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Sekihara T, Oka T, Ozu K, Yoshida A, Sakata Y. Pacing Cycle Length-Dependent Electrophysiological Changes in Left Atrium: Poor Validity of Using Low Voltage Area and Slow Conduction Area under Specific Pacing Cycle Length as Absolute Substrates of Atrial Fibrillation. Heart Rhythm 2024:S1547-5271(24)03335-6. [PMID: 39304004 DOI: 10.1016/j.hrthm.2024.09.034] [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: 03/30/2024] [Revised: 09/07/2024] [Accepted: 09/12/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND Pacing cycle length (PCL)-dependent changes in left atrial (LA) electrophysiological properties have not been fully elucidated. OBJECTIVE To elucidate these changes using a high-resolution mapping system. METHODS Forty-eight patients underwent atrial fibrillation ablation with RHYTHMIA HDx™. Paired LA maps under a baseline PCL (600 ms) and rapid PCL (300 ms) were acquired after pulmonary vein isolation under right atrial appendage pacing. The PCL-dependent change in the low-voltage area (LVA) (area with <0.5 mV bipolar voltage), LA activation time (interval from first LA activation to wavefront collision at lateral wall), regional mean voltage, regional mean wave propagation velocity, and slow conduction area (area with <0.3-m/s wave propagation velocity) were quantitatively analyzed. RESULTS Under the rapid PCL, the total LVA was significantly increased (7.6 ± 9.5 vs. 6.7 ± 7.6 cm2, p = 0.031), especially in patients with a ≥10 cm2 LVA on the baseline PCL map (21.5 ± 9.1 vs. 18.1 ± 6.5 cm2, p = 0.013). The LA activation time was also prolonged (87.9 ± 16.2 vs. 84.0 ± 14.0 ms, p < 0.0001). Although the rapid PCL did not decrease the regional mean voltage, it significantly decreased the regional mean wave propagation velocity and increased the slow conduction area in all measured regions. CONCLUSION LVA and slow conduction area can be emphasized by rapid PCL LA mapping. There may be poor validity in using these areas as absolute atrial fibrillation substrates without considering the PCL-dependent changes.
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Affiliation(s)
- Takayuki Sekihara
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takafumi Oka
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - Kentaro Ozu
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Akira Yoshida
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
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Huang W, Sun H, Xiong S, Luo Y, Tang Y, Zhang Z, Liu H. Sex-related differences in left atrial substrate among patients with atrial fibrillation: evidence from high-density voltage mapping. Eur J Med Res 2024; 29:354. [PMID: 38956703 PMCID: PMC11218306 DOI: 10.1186/s40001-024-01952-y] [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: 03/19/2024] [Accepted: 06/26/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND There is sufficient evidence that women with atrial fibrillation (AF) have a greater symptom burden than men with AF and are more likely to experience recurrence after catheter ablation. However, the mechanisms underlying these sex differences are unclear. METHODS We prospectively enrolled 125 consecutive patients, including 40 non-AF patients and 85 AF patients, who underwent high-density voltage mapping during sinus rhythm and AF patients who underwent first ablation. RESULTS Overall, 37 (44%) female patients with AF and 24 (60%) female non-AF patients with a mean age of 61.7 ± 11.6 years and 53.6 ± 16.7 years, respectively, were enrolled in this study. The results showed that the atrial voltage of female AF patients was significantly lower than that of male AF patients (1.11 ± 0.58 mV vs. 1.53 ± 0.65 mV; P = 0.003), while there were no significant sex differences in non-AF patients (3.02 ± 0.86 mV vs. 3.21 ± 0.84 mV; P = 0.498). Multiple linear regression analysis revealed that female sex (- 0.29, 95% confidence interval [CI] - 0.64 to - 0.13, P = 0.004) and AF type (- 0.32, 95% CI - 0.69 to - 0.13, P = 0.004) were the only factors independently associated with voltage. Compared with men, women in the paroxysmal AF group had a 3.5-fold greater incidence of recurrence (adjusted hazard ratio 4.49; 95% CI 1.101-18.332, P = 0.036). Both globally and regionally, the results showed that sex-related differences in voltage values occurred prominently in paroxysmal AF patients but not in nonparoxysmal AF patients. CONCLUSION Sex-related differences in atrial substrates and arrhythmia-free survival were found in paroxysmal AF patients, suggesting the existence of sex-related pathophysiological factors.
