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Toloubidokhti M, Gharbia OA, Parkosa A, Trayanova N, Nazarian S, Sapp JL, Wang L. Understanding the Utility of Endocardial Electrocardiographic Imaging in Epi-Endocardial Mapping of 3D Reentrant Circuits. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.03.13.24304259. [PMID: 38559058 PMCID: PMC10980114 DOI: 10.1101/2024.03.13.24304259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Background Studies of VT mechanisms are largely based on a 2D portrait of reentrant circuits on one surface of the heart. This oversimplifies the 3D circuit that involves the depth of the myocardium. Simultaneous epicardial and endocardial (epi-endo) mapping was shown to facilitate a 3D delineation of VT circuits, which is however difficult via invasive mapping. Objective This study investigates the capability of noninvasive epicardial-endocardial electrocardiographic imaging (ECGI) to elucidate the 3D construct of VT circuits, emphasizing the differentiation of epicardial, endocardial, and intramural circuits and to determine the proximity of mid-wall exits to the epicardial or endocardial surfaces. Methods 120-lead ECGs of VT in combination with subject-specific heart-torso geometry are used to compute unipolar electrograms (CEGM) on ventricular epicardium and endocardia. Activation isochrones are constructed, and the percentage of activation within VT cycle length is calculated on each surface. This classifies VT circuits into 2D (surface only), uniform transmural, nonuniform transmural, and mid-myocardial (focal on surfaces). Furthermore, the endocardial breakthrough time was accurately measured using Laplacian eigenmaps, and by correlating the delay time of the epi-endo breakthroughs, the relative distance of a mid-wall exit to the epicardium or the endocardium surfaces was identified. Results We analyzed 23 simulated and in-vivo VT circuits on post-infarction porcine hearts. In simulated circuits, ECGI classified 21% as 2D and 78% as 3D: 82.6% of these were correctly classified. The relative timing between epicardial and endocardial breakthroughs was correctly captured across all cases. In in-vivo circuits, ECGI classified 25% as 2D and 75% as 3D: in all cases, circuit exits and entrances were consistent with potential critical isthmus delineated from combined LGE-MRI and catheter mapping data. Conclusions ECGI epi-endo mapping has the potential for fast delineation of 3D VT circuits, which may augment detailed catheter mapping for VT ablation.
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Affiliation(s)
- Maryam Toloubidokhti
- College of Computing and Information Sciences, Rochester Institute of Technology, Rochester, NY, USA
| | - Omar A Gharbia
- Department of Otolaryngology, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Adityo Parkosa
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Natalia Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Saman Nazarian
- School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - John L Sapp
- Department of Medicine, QEII Health Sciences Centre, Halifax, NS, Canada
| | - Linwei Wang
- College of Computing and Information Sciences, Rochester Institute of Technology, Rochester, NY, USA
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Zaatari G, Mitrani R, Bohorquez J, Ng J, Ng J, Rivner H, Velasquez A, Lambrakos L, Arora R, Goldberger JJ. Electrogram Morphology Recurrence for Mapping Persistent Atrial Fibrillation: Initial vs Redo Catheter Ablation. JACC Clin Electrophysiol 2023; 9:526-540. [PMID: 36669899 PMCID: PMC10699542 DOI: 10.1016/j.jacep.2022.11.003] [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: 07/21/2022] [Revised: 09/30/2022] [Accepted: 11/02/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Electrogram (EGM) morphology recurrence (EMR) mapping of persistent atrial fibrillation (AF) quantifies consistency of activation and is expected to be high and rapid near AF drivers. OBJECTIVES The purpose of this study was to compare EMR in left atria (LA) and right atria (RA) in patients undergoing first vs redo ablation for persistent AF. METHODS Multisite LA/RA mapping (LA: 281 ± 176 sites/patient; RA: 239 ± 166 sites/patient) before persistent AF ablation was performed in 42 patients (30 males, age 63 ± 9 years) undergoing first (Group 1, n = 32) or redo ablation (Group 2, n = 10). After cross-correlation of each automatically detected EGM with every other EGM per recording, the most recurrent electrogram morphology was identified and its frequency (Rec%) and recurrence cycle length (CLR) were computed. RESULTS In Groups 1 and 2, minimum CLR was 172.8 ± 26.0 milliseconds (LA: 178.2 ± 37.6 milliseconds, RA: 204.4 ± 34.0 milliseconds, P = 0.0005) and 186.5 ± 28.3 milliseconds (LA: 196.1 ± 38.1 milliseconds vs RA: 199.0 ± 30.2 milliseconds, P = 0.75), with Rec% 94.7% ± 10% and 93.8% ± 9.2%. Group 2 minimum CLR was not different from Group 1 (P = 0.20). Shortest CLR was in the LA in 84% of Group 1 and 50% of Group 2 patients (P = 0.04). Only 1 of 10 patients in Group 2 had the shortest CLR in the pulmonary veins (PVs) compared with 19 of 32 in Group 1 (P = 0.01). Most sites (77.6%) had Rec% <50%. CONCLUSIONS EMR identified the shortest CLR sites in the PVs in 59% of patients undergoing initial persistent AF ablation, consistent with reported success rates of ∼50% for PV isolation. The majority of sites have low recurrence and may reflect bystander sites not critical for maintaining AF. EMR provides a robust new method for quantifying consistency and rapidity of activation direction at multiple atrial sites.
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Affiliation(s)
- Ghaith Zaatari
- Division of Cardiology, Department of Medicine, University of Miami, Miami, Florida, USA
| | - Raul Mitrani
- Division of Cardiology, Department of Medicine, University of Miami, Miami, Florida, USA
| | - Jorge Bohorquez
- Department of Biomedical Engineering, University of Miami, Miami, Florida, USA
| | - Jason Ng
- University of Illinois, College of Medicine, Chicago, Illinois, USA
| | - Justin Ng
- Northwestern University, Chicago, Illinois, USA
| | - Harold Rivner
- Division of Cardiology, Department of Medicine, University of Miami, Miami, Florida, USA
| | - Alex Velasquez
- Division of Cardiology, Department of Medicine, University of Miami, Miami, Florida, USA
| | - Litsa Lambrakos
- Division of Cardiology, Department of Medicine, University of Miami, Miami, Florida, USA
| | - Rishi Arora
- Northwestern University, Chicago, Illinois, USA
| | - Jeffrey J Goldberger
- Division of Cardiology, Department of Medicine, University of Miami, Miami, Florida, USA.
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Hernández-Romero I, Molero R, Fambuena-Santos C, Herrero-Martín C, Climent AM, Guillem MS. Electrocardiographic imaging in the atria. Med Biol Eng Comput 2023; 61:879-896. [PMID: 36370321 PMCID: PMC9988819 DOI: 10.1007/s11517-022-02709-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 10/26/2022] [Indexed: 11/13/2022]
Abstract
The inverse problem of electrocardiography or electrocardiographic imaging (ECGI) is a technique for reconstructing electrical information about cardiac surfaces from noninvasive or non-contact recordings. ECGI has been used to characterize atrial and ventricular arrhythmias. Although it is a technology with years of progress, its development to characterize atrial arrhythmias is challenging. Complications can arise when trying to describe the atrial mechanisms that lead to abnormal propagation patterns, premature or tachycardic beats, and reentrant arrhythmias. This review addresses the various ECGI methodologies, regularization methods, and post-processing techniques used in the atria, as well as the context in which they are used. The current advantages and limitations of ECGI in the fields of research and clinical diagnosis of atrial arrhythmias are outlined. In addition, areas where ECGI efforts should be concentrated to address the associated unsatisfied needs from the atrial perspective are discussed.
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Affiliation(s)
| | - Rubén Molero
- ITACA, Universitat Politècnica de València, Valencia, Spain
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Xu CH, Xiong F, Jiang WF, Liu X, Liu T, Qin M. Rotor mechanism and its mapping in atrial fibrillation. Europace 2023; 25:783-792. [PMID: 36734272 PMCID: PMC10062333 DOI: 10.1093/europace/euad002] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 12/28/2022] [Indexed: 02/04/2023] Open
Abstract
Treatment of atrial fibrillation (AF) remains challenging despite significant progress in understanding its underlying mechanisms. The first detailed, quantitative theory of functional re-entry, the 'leading circle' model, was developed more than 40 years ago. Subsequently, in decades of study, an alternative paradigm based on spiral waves has long been postulated to drive AF. The rotor as a 'spiral wave generator' is a curved 'vortex' formed by spin motion in the two-dimensional plane, identified using advanced mapping methods in experimental and clinical AF. However, it is challenging to achieve complementary results between experimental results and clinical studies due to the limitation in research methods and the complexity of the rotor mechanism. Here, we review knowledge garnered over decades on generation, electrophysiological properties, and three-dimensional (3D) structure diversity of the rotor mechanism and make a comparison among recent clinical approaches to identify rotors. Although initial studies of rotor ablation at many independent centres have achieved promising results, some inconclusive outcomes exist in others. We propose that the clinical rotor identification might be substantially influenced by (i) non-identical surface activation patterns, which resulted from a diverse 3D form of scroll wave, and (ii) inadequate resolution of mapping techniques. With rapidly advancing theoretical and technological developments, future work is required to resolve clinically relevant limitations in current basic and clinical research methodology, translate from one to the other, and resolve available mapping techniques.
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Affiliation(s)
- Chang-Hao Xu
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine,
Shanghai Jiao Tong University, 241 Huaihai West Road, Xuhui
District, Shanghai 200030, China
| | - Feng Xiong
- Montreal Heart Institute, Department of Medicine, University of
Montreal, 5000, Bélanger street, Montréal, Québec H1T
1C8, Canada
| | - Wei-Feng Jiang
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine,
Shanghai Jiao Tong University, 241 Huaihai West Road, Xuhui
District, Shanghai 200030, China
| | - Xu Liu
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine,
Shanghai Jiao Tong University, 241 Huaihai West Road, Xuhui
District, Shanghai 200030, China
| | - Tao Liu
- Corresponding authors. Tao Liu, 238 Jiefang Road, Wuchang
District, Wuhan, Hubei 430060, China. Tel: +86 (027) 8804 1911, Fax:+86-(027)-8804-2292.
E-mail address:; Mu Qin, 241 Huaihai
West Road, Xuhui District, Shanghai, 200030, China. Tel: +8621628219902603, Fax:
+862162821105. E-mail address:
| | - Mu Qin
- Corresponding authors. Tao Liu, 238 Jiefang Road, Wuchang
District, Wuhan, Hubei 430060, China. Tel: +86 (027) 8804 1911, Fax:+86-(027)-8804-2292.
E-mail address:; Mu Qin, 241 Huaihai
West Road, Xuhui District, Shanghai, 200030, China. Tel: +8621628219902603, Fax:
+862162821105. E-mail address:
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Vijayakumar R, Faddis MN, Cuculich PS, Rudy Y. Mechanisms of persistent atrial fibrillation and recurrences within 12 months post-ablation: Non-invasive mapping with electrocardiographic imaging. Front Cardiovasc Med 2022; 9:1052195. [PMID: 36518686 PMCID: PMC9742214 DOI: 10.3389/fcvm.2022.1052195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 10/28/2022] [Indexed: 11/23/2023] Open
Abstract
Introduction Catheter ablation of persistent AF has not been consistently successful in terminating AF or preventing arrhythmia recurrences. Non-invasive Electrocardiographic Imaging (ECGI) can help to understand recurrences by mapping the mechanisms of pre-ablation AF and comparing them with the patterns of recurrent arrhythmias in the same patient. Methods Seventeen persistent AF patients underwent ECGI before their first catheter ablation. Time-domain activation maps and phase progression maps were obtained on the bi-atrial epicardium. Location of arrhythmogenic drivers were annotated on the bi-atrial anatomy. Activation and phase movies were examined to understand the wavefront dynamics during AF. Eight patients recurred within 12 months of ablation and underwent a follow-up ECGI. Driver locations and movies were compared for pre- and post-ablation AF. Results A total of 243 focal drivers were mapped during pre-ablation AF. 62% of the drivers were mapped in the left atrium (LA). The pulmonary vein region harbored most of the drivers (43%). 35% of the drivers were mapped in the right atrium (RA). 59% (10/17) and 53% (9/17) of patients had repetitive sources in the left pulmonary veins (LPV) and left atrial appendage (LAA), and the lower half of RA, respectively. All patients had focal drivers. 29% (5/17) of patients had macro-reentry waves. 24% (4/17) of patients had rotors. Activation patterns during persistent AF varied from single macro-reentry to complex activity with multiple simultaneous wavefronts in both atria, resulting in frequent wave collisions. A total of 76 focal driver activities were mapped in 7/8 patients during recurrence. 59% of the post-ablation AF drivers were mapped in the LA. The pulmonary vein region harbored 50% of total drivers. 39% of sources were mapped in the RA. AF complexity remained similar post-ablation. 58% (44/76) of pre-ablation sources persisted during recurrence. 38% (3/8) of patients had macro-reentry and one patient had rotors. Conclusion ECGI provides patient-specific information on mechanisms of persistent AF and recurrent arrhythmia. More than half pre-ablation sources repeated during post-ablation recurrence. This study provides direct evidence for drivers that persist days and months after the ablation procedure. Patient-tailored bi-atrial ablation is needed to successfully target persistent AF and prevent recurrence. ECGI can potentially predict recurrence and assist in choice of therapy.
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Affiliation(s)
- Ramya Vijayakumar
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
- Cardiac Bioelectricity and Arrhythmia Center, Washington University in St. Louis, St. Louis, MO, United States
| | - Mitchell N. Faddis
- Cardiac Bioelectricity and Arrhythmia Center, Washington University in St. Louis, St. Louis, MO, United States
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, United States
| | - Phillip S. Cuculich
- Cardiac Bioelectricity and Arrhythmia Center, Washington University in St. Louis, St. Louis, MO, United States
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, United States
| | - Yoram Rudy
- Cardiac Bioelectricity and Arrhythmia Center, Washington University in St. Louis, St. Louis, MO, United States
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, United States
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, United States
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Regions of Highly Recurrent Electrogram Morphology With Low Cycle Length Reflect Substrate for Atrial Fibrillation. JACC. BASIC TO TRANSLATIONAL SCIENCE 2022; 8:68-84. [PMID: 36777167 PMCID: PMC9911322 DOI: 10.1016/j.jacbts.2022.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 07/20/2022] [Accepted: 07/20/2022] [Indexed: 11/27/2022]
Abstract
Traditional anatomically guided ablation and attempts to perform electrogram-guided atrial fibrillation (AF) ablation (CFAE, DF, and FIRM) have not been shown to be sufficient treatment for persistent AF. Using biatrial high-density electrophysiologic mapping in a canine rapid atrial pacing model of AF, we systematically investigated the relationship of electrogram morphology recurrence (EMR) (Rec% and CLR) with established AF electrogram parameters and tissue characteristics. Rec% correlates with stability of rotational activity and with the spatial distribution of parasympathetic nerve fibers. These results have indicated that EMR may therefore be a viable therapeutic target in persistent AF.
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Key Words
- AF, atrial fibrillation
- AI, anisotropy index
- CFAE, complex fractionated atrial electrogram
- CLR, cycle length of the most recurrent electrogram morphology
- DF, dominant frequency
- EGM, electrogram
- EMR, electrogram morphology recurrence
- FFT, fast Fourier transform
- FI, fractionation interval
- FIRM, focal impulse and rotor mapping
- LAA, left atrial appendage
- LAFW, left atrial free wall
- LAT, local activation time
- OI, organization index
- PLA, posterior left atrium
- PV, pulmonary vein
- RAA, right atrial appendage
- RAFW, right atrial free wall
- RAP, rapid atrial pacing
- Rec%, recurrence percentage
- ShEn, Shannon’s entropy
- arrhythmias
- atrial fibrillation
- fibrosis
- mapping
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Honarbakhsh S, Schilling RJ, Keating E, Finlay M, Hunter RJ. Coronary sinus electrogram characteristics predict termination of AF with ablation and long-term clinical outcome. J Cardiovasc Electrophysiol 2022; 33:2139-2151. [PMID: 35775822 PMCID: PMC9796101 DOI: 10.1111/jce.15618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 05/10/2022] [Accepted: 06/29/2022] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Markers predicting atrial fibrillation (AF) termination and freedom from AF/atrial tachycardia (AT) has been proposed. This study aimed to evaluate the role of novel coronary sinus (CS) electrogram characteristics in predicting the acute ablation response and freedom from AF/AT during follow-up. METHODS Patients undergoing ablation for persistent AF as part of the Stochastic Trajectory Analysis of Ranked signals mapping study were included. Novel CS electrogram characteristics including CS cycle length variability (CLV) and CS activation pattern stability (APS) and proportion of low voltage zones (LVZs) were reviewed as potential predictors for AF termination on ablation and freedom from AF/AT during follow-up. The relationship between localized driver characteristics and CS electrogram characteristics was also assessed. RESULTS Sixty-five patients were included. AF termination was achieved in 51 patients and 80% of patients were free from AF/AT during a follow-up of 29.5 ± 3.7 months. CS CLV of <30 ms, CS APS of ≥30% and proportion of LVZ < 30% showed high diagnostic accuracy in predicting AF termination on ablation and freedom from AF/AT during follow-up (CS CLV odds ratio [OR] 25.6, area under the curve [AUC] 0.91; CS APS OR 15.9, AUC 0.94; proportion of LVZs OR 21.4, AUC 0.88). These markers were independent predictors of AF termination on ablation and AF/AT recurrence during follow-up. Ablation of a smaller number of drivers that demonstrate greater dominance strongly correlate with greater CS organization. CONCLUSION Novel CS electrogram characteristics were independent predictors of AF termination and AF/AT recurrence during follow-up. These markers can potentially aid in predicting outcomes and guide ablation and follow-up strategies.
