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Mitrani RD, Zaatari G, Bohorquez J, Ng J, Ng J, Rivner H, Velasquez A, Lambrakos L, Arora R, Goldberger JJ. Electrogram morphology recurrence guided catheter ablation for repeat ablation of persistent atrial fibrillation. J Interv Card Electrophysiol 2024; 67:183-191. [PMID: 37395978 PMCID: PMC10761586 DOI: 10.1007/s10840-023-01594-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 06/09/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND There are no standard mapping approaches for patients with persistent atrial fibrillation (PeAF), particularly after failed prior catheter ablation (CA). In this study, we assess the feasibility of using Electrogram Morphology Recurrence (EMR) to guide ablation. METHODS Ten patients with recurrent PeAF after prior CA underwent detailed mapping of both atria during PeAF using the PentaRay (4 mm interelectrode spacing) and 3D mapping with CARTO. At each site, 15 s recordings were made. Custom software identified each electrogram and cross-correlation was used to identify the most recurrent electrogram morphology from which the % recurrence and cycle length of the most repeatable morphology (CLR) was calculated. Sites of shortest CLR and sites within 5 ms of shortest CLR with recurrence ≥ 80% were used to inform CA strategy. RESULTS A mean of 342.9 ± 131.9 LA and 328.6 ± 91.5 RA sites were recorded per patient. Nine had PV reconnection. Shortest CLR sites guided ablation in 6/10 patients while 1 patient failed to fulfill shortest CLR criteria, and another 3 did not undergo CA guided by shortest CLR due to operator preference. On 12-month follow-up, all 4 patients without shortest CLR guided CA had recurrent PeAF. Of the 6 patients with shortest CLR guided CA, 5 patients did not have recurrent PeAF (p = 0.048), although 1 had paroxysmal AF and 2 had atypical atrial flutter. CONCLUSION EMR is a feasible, novel technique to guide CA in patients with PeAF. Further evaluation is needed to provide an electrogram-based method for mapping guided targeted ablation of key areas.
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Affiliation(s)
- Raul D Mitrani
- Division of Cardiology, University of Miami, 1120 NW 14th St.Clinical Research Building, 1124, 33161, Miami, FL, USA
| | - Ghaith Zaatari
- Division of Cardiology, University of Miami, 1120 NW 14th St.Clinical Research Building, 1124, 33161, Miami, FL, USA
| | - Jorge Bohorquez
- Department of Biomedical Engineering, University of Miami, Miami, FL, USA
| | - Jason Ng
- Northwestern University, Evanston, IL, USA
| | - Justin Ng
- Northwestern University, Evanston, IL, USA
| | - Harold Rivner
- Division of Cardiology, University of Miami, 1120 NW 14th St.Clinical Research Building, 1124, 33161, Miami, FL, USA
| | - Alex Velasquez
- Division of Cardiology, University of Miami, 1120 NW 14th St.Clinical Research Building, 1124, 33161, Miami, FL, USA
| | - Litsa Lambrakos
- Division of Cardiology, University of Miami, 1120 NW 14th St.Clinical Research Building, 1124, 33161, Miami, FL, USA
| | | | - Jeffrey J Goldberger
- Division of Cardiology, University of Miami, 1120 NW 14th St.Clinical Research Building, 1124, 33161, Miami, FL, USA.
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Goldberger JJ, Zaatari G, Mitrani RD, Blandon C, Bohorquez J, Ng J, Ng J, Velasquez A, Lambrakos L, Arora R. Comparison of electrogram characteristics in persistent atrial fibrillation. J Cardiovasc Electrophysiol 2024; 35:182-197. [PMID: 38031313 DOI: 10.1111/jce.16133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/27/2023] [Accepted: 11/03/2023] [Indexed: 12/01/2023]
Abstract
INTRODUCTION Multiple analysis techniques evaluate electrograms during atrial fibrillation (AF), but none have been established to guide catheter ablation. This study compares electrogram properties recorded from multiple right (RA) and left atrial (LA) sites. METHODS Multisite LA/RA mapping (281 ± 176/239 ± 166 sites/patient) was performed in 42 patients (30 males, age 63 ± 9 years) undergoing first (n = 32) or redo-AF ablation (n = 10). All electrogram recordings were visually reviewed and artifactual signals were excluded leaving a total of 21 846 for analysis. Electrogram characteristics evaluated were cycle length (CL), amplitude, Shannon's entropy (ShEn), fractionation interval, dominant frequency, organizational index, and cycle length of most recurrent morphology (CLR ) from morphology recurrence plot analysis. RESULTS Electrogram characteristics were correlated to each other. All pairwise comparisons were significant (p < .001) except for dominant frequency and CLR (p = .59), and amplitude and dominant frequency (p = .38). Only ShEn and fractionation interval demonstrated a strong negative correlation (r = -.94). All other pairwise comparisons were poor to moderately correlated. The relationships are highly conserved among patients, in the RA versus LA, and in those undergoing initial versus redo ablations. Antiarrhythmic drug therapy did not have a significant effect on electrogram characteristics, except minimum ShEn. Electrogram characteristics associated with ablation outcome were shorter minimum CLR , lower minimum ShEn, and longer mimimum CL. There was minimal overlap between the top 10 sites identified by one electrogram characteristic and the top 10 sites identified by the other 10 characteristics. CONCLUSION Multiple techniques can be employed for electrogram analysis in AF. In this analysis of eight different electrogram characteristics, seven were poorly to moderately correlated and do not identify similar locations. Only some characteristics were predictive of ablation outcome. Further studies to consider electrogram properties, perhaps in combination, for categorizing and/or mapping AF are warranted.