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Affiliation(s)
- Wenchao Huang
- Department of Cardiology, The Third People's Hospital of Chengdu, 82 Qinglong St, Chengdu, 610031, Sichuan, China
| | - Huaxin Sun
- Department of Cardiology, The Third People's Hospital of Chengdu, 82 Qinglong St, Chengdu, 610031, Sichuan, China
| | - Shiqiang Xiong
- Department of Cardiology, The Third People's Hospital of Chengdu, 82 Qinglong St, Chengdu, 610031, Sichuan, China
| | - Yan Luo
- Department of Cardiology, The Third People's Hospital of Chengdu, 82 Qinglong St, Chengdu, 610031, Sichuan, China
| | - Yan Tang
- Department of Cardiology, The Third People's Hospital of Chengdu, 82 Qinglong St, Chengdu, 610031, Sichuan, China
| | - Zhen Zhang
- Department of Cardiology, The Third People's Hospital of Chengdu, 82 Qinglong St, Chengdu, 610031, Sichuan, China
| | - Hanxiong Liu
- Department of Cardiology, The Third People's Hospital of Chengdu, 82 Qinglong St, Chengdu, 610031, Sichuan, China.
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Wilhelm TI, Lewalter T, Reiser J, Werner J, Keil A, Oesterlein T, Gleirscher L, Tiemann K, Jilek C. Influence of Heart Rate and Change in Wavefront Direction through Pacing on Conduction Velocity and Voltage Amplitude in a Porcine Model: A High-Density Mapping Study. J Pers Med 2024; 14:473. [PMID: 38793055 PMCID: PMC11122149 DOI: 10.3390/jpm14050473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/04/2024] [Accepted: 04/23/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Understanding the dynamics of conduction velocity (CV) and voltage amplitude (VA) is crucial in cardiac electrophysiology, particularly for substrate-based catheter ablations targeting slow conduction zones and low voltage areas. This study utilizes ultra-high-density mapping to investigate the impact of heart rate and pacing location on changes in the wavefront direction, CV, and VA of healthy pig hearts. METHODS We conducted in vivo electrophysiological studies on four healthy juvenile pigs, involving various pacing locations and heart rates. High-resolution electroanatomic mapping was performed during intrinsic normal sinus rhythm (NSR) and electrical pacing. The study encompassed detailed analyses at three levels: entire heart cavities, subregions, and localized 5-mm-diameter circular areas. Linear mixed-effects models were used to analyze the influence of heart rate and pacing location on CV and VA in different regions. RESULTS An increase in heart rate correlated with an increase in conduction velocity and a decrease in voltage amplitude. Pacing influenced conduction velocity and voltage amplitude. Pacing also influenced conduction velocity and voltage amplitude, with varying effects observed based on the pacing location within different heart cavities. Pacing from the right atrium (RA) decreased CV in all heart cavities. The overall CV and VA changes in the whole heart cavities were not uniformly reflected in all subregions and subregional CV and VA changes were not always reflected in the overall analysis. Overall, there was a notable variability in absolute CV and VA changes attributed to pacing. CONCLUSIONS Heart rate and pacing location influence CV and VA within healthy juvenile pig hearts. Subregion analysis suggests that specific regions of the heart cavities are more susceptible to pacing. High-resolution mapping aids in detecting regional changes, emphasizing the substantial physiological variations in CV and VA.
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Affiliation(s)
- Theresa Isabelle Wilhelm
- Peter-Osypka Heart Centre Munich, Internistisches Klinikum München Süd, 81379 Munich, Germany (K.T.)
- Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- Medical Graduate Center, TUM School of Medicine and Health, Technical University of Munich, 81675 Munich, Germany
| | - Thorsten Lewalter
- Peter-Osypka Heart Centre Munich, Internistisches Klinikum München Süd, 81379 Munich, Germany (K.T.)
- Department of Medicine, University of Bonn, 53127 Bonn, Germany
| | - Judith Reiser
- Center for Preclinical Research, TUM School of Medicine and Health, Technical University of Munich, 81675 Munich, Germany; (J.R.)
| | - Julia Werner
- Center for Preclinical Research, TUM School of Medicine and Health, Technical University of Munich, 81675 Munich, Germany; (J.R.)
| | - Andreas Keil
- Boston Scientific Medizintechnik GmbH, 40468 Düsseldorf, Germany
| | | | - Lukas Gleirscher
- Peter-Osypka Heart Centre Munich, Internistisches Klinikum München Süd, 81379 Munich, Germany (K.T.)
| | - Klaus Tiemann
- Peter-Osypka Heart Centre Munich, Internistisches Klinikum München Süd, 81379 Munich, Germany (K.T.)