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Affiliation(s)
- Shohreh Honarbakhsh
- The Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS TrustLondonUK
| | - Richard J. Schilling
- The Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS TrustLondonUK
| | - Emily Keating
- The Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS TrustLondonUK
| | - Malcolm Finlay
- The Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS TrustLondonUK
| | - Ross J. Hunter
- The Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS TrustLondonUK
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An Evaluation of Phase Analysis to Interpret Atrial Activation Patterns during Persistent Atrial Fibrillation for Targeted Ablation. J Clin Med 2022; 11:jcm11195807. [PMID: 36233675 PMCID: PMC9572396 DOI: 10.3390/jcm11195807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/21/2022] [Accepted: 09/29/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Phase analysis has been used to identify and localize atrial fibrillation (AF) sources for targeted ablation. We previously demonstrated that repetitive wannabe reentry (incomplete reentry) often generated an apparent stable rotor using phase analysis. The misinterpretation caused by phase analysis using atrial electrograms (AEGs) may result from detecting inaccurate time points at phase inversion (π to -π) in the instantaneous phase waveform converted from AEG. The purpose of this study was to evaluate the accuracy of phase analysis to detect atrial activations recorded from the high-density mapping of AF in patients with persistent and long-standing persistent (LSP) AF. METHODS AND RESULTS During open heart surgery, we recorded activation from both atria simultaneously using 512 electrodes in 7 patients with persistent and LSP AF. The phase analysis was compared to manual measurements during 4 s of data. For the accuracy of activation sequence maps, a successful recording site was defined as having ≤4 mismatched activation times during the 4 s. In all AF episodes, the accuracy of the phase analysis was only 82% of the total number of activation times due to either activation time differences (14.7%), under-sensing (2.7%), or over-sensing (0.6%). Only 67.9% of the total recording sites met the requirement of a successful recording site by phase analysis. In unsuccessful recording sites, AEG characteristics were relatively irregular cycle length (CL), complex AEG, and double potential AEG. CONCLUSION The phase analysis was less accurate in recording sites with a relatively irregular CL, complex AEG, or double potential AEG. As a result, phase analysis may lead to the misinterpretation of atrial activation patterns during AF. A visual review of the original AEG is needed to confirm the detected AF sources of phase analysis before performing targeted ablation.
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Liu FZ, Zaman JAB, Ehdaie A, Xue YM, Cingolani E, Bresee C, Chugh SS, Wu SL, Shehata M, Wang X. Atrial Fibrillation Mechanisms Before and After Pulmonary Vein Isolation Characterized by Non-Contact Charge Density Mapping. Heart Rhythm 2022; 19:1423-1432. [PMID: 35381379 DOI: 10.1016/j.hrthm.2022.03.1232] [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: 05/05/2021] [Revised: 03/21/2022] [Accepted: 03/26/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND The interaction of pulmonary vein and putative non-pulmonary triggers of atrial fibrillation (AF) remains unclear, and has yet to translate into patient tailored ablation strategies. OBJECTIVE To use non-contact mapping to detail the global conduction patterns in paroxysmal and persistent AF and how they are modified during pulmonary vein ablation. METHODS 40 patients at atrial fibrillation ablation underwent mapping using a non-contact catheter (AcQMap, Acutus Medical Inc) before and after pulmonary vein isolation (PVI). Propagation history maps were analysed post-procedure for each patient to categorise conduction patterns into Focal, Organised reentrant and Disorganized patterns. RESULTS Activation patterns identified by using a non-contact mapping system can be sub-classified from three main patterns into subtypes (MacroReentrant and LocalisedReentrant subtypes, Disorganized 1 and Disorganized 2 subtypes). Persistent AF demonstrated more D-Patterns, and less O-Patterns and F-Patterns than paroxysmal AF. In addition, PAF patients inducible after PVI demonstrated a greater number and higher prevalence of MR subtypes than those non-inducible. PVs remained the critical region and included almost one third of all patterns across any AF-types. PVI was effective to eliminate PV-related functional phenotypes, and impacted on recurrence with other patterns. CONCLUSION Activation patterns identified using AcQMap can be classified into three main patterns (F-Patterns, O-Patterns and D-Patterns) as well as subtypes (MR and LR subtype, D1 and D2 subtype). PerAF was different from PAF in demonstrating a greater region number and prevalence of D-Patterns, but lower region number and prevalence of O-Patterns and F-Patterns.
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Affiliation(s)
- Fang-Zhou Liu
- Guandong Medical College, Guanzhou, China; Cedars Sinai Heart Institute, Los Angeles, CA USA
| | - Junaid A B Zaman
- Cedars Sinai Heart Institute, Los Angeles, CA USA; Keck Medicine of USC, Los Angeles, CA USA
| | | | - Yu-Mei Xue
- Guandong Medical College, Guanzhou, China
| | | | | | | | - Shu-Lin Wu
- Guandong Medical College, Guanzhou, China
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Honarbakhsh S, Dhillon G, Abbas H, Waddingham PH, Dennis A, Ahluwalia N, Welch S, Daw H, Sporton S, Chow A A, Earley MJ, Lambiase PD, Hunter RJ. Non-invasive Electrocardiographic Imaging guided targeting of drivers of persistent atrial fibrillation: the TARGET-AF1 trial. Heart Rhythm 2022; 19:875-884. [DOI: 10.1016/j.hrthm.2022.01.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/25/2022] [Accepted: 01/30/2022] [Indexed: 12/12/2022]
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11
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de Groot NMS, Shah D, Boyle PM, Anter E, Clifford GD, Deisenhofer I, Deneke T, van Dessel P, Doessel O, Dilaveris P, Heinzel FR, Kapa S, Lambiase PD, Lumens J, Platonov PG, Ngarmukos T, Martinez JP, Sanchez AO, Takahashi Y, Valdigem BP, van der Veen AJ, Vernooy K, Casado-Arroyo Co-Chair R. Critical appraisal of technologies to assess electrical activity during atrial fibrillation: a position paper from the European Heart Rhythm Association and European Society of Cardiology Working Group on eCardiology in collaboration with the Heart Rhythm Society, Asia Pacific Heart Rhythm Society, Latin American Heart Rhythm Society and Computing in Cardiology. Europace 2021; 24:313-330. [PMID: 34878119 DOI: 10.1093/europace/euab254] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 09/21/2021] [Indexed: 11/13/2022] Open
Abstract
We aim to provide a critical appraisal of basic concepts underlying signal recording and processing technologies applied for (i) atrial fibrillation (AF) mapping to unravel AF mechanisms and/or identifying target sites for AF therapy and (ii) AF detection, to optimize usage of technologies, stimulate research aimed at closing knowledge gaps, and developing ideal AF recording and processing technologies. Recording and processing techniques for assessment of electrical activity during AF essential for diagnosis and guiding ablative therapy including body surface electrocardiograms (ECG) and endo- or epicardial electrograms (EGM) are evaluated. Discussion of (i) differences in uni-, bi-, and multi-polar (omnipolar/Laplacian) recording modes, (ii) impact of recording technologies on EGM morphology, (iii) global or local mapping using various types of EGM involving signal processing techniques including isochronal-, voltage- fractionation-, dipole density-, and rotor mapping, enabling derivation of parameters like atrial rate, entropy, conduction velocity/direction, (iv) value of epicardial and optical mapping, (v) AF detection by cardiac implantable electronic devices containing various detection algorithms applicable to stored EGMs, (vi) contribution of machine learning (ML) to further improvement of signals processing technologies. Recording and processing of EGM (or ECG) are the cornerstones of (body surface) mapping of AF. Currently available AF recording and processing technologies are mainly restricted to specific applications or have technological limitations. Improvements in AF mapping by obtaining highest fidelity source signals (e.g. catheter-electrode combinations) for signal processing (e.g. filtering, digitization, and noise elimination) is of utmost importance. Novel acquisition instruments (multi-polar catheters combined with improved physical modelling and ML techniques) will enable enhanced and automated interpretation of EGM recordings in the near future.
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Affiliation(s)
- Natasja M S de Groot
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, Delft University of Technology, Delft the Netherlands
| | - Dipen Shah
- Cardiology Service, University Hospitals Geneva, Geneva, Switzerland
| | - Patrick M Boyle
- Department of Bioengineering, University of Washington, Seattle, Washington, USA
| | - Elad Anter
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gari D Clifford
- Department of Biomedical Informatics, Emory University, Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, USA
| | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich and Technical University of Munich, Munich, Germany
| | - Thomas Deneke
- Department of Cardiology, Rhon-klinikum Campus Bad Neustadt, Germany
| | - Pascal van Dessel
- Department of Cardiology, Medisch Spectrum Twente, Twente, the Netherlands
| | - Olaf Doessel
- Karlsruher Institut für Technologie (KIT), Karlsruhe, Germany
| | - Polychronis Dilaveris
- 1st University Department of Cardiology, National & Kapodistrian University of Athens School of Medicine, Hippokration Hospital, Athens, Greece
| | - Frank R Heinzel
- Department of Internal Medicine and Cardiology, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum and DZHK (German Centre for Cardiovascular Research), Berlin, Germany
| | - Suraj Kapa
- Department of Cardiology, Mayo Clinic, Rochester, USA
| | | | - Joost Lumens
- Cardiovascular Research Institute Maastricht (CARIM) Maastricht University, Maastricht, the Netherlands
| | - Pyotr G Platonov
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Tachapong Ngarmukos
- Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Juan Pablo Martinez
- Aragon Institute of Engineering Research/IIS-Aragon and University of Zaragoza, Zaragoza, Spain, CIBER Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Zaragoza, Spain
| | - Alejandro Olaya Sanchez
- Department of Cardiology, Hospital San José, Fundacion Universitaia de Ciencas de la Salud, Bogota, Colombia
| | - Yoshihide Takahashi
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Bruno P Valdigem
- Department of Cardiology, Hospital Rede D'or São Luiz, hospital Albert einstein and Dante pazzanese heart institute, São Paulo, Brasil
| | - Alle-Jan van der Veen
- Department Circuits and Systems, Delft University of Technology, Delft, the Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, the Netherlands
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Vila M, Rocher S, Rivolta MW, Saiz J, Sassi R. Directed Network Mapping Approach to Rotor Localization in Atrial Fibrillation Simulation. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2021; 2021:730-733. [PMID: 34891395 DOI: 10.1109/embc46164.2021.9629911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Catheter ablation for atrial fibrillation (AF) is one of the most commonly performed electrophysiology procedures. Despite significant advances in our understanding of AF mechanisms in the last years, ablation outcomes remain suboptimal for many patients, particularly those with persistent or long-standing AF. A possible reason is that ablation techniques mainly focus on anatomic, rather than patient-specific functional targets for ablation. The identification of such ablation targets remains challenging. The purpose of this study is to investigate a novel approach based on directed networks, which allow the automatic detection of important arrhythmia mechanisms, that can be convenient for guiding the ablation strategy. The networks are generated by processing unipolar electrograms (EGMs) collected by the catheters positioned at the different regions of the atria. Network vertices represent the locations of the recordings and edges are determined using cross-covariance time-delay estimation method. The algorithm identifies rotational activity, spreading from vertex to vertex creating a cycle. This work is a simulation study and it uses a highly detailed computational 3D model of human atria in which sustained rotor activation of the atria was achieved. Virtual electrodes were placed on the endocardial surface, and EGMs were calculated at each of these electrodes. The propagation of the electric wave fronts in the atrial myocardium during AF is very complex, so in order to properly capture wave propagation patterns, we split EGMs into multiple short time frames. Then, a specific network for each of these time frames was generated, and the cycles repeating in consecutive networks point us to the stable rotor's location. The respective atrial voltage map served as reference. By detecting a cycle between the same 3 nodes in 19 out of 58 networks, where 10 of these networks were in consecutive time frames, a stable rotor was successfully located.
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Onak O, Erenler T, Serinagaoglu Y. A Novel Data-Adaptive Regression Framework Based on Multivariate Adaptive Regression Splines for Electrocardiographic Imaging. IEEE Trans Biomed Eng 2021; 69:963-974. [PMID: 34495827 DOI: 10.1109/tbme.2021.3110767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Noninvasive electrocardiographic imaging (ECGI) is a promising tool for revealing crucial cardiac electrical events with diagnostic potential. We propose a novel nonparametric regression framework based on multivariate adaptive regression splines (MARS) for ECGI. METHODS The inverse problem was solved by using the regression model trained with body surface potentials (BSP) and corresponding electrograms (EGM). Simulated data as well as experimental data from torso-tank experiments were used as to assess the performance of the proposed method. The robustness of the method to measurement noise and geometric errors were assessed in terms of electrogram reconstruction quality, activation time accuracy, and localization error metrics. The methods were compared with Tikhonov regularization and neural network (NN)-based methods. The resulting mapping functions between the BSPs and EGMs were also used to evaluate the most influential measurement leads. RESULTS MARS-based method outperformed Tikhonov regularization in terms of reconstruction accuracy and robustness to measurement noise. The effects of geometric errors were remedied to some extent by enriching the training set composition including model errors. The MARS-based method had a comparable performance with NN-based methods, which require the adjustment of many parameters. CONCLUSION MARS-based method successfully discovers the inverse mapping functions between the BSPs and EGMs yielding accurate reconstructions, and quantifies the contribution of each BSP lead. SIGNIFICANCE MARS-based method is adaptive, requires fewer parameter adjustments than NN-based methods, and robust to errors. Thus, it can be a feasible data-driven approach for accurately solving inverse imaging problems.
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Schotten U, Lee S, Zeemering S, Waldo AL. Paradigm shifts in electrophysiological mechanisms of atrial fibrillation. Europace 2021; 23:ii9-ii13. [PMID: 33837750 DOI: 10.1093/europace/euaa384] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/03/2020] [Indexed: 11/12/2022] Open
Abstract
Determining the sequence of activation is a major source of information for understanding the electrophysiological mechanism(s) of atrial fibrillation (AF). However, the complex morphology of the electrograms hampers their analysis, and has stimulated generations of electrophysiologists to develop a large variety of technologies for recording, pre-processing, and analysis of fibrillation electrograms. This variability of approaches is mirrored by a large variability in the interpretation of fibrillation electrograms and, thereby, opinions regarding the basic electrophysiological mechanism(s) of AF vary widely. Multiple wavelets, different types of re-entry including rotors, double layers, multiple focal activation patterns all have been advocated, and a comprehensive and commonly accepted paradigm for the fundamental mechanisms of AF is still lacking. Here, we summarize the Maastricht perspective and Cleveland perspective regarding AF mechanism(s). We also describe some of the key observations in mapping of AF reported over the past decades, and how they changed over the years, often as results of new techniques introduced in the experimental field of AF research.
