristics of fractionation corresponding to EEA. Sensitivity of presence of EEA corresponding fractionation was high in patients (86-96%) and moderately high (65-78%) for the asynchronous surface area for unipolar and bipolar electrograms equally. In bipolar electrograms, signal-to-noise ratio of EEA corresponding fractionation decreased and additional fractionation increased for electrograms recorded at the endocardium. Sensitivity of fractionation corresponding to EEA is high for both unipolar and bipolar electrograms. Unipolar electrograms are more suited for detection of EEA due to a larger signal-to-noise ratio and less disturbance of additional fractionation. Unipolar electrograms are more suited than bipolar electrograms to detect endo-epicardial asynchrony on one side of the atrial wall using electrogram fractionation.
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Affiliation(s)
| | - Roeliene Starreveld
- Department of Cardiology, Erasmus Medical Center, Dr. Molewaterplein 40, 3015GD, Rotterdam, Netherlands
| | - Rohit K Kharbanda
- Department of Cardiology, Erasmus Medical Center, Dr. Molewaterplein 40, 3015GD, Rotterdam, Netherlands
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, Netherlands
| | - Paul Knops
- Department of Cardiology, Erasmus Medical Center, Dr. Molewaterplein 40, 3015GD, Rotterdam, Netherlands
| | - Charles Kik
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, Netherlands
| | - Natasja M S de Groot
- Department of Cardiology, Erasmus Medical Center, Dr. Molewaterplein 40, 3015GD, Rotterdam, Netherlands.
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16
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Ye Z, van Schie MS, de Groot NMS. Signal Fingerprinting as a Novel Diagnostic Tool to Identify Conduction Inhomogeneity. Front Physiol 2021; 12:652128. [PMID: 33841188 PMCID: PMC8033016 DOI: 10.3389/fphys.2021.652128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/04/2021] [Indexed: 12/03/2022] Open
Abstract
Background Inhomogeneous intra-atrial conduction facilitates both initiation and perpetuation of atrial fibrillation (AF) and is reflected in electrogram (EGM) morphology. Objective The primary objective of this study is to investigate regional differences in features of different EGM types during sinus rhythm (SR) and to design a patient-specific signal fingerprint, which quantifies the severity and extensiveness of inhomogeneity in conduction. Methods Patients (N = 189, 86% male; mean age 65 ± 9 years) undergoing coronary artery bypass grafting (CABG) underwent high-resolution mapping of the right atrium (RA), left atrium (LA), and pulmonary vein area (PVA) including Bachmann’s bundle (BB). EGMs during 5 s of SR were classified as single potentials (SPs), short double potentials (SDPs, interval between deflections < 15 ms), long double potentials (LDPs, deflection interval > 15 ms), or fractionated potentials (FPs, ≥3 deflections). Of all SPs, differences in relative R- and S-wave amplitude were calculated (R/S ratios). Time difference between first and last deflection was determined (fractionation duration, FD) and potentials with amplitudes < 1.0 mV were labeled as low-voltage. Conduction block (CB) was defined as a difference in local activation time (LAT) between adjacent electrodes of ≥12 ms. Results A total of 1,763,593 EGMs (9,331 ± 3,336 per patient) were classified (Table 1). Conclusion The signal fingerprint, consisting of quantified EGM features, including the R/S ratio of SPs, the relative frequency distribution of unipolar voltages, the proportion of low-voltage areas, the proportion of the different types of EGMs, and durations of LDP and FDP, may serve as a diagnostic tool to determine the severity and extensiveness of conduction inhomogeneity. Further studies are required to determine whether the signal fingerprint can be used to identify patients at risk for AF onset or progression.
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Affiliation(s)
- Ziliang Ye
- Department of Cardiology, Erasmus Medical Center, Rotterdam, Netherlands
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17
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Starreveld R, Knops P, Roos-Serote M, Kik C, Bogers AJJC, Brundel BJJM, de Groot NMS. The Impact of Filter Settings on Morphology of Unipolar Fibrillation Potentials. J Cardiovasc Transl Res 2020; 13:953-964. [PMID: 32410210 PMCID: PMC7708344 DOI: 10.1007/s12265-020-10011-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 04/17/2020] [Indexed: 12/16/2022]
Abstract
Using unipolar atrial electrogram morphology as guidance for ablative therapy is regaining interest. Although standardly used in clinical practice during ablative therapy, the impact of filter settings on morphology of unipolar AF potentials is unknown. Thirty different filters were applied to 2,557,045 high-resolution epicardial AF potentials recorded from ten patients. Deflections with slope ≤ - 0.05 mV/ms and amplitude ≥ 0.3 mV were marked. High-pass filtering decreased the number of detected potentials, deflection amplitude, and percentage of fractionated potentials (≥ 2 deflections) as well as fractionation delay time (FDT) and increased percentage of single potentials. Low-pass filtering decreased the number of potentials, percentage of fractionated potentials, whereas deflection amplitude, percentage of single potentials, and FDT increased. Notch filtering (50 Hz) decreased the number of potentials and deflection amplitude, whereas the percentage of complex fractionated potentials (≥ 3 deflections) increased. Filtering significantly impacted morphology of unipolar fibrillation potentials, becoming a potential source of error in identification of ablative targets. Graphical Abstract Impact of filtering on morphology of unipolar AF potentials. High-pass, low-pass and notch filters were applied to 2,557,045 high-resolution epicardial AF potentials recorded from ten patients. Filtering significantly impacted AF potential morphology, i.e., number of detected potentials, peak-to-peak amplitude, number of deflections, and fractionation delay time. CFP, complex fractionated potential (≥ 3 deflections); DP, double potential (two deflections); FDT, fractionation delay time; SP, single potential (one deflection).
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Affiliation(s)
- Roeliene Starreveld
- Department of Cardiology, Erasmus Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Paul Knops
- Department of Cardiology, Erasmus Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Maarten Roos-Serote
- Department of Cardiology, Erasmus Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Charles Kik
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Bianca J J M Brundel
- Department of Physiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Natasja M S de Groot
- Department of Cardiology, Erasmus Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
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18
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Mikhailov AV, Kalyanasundaram A, Li N, Scott SS, Artiga EJ, Subr MM, Zhao J, Hansen BJ, Hummel JD, Fedorov VV. Comprehensive evaluation of electrophysiological and 3D structural features of human atrial myocardium with insights on atrial fibrillation maintenance mechanisms. J Mol Cell Cardiol 2020; 151:56-71. [PMID: 33130148 DOI: 10.1016/j.yjmcc.2020.10.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/22/2020] [Accepted: 10/23/2020] [Indexed: 12/14/2022]
Abstract
Atrial fibrillation (AF) occurrence and maintenance is associated with progressive remodeling of electrophysiological (repolarization and conduction) and 3D structural (fibrosis, fiber orientations, and wall thickness) features of the human atria. Significant diversity in AF etiology leads to heterogeneous arrhythmogenic electrophysiological and structural substrates within the 3D structure of the human atria. Since current clinical methods have yet to fully resolve the patient-specific arrhythmogenic substrates, mechanism-based AF treatments remain underdeveloped. Here, we review current knowledge from in-vivo, ex-vivo, and in-vitro human heart studies, and discuss how these studies may provide new insights on the synergy of atrial electrophysiological and 3D structural features in AF maintenance. In-vitro studies on surgically acquired human atrial samples provide a great opportunity to study a wide spectrum of AF pathology, including functional changes in single-cell action potentials, ion channels, and gene/protein expression. However, limited size of the samples prevents evaluation of heterogeneous AF substrates and reentrant mechanisms. In contrast, coronary-perfused ex-vivo human hearts can be studied with state-of-the-art functional and structural technologies, such as high-resolution near-infrared optical mapping and contrast-enhanced MRI. These imaging modalities can resolve atrial arrhythmogenic substrates and their role in reentrant mechanisms maintaining AF and validate clinical approaches. Nonetheless, longitudinal studies are not feasible in explanted human hearts. As no approach is perfect, we suggest that combining the strengths of direct human atrial studies with high fidelity approaches available in the laboratory and in realistic patient-specific computer models would elucidate deeper knowledge of AF mechanisms. We propose that a comprehensive translational pipeline from ex-vivo human heart studies to longitudinal clinically relevant AF animal studies and finally to clinical trials is necessary to identify patient-specific arrhythmogenic substrates and develop novel AF treatments.
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Affiliation(s)
- Aleksei V Mikhailov
- Department of Physiology & Cell Biology, Bob and Corrine Frick Center for Heart Failure and Arrhythmia, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Arrhythmology Research Department, Almazov National Medical Research Centre, Saint-Petersburg, Russia
| | - Anuradha Kalyanasundaram
- Department of Physiology & Cell Biology, Bob and Corrine Frick Center for Heart Failure and Arrhythmia, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ning Li
- Department of Physiology & Cell Biology, Bob and Corrine Frick Center for Heart Failure and Arrhythmia, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Shane S Scott
- Department of Physiology & Cell Biology, Bob and Corrine Frick Center for Heart Failure and Arrhythmia, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Esthela J Artiga
- Department of Physiology & Cell Biology, Bob and Corrine Frick Center for Heart Failure and Arrhythmia, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Megan M Subr
- Department of Physiology & Cell Biology, Bob and Corrine Frick Center for Heart Failure and Arrhythmia, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jichao Zhao
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Brian J Hansen
- Department of Physiology & Cell Biology, Bob and Corrine Frick Center for Heart Failure and Arrhythmia, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - John D Hummel
- Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Vadim V Fedorov
- Department of Physiology & Cell Biology, Bob and Corrine Frick Center for Heart Failure and Arrhythmia, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Almeida TP, Soriano DC, Mase M, Ravelli F, Bezerra AS, Li X, Chu GS, Salinet J, Stafford PJ, Andre Ng G, Schlindwein FS, Yoneyama T. Unsupervised Classification of Atrial Electrograms for Electroanatomic Mapping of Human Persistent Atrial Fibrillation. IEEE Trans Biomed Eng 2020; 68:1131-1141. [PMID: 32881680 DOI: 10.1109/tbme.2020.3021480] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Ablation treatment for persistent atrial fibrillation (persAF) remains challenging due to the absence of a 'ground truth' for atrial substrate characterization and the presence of multiple mechanisms driving the arrhythmia. We implemented an unsupervised classification to identify clusters of atrial electrograms (AEGs) with similar patterns, which were then validated by AEG-derived markers. METHODS 956 bipolar AEGs were collected from 11 persAF patients. CARTO variables (Biosense Webster; ICL, ACI and SCI) were used to create a 3D space, and subsequently used to perform an unsupervised classification with k-means. The characteristics of the identified groups were investigated using nine AEG-derived markers: sample entropy (SampEn), dominant frequency, organization index (OI), determinism, laminarity, recurrence rate (RR), peak-to-peak (PP) amplitude, cycle length (CL), and wave similarity (WS). RESULTS Five AEG classes with distinct characteristics were identified (F = 582, P<0.0001). The presence of fractionation increased from class 1 to 5, as reflected by the nine markers. Class 1 (25%) included organized AEGs with high WS, determinism, laminarity, and RR, and low SampEn. Class 5 (20%) comprised fractionated AEGs with in low WS, OI, determinism, laminarity, and RR, and in high SampEn. Classes 2 (12%), 3 (13%) and 4 (30%) suggested different degrees of AEG organization. CONCLUSIONS Our results expand and reinterpret the criteria used for automated AEG classification. The nine markers highlighted electrophysiological differences among the five classes found by the k-means, which could provide a more complete characterization of persAF substrate during ablation target identification in future clinical studies.