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Affiliation(s)
- Jeffrey J Goldberger
- Department of Medicine, Division of Cardiology, University of Miami, Miami, Florida, USA
| | - Ghaith Zaatari
- Department of Medicine, Division of Cardiology, University of Miami, Miami, Florida, USA
| | - Raul D Mitrani
- Department of Medicine, Division of Cardiology, University of Miami, Miami, Florida, USA
| | - Catherine Blandon
- Department of Medicine, Division of Cardiology, University of Miami, Miami, Florida, USA
| | - Jorge Bohorquez
- Department of Biomedical Engineering, University of Miami, Miami, Florida, USA
| | - Jason Ng
- Department of Medicine, DIvision of Cardiology, Northwestern University, Evanston, Illinois, USA
| | - Justin Ng
- Department of Medicine, DIvision of Cardiology, Northwestern University, Evanston, Illinois, USA
| | - Alex Velasquez
- Department of Medicine, Division of Cardiology, University of Miami, Miami, Florida, USA
| | - Litsa Lambrakos
- Department of Medicine, Division of Cardiology, University of Miami, Miami, Florida, USA
| | - Rishi Arora
- Department of Medicine, DIvision of Cardiology, Northwestern University, Evanston, Illinois, 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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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: 1] [Impact Index Per Article: 0.5] [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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Luongo G, Schuler S, Luik A, Almeida TP, Soriano DC, Dossel O, Loewe A. Non-Invasive Characterization of Atrial Flutter Mechanisms Using Recurrence Quantification Analysis on the ECG: A Computational Study. IEEE Trans Biomed Eng 2021; 68:914-925. [PMID: 32746003 DOI: 10.1109/tbme.2020.2990655] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Atrial flutter (AFl) is a common arrhythmia that can be categorized according to different self-sustained electrophysiological mechanisms. The non-invasive discrimination of such mechanisms would greatly benefit ablative methods for AFl therapy as the driving mechanisms would be described prior to the invasive procedure, helping to guide ablation. In the present work, we sought to implement recurrence quantification analysis (RQA) on 12-lead ECG signals from a computational framework to discriminate different electrophysiological mechanisms sustaining AFl. METHODS 20 different AFl mechanisms were generated in 8 atrial models and were propagated into 8 torso models via forward solution, resulting in 1,256 sets of 12-lead ECG signals. Principal component analysis was applied on the 12-lead ECGs, and six RQA-based features were extracted from the most significant principal component scores in two different approaches: individual component RQA and spatial reduced RQA. RESULTS In both approaches, RQA-based features were significantly sensitive to the dynamic structures underlying different AFl mechanisms. Hit rate as high as 67.7% was achieved when discriminating the 20 AFl mechanisms. RQA-based features estimated for a clinical sample suggested high agreement with the results found in the computational framework. CONCLUSION RQA has been shown an effective method to distinguish different AFl electrophysiological mechanisms in a non-invasive computational framework. A clinical 12-lead ECG used as proof of concept showed the value of both the simulations and the methods. SIGNIFICANCE The non-invasive discrimination of AFl mechanisms helps to delineate the ablation strategy, reducing time and resources required to conduct invasive cardiac mapping and ablation procedures.
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Liu PR, Friedman DJ, Barnett AS, Jackson KP, Daubert JP, Piccini JP. Focal impulse and rotor modulation of atrial rotors during atrial fibrillation leads to organization of left atrial activation as reflected by waveform morphology recurrence quantification analysis and organizational index. J Arrhythm 2020; 36:311-318. [PMID: 32256880 PMCID: PMC7132180 DOI: 10.1002/joa3.12311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/19/2019] [Accepted: 12/26/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Focal impulse and rotor modulation (FIRM) can cause slowing, organization, and occasionally termination of atrial fibrillation (AF), although results have been mixed. To further characterize changes in AF during rotor ablation, we quantified morphologic and temporal activation changes following FIRM. METHODS In patients undergoing FIRM ablation for AF, we retrospectively analyzed coronary sinus bipolar EGMs before and after rotor ablation, including EGM activation frequency and regularity, dominant frequency (DF), and organizational index (OI). Changes in EGM waveform morphology were determined with recurrence quantification analysis (RQA) consisting of recurrence rate (RR), determinism (DET), laminarity (LAM), average diagonal line length (L), and trapping time (TT) using Wilcoxon signed-rank testing. RESULTS Overall, 36 rotors from 21 patients undergoing FIRM ablation were analyzed. All morphology RQA parameters demonstrated significant organization of atrial activation after rotor ablation (RR P = .03, DET P = .005, LAM P = .03, L P = .005, TT P = .009). The organizational index also showed a significant increase after rotor ablation (P = .01), and the change in OI correlated with changes in all morphology parameters. Of the rotors, 14/36 (39%) rotors showed organizational changes in all morphology parameters and OI, and an additional 5 rotors (19/36, 53%) showed organizational changes in 4 of 5 morphology parameters and OI. CONCLUSIONS Coronary sinus EGM waveform morphologies and activation patterns are significantly altered after FIRM ablation even when there is no fibrillatory slowing. RQA morphology analysis and organizational index may impart important information regarding underlying AF organization and may be useful in quantifying the acute response to ablation.