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Affiliation(s)
- Ulrich Schotten
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Universiteitssingel 50 6229 ER, Maastricht, The Netherlands
| | - Seungyup Lee
- Department of Medicine, Cardiovascular Research Institute, Case Western Reserve University/University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Stef Zeemering
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Universiteitssingel 50 6229 ER, Maastricht, The Netherlands
| | - Albert L Waldo
- Department of Medicine, Cardiovascular Research Institute, Case Western Reserve University/University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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Van Nieuwenhuyse E, Martinez-Mateu L, Saiz J, Panfilov AV, Vandersickel N. Directed graph mapping exceeds phase mapping in discriminating true and false rotors detected with a basket catheter in a complex in-silico excitation pattern. Comput Biol Med 2021; 133:104381. [PMID: 33901713 PMCID: PMC8204274 DOI: 10.1016/j.compbiomed.2021.104381] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/02/2021] [Accepted: 04/02/2021] [Indexed: 12/04/2022]
Abstract
Atrial fibrillation (AF) is the most frequently encountered arrhythmia in clinical practise. One of the major problems in the management of AF is the difficulty in identifying the arrhythmia sources from clinical recordings. That difficulty occurs because it is currently impossible to verify algorithms which determine these sources in clinical data, as high resolution true excitation patterns cannot be recorded in patients. Therefore, alternative approaches, like computer modelling are of great interest. In a recent published study such an approach was applied for the verification of one of the most commonly used algorithms, phase mapping (PM). A meandering rotor was simulated in the right atrium and a basket catheter was placed at 3 different locations: at the Superior Vena Cava (SVC), the Crista Terminalis (CT) and at the Coronary Sinus (CS). It was shown that although PM can identify the true source, it also finds several false sources due to the far-field effects and interpolation errors in all three positions. In addition, the detection efficiency strongly depended on the basket location. Recently, a novel tool was developed to analyse any arrhythmia called Directed Graph Mapping (DGM). DGM is based on network theory and creates a directed graph of the excitation pattern, from which the location and the source of the arrhythmia can be detected. Therefore, the objective of the current study was to compare the efficiency of DGM with PM on the basket dataset of this meandering rotor. The DGM-tool was applied for a wide variety of conduction velocities (minimal and maximal), which are input parameters of DGM. Overall we found that DGM was able to distinguish between the true rotor and false rotors for both the SVC and CT basket positions. For example, for the SVC position with a CVmin=0.01cmms, DGM detected the true core with a prevalence of 82% versus 94% for PM. Three false rotors where detected for 39.16% (DGM) versus 100% (PM); 22.64% (DGM) versus 100% (PM); and 0% (DGM) versus 57% (PM). Increasing CVmin to 0.02cmms had a stronger effect on the false rotors than on the true rotor. This led to a detection rate of 56.6% for the true rotor, while all the other false rotors disappeared. A similar trend was observed for the CT position. For the CS position, DGM already had a low performance for the true rotor for CVmin=0.01cmms (14.7%). For CVmin=0.02cmms the false and the true rotors could therefore not be distinguished. We can conclude that DGM can overcome some of the limitations of PM by varying one of its input parameters (CVmin). The true rotor is less dependent on this parameter than the false rotors, which disappear at a CVmin=0.02cmms. In order to increase to detection rate of the true rotor, one can decrease CVmin and discard the new rotors which also appear at lower values of CVmin.
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Affiliation(s)
| | - Laura Martinez-Mateu
- Departamento de Teoría de La Señal y Las Comunicaciones y Sistemas Telemáticos y Computación, Universidad Rey Juan Carlos, Madrid, Spain
| | - Javier Saiz
- Centro de Investigación e Innovación en Bioingeniería, Universitat Politècnica de València, Valencia, Spain
| | - Alexander V Panfilov
- Department of Physics and Astronomy, Ghent University, Ghent, Belgium; Ural Federal University, Ekaterinburg, Russia; World-Class Research Center "Digital Biodesign and Personalized Healthcare", Sechenov University, Moscow, Russia
| | - Nele Vandersickel
- Department of Physics and Astronomy, Ghent University, Ghent, Belgium
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16
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Lee S, Khrestian CM, Sahadevan J, Markowitz A, Waldo AL. New Insights Into Understanding Rotor Versus Focal Activation in Patients With Persistent Atrial Fibrillation. JACC Clin Electrophysiol 2021; 7:909-919. [PMID: 33640352 DOI: 10.1016/j.jacep.2020.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/09/2020] [Accepted: 12/01/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study was to test the hypotheses that: 1) when using phase analysis, repetitive Wannabe re-entry produces a phase singularity point (i.e., a rotor); and 2) the location of the stable rotor is close to the focal source. BACKGROUND Recent contact mapping studies in patients with persistent atrial fibrillation (AF) demonstrated that phase analysis produced a different mechanistic result than classical activation sequence analysis. Our studies in patients with persistent AF showed that focal sources sometimes produced repetitive Wannabe re-entry, that is, incomplete re-entry. METHODS During open heart surgery, we recorded activation from both atria simultaneously using 510 to 512 electrodes in 12 patients with persistent AF. We performed activation sequence mapping and phase analyses on 4 s of mapped data. For each detected stable rotor (>2 full rotations [720°] recurring at the same site), the corresponding activation patterns were examined from the activation sequence maps. RESULTS During AF, phase singularity points (rotors) were identified in both atria in all patients. However, stable phase singularity points were only present in 6 of 12 patients. The range of stable phase singularity points per patient was 0 to 6 (total 14). Stable phase singularity points were produced due to repetitive Wannabe re-entry generated from a focal source or by passive activation. A conduction block sometimes created a stable phase singularity point (n = 2). The average distance between a focal source and a stable rotor was 0.9 ± 0.3 cm. CONCLUSIONS Repetitive Wannabe re-entry generated stable rotors adjacent to a focal source. No true re-entry occurred.
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Affiliation(s)
- Seungyup Lee
- Departments of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Celeen M Khrestian
- Departments of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Jayakumar Sahadevan
- Departments of Medicine, Case Western Reserve University, Cleveland, Ohio, USA; Division of Cardiovascular Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Alan Markowitz
- Valve Center, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Albert L Waldo
- Departments of Medicine, Case Western Reserve University, Cleveland, Ohio, USA; Division of Cardiovascular Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA.
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17
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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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18
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Zolotarev AM, Hansen BJ, Ivanova EA, Helfrich KM, Li N, Janssen PML, Mohler PJ, Mokadam NA, Whitson BA, Fedorov MV, Hummel JD, Dylov DV, Fedorov VV. Optical Mapping-Validated Machine Learning Improves Atrial Fibrillation Driver Detection by Multi-Electrode Mapping. Circ Arrhythm Electrophysiol 2020; 13:e008249. [PMID: 32921129 DOI: 10.1161/circep.119.008249] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) can be maintained by localized intramural reentrant drivers. However, AF driver detection by clinical surface-only multielectrode mapping (MEM) has relied on subjective interpretation of activation maps. We hypothesized that application of machine learning to electrogram frequency spectra may accurately automate driver detection by MEM and add some objectivity to the interpretation of MEM findings. METHODS Temporally and spatially stable single AF drivers were mapped simultaneously in explanted human atria (n=11) by subsurface near-infrared optical mapping (NIOM; 0.3 mm2 resolution) and 64-electrode MEM (higher density or lower density with 3 and 9 mm2 resolution, respectively). Unipolar MEM and NIOM recordings were processed by Fourier transform analysis into 28 407 total Fourier spectra. Thirty-five features for machine learning were extracted from each Fourier spectrum. RESULTS Targeted driver ablation and NIOM activation maps efficiently defined the center and periphery of AF driver preferential tracks and provided validated annotations for driver versus nondriver electrodes in MEM arrays. Compared with analysis of single electrogram frequency features, averaging the features from each of the 8 neighboring electrodes, significantly improved classification of AF driver electrograms. The classification metrics increased when less strict annotation, including driver periphery electrodes, were added to driver center annotation. Notably, f1-score for the binary classification of higher-density catheter data set was significantly higher than that of lower-density catheter (0.81±0.02 versus 0.66±0.04, P<0.05). The trained algorithm correctly highlighted 86% of driver regions with higher density but only 80% with lower-density MEM arrays (81% for lower-density+higher-density arrays together). CONCLUSIONS The machine learning model pretrained on Fourier spectrum features allows efficient classification of electrograms recordings as AF driver or nondriver compared with the NIOM gold-standard. Future application of NIOM-validated machine learning approach may improve the accuracy of AF driver detection for targeted ablation treatment in patients.
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Affiliation(s)
- Alexander M Zolotarev
- Department of Physiology and Cell Biology and Bob and Corrine Frick Center for Heart Failure and Arrhythmia (A.M.Z., B.J.H., K.M.H., N.L., P.M.L.J., P.J.M., V.V.F.), The Ohio State University Wexner Medical Center, Columbus, OH.,Center of Computational and Data-Intensive Science and Engineering, Skolkovo Institute of Science and Technology, Moscow, Russia (A.M.Z., E.A.I., M.V.F., D.V.D.)
| | - Brian J Hansen
- Department of Physiology and Cell Biology and Bob and Corrine Frick Center for Heart Failure and Arrhythmia (A.M.Z., B.J.H., K.M.H., N.L., P.M.L.J., P.J.M., V.V.F.), The Ohio State University Wexner Medical Center, Columbus, OH
| | - Ekaterina A Ivanova
- Center of Computational and Data-Intensive Science and Engineering, Skolkovo Institute of Science and Technology, Moscow, Russia (A.M.Z., E.A.I., M.V.F., D.V.D.)
| | - Katelynn M Helfrich
- Department of Physiology and Cell Biology and Bob and Corrine Frick Center for Heart Failure and Arrhythmia (A.M.Z., B.J.H., K.M.H., N.L., P.M.L.J., P.J.M., V.V.F.), The Ohio State University Wexner Medical Center, Columbus, OH
| | - Ning Li
- Department of Physiology and Cell Biology and Bob and Corrine Frick Center for Heart Failure and Arrhythmia (A.M.Z., B.J.H., K.M.H., N.L., P.M.L.J., P.J.M., V.V.F.), The Ohio State University Wexner Medical Center, Columbus, OH.,Davis Heart and Lung Research Institute (N.L., P.M.L.J., P.J.M., N.A.M., B.A.W., J.D.H., V.V.F.), The Ohio State University Wexner Medical Center, Columbus, OH
| | - Paul M L Janssen
- Department of Physiology and Cell Biology and Bob and Corrine Frick Center for Heart Failure and Arrhythmia (A.M.Z., B.J.H., K.M.H., N.L., P.M.L.J., P.J.M., V.V.F.), The Ohio State University Wexner Medical Center, Columbus, OH.,Davis Heart and Lung Research Institute (N.L., P.M.L.J., P.J.M., N.A.M., B.A.W., J.D.H., V.V.F.), The Ohio State University Wexner Medical Center, Columbus, OH
| | - Peter J Mohler
- Department of Physiology and Cell Biology and Bob and Corrine Frick Center for Heart Failure and Arrhythmia (A.M.Z., B.J.H., K.M.H., N.L., P.M.L.J., P.J.M., V.V.F.), The Ohio State University Wexner Medical Center, Columbus, OH.,Davis Heart and Lung Research Institute (N.L., P.M.L.J., P.J.M., N.A.M., B.A.W., J.D.H., V.V.F.), The Ohio State University Wexner Medical Center, Columbus, OH
| | - Nahush A Mokadam
- Davis Heart and Lung Research Institute (N.L., P.M.L.J., P.J.M., N.A.M., B.A.W., J.D.H., V.V.F.), The Ohio State University Wexner Medical Center, Columbus, OH.,Division of Cardiac Surgery (N.A.M., B.A.W., J.D.H.), The Ohio State University Wexner Medical Center, Columbus, OH
| | - Bryan A Whitson
- Davis Heart and Lung Research Institute (N.L., P.M.L.J., P.J.M., N.A.M., B.A.W., J.D.H., V.V.F.), The Ohio State University Wexner Medical Center, Columbus, OH.,Division of Cardiac Surgery (N.A.M., B.A.W., J.D.H.), The Ohio State University Wexner Medical Center, Columbus, OH
| | - Maxim V Fedorov
- Center of Computational and Data-Intensive Science and Engineering, Skolkovo Institute of Science and Technology, Moscow, Russia (A.M.Z., E.A.I., M.V.F., D.V.D.)
| | - John D Hummel
- Davis Heart and Lung Research Institute (N.L., P.M.L.J., P.J.M., N.A.M., B.A.W., J.D.H., V.V.F.), The Ohio State University Wexner Medical Center, Columbus, OH.,Division of Cardiac Surgery (N.A.M., B.A.W., J.D.H.), The Ohio State University Wexner Medical Center, Columbus, OH.,Department of Internal Medicine (J.D.H), The Ohio State University Wexner Medical Center, Columbus, OH
| | - Dmitry V Dylov
- Center of Computational and Data-Intensive Science and Engineering, Skolkovo Institute of Science and Technology, Moscow, Russia (A.M.Z., E.A.I., M.V.F., D.V.D.)
| | - Vadim V Fedorov
- Department of Physiology and Cell Biology and Bob and Corrine Frick Center for Heart Failure and Arrhythmia (A.M.Z., B.J.H., K.M.H., N.L., P.M.L.J., P.J.M., V.V.F.), The Ohio State University Wexner Medical Center, Columbus, OH.,Davis Heart and Lung Research Institute (N.L., P.M.L.J., P.J.M., N.A.M., B.A.W., J.D.H., V.V.F.), The Ohio State University Wexner Medical Center, Columbus, OH
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R Schill M, S Cuculich P, M Andrews C, Vijayakumar R, Ruaengsri C, C Henn M, S Lancaster T, J Melby S, B Schuessler R, Rudy Y, J Damiano R. The Arrhythmic Substrate for Atrial Fibrillation in Patients with Mitral Regurgitation. J Atr Fibrillation 2020; 13:2304. [PMID: 34950292 DOI: 10.4022/jafib.2304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 03/30/2020] [Accepted: 04/07/2020] [Indexed: 11/10/2022]
Abstract
Objective Patients with severe mitral regurgitation commonly develop atrial fibrillation. The precise mechanisms of this relationship remain unknown. The objective of this study was to apply noninvasive electrocardiographic imaging of the atria during sinus rhythm to identify changes in atrial electrophysiology that may contribute to development of atrial fibrillation in patients with severe mitral regurgitation referred for mitral valve surgery. Methods Twenty subjects (9 atrial fibrillation and mitral regurgitation, 11 mitral regurgitation alone) underwent electrocardiographic imaging. Biatrial electrophysiology was imaged with activation maps in sinus rhythm. The reconstructed unipolar electrograms were analyzed for voltage amplitude, number of deflections and conduction heterogeneity. In subjects with mitral regurgitation, left atrial biopsies were obtained at the time of surgery. Results: Subjects with history of atrial fibrillation demonstrated prolonged left atrial conduction times (110±25 ms vs. mitral regurgitation alone (85±21), p=0.025); right atrial conduction times were unaffected. Variable patterns of conduction slowing were imaged in the left atria of most subjects, but those with prior history of atrial fibrillation had more complex patterns of conduction slowing or unidirectional block. The presence of atrial fibrillation was not associated with the extent of fibrosis in atrial biopsies. Conclusions Detailed changes in sinus rhythm atrial electrophysiology can be imaged noninvasively and can be used to assess the impact and evolution of atrial fibrillation on atrial conduction properties in patients with mitral regurgitation. If replicated in larger studies, electrocardiographic imaging may identify patients with mitral regurgitation at risk for atrial fibrillation and could be used to guide treatment strategies.