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Shi R, Chen Z, Butcher C, Zaman JAB, Boyalla V, Wang YK, Riad O, Sathishkumar A, Norman M, Haldar S, Jones DG, Hussain W, Markides V, Wong T. Diverse activation patterns during persistent atrial fibrillation by noncontact charge-density mapping of human atrium. J Arrhythm 2020; 36:692-702. [PMID: 32782641 PMCID: PMC7411208 DOI: 10.1002/joa3.12361] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 04/12/2020] [Accepted: 04/22/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Global simultaneous recording of atrial activation during atrial fibrillation (AF) can elucidate underlying mechanisms contributing to AF maintenance. A better understanding of these mechanisms may allow for an individualized ablation strategy to treat persistent AF. The study aims to characterize left atrial endocardial activation patterns during AF using noncontact charge-density mapping. METHODS Twenty-five patients with persistent AF were studied. Activation patterns were characterized into three subtypes: (i) focal with centrifugal activation (FCA); (ii) localized rotational activation (LRA); and (iii) localized irregular activation (LIA). Continuous activation patterns were analyzed and distributed in 18 defined regions in the left atrium. RESULTS A total of 144 AF segments with 1068 activation patterns were analyzed. The most common pattern during AF was LIA (63%) which consists of four disparate features of activation: slow conduction (45%), pivoting (30%), collision (16%), and acceleration (7%). LRA was the second-most common pattern (20%). FCA accounted for 17% of all activations, arising frequently from the pulmonary veins (PVs)/ostia. A majority of patients (24/25; 96%) showed continuous and highly dynamic patterns of activation comprising multiple combinations of FCA, LRA, and LIA, transitioning from one to the other without a discernible order. Preferential conduction areas were typically seen in the mid-anterior (48%) and lower-posterior (40%) walls. CONCLUSION Atrial fibrillation is characterized by heterogeneous activation patterns identified in PV-ostia and non-PV regions throughout the LA at varying locations between individuals. Clinical implications of individualized ablation strategies guided by charge-density mapping need to be determined.
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Affiliation(s)
- Rui Shi
- Department of Cardiovascular MedicineThe First Affliated Hospital of Xi'an Jiaotong UniversityXi'anChina
- Heart Rhythm CentreThe Royal Brompton and Harefield NHS Foundation TrustNational Heart and Lung InstituteImperial College LondonLondonUK
| | - Zhong Chen
- Heart Rhythm CentreThe Royal Brompton and Harefield NHS Foundation TrustNational Heart and Lung InstituteImperial College LondonLondonUK
| | - Charlie Butcher
- Heart Rhythm CentreThe Royal Brompton and Harefield NHS Foundation TrustNational Heart and Lung InstituteImperial College LondonLondonUK
| | - Junaid AB Zaman
- Heart Rhythm CentreThe Royal Brompton and Harefield NHS Foundation TrustNational Heart and Lung InstituteImperial College LondonLondonUK
| | - Vennela Boyalla
- Heart Rhythm CentreThe Royal Brompton and Harefield NHS Foundation TrustNational Heart and Lung InstituteImperial College LondonLondonUK
| | - Yi Kan Wang
- Auckland Bioengineering InstituteUniversity of AucklandAucklandNew Zealand
| | - Omar Riad
- Heart Rhythm CentreThe Royal Brompton and Harefield NHS Foundation TrustNational Heart and Lung InstituteImperial College LondonLondonUK
| | - Anitha Sathishkumar
- Heart Rhythm CentreThe Royal Brompton and Harefield NHS Foundation TrustNational Heart and Lung InstituteImperial College LondonLondonUK
| | - Mark Norman
- Heart Rhythm CentreThe Royal Brompton and Harefield NHS Foundation TrustNational Heart and Lung InstituteImperial College LondonLondonUK
| | - Shouvik Haldar
- Heart Rhythm CentreThe Royal Brompton and Harefield NHS Foundation TrustNational Heart and Lung InstituteImperial College LondonLondonUK
| | - David G Jones
- Heart Rhythm CentreThe Royal Brompton and Harefield NHS Foundation TrustNational Heart and Lung InstituteImperial College LondonLondonUK
| | - Wajid Hussain
- Heart Rhythm CentreThe Royal Brompton and Harefield NHS Foundation TrustNational Heart and Lung InstituteImperial College LondonLondonUK
| | - Vias Markides
- Heart Rhythm CentreThe Royal Brompton and Harefield NHS Foundation TrustNational Heart and Lung InstituteImperial College LondonLondonUK
| | - Tom Wong
- Heart Rhythm CentreThe Royal Brompton and Harefield NHS Foundation TrustNational Heart and Lung InstituteImperial College LondonLondonUK
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Tomii N, Asano K, Seno H, Ashihara T, Sakuma I, Yamazaki M. Validation of Intraoperative Catheter Phase Mapping Using a Simultaneous Optical Measurement System in Rabbit Ventricular Myocardium. Circ J 2020; 84:609-615. [DOI: 10.1253/circj.cj-19-1020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Naoki Tomii
- Faculty of Medicine, The University of Tokyo
| | | | | | - Takashi Ashihara
- Information Technology and Management Center, Shiga University of Medical Science
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Analysis of the driving mechanism in paroxysmal atrial fibrillation: comparison of the activation sequence between the left atrial body and pulmonary vein. J Cardiol 2020; 75:673-681. [PMID: 32037253 DOI: 10.1016/j.jjcc.2020.01.004] [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: 09/26/2019] [Revised: 12/09/2019] [Accepted: 01/01/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND It has been shown that most paroxysmal atrial fibrillation (AF) can be terminated by pulmonary vein (PV) isolation alone, suggesting that rapid discharges from PV drive AF. To define the driving mechanism of AF, we compared the activation sequence in the body of left atrium (LA) to that within PV. METHODS Endocardial noncontact mapping of LA body (LA group; n = 16) and selective endocardial mapping of left superior PV (LSPV) (PV group; n = 13) were performed in 29 paroxysmal AF patients. The frequency of pivoting activation, wave breakup, and wave fusion observed in LA were compared to those in LSPV to define the driving mechanism of AF. Circumferential ablation lesion around left PV was performed after right PV isolation to examine the effect of linear lesion around PV on AF termination both in LA and PV groups. RESULTS The frequency of pivoting activation, wave breakup, and wave fusion in PV group were significantly higher than those in LA group (36.5 ± 17.7 vs 5.0 ± 2.2 times/seconds, p < 0.001, 10.1 ± 4.3 vs 5.0 ± 2.2 times/seconds, p = 0.004, 18.1 ± 5.7 vs 11.0 ± 5.2, p = 0.002). Especially in the PV group, the frequency of pivoting activation was significantly higher than that of wave breakup and wave fusion (36.5 ± 17.7 vs 10.1 ± 4.3 times/seconds, p < 0.001, 36.5 ± 17.7 vs 18.1 ± 5.7 times/seconds, p < 0.001). These disorganized activations in LSPV were eliminated by the circumferential ablation lesion around left PV (pivoting activation; 36.5 ± 17.7 vs 9.3 ± 2.3 times/seconds, p < 0.001, wave breakup; 10.1±1.3 times/seconds, p = 0.003, wave fusion; 18.1 ± 5.7 vs 5.7 ± 1.8, p < 0.001), resulted in AF termination in all patients in both LA and PV groups. CONCLUSIONS Activation sequence within PV was more disorganized than that in LA body. Frequent episodes of pivoting activation rather than wave breakup and fusion observed within PV acted as the driving sources of paroxysmal AF.
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Abdi B, Hendriks RC, van der Veen AJ, de Groot NMS. Improved local activation time annotation of fractionated atrial electrograms for atrial mapping. Comput Biol Med 2019; 117:103590. [PMID: 31885355 DOI: 10.1016/j.compbiomed.2019.103590] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 12/11/2019] [Accepted: 12/18/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Local activation time (LAT) annotation in unipolar electrograms is complicated by interference from nonlocal atrial activities of neighboring tissue. This happens due to the spatial blurring that is inherent to electrogram recordings. In this study, we aim to exploit multi-electrode electrogram recordings to amplify the local activity in each electrogram and subsequently improve the annotation of LATs. METHODS An electrogram array can be modeled as a spatial convolution of per cell transmembrane currents with an appropriate distance kernel, which depends on the cells' distances to the electrodes. By deconvolving the effect of the distance kernel from the electrogram array, we undo the blurring and estimate the underlying transmembrane currents as our desired local activities. However, deconvolution problems are typically highly ill-posed and result in unstable solutions. To overcome this issue, we propose to use a regularization term that exploits the sparsity of the first-order time derivative of the transmembrane currents. RESULTS We perform experiments on simulated two-dimensional tissues, as well as clinically recorded electrograms during paroxysmal atrial fibrillation. The results show that the proposed approach for deconvolution can improve the annotation of the true LAT in the electrograms. We also discuss, in summary, the required electrode array specifications for an appropriate recording and subsequent deconvolution. CONCLUSION By ignoring small but local deflections, algorithms based on steepest descent are prone to generate smoother activation maps. However, by exploiting multi-electrode recordings, we can efficiently amplify small but local deflections and reveal new details in the activation maps that were previously missed.