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Affiliation(s)
- Peter R. Liu
- Department of MedicineJohns Hopkins HospitalBaltimoreMDUSA
| | - Daniel J. Friedman
- Duke Center for Atrial FibrillationDuke Clinical Research InstituteDuke University Medical CenterDurhamNCUSA
| | - Adam S. Barnett
- Duke Center for Atrial FibrillationDuke Clinical Research InstituteDuke University Medical CenterDurhamNCUSA
| | - Kevin P. Jackson
- Duke Center for Atrial FibrillationDuke Clinical Research InstituteDuke University Medical CenterDurhamNCUSA
| | - James P. Daubert
- Duke Center for Atrial FibrillationDuke Clinical Research InstituteDuke University Medical CenterDurhamNCUSA
| | - Jonathan P. Piccini
- Duke Center for Atrial FibrillationDuke Clinical Research InstituteDuke University Medical CenterDurhamNCUSA
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Classification of intracavitary electrograms in atrial fibrillation using information and complexity measures. Biomed Signal Process Control 2020. [DOI: 10.1016/j.bspc.2019.101753] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Almeida TP, Schlindwein FS, Salinet J, Li X, Chu GS, Tuan JH, Stafford PJ, André Ng G, Soriano DC. Characterization of human persistent atrial fibrillation electrograms using recurrence quantification analysis. CHAOS (WOODBURY, N.Y.) 2018; 28:085710. [PMID: 30180613 DOI: 10.1063/1.5024248] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 03/08/2018] [Indexed: 06/08/2023]
Abstract
Atrial fibrillation (AF) is regarded as a complex arrhythmia, with one or more co-existing mechanisms, resulting in an intricate structure of atrial activations. Fractionated atrial electrograms (AEGs) were thought to represent arrhythmogenic tissue and hence have been suggested as targets for radiofrequency ablation. However, current methods for ablation target identification have resulted in suboptimal outcomes for persistent AF (persAF) treatment, possibly due to the complex spatiotemporal dynamics of these mechanisms. In the present work, we sought to characterize the dynamics of atrial tissue activations from AEGs collected during persAF using recurrence plots (RPs) and recurrence quantification analysis (RQA). 797 bipolar AEGs were collected from 18 persAF patients undergoing pulmonary vein isolation (PVI). Automated AEG classification (normal vs. fractionated) was performed using the CARTO criteria (Biosense Webster). For each AEG, RPs were evaluated in a phase space estimated following Takens' theorem. Seven RQA variables were obtained from the RPs: recurrence rate; determinism; average diagonal line length; Shannon entropy of diagonal length distribution; laminarity; trapping time; and Shannon entropy of vertical length distribution. The results show that the RQA variables were significantly affected by PVI, and that the variables were effective in discriminating normal vs. fractionated AEGs. Additionally, diagonal structures associated with deterministic behavior were still present in the RPs from fractionated AEGs, leading to a high residual determinism, which could be related to unstable periodic orbits and suggesting a possible chaotic behavior. Therefore, these results contribute to a nonlinear perspective of the spatiotemporal dynamics of persAF.
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Affiliation(s)
- Tiago P Almeida
- Aeronautics Institute of Technology, ITA, São José dos Campos 12228-900, Brazil
| | | | - João Salinet
- Engineering, Modelling and Applied Social Sciences Centre, Federal ABC University, Santo André 09606-045, Brazil
| | - Xin Li
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, United Kingdom
| | - Gavin S Chu
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, United Kingdom
| | - Jiun H Tuan
- University Hospitals of Leicester NHS Trust, Leicester LE1 5WW, United Kingdom
| | - Peter J Stafford
- University Hospitals of Leicester NHS Trust, Leicester LE1 5WW, United Kingdom
| | - G André Ng
- National Institute for Health Research Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester LE3 9QP, United Kingdom
| | - Diogo C Soriano
- Engineering, Modelling and Applied Social Sciences Centre, Federal ABC University, Santo André 09606-045, Brazil
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