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Affiliation(s)
- Matthew R Schill
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University in St. Louis; 660 S. Euclid Ave., Campus Box 8234, St. Louis, MO 63110, USA
| | - Phillip S Cuculich
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis; 660 S. Euclid Ave., Campus Box 8086, St. Louis, MO 63110, USA
| | - Christopher M Andrews
- Department of Biomedical Engineering, Washington University in St. Louis; 1 Brookings Dr., Campus Box 1097, St. Louis MO 63130, USA
| | - Ramya Vijayakumar
- Department of Biomedical Engineering, Washington University in St. Louis; 1 Brookings Dr., Campus Box 1097, St. Louis MO 63130, USA
| | - Chawannuch Ruaengsri
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University in St. Louis; 660 S. Euclid Ave., Campus Box 8234, St. Louis, MO 63110, USA
| | - Matthew C Henn
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University in St. Louis; 660 S. Euclid Ave., Campus Box 8234, St. Louis, MO 63110, USA
| | - Timothy S Lancaster
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University in St. Louis; 660 S. Euclid Ave., Campus Box 8234, St. Louis, MO 63110, USA
| | - Spencer J Melby
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University in St. Louis; 660 S. Euclid Ave., Campus Box 8234, St. Louis, MO 63110, USA
| | - Richard B Schuessler
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University in St. Louis; 660 S. Euclid Ave., Campus Box 8234, St. Louis, MO 63110, USA.,Department of Biomedical Engineering, Washington University in St. Louis; 1 Brookings Dr., Campus Box 1097, St. Louis MO 63130, USA
| | - Yoram Rudy
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis; 660 S. Euclid Ave., Campus Box 8086, St. Louis, MO 63110, USA.,Department of Biomedical Engineering, Washington University in St. Louis; 1 Brookings Dr., Campus Box 1097, St. Louis MO 63130, USA
| | - Ralph J Damiano
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University in St. Louis; 660 S. Euclid Ave., Campus Box 8234, St. Louis, MO 63110, USA
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20
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Characterization of atrial arrhythmias in body surface potential mapping: A computational study. Comput Biol Med 2020; 127:103904. [PMID: 32928523 DOI: 10.1016/j.compbiomed.2020.103904] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 07/02/2020] [Accepted: 07/02/2020] [Indexed: 11/23/2022]
Abstract
PURPOSE Atrial tachycardia (AT), flutter (AFL) and fibrillation (AF) are very common cardiac arrhythmias and are driven by localized sources that can be ablation targets. Non-invasive body surface potential mapping (BSPM) can be useful for early diagnosis and ablation planning. We aimed to characterize and differentiate the arrhythmic mechanisms behind AT, AFL and AF from the BSPM perspective using basic features reflecting their electrophysiology. METHODS 19 simulations of 567-lead BSPMs were used to obtain dominant frequency (DF) maps and estimate the atrial driving frequencies using the highest DF (HDF). Regions with |DF-HDF|≤1Hz were segmented and characterized (size, area); the spatial distribution of the differences |DF-atrialHDFestimate| was qualitatively analyzed. Phase singularity points (SPs) were detected on maps generated with Hilbert transform after band-pass filtering around the HDF (±1Hz). Connected SPs along time (filaments) and their histogram (heatmaps) were used for rotational activity characterization (duration, spatiotemporal stability). Results were reproduced in clinical layouts (252 to 12 leads) and with different rotations and translations of the atria within the torso, and compared with the original 567-lead outcomes using structural similarity index (SSIM) between maps, sensitivity and precision in SP detection and direct feature comparison. Random forest and least-square based algorithms were used to classify the arrhythmias and their mechanisms' location, respectively, based on the obtained features. RESULTS Frequency and phase analyses revealed distinct behavior between arrhythmias. AT and AFL presented uniform DF maps with low variance, while AF maps were more heterogeneous. Lower differences from the atrial HDF regions correlated with the driver location. Rotational activity was most stable in AFL, followed by AT and AF. Features were robust to lower spatial resolution layouts and modifications in the atrial geometry; DF and heatmaps presented decreasing SSIM along the layouts. The classification of the arrhythmias and their mechanisms' location achieved balanced accuracy of 72.0% and 73.9%, respectively. CONCLUSION Non-invasive characterization of AT, AFL and AF based on realistic models highlights intrinsic differences between the arrhythmias, enhancing the BSPM utility as an auxiliary clinical tool.
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21
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Handa BS, Li X, Aras KK, Qureshi NA, Mann I, Chowdhury RA, Whinnett ZI, Linton NW, Lim PB, Kanagaratnam P, Efimov IR, Peters NS, Ng FS. Granger Causality-Based Analysis for Classification of Fibrillation Mechanisms and Localization of Rotational Drivers. Circ Arrhythm Electrophysiol 2020; 13:e008237. [PMID: 32064900 PMCID: PMC7069398 DOI: 10.1161/circep.119.008237] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 02/04/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND The mechanisms sustaining myocardial fibrillation remain disputed, partly due to a lack of mapping tools that can accurately identify the mechanism with low spatial resolution clinical recordings. Granger causality (GC) analysis, an econometric tool for quantifying causal relationships between complex time-series, was developed as a novel fibrillation mapping tool and adapted to low spatial resolution sequentially acquired data. METHODS Ventricular fibrillation (VF) optical mapping was performed in Langendorff-perfused Sprague-Dawley rat hearts (n=18), where novel algorithms were developed using GC-based analysis to (1) quantify causal dependence of neighboring signals and plot GC vectors, (2) quantify global organization with the causality pairing index, a measure of neighboring causal signal pairs, and (3) localize rotational drivers (RDs) by quantifying the circular interdependence of neighboring signals with the circular interdependence value. GC-based mapping tools were optimized for low spatial resolution from downsampled optical mapping data, validated against high-resolution phase analysis and further tested in previous VF optical mapping recordings of coronary perfused donor heart left ventricular wedge preparations (n=12), and adapted for sequentially acquired intracardiac electrograms during human persistent atrial fibrillation mapping (n=16). RESULTS Global VF organization quantified by causality pairing index showed a negative correlation at progressively lower resolutions (50% resolution: P=0.006, R2=0.38, 12.5% resolution, P=0.004, R2=0.41) with a phase analysis derived measure of disorganization, locations occupied by phase singularities. In organized VF with high causality pairing index values, GC vector mapping characterized dominant propagating patterns and localized stable RDs, with the circular interdependence value showing a significant difference in driver versus nondriver regions (0.91±0.05 versus 0.35±0.06, P=0.0002). These findings were further confirmed in human VF. In persistent atrial fibrillation, a positive correlation was found between the causality pairing index and presence of stable RDs (P=0.0005,R2=0.56). Fifty percent of patients had RDs, with a low incidence of 0.9±0.3 RDs per patient. CONCLUSIONS GC-based fibrillation analysis can measure global fibrillation organization, characterize dominant propagating patterns, and map RDs using low spatial resolution sequentially acquired data.
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Affiliation(s)
- Balvinder S. Handa
- National Heart & Lung Institute, Imperial College London, United Kingdom (B.S.H., X.L., N.A.Q., I.M., R.A.C., Z.I.W., N.W.F.L., P.B.L., P.K., N.S.P., F.S.N.)
| | - Xinyang Li
- National Heart & Lung Institute, Imperial College London, United Kingdom (B.S.H., X.L., N.A.Q., I.M., R.A.C., Z.I.W., N.W.F.L., P.B.L., P.K., N.S.P., F.S.N.)
| | - Kedar K. Aras
- Department of Biomedical Engineering, George Washington University, Washington, DC (K.K.A., I.R.E.)
| | - Norman A. Qureshi
- National Heart & Lung Institute, Imperial College London, United Kingdom (B.S.H., X.L., N.A.Q., I.M., R.A.C., Z.I.W., N.W.F.L., P.B.L., P.K., N.S.P., F.S.N.)
| | - Ian Mann
- National Heart & Lung Institute, Imperial College London, United Kingdom (B.S.H., X.L., N.A.Q., I.M., R.A.C., Z.I.W., N.W.F.L., P.B.L., P.K., N.S.P., F.S.N.)
| | - Rasheda A. Chowdhury
- National Heart & Lung Institute, Imperial College London, United Kingdom (B.S.H., X.L., N.A.Q., I.M., R.A.C., Z.I.W., N.W.F.L., P.B.L., P.K., N.S.P., F.S.N.)
| | - Zachary I. Whinnett
- National Heart & Lung Institute, Imperial College London, United Kingdom (B.S.H., X.L., N.A.Q., I.M., R.A.C., Z.I.W., N.W.F.L., P.B.L., P.K., N.S.P., F.S.N.)
| | - Nick W.F. Linton
- National Heart & Lung Institute, Imperial College London, United Kingdom (B.S.H., X.L., N.A.Q., I.M., R.A.C., Z.I.W., N.W.F.L., P.B.L., P.K., N.S.P., F.S.N.)
| | - Phang Boon Lim
- National Heart & Lung Institute, Imperial College London, United Kingdom (B.S.H., X.L., N.A.Q., I.M., R.A.C., Z.I.W., N.W.F.L., P.B.L., P.K., N.S.P., F.S.N.)
| | - Prapa Kanagaratnam
- National Heart & Lung Institute, Imperial College London, United Kingdom (B.S.H., X.L., N.A.Q., I.M., R.A.C., Z.I.W., N.W.F.L., P.B.L., P.K., N.S.P., F.S.N.)
| | - Igor R. Efimov
- Department of Biomedical Engineering, George Washington University, Washington, DC (K.K.A., I.R.E.)
| | - Nicholas S. Peters
- National Heart & Lung Institute, Imperial College London, United Kingdom (B.S.H., X.L., N.A.Q., I.M., R.A.C., Z.I.W., N.W.F.L., P.B.L., P.K., N.S.P., F.S.N.)
- Department of Biomedical Engineering, George Washington University, Washington, DC (K.K.A., I.R.E.)
| | - Fu Siong Ng
- National Heart & Lung Institute, Imperial College London, United Kingdom (B.S.H., X.L., N.A.Q., I.M., R.A.C., Z.I.W., N.W.F.L., P.B.L., P.K., N.S.P., F.S.N.)
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22
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Rodrigo M, Climent AM, Hernández-Romero I, Liberos A, Baykaner T, Rogers AJ, Alhusseini M, Wang PJ, Fernández-Avilés F, Guillem MS, Narayan SM, Atienza F. Noninvasive Assessment of Complexity of Atrial Fibrillation: Correlation With Contact Mapping and Impact of Ablation. Circ Arrhythm Electrophysiol 2020; 13:e007700. [PMID: 32078374 DOI: 10.1161/circep.119.007700] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND It is difficult to noninvasively phenotype atrial fibrillation (AF) in a way that reflects clinical end points such as response to therapy. We set out to map electrical patterns of disorganization and regions of reentrant activity in AF from the body surface using electrocardiographic imaging, calibrated to panoramic intracardiac recordings and referenced to AF termination by ablation. METHODS Bi-atrial intracardiac electrograms of 47 patients with AF at ablation (30 persistent, 29 male, 63±9 years) were recorded with 64-pole basket catheters and simultaneous 57-lead body surface ECGs. Atrial epicardial electrical activity was reconstructed and organized sites were invasively and noninvasively tracked in 3-dimension using phase singularity. In a subset of 17 patients, sites of AF organization were targeted for ablation. RESULTS Body surface mapping showed greater AF organization near intracardially detected drivers than elsewhere, both in phase singularity density (2.3±2.1 versus 1.9±1.6; P=0.02) and number of drivers (3.2±2.3 versus 2.7±1.7; P=0.02). Complexity, defined as the number of stable AF reentrant sites, was concordant between noninvasive and invasive methods (r2=0.5; CC=0.71). In the subset receiving targeted ablation, AF complexity showed lower values in those in whom AF terminated than those in whom AF did not terminate (P<0.01). CONCLUSIONS AF complexity tracked noninvasively correlates well with organized and disorganized regions detected by panoramic intracardiac mapping and correlates with the acute outcome by ablation. This approach may assist in bedside monitoring of therapy or in improving the efficacy of ongoing ablation procedures.
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Affiliation(s)
- Miguel Rodrigo
- ITACA Institute, Universitat Politècnica de València (M.R., A.M.C., A.L., M.S.G.)
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigacion Sanitaria Gregorio Marañon (IISGM) (M.R., A.M.C., I.H.-R., A.L., F.F.-A., F.A.), Madrid, Spain
- Cardiac Electrophysiology and Arrhythmia Service, Division of Cardiovascular Medicine, Stanford University School of Medicine, CA (M.R., T.B., A.J.R., M.A., P.J.W., S.M.N.)
| | - Andreu M Climent
- ITACA Institute, Universitat Politècnica de València (M.R., A.M.C., A.L., M.S.G.)
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigacion Sanitaria Gregorio Marañon (IISGM) (M.R., A.M.C., I.H.-R., A.L., F.F.-A., F.A.), Madrid, Spain
- CIBERCV, Centro de Investigacion Biomedica en Red de Enfermedades Cardiovasculares (A.M.C., F.F.-A., F.A.), Madrid, Spain
| | - Ismael Hernández-Romero
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigacion Sanitaria Gregorio Marañon (IISGM) (M.R., A.M.C., I.H.-R., A.L., F.F.-A., F.A.), Madrid, Spain
- Department of Signal Theory and Communications, Rey Juan Carlos University (I.H.-R.), Madrid, Spain
| | - Alejandro Liberos
- ITACA Institute, Universitat Politècnica de València (M.R., A.M.C., A.L., M.S.G.)
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigacion Sanitaria Gregorio Marañon (IISGM) (M.R., A.M.C., I.H.-R., A.L., F.F.-A., F.A.), Madrid, Spain
| | - Tina Baykaner
- Cardiac Electrophysiology and Arrhythmia Service, Division of Cardiovascular Medicine, Stanford University School of Medicine, CA (M.R., T.B., A.J.R., M.A., P.J.W., S.M.N.)
| | - Albert J Rogers
- Cardiac Electrophysiology and Arrhythmia Service, Division of Cardiovascular Medicine, Stanford University School of Medicine, CA (M.R., T.B., A.J.R., M.A., P.J.W., S.M.N.)
| | - Mahmood Alhusseini
- Cardiac Electrophysiology and Arrhythmia Service, Division of Cardiovascular Medicine, Stanford University School of Medicine, CA (M.R., T.B., A.J.R., M.A., P.J.W., S.M.N.)
| | - Paul J Wang
- Cardiac Electrophysiology and Arrhythmia Service, Division of Cardiovascular Medicine, Stanford University School of Medicine, CA (M.R., T.B., A.J.R., M.A., P.J.W., S.M.N.)
| | - Francisco Fernández-Avilés
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigacion Sanitaria Gregorio Marañon (IISGM) (M.R., A.M.C., I.H.-R., A.L., F.F.-A., F.A.), Madrid, Spain
- CIBERCV, Centro de Investigacion Biomedica en Red de Enfermedades Cardiovasculares (A.M.C., F.F.-A., F.A.), Madrid, Spain
- Facultad de Medicina, Universidad Complutense (F.F.-A., F.A.), Madrid, Spain
| | - Maria S Guillem
- ITACA Institute, Universitat Politècnica de València (M.R., A.M.C., A.L., M.S.G.)
| | - Sanjiv M Narayan
- Cardiac Electrophysiology and Arrhythmia Service, Division of Cardiovascular Medicine, Stanford University School of Medicine, CA (M.R., T.B., A.J.R., M.A., P.J.W., S.M.N.)
| | - Felipe Atienza
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigacion Sanitaria Gregorio Marañon (IISGM) (M.R., A.M.C., I.H.-R., A.L., F.F.-A., F.A.), Madrid, Spain
- CIBERCV, Centro de Investigacion Biomedica en Red de Enfermedades Cardiovasculares (A.M.C., F.F.-A., F.A.), Madrid, Spain
- Facultad de Medicina, Universidad Complutense (F.F.-A., F.A.), Madrid, Spain
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23
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Vandersickel N, Van Nieuwenhuyse E, Van Cleemput N, Goedgebeur J, El Haddad M, De Neve J, Demolder A, Strisciuglio T, Duytschaever M, Panfilov AV. Directed Networks as a Novel Way to Describe and Analyze Cardiac Excitation: Directed Graph Mapping. Front Physiol 2019; 10:1138. [PMID: 31551814 PMCID: PMC6746922 DOI: 10.3389/fphys.2019.01138] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 08/19/2019] [Indexed: 12/31/2022] Open
Abstract
Networks provide a powerful methodology with applications in a variety of biological, technological and social systems such as analysis of brain data, social networks, internet search engine algorithms, etc. To date, directed networks have not yet been applied to characterize the excitation of the human heart. In clinical practice, cardiac excitation is recorded by multiple discrete electrodes. During (normal) sinus rhythm or during cardiac arrhythmias, successive excitation connects neighboring electrodes, resulting in their own unique directed network. This in theory makes it a perfect fit for directed network analysis. In this study, we applied directed networks to the heart in order to describe and characterize cardiac arrhythmias. Proof-of-principle was established using in-silico and clinical data. We demonstrated that tools used in network theory analysis allow determination of the mechanism and location of certain cardiac arrhythmias. We show that the robustness of this approach can potentially exceed the existing state-of-the art methodology used in clinics. Furthermore, implementation of these techniques in daily practice can improve the accuracy and speed of cardiac arrhythmia analysis. It may also provide novel insights in arrhythmias that are still incompletely understood.