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Affiliation(s)
- Bahareh Abdi
- Circuits and Systems (CAS) Group, Delft University of Technology, The Netherlands.
| | - Richard C Hendriks
- Circuits and Systems (CAS) Group, Delft University of Technology, The Netherlands
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Johner N, Namdar M, Shah DC. Sustained and self-terminating atrial fibrillation induced immediately after pulmonary vein isolation exhibit differences in coronary sinus electrical activity from onset. J Cardiovasc Electrophysiol 2019; 31:150-159. [PMID: 31778260 DOI: 10.1111/jce.14296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 10/16/2019] [Accepted: 10/27/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Little data exists on the electrophysiological differences between sustained atrial fibrillation (sAF; >5 minutes) vs self-terminating nonsustained AF (nsAF; <5 minutes). We sought to investigate the electrophysiological characteristics of coronary sinus (CS) activity during postpulmonary vein isolation (PVI) sAF vs nsAF. METHODS AND RESULTS We studied 142 patients post-PVI for paroxysmal AF (PAF). In a 50-patient subset, CS electrograms in the first 30 seconds of induced AF were analyzed manually. A custom-made algorithm for automated electrogram annotation was derived for validation on the whole patient set. In patients with sAF post-PVI, CS fractionated potentials were ablated. Manual analysis showed that patients with sAF exhibited higher activation pattern variability (2.1 vs 0.5 changes/sec; P < .001); fewer proximal-to-distal wavefronts (25 vs 61%; P < .001); fewer unidirectional wavefronts (60 vs 86%; P < .001); more pivot locations (4.3 vs 2.1; P < .001); shorter cycle lengths (190 vs 220 ms; P < .001); and shorter cumulative isoelectric segments (35 vs 44%; P = .045) compared to nsAF. These observations were confirmed on the whole study population by automated electrogram annotation and sample entropy computation (SampEn: 0.29 ± 0.15 in sAF vs 0.15 ± 0.05 in nsAF; P < .0001). The derived model predicted sAF with 78% sensitivity, 88% specificity; agreement with manual model: 88% (Cohen's kappa= 0.76). CS defragmentation resulted in AF termination or noninducibility in 49% of sAF. CONCLUSION In PAF patients post-PVI, induced sAF shows greater activation sequence variability, shorter cycle length, and higher SampEn in the CS compared to nsAF. Automated electrogram annotation confirmed these results and accurately distinguished self-terminating nsAF episodes from sAF based on 30-second recordings at AF onset.
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Affiliation(s)
- Nicolas Johner
- Cardiology Division, Geneva University Hospitals, Geneva, Switzerland
| | - Mehdi Namdar
- Cardiology Division, Geneva University Hospitals, Geneva, Switzerland
| | - Dipen C Shah
- Cardiology Division, Geneva University Hospitals, Geneva, Switzerland
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Ahmed N, Perveen S, Mehmood A, Rani G, Molon G. Coronary Sinus Ablation Is a Key Player Substrate in Recurrence of Persistent Atrial Fibrillation. Cardiology 2019; 143:107-113. [DOI: 10.1159/000501819] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 06/18/2019] [Indexed: 11/19/2022]
Abstract
Atrial fibrillation (AF) is the most frequent atrial arrhythmia. During the last few decades, owing to numerous advancements in the field of electrophysiology, we reached satisfactory outcomes for paroxysmal AF with the help of ablation procedures. But the most challenging type is still persistent AF. The recurrence rate of AF in patients with persistent AF is very high, which shows the inadequacy of pulmonary vein isolation (PVI). Over the last few decades, we have been trying to gain insight into AF mechanisms, and have come to the conclusion that there must be some triggers and substrates other than pulmonary veins. According to many studies, PVI alone is not enough to deal with persistent AF. The purpose of our review is to summarize updates and to clarify the role of coronary sinus (CS) in AF induction and propagation. This review will provide updated knowledge on developmental, histological, and macroscopic anatomical aspects of CS with its role as arrhythmogenic substrate. This review will also inform readers about application of CS in other electrophysiological procedures.
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26
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Kharbanda RK, Özdemir EH, Taverne YJ, Kik C, Bogers AJ, de Groot NM. Current Concepts of Anatomy, Electrophysiology, and Therapeutic Implications of the Interatrial Septum. JACC Clin Electrophysiol 2019; 5:647-656. [DOI: 10.1016/j.jacep.2019.04.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 04/26/2019] [Accepted: 04/30/2019] [Indexed: 12/28/2022]
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Ganesan P, Cherry EM, Huang DT, Pertsov AM, Ghoraani B. Locating Atrial Fibrillation Rotor and Focal Sources Using Iterative Navigation of Multipole Diagnostic Catheters. Cardiovasc Eng Technol 2019; 10:354-366. [PMID: 30989616 PMCID: PMC6527788 DOI: 10.1007/s13239-019-00414-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 04/08/2019] [Indexed: 01/14/2023]
Abstract
Purpose Multi-polar diagnostic catheters are used to construct the 3D electro-anatomic mapping of the atrium during atrial fibrillation (AF) ablation procedures; however, it remains unclear how to use the electrograms recorded by these catheters to locate AF-driving sites known as focal and rotor source types. The purpose of this study is to present the first algorithm to iteratively navigate a circular multi-polar catheter to locate AF focal and rotor sources without the need to map the entire atria. Methods Starting from an initial location, the algorithm, which was blinded to the location and type of the AF source, iteratively advanced a Lasso catheter based on its electrogram characteristics. The algorithm stopped the catheter when it located of an AF source and identified the type. The efficiency of the algorithm is validated using a set of simulated focal and rotor-driven arrhythmias in fibrotic human 2D and 3D atrial tissue. Results Our study shows the feasibility of locating AF sources with a success rate of greater than 95.25% within average 7.56 ± 2.28 placements independently of the initial position of the catheter and the source type. Conclusions The algorithm could play a critical role in clinical electrophysiology laboratories for mapping patient-specific ablation of AF sources located outside the pulmonary veins and improving the procedure success. Electronic supplementary material The online version of this article (10.1007/s13239-019-00414-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Prasanth Ganesan
- Department of Computer and Electrical Engineering, Florida Atlantic University, Boca Raton, FL, USA
| | - Elizabeth M Cherry
- School of Mathematical Sciences, Rochester Institute of Technology, Rochester, NY, USA
| | - David T Huang
- Department of Cardiology, University of Rochester Medical Center, Rochester, NY, USA
| | - Arkady M Pertsov
- Department of Pharmacology, SUNY Upstate Medical Center, Syracuse, NY, USA
| | - Behnaz Ghoraani
- Department of Computer and Electrical Engineering, Florida Atlantic University, Boca Raton, FL, USA. .,, 777 Glades Road, EE (Bldg. 96) Room 319, Boca Raton, FL, 33431, USA.
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Zuo K, Li K, Liu M, Li J, Liu X, Liu X, Zhong J, Yang X. Correlation of left atrial wall thickness and atrial remodeling in atrial fibrillation: Study based on low-dose-ibutilide-facilitated catheter ablation. Medicine (Baltimore) 2019; 98:e15170. [PMID: 30985700 PMCID: PMC6485781 DOI: 10.1097/md.0000000000015170] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Atrial remodeling plays a significant role during the progression of atrial fibrillation (AF). Left atrial wall thickness (LAT) is a subjective and easily acquirable indicator referring to structural remodeling. Therefore, we aimed to investigate the association between LAT and atrial remodeling substrate, and to explore the predictive role of LAT about strong maintenance substrate and poor response to catheter ablation.LAT was measured by cardiac computed tomography in 2 selected locations (roof and floor) in 100 persistent AF patients. Then the low-dose-ibutilide-facilitated catheter ablation was performed and atrial maintenance substrate was categorized as weak, mild, and strong, based on the response to circumferential pulmonary vein isolation or complex fractionated atrial electrograms ablation. During follow-up, the success rate was evaluated. LAT showed a progressive thickening tendency from weak, mild, to strong maintenance substrate (roof: 2.2 mm vs. 2.6 mm vs. 3.9 mm, P < .0001; floor: 1.7 mm vs. 2.0 mm vs. 2.5 mm, P < .0001). During follow-up, the success rate of ablation was decreased with the maintenance substrate strengthening (weak 80%, mild 64.53%, strong 31.43%, P = .009). LA roof thickness >3.10 mm might be the predictor to strong atrial maintenance substrate and poor response to ablation.LAT was associated with the remodeling extent of atrial maintenance substrate and might predict the response to catheter ablation. These findings could help the clinicians to select the appropriate ablative strategy and predict the complexity and prognosis before catheter ablation.
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Affiliation(s)
- Kun Zuo
- Heart Center & Beijing Key Laboratory of Hypertension
| | - Kuibao Li
- Heart Center & Beijing Key Laboratory of Hypertension
| | - Min Liu
- Department of Radiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Jing Li
- Heart Center & Beijing Key Laboratory of Hypertension
| | - Xiaoqing Liu
- Heart Center & Beijing Key Laboratory of Hypertension
| | - Xingpeng Liu
- Heart Center & Beijing Key Laboratory of Hypertension
| | | | - Xinchun Yang
- Heart Center & Beijing Key Laboratory of Hypertension
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Ganesan P, Salmin A, Cherry EM, Huang DT, Pertsov AM, Ghoraani B. Iterative navigation of multipole diagnostic catheters to locate repeating-pattern atrial fibrillation drivers. J Cardiovasc Electrophysiol 2019; 30:758-768. [PMID: 30725499 PMCID: PMC6554033 DOI: 10.1111/jce.13872] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/16/2019] [Accepted: 01/31/2019] [Indexed: 01/01/2023]
Abstract
Introduction Targeting repeating‐pattern atrial fibrillation (AF) sources (reentry or focal drivers) can help in patient‐specific ablation therapy for AF; however, the development of reliable and accurate tools for locating such sources remains a major challenge. We describe iterative catheter navigation (ICAN) algorithm to locate AF drivers using a conventional circular Lasso catheter. Methods and Results At each step, the algorithm analyzes 10 bipolar electrograms recoded at a given catheter location and the history of previous catheter movements to determine if the source is inside the catheter loop. If not, it calculates new coordinates and selects a new position for the catheter. The process continues until a source is located. The algorithm was evaluated in a computer model of atrial tissue with various degrees of fibrosis under a broad range of arrhythmia scenarios. The latter included slow and fast reentry, macroreentry, figure‐of‐eight reentry, and fibrillatory conduction. Depending on the initial distance of the catheter from the source and scenario, it took about 3 to 16 steps to localize an AF source. In 94% of cases, the identified location was within 4 mm from the source, independently of the initial position of the catheter. The algorithm worked equally well in the presence of patchy fibrosis, low‐voltage areas, fragmented electrograms, and dominant‐frequency gradients. Conclusions AF repeating‐pattern sources can be localized using circular catheters without the need to map the entire tissue. The proposed algorithm has the potential to become a useful tool for patient‐specific ablation of AF sources located outside the pulmonary veins.
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Affiliation(s)
- Prasanth Ganesan
- Computer and Electrical Engineering and Computer Science, Florida Atlantic University, Boca Raton, Florida
| | - Anthony Salmin
- School of Mathematical Sciences, Rochester Institute of Technology, Rochester, New York
| | - Elizabeth M Cherry
- School of Mathematical Sciences, Rochester Institute of Technology, Rochester, New York
| | - David T Huang
- Department of Cardiology, University of Rochester Medical Center, Rochester, New York
| | - Arkady M Pertsov
- Department of Pharmacology, SUNY Upstate Medical Center, Syracuse, New York
| | - Behnaz Ghoraani
- Computer and Electrical Engineering and Computer Science, Florida Atlantic University, Boca Raton, Florida
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Pak HN. Catheter Ablation of Long-standing Persistent Atrial Fibrillation: a Reckless Challenge or a Way to Real Cure? Korean Circ J 2019; 49:134-145. [PMID: 30693681 PMCID: PMC6351275 DOI: 10.4070/kcj.2018.0418] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 12/10/2018] [Indexed: 11/11/2022] Open
Abstract
Long-standing persistent atrial fibrillation (L-PeAF) is a category in which rhythm control is attempted while atrial fibrillation (AF) is maintained for more than 1 year. Because AF is a progressive disease and L-PeAF accompanies significant electrical and structural remodeling of atria, it is difficult to restore and maintain sinus rhythm in patients with L-PeAF. Nonetheless, the rhythm outcome is being increasingly improved by the development of sophisticated mapping devices, highly efficient catheters, and evidence-based ablation strategies, and the rational choice of patient selection criteria. This review discusses the evolution of the rhythm control outcome of L-PeAF and its future direction of development.
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Affiliation(s)
- Hui Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, Korea.
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31
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Starreveld R, van der Does LJME, de Groot NMS. Anatomical hotspots of fractionated electrograms in the left and right atrium: do they exist? Europace 2019; 21:60-72. [PMID: 29688325 DOI: 10.1093/europace/euy059] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 03/08/2018] [Indexed: 11/14/2022] Open
Abstract
Aims Targeting of complex fractionated electrograms (CFEs) in the atria is not yet beneficial in treating drug-refractory atrial fibrillation (AF). In order to gain insight into potential anatomical hotspots of fractionated electrograms, a structured literature search was performed. Methods and results PubMed was searched for studies describing fractionation during human atrial electrophysiological measurements (n = 565), of which 36 articles described the pre-ablation distribution of fractionated electrograms for the left atrium and/or right atrium in at least four regions. Fractionation was commonly found in high proportions within all regions of both atria, without clear preference for specific regions. Furthermore, no differences in the fractionation distribution between paroxysmal AF and persistent AF patients were observed. Conclusion Whereas atrial inhomogeneous conduction is widely believed to play a key role in AF initiation and perpetuation, different electrophysiological causes for fractionation and the influence of measurement properties complicate identification of the arrhythmogenic substrate. Thereby, simply targeting all CFEs would be short-sighted. Further research is warranted on how to distinguish 'physiologic CFEs' from 'pathologic CFEs', with only the latter reflecting potential targets for ablative therapy of AF.
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Affiliation(s)
- Roeliene Starreveld
- Department of Cardiology, Erasmus University Medical Center, 's Gravendijkwal 230, CA, Rotterdam, the Netherlands
| | - Lisette J M E van der Does
- Department of Cardiology, Erasmus University Medical Center, 's Gravendijkwal 230, CA, Rotterdam, the Netherlands
| | - Natasja M S de Groot
- Department of Cardiology, Erasmus University Medical Center, 's Gravendijkwal 230, CA, Rotterdam, the Netherlands
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Handa BS, Roney CH, Houston C, Qureshi NA, Li X, Pitcher DS, Chowdhury RA, Lim PB, Dupont E, Niederer SA, Cantwell CD, Peters NS, Ng FS. Analytical approaches for myocardial fibrillation signals. Comput Biol Med 2018; 102:315-326. [PMID: 30025847 PMCID: PMC6215772 DOI: 10.1016/j.compbiomed.2018.07.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 07/11/2018] [Accepted: 07/11/2018] [Indexed: 12/11/2022]
Abstract
Atrial and ventricular fibrillation are complex arrhythmias, and their underlying mechanisms remain widely debated and incompletely understood. This is partly because the electrical signals recorded during myocardial fibrillation are themselves complex and difficult to interpret with simple analytical tools. There are currently a number of analytical approaches to handle fibrillation data. Some of these techniques focus on mapping putative drivers of myocardial fibrillation, such as dominant frequency, organizational index, Shannon entropy and phase mapping. Other techniques focus on mapping the underlying myocardial substrate sustaining fibrillation, such as voltage mapping and complex fractionated electrogram mapping. In this review, we discuss these techniques, their application and their limitations, with reference to our experimental and clinical data. We also describe novel tools including a new algorithm to map microreentrant circuits sustaining fibrillation.
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Affiliation(s)
- Balvinder S Handa
- ElectroCardioMaths, Imperial Centre for Cardiac Engineering, National Heart & Lung Institute, Imperial College London, United Kingdom
| | - Caroline H Roney
- Division of Imaging Sciences and Bioengineering, King's College London, United Kingdom
| | - Charles Houston
- ElectroCardioMaths, Imperial Centre for Cardiac Engineering, National Heart & Lung Institute, Imperial College London, United Kingdom
| | - Norman A Qureshi
- ElectroCardioMaths, Imperial Centre for Cardiac Engineering, National Heart & Lung Institute, Imperial College London, United Kingdom
| | - Xinyang Li
- ElectroCardioMaths, Imperial Centre for Cardiac Engineering, National Heart & Lung Institute, Imperial College London, United Kingdom
| | - David S Pitcher
- ElectroCardioMaths, Imperial Centre for Cardiac Engineering, National Heart & Lung Institute, Imperial College London, United Kingdom
| | - Rasheda A Chowdhury
- ElectroCardioMaths, Imperial Centre for Cardiac Engineering, National Heart & Lung Institute, Imperial College London, United Kingdom
| | - Phang Boon Lim
- ElectroCardioMaths, Imperial Centre for Cardiac Engineering, National Heart & Lung Institute, Imperial College London, United Kingdom
| | - Emmanuel Dupont
- ElectroCardioMaths, Imperial Centre for Cardiac Engineering, National Heart & Lung Institute, Imperial College London, United Kingdom
| | - Steven A Niederer
- Division of Imaging Sciences and Bioengineering, King's College London, United Kingdom
| | - Chris D Cantwell
- ElectroCardioMaths, Imperial Centre for Cardiac Engineering, National Heart & Lung Institute, Imperial College London, United Kingdom; Department of Aeronautics, Imperial College London, United Kingdom
| | - Nicholas S Peters
- ElectroCardioMaths, Imperial Centre for Cardiac Engineering, National Heart & Lung Institute, Imperial College London, United Kingdom
| | - Fu Siong Ng
- ElectroCardioMaths, Imperial Centre for Cardiac Engineering, National Heart & Lung Institute, Imperial College London, United Kingdom.
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33
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Cheniti G, Vlachos K, Pambrun T, Hooks D, Frontera A, Takigawa M, Bourier F, Kitamura T, Lam A, Martin C, Dumas-Pommier C, Puyo S, Pillois X, Duchateau J, Klotz N, Denis A, Derval N, Jais P, Cochet H, Hocini M, Haissaguerre M, Sacher F. Atrial Fibrillation Mechanisms and Implications for Catheter Ablation. Front Physiol 2018; 9:1458. [PMID: 30459630 PMCID: PMC6232922 DOI: 10.3389/fphys.2018.01458] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 09/26/2018] [Indexed: 01/14/2023] Open
Abstract
AF is a heterogeneous rhythm disorder that is related to a wide spectrum of etiologies and has broad clinical presentations. Mechanisms underlying AF are complex and remain incompletely understood despite extensive research. They associate interactions between triggers, substrate and modulators including ionic and anatomic remodeling, genetic predisposition and neuro-humoral contributors. The pulmonary veins play a key role in the pathogenesis of AF and their isolation is associated to high rates of AF freedom in patients with paroxysmal AF. However, ablation of persistent AF remains less effective, mainly limited by the difficulty to identify the sources sustaining AF. Many theories were advanced to explain the perpetuation of this form of AF, ranging from a single localized focal and reentrant source to diffuse bi-atrial multiple wavelets. Translating these mechanisms to the clinical practice remains challenging and limited by the spatio-temporal resolution of the mapping techniques. AF is driven by focal or reentrant activities that are initially clustered in a relatively limited atrial surface then disseminate everywhere in both atria. Evidence for structural remodeling, mainly represented by atrial fibrosis suggests that reentrant activities using anatomical substrate are the key mechanism sustaining AF. These reentries can be endocardial, epicardial, and intramural which makes them less accessible for mapping and for ablation. Subsequently, early interventions before irreversible remodeling are of major importance. Circumferential pulmonary vein isolation remains the cornerstone of the treatment of AF, regardless of the AF form and of the AF duration. No ablation strategy consistently demonstrated superiority to pulmonary vein isolation in preventing long term recurrences of atrial arrhythmias. Further research that allows accurate identification of the mechanisms underlying AF and efficient ablation should improve the results of PsAF ablation.