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Affiliation(s)
- Nele Vandersickel
- Department of Physics and Astronomy, Ghent University, Ghent, Belgium
| | | | - Nico Van Cleemput
- Department of Applied Mathematics, Computer Science and Statistics, Ghent University, Ghent, Belgium
| | - Jan Goedgebeur
- Department of Applied Mathematics, Computer Science and Statistics, Ghent University, Ghent, Belgium
- Computer Science Department, University of Mons, Mons, Belgium
| | - Milad El Haddad
- Ghent University Hospital Heart Center, Ghent University, Ghent, Belgium
| | - Jan De Neve
- Department of Data Analysis, Ghent University, Ghent, Belgium
| | - Anthony Demolder
- Ghent University Hospital Heart Center, Ghent University, Ghent, Belgium
| | | | - Mattias Duytschaever
- Ghent University Hospital Heart Center, Ghent University, Ghent, Belgium
- Cardiology Department, AZ Sint-Jan, Bruges, Belgium
| | - Alexander V. Panfilov
- Department of Physics and Astronomy, Ghent University, Ghent, Belgium
- Laboratory of Computational Biology and Medicine, Ural Federal University, Ekaterinburg, Russia
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24
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Podziemski P, Zeemering S, Kuklik P, van Hunnik A, Maesen B, Maessen J, Crijns HJ, Verheule S, Schotten U. Rotors Detected by Phase Analysis of Filtered, Epicardial Atrial Fibrillation Electrograms Colocalize With Regions of Conduction Block. Circ Arrhythm Electrophysiol 2019; 11:e005858. [PMID: 30354409 PMCID: PMC6553551 DOI: 10.1161/circep.117.005858] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Several recent studies suggest rotors detected by phase mapping may act as main drivers of persistent atrial fibrillation. However, the electrophysiological nature of detected rotors remains unclear. We performed a direct, 1:1 comparison between phase and activation time mapping in high-density, epicardial, direct-contact mapping files of human atrial fibrillation. METHODS Thirty-eight unipolar electrogram files of 10 s duration were recorded in patients with atrial fibrillation (n=20 patients) using a 16×16 electrode array placed on the epicardial surface of the left atrial posterior wall or the right atrial free wall. Phase maps and isochrone wave maps were constructed for all recordings. For each detected phase singularity (PS) with a lifespan of >1 cycle length, the corresponding conduction pattern was investigated in the isochrone wave maps. RESULTS When using sinusoidal recomposition and Hilbert Transform, 138 PSs were detected. One hundred and four out of 138 PSs were detected within 1 electrode distance (1.5 mm) from a line of conduction block between nonrotating wavefronts detected by activation mapping. Far fewer rotating wavefronts were detected when rotating activity was identified based on wave mapping (18 out of 8219 detected waves). Fourteen out of these 18 cases were detected as PSs in phase mapping. Phase analysis of filtered electrograms produced by simulated wavefronts separated by conduction block also identified PSs on the line of conduction block. CONCLUSIONS PSs identified by phase analysis of filtered epicardial electrograms colocalize with conduction block lines identified by activation mapping. Detection of PSs using phase analysis has a low specificity for identifying rotating wavefronts during human atrial fibrillation using activation mapping.
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Affiliation(s)
- Piotr Podziemski
- Department of Physiology, Maastricht University, the Netherlands (P.P., S.Z., A.v.H., S.V.).,Cardiovascular Research Institute Maastricht (CARIM), the Netherlands (P.P., S.Z., A.v.H., B.M., J.M., H.J.C., S.V., U.S.)
| | - Stef Zeemering
- Department of Physiology, Maastricht University, the Netherlands (P.P., S.Z., A.v.H., S.V.).,Cardiovascular Research Institute Maastricht (CARIM), the Netherlands (P.P., S.Z., A.v.H., B.M., J.M., H.J.C., S.V., U.S.)
| | - Pawel Kuklik
- Department of Cardiology, Electrophysiology, University Medical Center Hamburg-Eppendorf, Germany (P.K.)
| | - Arne van Hunnik
- Department of Physiology, Maastricht University, the Netherlands (P.P., S.Z., A.v.H., S.V.).,Cardiovascular Research Institute Maastricht (CARIM), the Netherlands (P.P., S.Z., A.v.H., B.M., J.M., H.J.C., S.V., U.S.)
| | - Bart Maesen
- Cardiovascular Research Institute Maastricht (CARIM), the Netherlands (P.P., S.Z., A.v.H., B.M., J.M., H.J.C., S.V., U.S.).,Department of Cardiothoracic Surgery, Maastricht University Medical Center, the Netherlands (B.M., J.M.)
| | - Jos Maessen
- Cardiovascular Research Institute Maastricht (CARIM), the Netherlands (P.P., S.Z., A.v.H., B.M., J.M., H.J.C., S.V., U.S.).,Department of Cardiothoracic Surgery, Maastricht University Medical Center, the Netherlands (B.M., J.M.)
| | - Harry J Crijns
- Cardiovascular Research Institute Maastricht (CARIM), the Netherlands (P.P., S.Z., A.v.H., B.M., J.M., H.J.C., S.V., U.S.).,Department of Cardiology, Maastricht University Medical Center, the Netherlands (H.J.C.)
| | - Sander Verheule
- Department of Physiology, Maastricht University, the Netherlands (P.P., S.Z., A.v.H., S.V.).,Cardiovascular Research Institute Maastricht (CARIM), the Netherlands (P.P., S.Z., A.v.H., B.M., J.M., H.J.C., S.V., U.S.)
| | - Ulrich Schotten
- Department of Physiology, Maastricht University, the Netherlands (P.P., S.Z., A.v.H., S.V.).,Cardiovascular Research Institute Maastricht (CARIM), the Netherlands (P.P., S.Z., A.v.H., B.M., J.M., H.J.C., S.V., U.S.)
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25
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Ciaccio EJ, Wan EY, Saluja DS, Acharya UR, Peters NS, Garan H. Addressing challenges of quantitative methodologies and event interpretation in the study of atrial fibrillation. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2019; 178:113-122. [PMID: 31416540 PMCID: PMC6748794 DOI: 10.1016/j.cmpb.2019.06.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 05/21/2019] [Accepted: 06/14/2019] [Indexed: 05/06/2023]
Abstract
Atrial fibrillation (AF) is the commonest arrhythmia, yet the mechanisms of its onset and persistence are incompletely known. Although techniques for quantitative assessment have been investigated, there have been few attempts to integrate this information to advance disease treatment protocols. In this review, key quantitative methods for AF analysis are described, and suggestions are provided for the coordination of the available information, and to develop foci and directions for future research efforts. Quantitative biologists may have an interest in this topic in order to develop machine learning and tools for arrhythmia characterization, but they may perhaps have a minimal background in the clinical methodology and in the types of observed events and mechanistic hypotheses that have thus far been developed. We attempt to address these issues via exploration of the published literature. Although no new data is presented in this review, examples are shown of current lines of investigation, and in particular, how electrogram analysis and whole-chamber quantitative modeling of the left atrium may be useful to characterize fibrillatory patterns of activity, so as to propose avenues for more efficacious acquisition and interpretation of AF data.
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Affiliation(s)
- Edward J Ciaccio
- Department of Medicine - Division of Cardiology, Columbia University Medical Center, New York, NY, USA; ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, UK.
| | - Elaine Y Wan
- Department of Medicine - Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Deepak S Saluja
- Department of Medicine - Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - U Rajendra Acharya
- Department of Electronics and Computer Engineering, Ngee Ann Polytechnic, Singapore
| | - Nicholas S Peters
- ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Hasan Garan
- Department of Medicine - Division of Cardiology, Columbia University Medical Center, New York, NY, USA
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26
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Kowalewski CAB, Shenasa F, Rodrigo M, Clopton P, Meckler G, Alhusseini MI, Swerdlow MA, Joshi V, Hossainy S, Zaman JAB, Baykaner T, Rogers AJ, Brachmann J, Miller JM, Krummen DE, Sauer WH, Peters NS, Wang PJ, Narayan SM. Interaction of Localized Drivers and Disorganized Activation in Persistent Atrial Fibrillation: Reconciling Putative Mechanisms Using Multiple Mapping Techniques. Circ Arrhythm Electrophysiol 2019; 11:e005846. [PMID: 29884620 DOI: 10.1161/circep.117.005846] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 04/05/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Mechanisms for persistent atrial fibrillation (AF) are unclear. We hypothesized that putative AF drivers and disorganized zones may interact dynamically over short time scales. We studied this interaction over prolonged durations, focusing on regions where ablation terminates persistent AF using 2 mapping methods. METHODS We recruited 55 patients with persistent AF in whom ablation terminated AF prior to pulmonary vein isolation from a multicenter registry. AF was mapped globally using electrograms for 360±45 cycles using (1) a published phase method and (2) a commercial activation/phase method. RESULTS Patients were 62.2±9.7 years, 76% male. Sites of AF termination showed rotational/focal patterns by methods 1 and 2 (51/55 vs 55/55; P=0.13) in spatially conserved regions, yet fluctuated over time. Time points with no AF driver showed competing drivers elsewhere or disordered waves. Organized regions were detected for 61.6±23.9% and 70.6±20.6% of 1 minute per method (P=nonsignificant), confirmed by automatic phase tracking (P<0.05). To detect AF drivers with >90% sensitivity, 8 to 32 s of AF recordings were required depending on driver definition. CONCLUSIONS Sites at which persistent AF terminated by ablation show organized activation that fluctuate over time, because of collision from concurrent organized zones or fibrillatory waves, yet recur in conserved spatial regions. Results were similar by 2 mapping methods. This network of competing mechanisms should be reconciled with existing disorganized or driver mechanisms for AF, to improve clinical mapping and ablation of persistent AF. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT02997254.
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Affiliation(s)
- Christopher A B Kowalewski
- Department of Medicine, Stanford University, CA (C.A.B.K., F.S., M.R., P.C., G.M., M.I.A., M.A.S., V.J., J.A.B.Z., T.B., A.J.R., P.J.W., S.M.N.).,Department of Cardiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.)
| | - Fatemah Shenasa
- Department of Medicine, Stanford University, CA (C.A.B.K., F.S., M.R., P.C., G.M., M.I.A., M.A.S., V.J., J.A.B.Z., T.B., A.J.R., P.J.W., S.M.N.)
| | - Miguel Rodrigo
- Department of Medicine, Stanford University, CA (C.A.B.K., F.S., M.R., P.C., G.M., M.I.A., M.A.S., V.J., J.A.B.Z., T.B., A.J.R., P.J.W., S.M.N.)
| | - Paul Clopton
- Department of Medicine, Stanford University, CA (C.A.B.K., F.S., M.R., P.C., G.M., M.I.A., M.A.S., V.J., J.A.B.Z., T.B., A.J.R., P.J.W., S.M.N.)
| | - Gabriela Meckler
- Department of Medicine, Stanford University, CA (C.A.B.K., F.S., M.R., P.C., G.M., M.I.A., M.A.S., V.J., J.A.B.Z., T.B., A.J.R., P.J.W., S.M.N.)
| | - Mahmood I Alhusseini
- Department of Medicine, Stanford University, CA (C.A.B.K., F.S., M.R., P.C., G.M., M.I.A., M.A.S., V.J., J.A.B.Z., T.B., A.J.R., P.J.W., S.M.N.)
| | - Mark A Swerdlow
- Department of Medicine, Stanford University, CA (C.A.B.K., F.S., M.R., P.C., G.M., M.I.A., M.A.S., V.J., J.A.B.Z., T.B., A.J.R., P.J.W., S.M.N.)
| | - Vijay Joshi
- Department of Medicine, Stanford University, CA (C.A.B.K., F.S., M.R., P.C., G.M., M.I.A., M.A.S., V.J., J.A.B.Z., T.B., A.J.R., P.J.W., S.M.N.)
| | - Samir Hossainy
- Department of Engineering, University of California, Berkeley (S.H.)
| | - Junaid A B Zaman
- Department of Medicine, Stanford University, CA (C.A.B.K., F.S., M.R., P.C., G.M., M.I.A., M.A.S., V.J., J.A.B.Z., T.B., A.J.R., P.J.W., S.M.N.).,ElectroCardioMaths Programme, Imperial College, London, United Kingdom (J.A.B.Z., N.S.P.)
| | - Tina Baykaner
- Department of Medicine, Stanford University, CA (C.A.B.K., F.S., M.R., P.C., G.M., M.I.A., M.A.S., V.J., J.A.B.Z., T.B., A.J.R., P.J.W., S.M.N.)
| | - Albert J Rogers
- Department of Medicine, Stanford University, CA (C.A.B.K., F.S., M.R., P.C., G.M., M.I.A., M.A.S., V.J., J.A.B.Z., T.B., A.J.R., P.J.W., S.M.N.)
| | | | - John M Miller
- Department of Medicine, Indiana University, Indianapolis (J.M.M.)
| | - David E Krummen
- Department of Medicine, University of California San Diego (D.E.K.)
| | - William H Sauer
- Department of Medicine, University of Colorado, Denver (W.H.S.)
| | - Nicholas S Peters
- ElectroCardioMaths Programme, Imperial College, London, United Kingdom (J.A.B.Z., N.S.P.)
| | - Paul J Wang
- Department of Medicine, Stanford University, CA (C.A.B.K., F.S., M.R., P.C., G.M., M.I.A., M.A.S., V.J., J.A.B.Z., T.B., A.J.R., P.J.W., S.M.N.)
| | - Sanjiv M Narayan
- Department of Medicine, Stanford University, CA (C.A.B.K., F.S., M.R., P.C., G.M., M.I.A., M.A.S., V.J., J.A.B.Z., T.B., A.J.R., P.J.W., S.M.N.).
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27
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Leef G, Shenasa F, Bhatia NK, Rogers AJ, Sauer W, Miller JM, Swerdlow M, Tamboli M, Alhusseini MI, Armenia E, Baykaner T, Brachmann J, Turakhia MP, Atienza F, Rappel WJ, Wang PJ, Narayan SM. Wavefront Field Mapping Reveals a Physiologic Network Between Drivers Where Ablation Terminates Atrial Fibrillation. Circ Arrhythm Electrophysiol 2019; 12:e006835. [PMID: 31352796 DOI: 10.1161/circep.118.006835] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Localized drivers are proposed mechanisms for persistent atrial fibrillation (AF) from optical mapping of human atria and clinical studies of AF, yet are controversial because drivers fluctuate and ablating them may not terminate AF. We used wavefront field mapping to test the hypothesis that AF drivers, if concurrent, may interact to produce fluctuating areas of control to explain their appearance/disappearance and acute impact of ablation. METHODS We recruited 54 patients from an international registry in whom persistent AF terminated by targeted ablation. Unipolar AF electrograms were analyzed from 64-pole baskets to reconstruct activation times, map propagation vectors each 20 ms, and create nonproprietary phase maps. RESULTS Each patient (63.6±8.5 years, 29.6% women) showed 4.0±2.1 spatially anchored rotational or focal sites in AF in 3 patterns. First, a single (type I; n=7) or, second, paired chiral-antichiral (type II; n=5) rotational drivers controlled most of the atrial area. Ablation of 1 to 2 large drivers terminated all cases of types I or II AF. Third, interaction of 3 to 5 drivers (type III; n=42) with changing areas of control. Targeted ablation at driver centers terminated AF and required more ablation in types III versus I (P=0.02 in left atrium). CONCLUSIONS Wavefront field mapping of persistent AF reveals a pathophysiologic network of a small number of spatially anchored rotational and focal sites, which interact, fluctuate, and control varying areas. Future work should define whether AF drivers that control larger atrial areas are attractive targets for ablation.
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Affiliation(s)
- George Leef
- Department of Medicine, Stanford University, California (G.L., F.S., N.K.B., A.J.R., M.S., M.T., M.I.A., T.B., P.J.W., S.M.N.)
| | - Fatemah Shenasa
- Department of Medicine, Stanford University, California (G.L., F.S., N.K.B., A.J.R., M.S., M.T., M.I.A., T.B., P.J.W., S.M.N.)
| | - Neal K Bhatia
- Department of Medicine, Stanford University, California (G.L., F.S., N.K.B., A.J.R., M.S., M.T., M.I.A., T.B., P.J.W., S.M.N.)
| | - Albert J Rogers
- Department of Medicine, Stanford University, California (G.L., F.S., N.K.B., A.J.R., M.S., M.T., M.I.A., T.B., P.J.W., S.M.N.)
| | - William Sauer
- Department of Medicine, University of Colorado, Denver (W.S., E.A.)
| | - John M Miller
- Department of Medicine, University of Indiana, Indianapolis (J.M.M.)
| | - Mark Swerdlow
- Department of Medicine, Stanford University, California (G.L., F.S., N.K.B., A.J.R., M.S., M.T., M.I.A., T.B., P.J.W., S.M.N.)
| | - Mallika Tamboli
- Department of Medicine, Stanford University, California (G.L., F.S., N.K.B., A.J.R., M.S., M.T., M.I.A., T.B., P.J.W., S.M.N.)
| | - Mahmood I Alhusseini
- Department of Medicine, Stanford University, California (G.L., F.S., N.K.B., A.J.R., M.S., M.T., M.I.A., T.B., P.J.W., S.M.N.)
| | - Erin Armenia
- Department of Medicine, University of Colorado, Denver (W.S., E.A.)
| | - Tina Baykaner
- Department of Medicine, Stanford University, California (G.L., F.S., N.K.B., A.J.R., M.S., M.T., M.I.A., T.B., P.J.W., S.M.N.)
| | | | - Mintu P Turakhia
- Department of Medicine, Veterans Affairs Palo Alto Health Care System, CA (M.P.T.)
| | - Felipe Atienza
- Departamento de Cardiologia, Hospital General Universitario Gregorio Maranon, Madrid, Spain (F.A.)
| | | | - Paul J Wang
- Department of Medicine, Stanford University, California (G.L., F.S., N.K.B., A.J.R., M.S., M.T., M.I.A., T.B., P.J.W., S.M.N.)
| | - Sanjiv M Narayan
- Department of Medicine, Stanford University, California (G.L., F.S., N.K.B., A.J.R., M.S., M.T., M.I.A., T.B., P.J.W., S.M.N.)