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Affiliation(s)
- Ghassen Cheniti
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France.,Cardiology Department, Hopital Sahloul, Universite de Sousse, Sousse, Tunisia
| | - Konstantinos Vlachos
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Thomas Pambrun
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Darren Hooks
- Cardiology Department, Wellington Hospital, Wellington, New Zealand
| | - Antonio Frontera
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Masateru Takigawa
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Felix Bourier
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Takeshi Kitamura
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Anna Lam
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Claire Martin
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | | | - Stephane Puyo
- Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Xavier Pillois
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France
| | - Josselin Duchateau
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Nicolas Klotz
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Arnaud Denis
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Nicolas Derval
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Pierre Jais
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Hubert Cochet
- Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France.,Department of Cardiovascular Imaging, Hopital Haut Leveque, Bordeaux, France
| | - Meleze Hocini
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Michel Haissaguerre
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Frederic Sacher
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
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Valinoti M, Masci A, Berto F, Severi S, Corsi C. Towards a repository of synthetic electrograms for atrial activation detection in atrial fibrillation. Comput Biol Med 2018; 101:229-235. [PMID: 30212744 DOI: 10.1016/j.compbiomed.2018.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 08/31/2018] [Accepted: 09/01/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Recently, the analysis of the spatio-temporal behavior of atrial fibrillation activation patterns has been widely investigated with the aim to better understand the arrhythmia implications on the heart electrical activity. Most of the proposed techniques are based on atrial activation timing detections. Unfortunately atrial activation timings are not easily recognizable on the electrograms (EGMs) and an approach to support the validation of such techniques is highly desirable. The aim of this study is to provide an effective workflow for the generation of synthetic unipolar atrial electrograms (SEGMs) in atrial fibrillation (AF) condition and with different levels of noise. METHOD Real EGMs signals were obtained from a dataset of 6 subjects that underwent ablation. Each SEGM was obtained by modeling the three principal components of an EGM starting from real signals: atrial far-field (Afar), atrial near-field (Anear) and the ventricular far-field (Vfar). Afar was generated using an autoregressive model applied on segments from real EGMs not characterized by ventricular or atrial activations; Anear and Vfar were extracted directly from the real signals. A Gamma distribution and an atrio-ventricular node model were used to locate both Anear and Vfar on Afar, respectively. Three electrophysiologists with different levels of expertise evaluated the realism of the SEGMs on a set of 100 randomly selected signals including 50 EGMs and 50 SEGMs. Analysis was repeated by the three experts on a subset of 21 signals. RESULTS The time required to generate the synthetic EGMs was less than 1 min once annotated EGMs are available. The cardiologists succeeded in distinguishing real from synthetic EGMs in 45%, 43% and 35% of the signals, respectively. By repeating the evaluation, 28%, 0% and 48% of signals were classified differently, including 67%, 52% and 36% of correct classifications. CONCLUSION The proposed approach proved to be effective in producing SEGMs which are difficult to distinguish from real EGMs. This study provides a tool for realistic SEGM generation from real EGMs in AF condition with different levels of noise and at different AF rates. The tool may be easily adopted to obtain SEGMs in different arrhythmic conditions. SEGMs generated in this study are shared with the scientific community as a first step towards a repository of synthetic and real atrial signals supporting the benchmarking of new approaches to investigate AF.
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Affiliation(s)
- Maddalena Valinoti
- Department of Electrical, Electronic, and Information Engineering "Guglielmo Marconi", University of Bologna, Via Venezia 52, 47521, Bologna, Cesena, Italy
| | - Alessandro Masci
- Department of Electrical, Electronic, and Information Engineering "Guglielmo Marconi", University of Bologna, Via Venezia 52, 47521, Bologna, Cesena, Italy.
| | - Francesca Berto
- Department of Electrical, Electronic, and Information Engineering "Guglielmo Marconi", University of Bologna, Via Venezia 52, 47521, Bologna, Cesena, Italy
| | - Stefano Severi
- Department of Electrical, Electronic, and Information Engineering "Guglielmo Marconi", University of Bologna, Via Venezia 52, 47521, Bologna, Cesena, Italy
| | - Cristiana Corsi
- Department of Electrical, Electronic, and Information Engineering "Guglielmo Marconi", University of Bologna, Via Venezia 52, 47521, Bologna, Cesena, Italy.
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Ammar-Busch S, Reents T, Knecht S, Rostock T, Arentz T, Duytschaever M, Neumann T, Cauchemez B, Albenque JP, Hessling G, Deisenhofer I. Correlation between atrial fibrillation driver locations and complex fractionated atrial electrograms in patients with persistent atrial fibrillation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:1279-1285. [DOI: 10.1111/pace.13483] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 06/13/2018] [Accepted: 06/15/2018] [Indexed: 12/01/2022]
Affiliation(s)
- Sonia Ammar-Busch
- Klinikum Coburg; Coburg Germany
- Department of Electrophysiology, Deutsches Herzzentrum München; Technische Universitaet; Munich Germany
| | - Tilko Reents
- Department of Electrophysiology, Deutsches Herzzentrum München; Technische Universitaet; Munich Germany
| | | | - Thomas Rostock
- Johannes Gutenberg-University Mainz; University Hospital; II. Medical Clinic Germany
| | - Thomas Arentz
- Universitäts-Herzzentrum Freiburg-Bad Krozingen; Bad Krozingen Germany
| | | | | | | | | | - Gabriele Hessling
- Department of Electrophysiology, Deutsches Herzzentrum München; Technische Universitaet; Munich Germany
| | - Isabel Deisenhofer
- Department of Electrophysiology, Deutsches Herzzentrum München; Technische Universitaet; Munich Germany
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36
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Rubenstein DS, Yin H, Azami SA. Compass Mapping, Double Potentials, Activation Patterns Can Identify and Track Rotational Activity Sites in the Left Atrium of Humans with Persistent Atrial Fibrillation. J Atr Fibrillation 2018; 11:2053. [PMID: 30505380 PMCID: PMC6244311 DOI: 10.4022/jafib.2053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 06/28/2018] [Accepted: 07/25/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND Rotational circuits that occur between bipolar electrodes exhibit double potentials (DPs). It had been previously surmised that rotors could not be electrically tracked directly. PURPOSE Our purpose was twofold; first, to show that the use of compass mapping, one can regionally identify rotational activity; and second, to show that by combining simultaneous compass map recordings, standard narrow-adjacent bipolar, and unipolar recordings, that specific signature recording patterns emerge that allow one to identify the accurate time, location, and path of a rotational mechanism. METHODS This was an observational study in 20 patients with persistent atrial fibrillation in which the electrode configuration of a circular mapping catheter was changed to wide cross-circle electrode pairing (compass mapping). DPs were recorded and analyzed from 12 left atrial (LA) sites and identified electrical wavefront patterns and direction. A substudy analyzed transitions patterns with simultaneous narrow-adjacent bipolar and unipolar recordings. RESULTS Four wavefront patterns were identified: DPs, peripheral waves (PWs), distal peripheral waves and fibrillatory activity. DP wavefront patterns exhibited significantly shorter cycle lengths than PWs in 8 of 12 LA sites. Patients had 2.9± 2.1 regions that exhibited DPs. DPs of varying duration were found, few (25%) were of stable duration and location. Detailed electrical examination at the transition between a PW to a DP identified a highly consistent pattern of simultaneous reversal of activation sequence, a special form of Doppler effect for spiral waves as a rotor passes between 2 electrodes, and a ½ cycle drop-off of activation signals along the line of electrodes. CONCLUSION DP recordings in compass mode can provide a regional assessment for the existence of rotational activity. Simultaneous DP recordings in compass mode, narrow-adjacent bipolar, and unipolar recording provide an accurate assessment of the time, location, and path that a rotational mechanism breaches a perimeter of electrodes. Accurate time, location and path of perimeter breaches can be used to electrically track rotational mechanisms during atrial fibrillation.
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Affiliation(s)
- Donald S Rubenstein
- Greenville Health System, Greenville Health System, 701 Grove Road, Greenville, SC 29605
| | - Hang Yin
- Provident Sacred Heart Medical Center, 101 W 8th Ave, Spokane, WA 99204
| | - Sana A Azami
- Greenville Health System, 701 Grove Road, Greenville, SC 29605
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37
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van Hunnik A, Zeemering S, Podziemski P, Simons J, Gatta G, Hannink L, Maesen B, Kuiper M, Verheule S, Schotten U. Stationary Atrial Fibrillation Properties in the Goat Do Not Entail Stable or Recurrent Conduction Patterns. Front Physiol 2018; 9:947. [PMID: 30100877 PMCID: PMC6072874 DOI: 10.3389/fphys.2018.00947] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 06/28/2018] [Indexed: 12/04/2022] Open
Abstract
Introduction: Electro-anatomical mapping of the atria is used to identify the substrate of atrial fibrillation (AF). Targeting this substrate by ablation in addition to pulmonary vein ablation did not consistently improve outcome in clinical trials. Generally, the assessment of the substrate is based on short recordings (≤10 s, often even shorter). Thus, targeting the AF substrate assumes spatiotemporal stationarity but little is known about the variability of electrophysiological properties of AF over time. Methods: Atrial fibrillation (AF) was maintained for 3–4 weeks after pericardial electrode implantation in 12 goats. Within a single AF episode 10 consecutive minutes were mapped on the left atrial free wall using a 249-electrode array (2.25 mm inter-electrode spacing). AF cycle length, fractionation index (FI), lateral dissociation, conduction velocity, breakthroughs, and preferentiality of conduction (Pref) were assessed per electrode and AF property maps were constructed. The Pearson correlation coefficient (PCC) between the 10 AF-property maps was calculated to quantify the degree spatiotemporal stationarity of AF properties. Furthermore, the number of waves and presence of re-entrant circuits were analyzed in the first 60-s file. Comparing conduction patterns over time identified recurrent patterns of AF with the use of recurrence plots. Results: The averages of AF property maps were highly stable throughout the ten 60-s-recordings. Spatiotemporal stationarity was high for all 6 property maps, PCC ranged from 0.66 ± 0.11 for Pref to 0.98 ± 0.01 for FI. High stationarity was lost when AF was interrupted for about 1 h. However, the time delay between the recorded files within one episode did not affect PCC. Yet, multiple waves (7.7 ± 2.3) were present simultaneously within the recording area and during 9.2 ± 11% of the analyzed period a re-entrant circuit was observed. Recurrent patterns occurred rarely and were observed in only 3 out of 12 goats. Conclusions: During non-self-terminating AF in the goat, AF properties were stationary. Since this could not be attributed to stable recurrent conduction patterns during AF, it is suggested that AF properties are determined by anatomical and structural properties of the atria even when the conduction patterns are very variable.