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Wang L, Gharbia OA, Nazarian S, Horácek BM, Sapp JL. Non-invasive epicardial and endocardial electrocardiographic imaging for scar-related ventricular tachycardia. Europace 2019; 20:f263-f272. [PMID: 29684187 DOI: 10.1093/europace/euy082] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 03/22/2018] [Indexed: 11/13/2022] Open
Abstract
Aims Contact mapping is currently used to guide catheter ablation of scar-related ventricular tachycardia (VT) but usually provides incomplete assessment of 3D re-entry circuits and their arrhythmogenic substrates. This study investigates the feasibility of non-invasive electrocardiographic imaging (ECGi) in mapping scar substrates and re-entry circuits throughout the epicardium and endocardium. Methods and results Four patients undergoing endocardial and epicardial mapping and ablation of scar-related VT had computed tomography scans and a 120-lead electrocardiograms, which were used to compute patient-specific ventricular epicardial and endocardial unipolar electrograms (CEGMs). Native-rhythm CEGMs were used to identify sites of myocardial scar and signal fractionation. Computed electrograms of induced VT were used to localize re-entrant circuits and exit sites. Results were compared to in vivo contact mapping data and epicardium-based ECGi solutions. During native rhythm, an average of 493 ± 18 CEGMs were analysed on each patient. Identified regions of scar and fractionation comprised, respectively, 25 ± 4% and 2 ± 1% of the ventricular surface area. Using a linear mixed-effects model grouped at the level of an individual patient, CEGM voltage and duration were significantly associated with contact bipolar voltage. During induced VT, the inclusion of endocardial layer in ECGi made it possible to identify two epicardial vs. three endocardial VT exit sites among five reconstructed re-entry circuits. Conclusion Electrocardiographic imaging may be used to reveal sites of signal fractionation and to map short-lived VT circuits. Its capacity to map throughout epicardial and endocardial layers may improve the delineation of 3D re-entry circuits and their arrhythmogenic substrates.
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Affiliation(s)
- Linwei Wang
- College of Computing and Information Sciences, Rochester Institute of Technology, Room 74-1075, 102 Lomb Memorial Drive, Rochester, NY, USA
| | - Omar A Gharbia
- College of Computing and Information Sciences, Rochester Institute of Technology, Room 74-1075, 102 Lomb Memorial Drive, Rochester, NY, USA
| | - Saman Nazarian
- School of Medicine, The University of Pennsylvania, Philadelphia, PA, USA
| | - B Milan Horácek
- School of Biomedical Engineering, Dalhousie University, Halifax, NS, Canada
| | - John L Sapp
- School of Biomedical Engineering, Dalhousie University, Halifax, NS, Canada
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29
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Vicera JJB, Lo LW, Shinya Y, Chou YH, Lin YJ, Lo MT, Lin WL, Liu SH, Cheng WH, Tsai TY, Chen SA. Ultra-rapid high-density mapping system with the phase singularity technique is feasible in identifying rotors and focal sources and predicting AF termination. J Cardiovasc Electrophysiol 2019; 30:952-963. [PMID: 30983063 DOI: 10.1111/jce.13952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 03/12/2019] [Accepted: 03/13/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Phase singularity (PS) mapping provides additional insight into the AF mechanism and is accurate in identifying rotors. The study aimed to evaluate the feasibility of PS mapping in identifying AF rotors using data obtained from an automatic ultra-rapid high-resolution mapping system with a high-density mini-basket catheter. METHODS Twenty-three pigs underwent rapid right atrial (RA) pacing (RAP 480 bpm) for 5 weeks before the experiment. During AF, RA endocardial automatic continuous mappings with a mini-basket catheter were generated using an automatic ultra-rapid mapping system. Both fractionation mapping and waveform similarity measurements using a PS mapping algorithm were applied on the same recording signals to localize substrates maintaining AF. RESULTS Seventeen (74%) pigs developed sustained AF after RAP. Three were excluded because of periprocedural ventricular arrhythmia and corrupted digital data. RA fractionation maps were acquired with 6.17 ± 4.29 minutes mean acquisition time, 13768 ± 12698 acquisition points mapped during AF from 581 ± 387 beats. Fractionation mapping identified extensively distributed (66.7%) RA complex fractionated atrial electrogram (CFAE), whereas the nonlinear analysis identified high similarity index (SI > 0.7) parts in limited areas (23.7%). There was an average of 1.67 ± 0.87 SI sites with 0.43 ± 0.76 rotor/focal source/chamber. AF termination occurred in 11/16 (68.75%) AF events in 14 pigs during ablation targeting max CFAE. There was a higher incidence of rotor/focal source at AF termination sites compared with non-AF termination sites (54.5% vs 0%, P = 0.011). CONCLUSIONS The data obtained from ultra-rapid high-density automatic mapping is feasible and effective in identifying AF rotors/focal sources using PS technique, and those critical substrates were closely related to AF procedural termination.
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Affiliation(s)
- Jennifer Jeanne B Vicera
- Heart Rhythm Center and Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Li-Wei Lo
- Heart Rhythm Center and Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Yamada Shinya
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Yu-Hui Chou
- Heart Rhythm Center and Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Heart Rhythm Center and Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Men-Tzung Lo
- Department of Biomedical Sciences and Engineering National Central University, Taoyuan, Taiwan
| | - Wei-Lun Lin
- Heart Rhythm Center and Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Shin-Huei Liu
- Heart Rhythm Center and Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Wen-Han Cheng
- Heart Rhythm Center and Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Tsung-Ying Tsai
- Heart Rhythm Center and Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Shih-Ann Chen
- Heart Rhythm Center and Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
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30
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Swerdlow M, Tamboli M, Alhusseini MI, Moosvi N, Rogers AJ, Leef G, Wang PJ, Rillig A, Brachmann J, Sauer WH, Ruppersberg P, Narayan SM, Baykaner T. Comparing phase and electrographic flow mapping for persistent atrial fibrillation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:499-507. [PMID: 30882924 DOI: 10.1111/pace.13649] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/17/2019] [Accepted: 02/04/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND An increasing number of methods are being used to map atrial fibrillation (AF), yet the sensitivity of identifying potential localized AF sources of these novel methods are unclear. Here, we report a comparison of two approaches to map AF based upon (1) electrographic flow mapping and (2) phase mapping in a multicenter registry of patients in whom ablation terminated persistent AF. METHODS Fifty-three consecutive patients with persistent AF in whom ablation terminated AF in an international multicenter registry were enrolled. Electrographic flow mapping (EGF) and phase mapping were applied to the multipolar simultaneous electrograms recorded from a 64-pole basket catheter in the chamber (left vs right atrium) where AF termination occurred. We analyzed if the mapping methods were able to detect localized sources at the AF termination site. We also analyzed global results of mapping AF for each method, patterns of activation of localized sources. RESULTS Patients were 64.3 ± 9.4 years old and 69.8% were male. EGF and phase mapping identified localized sources at AF termination sites in 81% and 83% of the patients, respectively. Methods were complementary and in only n = 2 (3.7%) neither method identified a source. Globally, EGF identified more localized sources than phase mapping (5.3 ± 2.8 vs 1.8 ± 0.5, P < 0.001), with a higher prevalence of focal (compared to rotational) activation pattern (49% vs 2%, P < 0.01). CONCLUSIONS EGF is a novel vectorial-based AF mapping method, which can detect sites of AF termination, agreeing with, and complementary to, an alternative AF mapping method using phase analysis.
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Affiliation(s)
- M Swerdlow
- Cardiovascular Medicine, Stanford University, Stanford, California
| | - M Tamboli
- Cardiovascular Medicine, Stanford University, Stanford, California
| | - M I Alhusseini
- Cardiovascular Medicine, Stanford University, Stanford, California
| | - N Moosvi
- Cardiovascular Medicine, Stanford University, Stanford, California
| | - A J Rogers
- Cardiovascular Medicine, Stanford University, Stanford, California
| | - G Leef
- Cardiovascular Medicine, Stanford University, Stanford, California
| | - P J Wang
- Cardiovascular Medicine, Stanford University, Stanford, California
| | - A Rillig
- Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - J Brachmann
- Cardiology, II Medizinische Klinik Klinikum Coburg, Coburg, Germany
| | - W H Sauer
- Cardiology, University of Colorado at Denver and Health Sciences Center, Denver, Colorado
| | | | - S M Narayan
- Cardiovascular Medicine, Stanford University, Stanford, California
| | - T Baykaner
- Cardiovascular Medicine, Stanford University, Stanford, California
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Honarbakhsh S, Hunter RJ, Finlay M, Ullah W, Keating E, Tinker A, Schilling RJ. Development, in vitro validation and human application of a novel method to identify arrhythmia mechanisms: The stochastic trajectory analysis of ranked signals mapping method. J Cardiovasc Electrophysiol 2019; 30:691-701. [PMID: 30801836 PMCID: PMC8609431 DOI: 10.1111/jce.13882] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 01/31/2019] [Accepted: 01/31/2019] [Indexed: 11/29/2022]
Abstract
Introduction Methods and Results Conclusions
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Affiliation(s)
- Shohreh Honarbakhsh
- Electrophysiology DepartmentThe Barts Heart Centre, Barts Health NHS trust London United Kingdom
| | - Ross J. Hunter
- Electrophysiology DepartmentThe Barts Heart Centre, Barts Health NHS trust London United Kingdom
| | - Malcolm Finlay
- Electrophysiology DepartmentThe Barts Heart Centre, Barts Health NHS trust London United Kingdom
| | - Waqas Ullah
- Electrophysiology DepartmentThe Barts Heart Centre, Barts Health NHS trust London United Kingdom
| | - Emily Keating
- Electrophysiology DepartmentThe Barts Heart Centre, Barts Health NHS trust London United Kingdom
| | | | - Richard J. Schilling
- Electrophysiology DepartmentThe Barts Heart Centre, Barts Health NHS trust London United Kingdom
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32
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Orozco-Duque A, Tobón C, Ugarte JP, Morillo C, Bustamante J. Electroanatomical mapping based on discrimination of electrograms clusters for localization of critical sites in atrial fibrillation. PROGRESS IN BIOPHYSICS AND MOLECULAR BIOLOGY 2019; 141:37-46. [DOI: 10.1016/j.pbiomolbio.2018.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 05/07/2018] [Accepted: 07/03/2018] [Indexed: 11/30/2022]
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Hansen BJ, Zhao J, Li N, Zolotarev A, Zakharkin S, Wang Y, Atwal J, Kalyanasundaram A, Abudulwahed SH, Helfrich KM, Bratasz A, Powell KA, Whitson B, Mohler PJ, Janssen PML, Simonetti OP, Hummel JD, Fedorov VV. Human Atrial Fibrillation Drivers Resolved With Integrated Functional and Structural Imaging to Benefit Clinical Mapping. JACC Clin Electrophysiol 2018; 4:1501-1515. [PMID: 30573112 DOI: 10.1016/j.jacep.2018.08.024] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 07/19/2018] [Accepted: 08/23/2018] [Indexed: 12/23/2022]
Abstract
OBJECTIVES This study sought to improve atrial fibrillation (AF) driver identification by integrating clinical multielectrode mapping with driver fingerprints defined by high-resolution ex vivo 3-dimensional (3D) functional and structural imaging. BACKGROUND Clinical multielectrode mapping of AF drivers suffers from variable contact, signal processing, and structural complexity within the 3D human atrial wall, raising questions on the validity of such drivers. METHODS Sustained AF was mapped in coronary-perfused explanted human hearts (n = 11) with transmural near-infrared optical mapping (∼0.3 mm2 resolution). Simultaneously, custom FIRMap catheters (∼9 × 9 mm2 resolution) mapped endocardial and epicardial surfaces, which were analyzed by Focal Impulse and Rotor Mapping activation and Rotational Activity Profile (Abbott Labs, Chicago, Illinois). Functional maps were integrated with contrast-enhanced cardiac magnetic resonance imaging (∼0.1 mm3 resolution) analysis of 3D fibrosis architecture. RESULTS During sustained AF, near-infrared optical mapping identified 1 to 2 intramural, spatially stable re-entrant AF drivers per heart. Driver targeted ablation affecting 2.2 ± 1.1% of the atrial surface terminated and prevented AF. Driver regions had significantly higher phase singularity density and dominant frequency than neighboring nondriver regions. Focal Impulse and Rotor Mapping had 80% sensitivity to near-infrared optical mapping-defined driver locations (16 of 20), and matched 14 of 20 driver visualizations: 10 of 14 re-entries seen with Rotational Activity Profile; and 4 of 6 breakthrough/focal patterns. Focal Impulse and Rotor Mapping detected 1.1 ± 0.9 false-positive rotational activity profiles per recording, but these regions had lower intramural contrast-enhanced cardiac magnetic resonance imaging fibrosis than did driver regions (14.9 ± 7.9% vs. 23.2 ± 10.5%; p < 0.005). CONCLUSIONS The study revealed that both re-entrant and breakthrough/focal AF driver patterns visualized by surface-only clinical multielectrodes can represent projections of 3D intramural microanatomic re-entries. Integration of multielectrode mapping and 3D fibrosis analysis may enhance AF driver detection, thereby improving the efficacy of driver-targeted ablation.
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Affiliation(s)
- Brian J Hansen
- Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio; Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jichao Zhao
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Ning Li
- Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio; Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Alexander Zolotarev
- Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio; Phystech School of Biological and Medical Physics, Moscow Institute of Physic and Technology, Dolgoprudny, Russian Federation
| | - Stanislav Zakharkin
- Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Yufeng Wang
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Josh Atwal
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Anuradha Kalyanasundaram
- Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio; Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Suhaib H Abudulwahed
- Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Katelynn M Helfrich
- Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Anna Bratasz
- Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Kimerly A Powell
- Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Bryan Whitson
- Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Peter J Mohler
- Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Paul M L Janssen
- Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio; Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Orlando P Simonetti
- Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Biomedical Engineering, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - John D Hummel
- Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Vadim V Fedorov
- Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio; Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio.
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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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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: 33] [Impact Index Per Article: 5.5] [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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Cluitmans M, Brooks DH, MacLeod R, Dössel O, Guillem MS, van Dam PM, Svehlikova J, He B, Sapp J, Wang L, Bear L. Validation and Opportunities of Electrocardiographic Imaging: From Technical Achievements to Clinical Applications. Front Physiol 2018; 9:1305. [PMID: 30294281 PMCID: PMC6158556 DOI: 10.3389/fphys.2018.01305] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 08/29/2018] [Indexed: 11/23/2022] Open
Abstract
Electrocardiographic imaging (ECGI) reconstructs the electrical activity of the heart from a dense array of body-surface electrocardiograms and a patient-specific heart-torso geometry. Depending on how it is formulated, ECGI allows the reconstruction of the activation and recovery sequence of the heart, the origin of premature beats or tachycardia, the anchors/hotspots of re-entrant arrhythmias and other electrophysiological quantities of interest. Importantly, these quantities are directly and non-invasively reconstructed in a digitized model of the patient's three-dimensional heart, which has led to clinical interest in ECGI's ability to personalize diagnosis and guide therapy. Despite considerable development over the last decades, validation of ECGI is challenging. Firstly, results depend considerably on implementation choices, which are necessary to deal with ECGI's ill-posed character. Secondly, it is challenging to obtain (invasive) ground truth data of high quality. In this review, we discuss the current status of ECGI validation as well as the major challenges remaining for complete adoption of ECGI in clinical practice. Specifically, showing clinical benefit is essential for the adoption of ECGI. Such benefit may lie in patient outcome improvement, workflow improvement, or cost reduction. Future studies should focus on these aspects to achieve broad adoption of ECGI, but only after the technical challenges have been solved for that specific application/pathology. We propose 'best' practices for technical validation and highlight collaborative efforts recently organized in this field. Continued interaction between engineers, basic scientists, and physicians remains essential to find a hybrid between technical achievements, pathological mechanisms insights, and clinical benefit, to evolve this powerful technique toward a useful role in clinical practice.
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Affiliation(s)
- Matthijs Cluitmans
- Department of Cardiology, Cardiovascular Research Institute Maastricht Maastricht University, Maastricht, Netherlands
| | - Dana H. Brooks
- Department of Electrical and Computer Engineering, Northeastern University, Boston, MA, United States
| | - Rob MacLeod
- Biomedical Engineering Department, Scientific Computing and Imaging Institute (SCI), and Cardiovascular Research and Training Institute (CVRTI), The University of Utah, Salt Lake City, UT, United States
| | - Olaf Dössel
- Karlsruhe Institute of Technology, Karlsruhe, Germany
| | | | - Peter M. van Dam
- Donders Institute for Brain, Cognition and Behaviour, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands
| | - Jana Svehlikova
- Institute of Measurement Science, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Bin He
- Department of Biomedical Engineering Carnegie Mellon University, Pittsburgh, PA, United States
| | - John Sapp
- QEII Health Sciences Centre and Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Linwei Wang
- Rochester Institute of Technology, Rochester, NY, United States
| | - Laura Bear
- IHU LIRYC, Fondation Bordeaux Université, Inserm U1045 and Université de Bordeaux, Bordeaux, France
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37
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Ríos-Muñoz GR, Arenal Á, Artés-Rodríguez A. Real-Time Rotational Activity Detection in Atrial Fibrillation. Front Physiol 2018; 9:208. [PMID: 29593566 PMCID: PMC5859379 DOI: 10.3389/fphys.2018.00208] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 02/23/2018] [Indexed: 12/31/2022] Open
Abstract
Rotational activations, or spiral waves, are one of the proposed mechanisms for atrial fibrillation (AF) maintenance. We present a system for assessing the presence of rotational activity from intracardiac electrograms (EGMs). Our system is able to operate in real-time with multi-electrode catheters of different topologies in contact with the atrial wall, and it is based on new local activation time (LAT) estimation and rotational activity detection methods. The EGM LAT estimation method is based on the identification of the highest sustained negative slope of unipolar signals. The method is implemented as a linear filter whose output is interpolated on a regular grid to match any catheter topology. Its operation is illustrated on selected signals and compared to the classical Hilbert-Transform-based phase analysis. After the estimation of the LAT on the regular grid, the detection of rotational activity in the atrium is done by a novel method based on the optical flow of the wavefront dynamics, and a rotation pattern match. The methods have been validated using in silico and real AF signals.
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Affiliation(s)
- Gonzalo R Ríos-Muñoz
- Signal Theory and Communications Department, Universidad Carlos III de Madrid, Madrid, Spain.,Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Ángel Arenal
- Gregorio Marañón Health Research Institute, Madrid, Spain.,Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Antonio Artés-Rodríguez
- Signal Theory and Communications Department, Universidad Carlos III de Madrid, Madrid, Spain.,Gregorio Marañón Health Research Institute, Madrid, Spain
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38
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Fedorov VV, Hansen BJ. A Secret Marriage Between Fibrosis and Atrial Fibrillation Drivers. JACC Clin Electrophysiol 2018; 4:30-32. [PMID: 29600783 DOI: 10.1016/j.jacep.2017.09.176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 09/21/2017] [Indexed: 11/20/2022]
Affiliation(s)
- Vadim V Fedorov
- Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio.
| | - Brian J Hansen
- Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Narayan SM, Vishwanathan MN, Kowalewski CAB, Baykaner T, Rodrigo M, Zaman JAB, Wang PJ. The continuous challenge of AF ablation: From foci to rotational activity. Rev Port Cardiol 2017; 36 Suppl 1:9-17. [PMID: 29126896 DOI: 10.1016/j.repc.2017.09.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 08/18/2017] [Accepted: 09/11/2017] [Indexed: 11/24/2022] Open
Abstract
Pulmonary vein isolation (PVI) is central to ablation approaches for atrial fibrillation (AF), yet many patients still have arrhythmia recurrence after one or more procedures despite the latest technology for PVI. Ablation of rotational or focal sources for AF, which lie outside the pulmonary veins in many patients, is a practical approach that has been shown to improve success by many groups. Localized sources lie in atrial regions shown mechanistically to sustain AF in optical mapping and clinical studies of human AF, as well as computational and animal studies. Because they arise in localized atrial regions, AF sources may explain central paradoxes in clinical practice - such as how limited ablation in patient specific sites can terminate persistent AF yet extensive anatomical ablation at stereotypical locations, which should extinguish disordered waves, does not improve success in clinical trials. Ongoing studies may help to resolve many controversies in the field of rotational sources for AF. Studies now verify rotational activation by multiple mapping approaches in the same patients, at sites where ablation terminates persistent AF. However, these studies also show that certain mapping methods are less effective for detecting AF sources than others. It is also recognized that the success of AF source ablation is technique dependent. This review article provides a mechanistic and clinical rationale to ablate localized sources (rotational and focal), and describes successful techniques for their ablation as well as pitfalls to avoid. We hope that this review will serve as a platform for future improvements in the patient-tailored ablation for complex arrhythmias.
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Affiliation(s)
| | | | | | | | | | | | - Paul J Wang
- Stanford University, Palo Alto, CA, United States
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40
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Cochet H, Dubois R, Yamashita S, Al Jefairi N, Berte B, Sellal JM, Hooks D, Frontera A, Amraoui S, Zemoura A, Denis A, Derval N, Sacher F, Corneloup O, Latrabe V, Clément-Guinaudeau S, Relan J, Zahid S, Boyle PM, Trayanova NA, Bernus O, Montaudon M, Laurent F, Hocini M, Haïssaguerre M, Jaïs P. Relationship Between Fibrosis Detected on Late Gadolinium-Enhanced Cardiac Magnetic Resonance and Re-Entrant Activity Assessed With Electrocardiographic Imaging in Human Persistent Atrial Fibrillation. JACC Clin Electrophysiol 2017; 4:17-29. [PMID: 29479568 DOI: 10.1016/j.jacep.2017.07.019] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES This study sought to assess the relationship between fibrosis and re-entrant activity in persistent atrial fibrillation (AF). BACKGROUND The mechanisms involved in sustaining re-entrant activity during AF are poorly understood. METHODS Forty-one patients with persistent AF (age 56 ± 12 years; 6 women) were evaluated. High-resolution electrocardiographic imaging (ECGI) was performed during AF by using a 252-chest electrode array, and phase mapping was applied to locate re-entrant activity. Sites of high re-entrant activity were defined as re-entrant regions. Late gadolinium-enhanced (LGE) cardiac magnetic resonance (CMR) was performed at 1.25 × 1.25 × 2.5 mm resolution to characterize atrial fibrosis and measure atrial volumes. The relationship between LGE burden and the number of re-entrant regions was analyzed. Local LGE density was computed and characterized at re-entrant sites. All patients underwent catheter ablation targeting re-entrant regions, the procedural endpoint being AF termination. Clinical, CMR, and ECGI predictors of acute procedural success were then analyzed. RESULTS Left atrial (LA) LGE burden was 22.1 ± 5.9% of the wall, and LA volume was 74 ± 21 ml/m2. The number of re-entrant regions was 4.3 ± 1.7 per patient. LA LGE imaging was significantly associated with the number of re-entrant regions (R = 0.52, p = 0.001), LA volume (R = 0.62, p < 0.0001), and AF duration (R = 0.54, p = 0.0007). Regional analysis demonstrated a clustering of re-entrant activity at LGE borders. Areas with high re-entrant activity showed higher local LGE density as compared with the remaining atrial areas (p < 0.0001). Failure to achieve AF termination during ablation was associated with higher LA LGE burden (p < 0.001), higher number of re-entrant regions (p < 0.001), and longer AF duration (p = 0.008). CONCLUSIONS The number of re-entrant regions during AF relates to the extent of LGE on CMR, with the location of these regions clustering to LGE areas. These characteristics affect procedural outcomes of ablation.
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Affiliation(s)
- Hubert Cochet
- Haut-Lévêque Cardiology Hospital, Bordeaux University Hospital Center, University of Bordeaux, France
- National Institute for Health and Medical Research (INSERM) U1045 - Electrophysiology and Heart Modeling Institute, Bordeaux, France
| | - Rémi Dubois
- National Institute for Health and Medical Research (INSERM) U1045 - Electrophysiology and Heart Modeling Institute, Bordeaux, France
| | - Seigo Yamashita
- Haut-Lévêque Cardiology Hospital, Bordeaux University Hospital Center, University of Bordeaux, France
| | - Nora Al Jefairi
- Haut-Lévêque Cardiology Hospital, Bordeaux University Hospital Center, University of Bordeaux, France
| | - Benjamin Berte
- Haut-Lévêque Cardiology Hospital, Bordeaux University Hospital Center, University of Bordeaux, France
| | - Jean-Marc Sellal
- Haut-Lévêque Cardiology Hospital, Bordeaux University Hospital Center, University of Bordeaux, France
| | - Darren Hooks
- Haut-Lévêque Cardiology Hospital, Bordeaux University Hospital Center, University of Bordeaux, France
| | - Antonio Frontera
- Haut-Lévêque Cardiology Hospital, Bordeaux University Hospital Center, University of Bordeaux, France
| | - Sana Amraoui
- Haut-Lévêque Cardiology Hospital, Bordeaux University Hospital Center, University of Bordeaux, France
- National Institute for Health and Medical Research (INSERM) U1045 - Electrophysiology and Heart Modeling Institute, Bordeaux, France
| | - Adlane Zemoura
- Haut-Lévêque Cardiology Hospital, Bordeaux University Hospital Center, University of Bordeaux, France
- National Institute for Health and Medical Research (INSERM) U1045 - Electrophysiology and Heart Modeling Institute, Bordeaux, France
| | - Arnaud Denis
- Haut-Lévêque Cardiology Hospital, Bordeaux University Hospital Center, University of Bordeaux, France
- National Institute for Health and Medical Research (INSERM) U1045 - Electrophysiology and Heart Modeling Institute, Bordeaux, France
| | - Nicolas Derval
- Haut-Lévêque Cardiology Hospital, Bordeaux University Hospital Center, University of Bordeaux, France
- National Institute for Health and Medical Research (INSERM) U1045 - Electrophysiology and Heart Modeling Institute, Bordeaux, France
| | - Frederic Sacher
- Haut-Lévêque Cardiology Hospital, Bordeaux University Hospital Center, University of Bordeaux, France
- National Institute for Health and Medical Research (INSERM) U1045 - Electrophysiology and Heart Modeling Institute, Bordeaux, France
| | - Olivier Corneloup
- Haut-Lévêque Cardiology Hospital, Bordeaux University Hospital Center, University of Bordeaux, France
| | - Valérie Latrabe
- Haut-Lévêque Cardiology Hospital, Bordeaux University Hospital Center, University of Bordeaux, France
| | | | | | - Sohail Zahid
- Institute for Computational Medicine, Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Patrick M Boyle
- Institute for Computational Medicine, Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Natalia A Trayanova
- Institute for Computational Medicine, Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Olivier Bernus
- National Institute for Health and Medical Research (INSERM) U1045 - Electrophysiology and Heart Modeling Institute, Bordeaux, France
| | - Michel Montaudon
- Haut-Lévêque Cardiology Hospital, Bordeaux University Hospital Center, University of Bordeaux, France
- National Institute for Health and Medical Research (INSERM) U1045 - Electrophysiology and Heart Modeling Institute, Bordeaux, France
| | - François Laurent
- Haut-Lévêque Cardiology Hospital, Bordeaux University Hospital Center, University of Bordeaux, France
- National Institute for Health and Medical Research (INSERM) U1045 - Electrophysiology and Heart Modeling Institute, Bordeaux, France
| | - Mélèze Hocini
- Haut-Lévêque Cardiology Hospital, Bordeaux University Hospital Center, University of Bordeaux, France
- National Institute for Health and Medical Research (INSERM) U1045 - Electrophysiology and Heart Modeling Institute, Bordeaux, France
| | - Michel Haïssaguerre
- Haut-Lévêque Cardiology Hospital, Bordeaux University Hospital Center, University of Bordeaux, France
- National Institute for Health and Medical Research (INSERM) U1045 - Electrophysiology and Heart Modeling Institute, Bordeaux, France
| | - Pierre Jaïs
- Haut-Lévêque Cardiology Hospital, Bordeaux University Hospital Center, University of Bordeaux, France
- National Institute for Health and Medical Research (INSERM) U1045 - Electrophysiology and Heart Modeling Institute, Bordeaux, France
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41
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Narayan SM, Vishwanathan MN, Kowalewski CA, Baykaner T, Rodrigo M, Zaman JA, Wang PJ. The continuous challenge of AF ablation: From foci to rotational activity. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.repce.2017.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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42
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Jacquemet V. A statistical model of false negative and false positive detection of phase singularities. CHAOS (WOODBURY, N.Y.) 2017; 27:103124. [PMID: 29092458 DOI: 10.1063/1.4999939] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The complexity of cardiac fibrillation dynamics can be assessed by analyzing the distribution of phase singularities (PSs) observed using mapping systems. Interelectrode distance, however, limits the accuracy of PS detection. To investigate in a theoretical framework the PS false negative and false positive rates in relation to the characteristics of the mapping system and fibrillation dynamics, we propose a statistical model of phase maps with controllable number and locations of PSs. In this model, phase maps are generated from randomly distributed PSs with physiologically-plausible directions of rotation. Noise and distortion of the phase are added. PSs are detected using topological charge contour integrals on regular grids of varying resolutions. Over 100 × 106 realizations of the random field process are used to estimate average false negative and false positive rates using a Monte-Carlo approach. The false detection rates are shown to depend on the average distance between neighboring PSs expressed in units of interelectrode distance, following approximately a power law with exponents in the range of 1.14 to 2 for false negatives and around 2.8 for false positives. In the presence of noise or distortion of phase, false detection rates at high resolution tend to a non-zero noise-dependent lower bound. This model provides an easy-to-implement tool for benchmarking PS detection algorithms over a broad range of configurations with multiple PSs.
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Affiliation(s)
- Vincent Jacquemet
- Département de Pharmacologie et Physiologie, Institut de Génie Biomédical, Université de Montréal, Montréal, Québec H4J 1C5, Canada
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43
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Rodrigo M, Climent AM, Liberos A, Fernández-Avilés F, Berenfeld O, Atienza F, Guillem MS. Technical Considerations on Phase Mapping for Identification of Atrial Reentrant Activity in Direct- and Inverse-Computed Electrograms. Circ Arrhythm Electrophysiol 2017; 10:CIRCEP.117.005008. [PMID: 28887361 DOI: 10.1161/circep.117.005008] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 07/10/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Phase mapping has become a broadly used technique to identify atrial reentrant circuits for ablative therapy guidance. This work studies the phase mapping process and how the signal nature and its filtering affect the reentrant pattern characterization in electrogram (EGM), body surface potential mapping, and electrocardiographic imaging signals. METHODS AND RESULTS EGM, body surface potential mapping, and electrocardiographic imaging phase maps were obtained from 17 simulations of atrial fibrillation, atrial flutter, and focal atrial tachycardia. Reentrant activity was identified by singularity point recognition in raw signals and in signals after narrow band-pass filtering at the highest dominant frequency (HDF). Reentrant activity was dominantly present in the EGM recordings only for atrial fibrillation and some atrial flutter propagations patterns, and HDF filtering allowed increasing the reentrant activity detection from 60% to 70% of time in atrial fibrillation in unipolar recordings and from 0% to 62% in bipolar. In body surface potential mapping maps, HDF filtering increased from 10% to 90% the sensitivity, although provoked a residual false reentrant activity ≈30% of time. In electrocardiographic imaging, HDF filtering allowed to increase ≤100% the time with detected rotors, although provoked the apparition of false rotors during 100% of time. Nevertheless, raw electrocardiographic imaging phase maps presented reentrant activity just in atrial fibrillation recordings accounting for ≈80% of time. CONCLUSIONS Rotor identification is accurate and sensitive and does not require additional signal processing in measured or noninvasively computed unipolar EGMs. Bipolar EGMs and body surface potential mapping do require HDF filtering to detect rotors at the expense of a decreased specificity.