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Affiliation(s)
- Arne van Hunnik
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Stef Zeemering
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Piotr Podziemski
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Jorik Simons
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Giulia Gatta
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Laura Hannink
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Bart Maesen
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Marion Kuiper
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Sander Verheule
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Ulrich Schotten
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
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38
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Dharmaprani D, Dykes L, McGavigan AD, Kuklik P, Pope K, Ganesan AN. Information Theory and Atrial Fibrillation (AF): A Review. Front Physiol 2018; 9:957. [PMID: 30050471 PMCID: PMC6052893 DOI: 10.3389/fphys.2018.00957] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 06/29/2018] [Indexed: 11/13/2022] Open
Abstract
Atrial Fibrillation (AF) is the most common cardiac rhythm disorder seen in hospitals and in general practice, accounting for up to a third of arrhythmia related hospitalizations. Unfortunately, AF treatment is in practice complicated by the lack of understanding of the fundamental mechanisms underlying the arrhythmia, which makes detection of effective ablation targets particularly difficult. Various approaches to AF mapping have been explored in the hopes of better pinpointing these effective targets, such as Dominant Frequency (DF) analysis, complex fractionated electrograms (CFAE) and unipolar reconstruction (FIRM), but many of these methods have produced conflicting results or require further investigation. Exploration of AF using information theoretic-based approaches may have the potential to provide new insights into the complex system dynamics of AF, whilst also providing the benefit of being less reliant on empirically derived definitions in comparison to alternate mapping approaches. This work provides an overview of information theory and reviews its applications in AF analysis, with particular focus on AF mapping. The works discussed in this review demonstrate how understanding AF from a signal property perspective can provide new insights into the arrhythmic phenomena, which may have valuable clinical implications for AF mapping and ablation in the future.
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Affiliation(s)
- Dhani Dharmaprani
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, SA, Australia
| | - Lukah Dykes
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia
| | - Andrew D. McGavigan
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, SA, Australia
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia
| | - Pawel Kuklik
- Department of Cardiology, University Medical Centre, Hamburg, Germany
| | - Kenneth Pope
- College of Science and Engineering, Flinders University of South Australia, Adelaide, SA, Australia
| | - Anand N. Ganesan
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, SA, Australia
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia
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Alagoz C, Cohen AR, Frisch DR, Tunç B, Phatharodom S, Guez A. Spiral waves characterization: Implications for an automated cardiodynamic tissue characterization. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2018; 161:15-24. [PMID: 29852958 DOI: 10.1016/j.cmpb.2018.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 02/25/2018] [Accepted: 04/04/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND AND OBJECTIVE Spiral waves are phenomena observed in cardiac tissue especially during fibrillatory activities. Spiral waves are revealed through in-vivo and in-vitro studies using high density mapping that requires special experimental setup. Also, in-silico spiral wave analysis and classification is performed using membrane potentials from entire tissue. In this study, we report a characterization approach that identifies spiral wave behaviors using intracardiac electrogram (EGM) readings obtained with commonly used multipolar diagnostic catheters that perform localized but high-resolution readings. Specifically, the algorithm is designed to distinguish between stationary, meandering, and break-up rotors. METHODS The clustering and classification algorithms are tested on simulated data produced using a phenomenological 2D model of cardiac propagation. For EGM measurements, unipolar-bipolar EGM readings from various locations on tissue using two catheter types are modeled. The distance measure between spiral behaviors are assessed using normalized compression distance (NCD), an information theoretical distance. NCD is a universal metric in the sense it is solely based on compressibility of dataset and not requiring feature extraction. We also introduce normalized FFT distance (NFFTD) where compressibility is replaced with a FFT parameter. RESULTS Overall, outstanding clustering performance was achieved across varying EGM reading configurations. We found that effectiveness in distinguishing was superior in case of NCD than NFFTD. We demonstrated that distinct spiral activity identification on a behaviorally heterogeneous tissue is also possible. CONCLUSIONS This report demonstrates a theoretical validation of clustering and classification approaches that provide an automated mapping from EGM signals to assessment of spiral wave behaviors and hence offers a potential mapping and analysis framework for cardiac tissue wavefront propagation patterns.
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Affiliation(s)
- Celal Alagoz
- ECE Department, Drexel University, Philadelphia, PA 19104, USA.
| | - Andrew R Cohen
- ECE Department, Drexel University, Philadelphia, PA 19104, USA
| | - Daniel R Frisch
- Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA
| | - Birkan Tunç
- Center for Biomedical Image Computing and Analytics, Department of Radiology, University of Pennsylvania, Philadelphia, PA 19104, USA
| | | | - Allon Guez
- ECE Department, Drexel University, Philadelphia, PA 19104, USA.
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40
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Chowdhury RA, Tzortzis KN, Dupont E, Selvadurai S, Perbellini F, Cantwell CD, Ng FS, Simon AR, Terracciano CM, Peters NS. Concurrent micro- to macro-cardiac electrophysiology in myocyte cultures and human heart slices. Sci Rep 2018; 8:6947. [PMID: 29720607 PMCID: PMC5932023 DOI: 10.1038/s41598-018-25170-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 04/17/2018] [Indexed: 11/25/2022] Open
Abstract
The contact cardiac electrogram is derived from the extracellular manifestation of cellular action potentials and cell-to-cell communication. It is used to guide catheter based clinical procedures. Theoretically, the contact electrogram and the cellular action potential are directly related, and should change in conjunction with each other during arrhythmogenesis, however there is currently no methodology by which to concurrently record both electrograms and action potentials in the same preparation for direct validation of their relationships and their direct mechanistic links. We report a novel dual modality apparatus for concurrent electrogram and cellular action potential recording at a single cell level within multicellular preparations. We further demonstrate the capabilities of this system to validate the direct link between these two modalities of voltage recordings.
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Affiliation(s)
- Rasheda A Chowdhury
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, 4th floor Imperial Centre for Translational and Experimental Medicine, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK. .,ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, UK.
| | - Konstantinos N Tzortzis
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, 4th floor Imperial Centre for Translational and Experimental Medicine, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK.,ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Emmanuel Dupont
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, 4th floor Imperial Centre for Translational and Experimental Medicine, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK.,ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Shaun Selvadurai
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, 4th floor Imperial Centre for Translational and Experimental Medicine, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK.,ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Filippo Perbellini
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, 4th floor Imperial Centre for Translational and Experimental Medicine, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK
| | - Chris D Cantwell
- Department of Aeronautics, Imperial College London, South Kensington Campus, London, SW7 2AZ, UK. .,ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, UK.
| | - Fu Siong Ng
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, 4th floor Imperial Centre for Translational and Experimental Medicine, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK.,ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Andre R Simon
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, London, UB9 6JH, UK
| | - Cesare M Terracciano
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, 4th floor Imperial Centre for Translational and Experimental Medicine, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK
| | - Nicholas S Peters
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, 4th floor Imperial Centre for Translational and Experimental Medicine, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK.,ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
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41
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Grieco D, Palamà Z, Borrelli A, De Ruvo E, Sciarra L, Scarà A, Goanta E, Calabrese V, Pozzilli P, Di Sciascio G, Calò L. Diabetes mellitus and atrial remodelling in patients with paroxysmal atrial fibrillation: Role of electroanatomical mapping and catheter ablation. Diab Vasc Dis Res 2018; 15:185-195. [PMID: 29338326 DOI: 10.1177/1479164117752492] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Complex fractionated atrial electrograms (CFAEs) are related to atrial fibrosis, but their ablation has not yet shown superiority. The aim of the study was to compare, in terms of clinical outcome, two strategies of paroxysmal atrial fibrillation (AF) ablation in patients with type 1 diabetes mellitus (DM): pulmonary vein isolation (PVI) vs. PVI + CFAEs. Compared to an historical population of patient with paroxysmal AF and without DM, a higher percentage of patients with DM showed more than 25% of atrial area interested by CFAEs (study population, 58% vs historical group, 15%; p < 0.05). In PVI group, recurrences rate was similar in patients with HbA1c ⩽ 7.5% vs HbA1c > 7.5% (30% vs 22%; p = not significant), but a greater AF burden was observed in patients with HbA1c > 7.5% (6 ± 2 vs 1 ± 2; p < 0.05). In hazard ratios analysis PVI+CFAEs seems more effective than PVI alone in patients with HbA1c > 7.5% (hazard ratio, 1.28; p < 0.05), more than 25 years from DM diagnosis (hazard ratio, 1.25; p < 0.05) and more than five AF episodes/year (hazard ratio, 1.2; p < 0.05). Type 1 DM patients had complex atrial 'substrate', as documented by wider CFAEs areas. Despite this, 1-year follow-up recurrence rate was similar between two ablation approaches (PVI 27% vs. PVI+CFAEs 21%; p = not significant). In our study, only specific subgroups, like patients with disglycaemic state (HbA1c > 7.5%), long diabetes mellitus history and high AF burden, benefit from PVI+ CFAEs approach.
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Affiliation(s)
| | | | | | | | - Luigi Sciarra
- 1 Cardiology Unit, Policlinico Casilino, Rome, Italy
| | - Antonio Scarà
- 1 Cardiology Unit, Policlinico Casilino, Rome, Italy
| | - Emilia Goanta
- 2 Institutul De Boli Cardiovasculare Timisoara, Timisoara, Romania
| | - Vito Calabrese
- 3 Cardiology Unit, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Paolo Pozzilli
- 4 Endocrinology and Diabetes Unit, Università Campus Bio-Medico di Roma, Rome, Italy
| | | | - Leonardo Calò
- 1 Cardiology Unit, Policlinico Casilino, Rome, Italy
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Attuel G, Gerasimova-Chechkina E, Argoul F, Yahia H, Arneodo A. Multifractal Desynchronization of the Cardiac Excitable Cell Network During Atrial Fibrillation. I. Multifractal Analysis of Clinical Data. Front Physiol 2018; 8:1139. [PMID: 29632492 PMCID: PMC5880174 DOI: 10.3389/fphys.2017.01139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 12/24/2017] [Indexed: 12/19/2022] Open
Abstract
Atrial fibrillation (AF) is a cardiac arrhythmia characterized by rapid and irregular atrial electrical activity with a high clinical impact on stroke incidence. Best available therapeutic strategies combine pharmacological and surgical means. But when successful, they do not always prevent long-term relapses. Initial success becomes all the more tricky to achieve as the arrhythmia maintains itself and the pathology evolves into sustained or chronic AF. This raises the open crucial issue of deciphering the mechanisms that govern the onset of AF as well as its perpetuation. In this study, we develop a wavelet-based multi-scale strategy to analyze the electrical activity of human hearts recorded by catheter electrodes, positioned in the coronary sinus (CS), during episodes of AF. We compute the so-called multifractal spectra using two variants of the wavelet transform modulus maxima method, the moment (partition function) method and the magnitude cumulant method. Application of these methods to long time series recorded in a patient with chronic AF provides quantitative evidence of the multifractal intermittent nature of the electric energy of passing cardiac impulses at low frequencies, i.e., for times (≳0.5 s) longer than the mean interbeat (≃ 10-1 s). We also report the results of a two-point magnitude correlation analysis which infers the absence of a multiplicative time-scale structure underlying multifractal scaling. The electric energy dynamics looks like a "multifractal white noise" with quadratic (log-normal) multifractal spectra. These observations challenge concepts of functional reentrant circuits in mechanistic theories of AF, still leaving open the role of the autonomic nervous system (ANS). A transition is indeed observed in the computed multifractal spectra which group according to two distinct areas, consistently with the anatomical substrate binding to the CS, namely the left atrial posterior wall, and the ligament of Marshall which is innervated by the ANS. In a companion paper (II. Modeling), we propose a mathematical model of a denervated heart where the kinetics of gap junction conductance alone induces a desynchronization of the myocardial excitable cells, accounting for the multifractal spectra found experimentally in the left atrial posterior wall area.
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Affiliation(s)
- Guillaume Attuel
- Geometry and Statistics in Acquisition Data, Centre de Recherche INRIA, Talence, France
| | | | - Francoise Argoul
- Laboratoire Ondes et Matières d'Aquitaine, Université de Bordeaux, Centre National de la Recherche Scientifique, UMR 5798, Talence, France
| | - Hussein Yahia
- Geometry and Statistics in Acquisition Data, Centre de Recherche INRIA, Talence, France
| | - Alain Arneodo
- Laboratoire Ondes et Matières d'Aquitaine, Université de Bordeaux, Centre National de la Recherche Scientifique, UMR 5798, Talence, France
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Sahli Costabal F, Zaman JAB, Kuhl E, Narayan SM. Interpreting Activation Mapping of Atrial Fibrillation: A Hybrid Computational/Physiological Study. Ann Biomed Eng 2018; 46:257-269. [PMID: 29214421 PMCID: PMC5880222 DOI: 10.1007/s10439-017-1969-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 11/23/2017] [Indexed: 11/30/2022]
Abstract
Atrial fibrillation is the most common rhythm disorder of the heart associated with a rapid and irregular beating of the upper chambers. Activation mapping remains the gold standard to diagnose and interpret atrial fibrillation. However, fibrillatory activation maps are highly sensitive to far-field effects, and often disagree with other optical mapping modalities. Here we show that computational modeling can identify spurious non-local components of atrial fibrillation electrograms and improve activation mapping. We motivate our approach with a cohort of patients with potential drivers of persistent atrial fibrillation. In a computational study using a monodomain Maleckar model, we demonstrate that in organized rhythms, electrograms successfully track local activation, whereas in atrial fibrillation, electrograms are sensitive to spiral wave distance and number, spiral tip trajectories, and effects of fibrosis. In a clinical study, we analyzed n = 15 patients with persistent atrial fibrillation that was terminated by limited ablation. In five cases, traditional activation maps revealed a spiral wave at sites of termination; in ten cases, electrogram timings were ambiguous and activation maps showed incomplete reentry. By adjusting electrogram timing through computational modeling, we found rotational activation, which was undetectable with conventional methods. Our results demonstrate that computational modeling can identify non-local deflections to improve activation mapping and explain how and where ablation can terminate persistent atrial fibrillation. Our hybrid computational/physiological approach has the potential to optimize map-guided ablation and improve ablation therapy in atrial fibrillation.
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Mann I, Sandler B, Linton N, Kanagaratnam P. Drivers of Atrial Fibrillation: Theoretical Considerations and Practical Concerns. Arrhythm Electrophysiol Rev 2018; 7:49-54. [PMID: 29636973 DOI: 10.15420/aer.2017.40.3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Understanding the mechanisms responsible for driving AF is key to improving the procedural success for AF ablation. In this review, we look at some of the proposed drivers of AF, the disagreement between experts and the challenges confronted in attempting to map AF. Defining a 'driver' is also controversial, but for the purposes of this review we will consider an AF driver to be either a focal or localised source demonstrating fast, repetitive activity that propagates outward from this source, breaking down in to disorganisation further away from its origin.
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Affiliation(s)
- Ian Mann
- Imperial College Healthcare NHS TrustLondon, UK
| | | | - Nick Linton
- Imperial College Healthcare NHS TrustLondon, UK
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Zaman JAB, Sauer WH, Alhusseini MI, Baykaner T, Borne RT, Kowalewski CAB, Busch S, Zei PC, Park S, Viswanathan MN, Wang PJ, Brachmann J, Krummen DE, Miller JM, Rappel WJ, Narayan SM, Peters NS. Identification and Characterization of Sites Where Persistent Atrial Fibrillation Is Terminated by Localized Ablation. Circ Arrhythm Electrophysiol 2018; 11:e005258. [PMID: 29330332 PMCID: PMC5769709 DOI: 10.1161/circep.117.005258] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 12/04/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND The mechanisms by which persistent atrial fibrillation (AF) terminates via localized ablation are not well understood. To address the hypothesis that sites where localized ablation terminates persistent AF have characteristics identifiable with activation mapping during AF, we systematically examined activation patterns acquired only in cases of unequivocal termination by ablation. METHODS AND RESULTS We recruited 57 patients with persistent AF undergoing ablation, in whom localized ablation terminated AF to sinus rhythm or organized tachycardia. For each site, we performed an offline analysis of unprocessed unipolar electrograms collected during AF from multipolar basket catheters using the maximum -dV/dt assignment to construct isochronal activation maps for multiple cycles. Additional computational modeling and phase analysis were used to study mechanisms of map variability. At all sites of AF termination, localized repetitive activation patterns were observed. Partial rotational circuits were observed in 26 of 57 (46%) cases, focal patterns in 19 of 57 (33%), and complete rotational activity in 12 of 57 (21%) cases. In computer simulations, incomplete segments of partial rotations coincided with areas of slow conduction characterized by complex, multicomponent electrograms, and variations in assigning activation times at such sites substantially altered mapped mechanisms. CONCLUSIONS Local activation mapping at sites of termination of persistent AF showed repetitive patterns of rotational or focal activity. In computer simulations, complete rotational activation sequence was observed but was sensitive to assignment of activation timing particularly in segments of slow conduction. The observed phenomena of repetitive localized activation and the mechanism by which local ablation terminates putative AF drivers require further investigation.
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Affiliation(s)
- Junaid A B Zaman
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| | - William H Sauer
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| | - Mahmood I Alhusseini
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| | - Tina Baykaner
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| | - Ryan T Borne
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| | - Christopher A B Kowalewski
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| | - Sonia Busch
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| | - Paul C Zei
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| | - Shirley Park
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| | - Mohan N Viswanathan
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| | - Paul J Wang
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| | - Johannes Brachmann
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| | - David E Krummen
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| | - John M Miller
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| | - Wouter Jan Rappel
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| | - Sanjiv M Narayan
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.).
| | - Nicholas S Peters
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
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Feature subset selection and classification of intracardiac electrograms during atrial fibrillation. Biomed Signal Process Control 2017. [DOI: 10.1016/j.bspc.2017.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Song JS, Wi J, Lee HJ, Hwang M, Lim B, Kim TH, Uhm J, Joung B, Lee M, Seo JW, Pak HN. Role of atrial wall thickness in wave-dynamics of atrial fibrillation. PLoS One 2017; 12:e0182174. [PMID: 28827810 PMCID: PMC5565105 DOI: 10.1371/journal.pone.0182174] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 07/13/2017] [Indexed: 01/13/2023] Open
Abstract
Background/Aims Atrial anatomy and thickness may affect the electrical wave-dynamics of atrial fibrillation (AF). We explored the relationship between left atrial (LA) wall thickness (LAWT) or LA geometry and AF wave-dynamics. Methods We included 15 patients with persistent AF (age, 62.3 ± 11.9 years) who underwent AF catheter ablation. We measured the LAWT, LA endocardial curvature, and SD-curvature (surface bumpiness) from preprocedural computed tomography images. We compared those anatomical characteristics with electrophysiologic parameters such as dominant frequency (DF), Shannon entropy (ShEn), or complex fractionated atrial electrogram (CFAE)-cycle length (CL), calculated from intracardiac bipolar electrograms (300–500 points, 5 s), acquired during ablation procedures. Results 1. LAWT (excluding fat) varied widely among patients, locations, and types of AF. LAWT was inversely correlated with LA volume (r = -0.565, p = 0.028) and positively correlated with SD-curvature (r = 0.272, p < 0.001). 2. LAWT was positively correlated with ShEn (r = 0.233, p < 0.001) and negatively correlated with CFAE-CL (r = -0.107, p = 0.038). 3. In the multivariate linear regression analyses for AF wave-dynamics parameters, DF (β = -0.29 [95% CI -0.44–-0.14], p < 0.001), ShEn (β = 0.19 [95% CI 0.12–0.25], p < 0.001), and CFAE-CL (β = 7.49 [95% CI 0.65–14.34], p = 0.032) were independently associated with LAWT. Conclusion Regional LAWT is associated with LA structural features, and has significant correlations with the wave-dynamics parameters associated with electrical wavebreaks or rotors in patients with persistent AF.