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Affiliation(s)
- Miguel Rodrigo
- From the ITACA Institute, Universitat Politècnica de València, Spain (M.R., M.S.G.); CIBERCV, Hospital General Universitario Gregorio Marañón, Instituto de investigación sanitaria Gregorio Marañón, Madrid, Spain (A.M.C., A.L., F.F.-A., F.A.); Facultad de Medicina, Universidad Complutense de Madrid, Spain (F.F.-A., F.A.); and Center for Arrhythmia Research, University of Michigan, Ann Arbor (O.B.)
| | - Andreu M Climent
- From the ITACA Institute, Universitat Politècnica de València, Spain (M.R., M.S.G.); CIBERCV, Hospital General Universitario Gregorio Marañón, Instituto de investigación sanitaria Gregorio Marañón, Madrid, Spain (A.M.C., A.L., F.F.-A., F.A.); Facultad de Medicina, Universidad Complutense de Madrid, Spain (F.F.-A., F.A.); and Center for Arrhythmia Research, University of Michigan, Ann Arbor (O.B.)
| | - Alejandro Liberos
- From the ITACA Institute, Universitat Politècnica de València, Spain (M.R., M.S.G.); CIBERCV, Hospital General Universitario Gregorio Marañón, Instituto de investigación sanitaria Gregorio Marañón, Madrid, Spain (A.M.C., A.L., F.F.-A., F.A.); Facultad de Medicina, Universidad Complutense de Madrid, Spain (F.F.-A., F.A.); and Center for Arrhythmia Research, University of Michigan, Ann Arbor (O.B.)
| | - Francisco Fernández-Avilés
- From the ITACA Institute, Universitat Politècnica de València, Spain (M.R., M.S.G.); CIBERCV, Hospital General Universitario Gregorio Marañón, Instituto de investigación sanitaria Gregorio Marañón, Madrid, Spain (A.M.C., A.L., F.F.-A., F.A.); Facultad de Medicina, Universidad Complutense de Madrid, Spain (F.F.-A., F.A.); and Center for Arrhythmia Research, University of Michigan, Ann Arbor (O.B.)
| | - Omer Berenfeld
- From the ITACA Institute, Universitat Politècnica de València, Spain (M.R., M.S.G.); CIBERCV, Hospital General Universitario Gregorio Marañón, Instituto de investigación sanitaria Gregorio Marañón, Madrid, Spain (A.M.C., A.L., F.F.-A., F.A.); Facultad de Medicina, Universidad Complutense de Madrid, Spain (F.F.-A., F.A.); and Center for Arrhythmia Research, University of Michigan, Ann Arbor (O.B.)
| | - Felipe Atienza
- From the ITACA Institute, Universitat Politècnica de València, Spain (M.R., M.S.G.); CIBERCV, Hospital General Universitario Gregorio Marañón, Instituto de investigación sanitaria Gregorio Marañón, Madrid, Spain (A.M.C., A.L., F.F.-A., F.A.); Facultad de Medicina, Universidad Complutense de Madrid, Spain (F.F.-A., F.A.); and Center for Arrhythmia Research, University of Michigan, Ann Arbor (O.B.)
| | - Maria S Guillem
- From the ITACA Institute, Universitat Politècnica de València, Spain (M.R., M.S.G.); CIBERCV, Hospital General Universitario Gregorio Marañón, Instituto de investigación sanitaria Gregorio Marañón, Madrid, Spain (A.M.C., A.L., F.F.-A., F.A.); Facultad de Medicina, Universidad Complutense de Madrid, Spain (F.F.-A., F.A.); and Center for Arrhythmia Research, University of Michigan, Ann Arbor (O.B.).
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44
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You MJ, Langfield P, Campanari L, Dobbs M, Shrier A, Glass L. Demonstration of cardiac rotor and source mapping techniques in embryonic chick monolayers. CHAOS (WOODBURY, N.Y.) 2017; 27:093938. [PMID: 28964155 DOI: 10.1063/1.5001459] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Excitable media, such as the heart, display propagating waves with different geometries including target patterns and rotors (spiral waves). Collision of two waves leads to annihilation of both. We present algorithms for data processing and analysis to identify the core of rotors. In this work, we show that as the spatial sampling resolution decreases it becomes increasingly difficult to identify rotors-there are instances of false negatives and false positives. These observations are relevant to current controversies concerning the role of rotors in the initiation, maintenance, and treatment of cardiac arrhythmias, especially atrial fibrillation. Currently some practitioners target the core of rotors for ablation, but the effectiveness of this procedure has been questioned. In view of the difficulties inherent in the identification of rotors, we conclude that methods to identify rotors need to first be validated prior to assessing the efficacy of ablation.
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Affiliation(s)
- Min Ju You
- Department of Physiology, McGill University, 3655 Promenade Sir William Osler, Montreal, Quebec H3G 1Y6, Canada
| | - Peter Langfield
- Department of Physiology, McGill University, 3655 Promenade Sir William Osler, Montreal, Quebec H3G 1Y6, Canada
| | - Lucas Campanari
- Department of Physiology, McGill University, 3655 Promenade Sir William Osler, Montreal, Quebec H3G 1Y6, Canada
| | - Matt Dobbs
- Department of Physics and McGill Space Institute, McGill University, Montreal, Quebec H3A 2T8, Canada
| | - Alvin Shrier
- Department of Physiology, McGill University, 3655 Promenade Sir William Osler, Montreal, Quebec H3G 1Y6, Canada
| | - Leon Glass
- Department of Physiology, McGill University, 3655 Promenade Sir William Osler, Montreal, Quebec H3G 1Y6, Canada
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45
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Ablation of Focal Impulses and Rotational Sources: What Can Be Learned from Differing Procedural Outcomes? CURRENT CARDIOVASCULAR RISK REPORTS 2017. [DOI: 10.1007/s12170-017-0552-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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46
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Fibrosis and Atrial Fibrillation: Computerized and Optical Mapping; A View into the Human Atria at Submillimeter Resolution. JACC Clin Electrophysiol 2017; 3:531-546. [PMID: 29159313 DOI: 10.1016/j.jacep.2017.05.002] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Recent studies strongly suggest that the majority of atrial fibrillation (AF) patients with diagnosed or subclinical cardiac diseases have established or even pre-existing fibrotic structural remodeling, which may lead to conduction abnormalities and reentrant activity that sustain AF. As conventional treatments fail to treat AF in far too many cases, an urgent need exists to identify specific structural arrhythmogenic fibrosis patterns, which may maintain AF, in order to identify effective ablation targets for AF treatment. However, the existing challenge is to define what exact structural remodeling within the complex 3D human atrial wall is arrhythmogenic, as well as linking arrhythmogenic fibrosis to an underlying mechanism of AF maintenance in the clinical setting. This review is focused on the role of 3D fibrosis architecture in the mechanisms of AF maintenance revealed by submillimeter, high-resolution ex-vivo imaging modalities directly of human atria, as well as from in-silico 3D computational techniques that can be able to overcome in-vivo clinical limitations. The systematic integration of functional and structural imaging ex-vivo may inform the necessary integration of electrode and structural mapping in-vivo. A holistic view of AF driver mechanisms may begin to identify the defining characteristics or "fingerprints" of reentrant AF drivers, such as 3D fibrotic architecture, in order to design optimal patient-specific ablation strategies.
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47
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Lau DH, Linz D, Schotten U, Mahajan R, Sanders P, Kalman JM. Pathophysiology of Paroxysmal and Persistent Atrial Fibrillation: Rotors, Foci and Fibrosis. Heart Lung Circ 2017; 26:887-893. [PMID: 28610723 DOI: 10.1016/j.hlc.2017.05.119] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 05/15/2017] [Indexed: 12/12/2022]
Abstract
Recent advances in our understanding of the mechanisms underlying atrial fibrillation (AF) have further underscored the complex pathophysiological basis of the arrhythmia. It has become apparent that the current clinical classification of AF does not reflect the severity of the underlying atrial disease. Atrial fibrosis has been identified as the key structural change in different substrates that are responsible for the perpetuation of AF. Three-dimensional electroanatomical mapping and late gadolinium-enhanced magnetic resonance imaging are novel modalities that can be used to facilitate identification and quantitation of atrial fibrosis for improved delineation of the AF substrate. Advances in AF mapping technology using endocardial 'panaromic' basket-type catheter and non-invasive body surface electrodes have facilitated the identification of two major arrhythmic mechanisms of interest, namely rotational ('rotors') and ectopic focal activations ('foci'). Ongoing research on these potential drivers of AF may provide guidance to more mechanistic based therapies to improve outcomes for this complex arrhythmia in the future. Here, we aim to review the differences in AF substrate in those with paroxysmal and more persistent forms of the arrhythmia by evaluating fibrosis, rotors and foci, towards improved AF substrate classification and individualised substrate based therapies.
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Affiliation(s)
- Dennis H Lau
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, SA, Australia.
| | - Dominik Linz
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, SA, Australia; Pathophysiology of Atrial Fibrillation, University Hospital of Saarland, Homburg/Saar, Germany
| | - Ulrich Schotten
- Department of Physiology, Maastricht University, Cardiovascular Research Institute Maastricht (CARIM), The Netherlands
| | - Rajiv Mahajan
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Jonathan M Kalman
- Department of Cardiology, Royal Melbourne Hospital and Department of Medicine, The University of Melbourne, Melbourne, Vic, Australia
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48
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Nattel S, Xiong F, Aguilar M. Demystifying rotors and their place in clinical translation of atrial fibrillation mechanisms. Nat Rev Cardiol 2017; 14:509-520. [PMID: 28383023 DOI: 10.1038/nrcardio.2017.37] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Treatment of atrial fibrillation (AF), the most common arrhythmia in clinical practice, remains challenging. Improved understanding of underlying mechanisms is needed to improve therapy. Functional re-entry is central to AF maintenance. The first detailed, quantitative theory of functional re-entry, the 'leading circle' model, was developed 40 years ago. Subsequently, an alternative paradigm based on 'spiral waves' has evolved. Spiral-wave generators, or 'rotors', have been identified using advanced mapping methods in experimental and clinical AF. A central tool in the analysis of spiral-wave rotors is the phase transformation, allowing for easier visualization of rotors and tracking of 'phase singularity' points at the rotor tip. In contrast to leading circle theory, which is expressed in terms familiar to (and easily understood by) cardiologists, the ideas needed to understand rotors are much more theoretical and harder for clinicians to apply. In this Review, we summarize the basic notions of phase mapping and spiral-wave rotors, and the ways in which rotor sources might be involved in AF maintenance. We discuss competing observations about the role of spatially confined rotors, short-lived rotors clustered at the edge of fibrotic zones, endocardial-epicardial interactive breeder properties and transmural re-entry, as well as studies underway to resolve them. We conclude with consideration of the clinical relevance of the issues discussed and their potential implications for the management of patients with AF.
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Affiliation(s)
- Stanley Nattel
- Department of Medicine and Research Center, Montreal Heart Institute and Université de Montréal, 5000 Belanger Street East, Montreal, Quebec H1T 1C8, Canada.,Department of Pharmacology and Therapeutics, McGill University, 3655 Promenade Sir William Osler, Montreal, Quebec H3G 1Y6, Canada.,Institute of Pharmacology, West German Heart and Vascular Center, University Duisburg-Essen, Hufeland Strasse 55, 45122 Essen, Germany
| | - Feng Xiong
- Department of Medicine and Research Center, Montreal Heart Institute and Université de Montréal, 5000 Belanger Street East, Montreal, Quebec H1T 1C8, Canada
| | - Martin Aguilar
- Department of Medicine and Research Center, Montreal Heart Institute and Université de Montréal, 5000 Belanger Street East, Montreal, Quebec H1T 1C8, Canada
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49
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Alhusseini M, Vidmar D, Meckler GL, Kowalewski CA, Shenasa F, Wang PJ, Narayan SM, Rappel WJ. Two Independent Mapping Techniques Identify Rotational Activity Patterns at Sites of Local Termination During Persistent Atrial Fibrillation. J Cardiovasc Electrophysiol 2017; 28:615-622. [PMID: 28185348 PMCID: PMC5466451 DOI: 10.1111/jce.13177] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 01/14/2017] [Accepted: 01/30/2017] [Indexed: 12/02/2022]
Abstract
Introduction The mechanisms for atrial fibrillation (AF) are unclear in part because diverse mapping techniques yield diverse maps, ranging from stable organized sources to highly disordered waves. We hypothesized that AF mechanisms may be clarified if mapping techniques were compared in the same patients, and referenced to a clinical endpoint. We compared two independent AF mapping techniques in patients in whom ablation terminated persistent AF before pulmonary vein isolation (PVI). Methods and Results We identified 12 patients with persistent AF (61.2 ± 10.8 years, four female) in whom mapping with 64 pole baskets and technique 1 (activation/phase mapping, FIRM) identified rotational activation patterns during at least 50% of the 4‐second mapping interval and targeted ablation at these rotational sites terminated AF to sinus rhythm (n = 10) or atrial tachycardia. We analyzed the unipolar electrograms of these patients to determine phase maps of activation by an independent technique 2 (Kuklik, Schotten et al., IEEE Trans Biomed Eng 2015). Compared to technique 1, technique 2 revealed a source in 12 of 12 (100%) cases with spatial concordance in all cases (P <0.05) and similar rotational characteristics. Conclusion At sites where ablation terminated persistent AF, two independent mapping techniques identified stable rotational activation for multiple cycles that drove peripheral disorder. Future comparative studies referenced to a clinical endpoint may help reconcile if discrepancies between AF mapping studies reports represent techniques, patient populations or models of AF, and improve mapping to better guide ablation.
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Affiliation(s)
- Mahmood Alhusseini
- Department of Medicine/Division of Cardiology, Stanford University, Stanford, California, USA
| | - David Vidmar
- Department of Physics, University of California, San Diego, California, USA
| | - Gabriela L Meckler
- Department of Medicine/Division of Cardiology, Stanford University, Stanford, California, USA
| | | | - Fatemah Shenasa
- Department of Medicine/Division of Cardiology, Stanford University, Stanford, California, USA
| | - Paul J Wang
- Department of Medicine/Division of Cardiology, Stanford University, Stanford, California, USA
| | - Sanjiv M Narayan
- Department of Medicine/Division of Cardiology, Stanford University, Stanford, California, USA
| | - Wouter-Jan Rappel
- Department of Physics, University of California, San Diego, California, USA
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50
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Lee S, Sahadevan J, Khrestian CM, Markowitz A, Waldo AL. Characterization of Foci and Breakthrough Sites During Persistent and Long-Standing Persistent Atrial Fibrillation in Patients: Studies Using High-Density (510-512 Electrodes) Biatrial Epicardial Mapping. J Am Heart Assoc 2017; 6:JAHA.116.005274. [PMID: 28314801 PMCID: PMC5524032 DOI: 10.1161/jaha.116.005274] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background We previously demonstrated that persistent and long‐standing persistent atrial fibrillation is maintained by activation emanating from foci and breakthrough sites of different cycle lengths (CLs). The purpose of this study was to characterize the behavior of focal and nonrandom breakthrough activation identified during high‐density mapping of atrial fibrillation in these patients. Methods and Results During open heart surgery, we recorded activation from both atria simultaneously using 510 to 512 epicardial electrodes along with ECG lead II in 12 patients with persistent and long‐standing persistent atrial fibrillation. For each patient, analysis of 32 consecutive seconds of activation from identified focal (sustained and/or intermittent) and nonrandom breakthrough sites was performed. Multiple foci (sustained and/or intermittent) of different CLs were present in both atria in 11 of 12 patients; 8 foci were sustained, and 22 were intermittent. Temporal CL behavior of sustained foci varied over time (≤20 ms of the mean CL). For intermittent foci, no activation periods were due to a spontaneous pause (18 of 22) or activation of the focus by another wave front (11 of 22). All patients had breakthrough activation. Seven patients had 12 nonrandom breakthrough sites. Periods of no breakthrough activation were caused by a spontaneous pause (6 of 12 patients) or activation from another wave front (4 of 12) or were uncertain (5 of 12). Focal and nonrandom breakthrough activation sometimes produced repetitive “wannabe” (incomplete) reentry in 6 of 12 patients. Conclusions During persistent and long‐standing persistent atrial fibrillation, sustained foci manifested variable CLs. Spontaneous pauses or activation from other wave fronts explained the intermittency of foci and nonrandom breakthrough. Focal and nonrandom breakthrough activation occasionally produced wannabe reentry.
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Affiliation(s)
- Seungyup Lee
- Department of Medicine, Case Western Reserve University, Cleveland, OH
| | - Jayakumar Sahadevan
- Department of Medicine, Case Western Reserve University, Cleveland, OH.,Division of Cardiovascular Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH
| | | | - Alan Markowitz
- Valve Center, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Albert L Waldo
- Department of Medicine, Case Western Reserve University, Cleveland, OH .,Division of Cardiovascular Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH
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