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Affiliation(s)
- Jun-Seop Song
- Yonsei University Health System, Seoul, Republic of Korea
| | - Jin Wi
- Yonsei University Health System, Seoul, Republic of Korea
| | - Hye-Jeong Lee
- Yonsei University Health System, Seoul, Republic of Korea
| | - Minki Hwang
- Yonsei University Health System, Seoul, Republic of Korea
| | - Byounghyun Lim
- Yonsei University Health System, Seoul, Republic of Korea
| | - Tae-Hoon Kim
- Yonsei University Health System, Seoul, Republic of Korea
| | - Jae‐Sun Uhm
- Yonsei University Health System, Seoul, Republic of Korea
| | - Boyoung Joung
- Yonsei University Health System, Seoul, Republic of Korea
| | | | - Jeong-Wook Seo
- Department of Pathology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hui-Nam Pak
- Yonsei University Health System, Seoul, Republic of Korea
- * E-mail:
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Frontera A, Takigawa M, Martin R, Thompson N, Cheniti G, Massoullié G, Duchateau J, Wielandts JY, Teijeira E, Kitamura T, Wolf M, Al-Jefairi N, Vlachos K, Yamashita S, Amraoui S, Denis A, Hocini M, Cochet H, Sacher F, Jaïs P, Haïssaguerre M, Derval N. Electrogram signature of specific activation patterns: Analysis of atrial tachycardias at high-density endocardial mapping. Heart Rhythm 2017; 15:28-37. [PMID: 28797676 DOI: 10.1016/j.hrthm.2017.08.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND The significance of fractionated electrograms (EGMs) is object of debate, with multiple mechanisms described. OBJECTIVE Using Rhythmia, a high-density mapping system, we sought to investigate the relationship between specific electrophysiological phenomena and EGM characteristics at those sites. METHODS Twenty-five consecutive patients underwent high-density atrial mapping during atrial tachycardias. Bipolar EGMs were recorded with a 64-electrode basket catheter. The following atrial phenomena were identified: slow conduction (SC) areas, lines of block (LB), wavefront collisions (WFC), pivot sites (PS), and gaps. EGMs collected at these predefined areas were analyzed in terms of amplitude, duration, and morphology. RESULTS Twenty-five atrial maps with 195 sites of interest (1755 EGMs) were object of our analysis. Thirty-five percent were sites of SC: fractionation had low amplitude (0.16 ± 0.07 mV) and long duration (87.8 ± 10.7 ms); wavefront collisions were seen in 38% of sites with EGMs shorter in duration (46.5 ± 4.5 ms) and higher in voltage (0.58 ± 0.13 mV); 17% were lines of block, never responsible for fractionation (0.13 ± 0.05 mV; 122.4 ms ± 24.8 ms); 9% were PS with a high degree of fractionation (0.55 ± 0.15 mV; 85.8 ± 7.9 ms). Two gaps were identified (1%) with a low degree of fractionation. CONCLUSION Specific EGM characteristics in atrial tachycardia can be reproducibly linked to electrophysiological mechanisms. High-voltage and short-duration EGMs are associated with collision sites and PS that are unlikely to form critical sites for ablation; long-duration, low-voltage EGMs are associated with SC. However, not all SC regions will lie within the critical circuit and identification by only EGM characteristics cannot guide ablation.
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Affiliation(s)
- Antonio Frontera
- Hôpital Haut-Lèvêque, Pessac (Bordeaux), France; LIRYC Institute, Bordeaux, France.
| | - Masateru Takigawa
- Hôpital Haut-Lèvêque, Pessac (Bordeaux), France; LIRYC Institute, Bordeaux, France
| | | | | | | | | | - Josselin Duchateau
- Hôpital Haut-Lèvêque, Pessac (Bordeaux), France; LIRYC Institute, Bordeaux, France
| | | | | | | | | | | | | | | | | | | | - Meleze Hocini
- Hôpital Haut-Lèvêque, Pessac (Bordeaux), France; LIRYC Institute, Bordeaux, France
| | - Hubert Cochet
- Hôpital Haut-Lèvêque, Pessac (Bordeaux), France; LIRYC Institute, Bordeaux, France
| | - Frederic Sacher
- Hôpital Haut-Lèvêque, Pessac (Bordeaux), France; LIRYC Institute, Bordeaux, France
| | - Pierre Jaïs
- Hôpital Haut-Lèvêque, Pessac (Bordeaux), France; LIRYC Institute, Bordeaux, France
| | - Michel Haïssaguerre
- Hôpital Haut-Lèvêque, Pessac (Bordeaux), France; LIRYC Institute, Bordeaux, France
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49
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Kochhäuser S, Verma A, Dalvi R, Suszko A, Alipour P, Sanders P, Champagne J, Macle L, Nair GM, Calkins H, Wilber DJ, Chauhan VS. Spatial Relationships of Complex Fractionated Atrial Electrograms and Continuous Electrical Activity to Focal Electrical Sources: Implications for Substrate Ablation in Human Atrial Fibrillation. JACC Clin Electrophysiol 2017; 3:1220-1228. [PMID: 29759616 DOI: 10.1016/j.jacep.2017.05.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 04/26/2017] [Accepted: 05/26/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES This study sought to evaluate the spatial relationships of focal electrical sources (FSs) to complex fractionated atrial electrograms (CFAE) and continuous electrical activity (CEA). BACKGROUND Fractionated atrial electrograms have been associated with atrial fibrillation (AF) drivers in computational studies and represent ablation targets in the management of persistent AF. METHODS We included a subset of 66 patients (age: 63 [56, 67] years, 69% persistent AF) with electroanatomic data from the SELECT AF (Selective complex fractionated atrial electrograms targeting for atrial fibrillation) randomized control trial that compared the efficacy of CFAE with CEA ablation in AF patients undergoing pulmonary vein antral ablation. Focal sources were identified based on bipolar electrogram periodicity and QS unipolar electrogram morphology. RESULTS A total of 77 FSs (median: 1 [1st quartile, 3rd quartile: 1, 2] per patient) were identified most commonly in the pulmonary vein antrum and left atrial appendage. The proportions of FSs inside CFAE and CEA regions were similar (13% vs. 1.3%, respectively; p = 0.13). Focal sources were more likely to be on the border zone of CFAEs than in CEAs (49% vs. 7.8%, respectively; p = 0.012). Following ablation, 53% of patients had ≥1 unablated extrapulmonary vein FS. The median number of unablated FS was higher in patients with AF recurrence post ablation than in patients without (median: 1 [0, 1] vs. 0 [0, 1], respectively; p = 0.026). CONCLUSIONS One-half of the FSs detected during AF localized to the border of CFAE areas, whereas most of the FSs were found outside CEA areas. CFAE or CEA ablation leaves a number of FS unablated, which is associated with AF recurrence. These findings suggest that many CFAEs may arise from passive wave propagation, remote from FS, which may limit their therapeutic efficacy in AF substrate modification.
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Affiliation(s)
- Simon Kochhäuser
- Southlake Regional Health Centre, Newmarket, Ontario, Canada; Division of Electrophysiology, Department of Cardiovascular Medicine, University of Münster, Münster, Germany
| | - Atul Verma
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Rupin Dalvi
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Adrian Suszko
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Pouria Alipour
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Prashanthan Sanders
- University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jean Champagne
- Institut de Cardiologie et Pneumologie de l'Université Laval, Quebec City, Quebec, Canada
| | | | - Girish M Nair
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Hugh Calkins
- Johns Hopkins University Hospital, Baltimore, Maryland
| | | | - Vijay S Chauhan
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada.
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50
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Mody BP, Raza A, Jacobson J, Iwai S, Frenkel D, Rojas R, Aronow WS. Ablation of long-standing persistent atrial fibrillation. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:305. [PMID: 28856145 DOI: 10.21037/atm.2017.05.21] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Atrial fibrillation (AF) is the most commonly encountered arrhythmia in the clinical setting affecting nearly 6 million people in United States and the numbers are only expected to rise as the population continues to age. Broadly it is classified into paroxysmal, persistent and longstanding persistent AF. Electrical, structural and autonomic remodeling are some of the diverse pathophysiological mechanisms that contribute to the persistence of AF. Our review article emphasizes particularly on long standing persistent atrial fibrillation (LSPAF) aspect of the disease which poses a great challenge for electrophysiologists. While pulmonary vein isolation (PVI) has been established as a successful ablation strategy for paroxysmal AF, same cannot be said for LSPAF owing to its long duration, complexity of mechanisms, multiple triggers and substrate sites that are responsible for its perpetuation. The article explains different approaches currently being adopted to achieve freedom from atrial arrhythmias. These mainly include ablation techniques chiefly targeting complex fractionated atrial electrograms (CFAE), rotors, linear lesions, scars and even considering hybrid approaches in a few cases while exploring the role of delayed enhancement magnetic resonance imaging (deMRI) in the pre-procedural planning to improve the overall short and long term outcomes of catheter ablation.
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Affiliation(s)
- Behram P Mody
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Anoshia Raza
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Jason Jacobson
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Sei Iwai
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Daniel Frenkel
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Rhadames Rojas
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Wilbert S Aronow
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
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