- Department of Internal Medicine I, TUM School of Medicine and Health, Technical University of Munich, 81675 Munich, Germany
| | - Clemens Jilek
- Peter-Osypka Heart Centre Munich, Internistisches Klinikum München Süd, 81379 Munich, Germany (K.T.)
- Department of Internal Medicine I, TUM School of Medicine and Health, Technical University of Munich, 81675 Munich, Germany
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Vázquez-Calvo S, Garre P, Ferró E, Sánchez-Somonte P, Guichard JB, Falzone PV, Guasch E, Porta-Sánchez A, Tolosana JM, Borras R, Arbelo E, Ortiz-Pérez JT, Prats S, Perea RJ, Brugada J, Mont L, Roca-Luque I. Personalized voltage maps guided by cardiac magnetic resonance in the era of high-density mapping. Heart Rhythm 2024:S1547-5271(24)02501-3. [PMID: 38670249 DOI: 10.1016/j.hrthm.2024.04.074] [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: 01/24/2024] [Revised: 04/17/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Voltage mapping could identify the conducting channels potentially responsible for ventricular tachycardia (VT). Standard thresholds (0.5-1.5 mV) were established using bipolar catheters. No thresholds have been analyzed with high-density mapping catheters. In addition, channels identified by cardiac magnetic resonance (CMR) has been proven to be related with VT. OBJECTIVE The purpose of this study was to analyze the diagnostic yield of a personalized voltage map using CMR to guide the adjustment of voltage thresholds. METHODS All consecutive patients with scar-related VT undergoing ablation after CMR (from October 2018 to December 2020) were included. First, personalized CMR-guided voltage thresholds were defined systematically according to the distribution of the scar and channels. Second, to validate these new thresholds, a comparison with standard thresholds (0.5-1.5 mV) was performed. Tissue characteristics of areas identified as deceleration zones (DZs) were recorded for each pair of thresholds. In addition, the relation of VT circuits with voltage channels was analyzed for both maps. RESULTS Thirty-two patients were included [mean age 66.6 ± 11.2 years; 25 (78.1%) ischemic cardiomyopathy]. Overall, 52 DZs were observed: 44.2% were identified as border zone tissue with standard cutoffs vs 75.0% using personalized voltage thresholds (P = .003). Of the 31 VT isthmuses detected, only 35.5% correlated with a voltage channel with standard thresholds vs 74.2% using adjusted thresholds (P = .005). Adjusted cutoff bipolar voltages that better matched CMR images were 0.51 ± 0.32 and 1.79 ± 0.71 mV with high interindividual variability (from 0.14-1.68 to 0.7-3.21 mV). CONCLUSION Personalized voltage CMR-guided personalized voltage maps enable a better identification of the substrate with a higher correlation with both DZs and VT isthmuses than do conventional voltage maps using fixed thresholds.
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Affiliation(s)
- Sara Vázquez-Calvo
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Paz Garre
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Elisenda Ferró
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Paula Sánchez-Somonte
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Jean-Baptiste Guichard
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Pasquale Valerio Falzone
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Eduard Guasch
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Andreu Porta-Sánchez
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - José Maria Tolosana
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Roger Borras
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Instituto de Salud Carlos III, Madrid, Spain
| | - Elena Arbelo
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - José T Ortiz-Pérez
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Susana Prats
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Rosario J Perea
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Josep Brugada
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Lluís Mont
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Ivo Roca-Luque
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.
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5
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Jin Z, Hwang T, Kim D, Lim B, Kwon OS, Kim S, Kim MH, Park JW, Yu HT, Kim TH, Uhm JS, Joung B, Lee MH, Pak HN. Anti- and pro-fibrillatory effects of pulmonary vein isolation gaps in human atrial fibrillation digital twins. NPJ Digit Med 2024; 7:81. [PMID: 38532181 DOI: 10.1038/s41746-024-01075-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 03/07/2024] [Indexed: 03/28/2024] Open
Abstract
Although pulmonary vein isolation (PVI) gaps and extrapulmonary vein triggers contribute to recurrence after atrial fibrillation (AF) ablation, their precise mechanisms remain unproven. Our study assessed the impact of PVI gaps on rhythm outcomes using a human AF digital twin. We included 50 patients (76.0% with persistent AF) who underwent catheter ablation with a realistic AF digital twin by integrating computed tomography and electroanatomical mapping. We evaluated the final rhythm status, including AF and atrial tachycardia (AT), across 600 AF episodes, considering factors including PVI level, PVI gap number, and pacing locations. Our findings revealed that antral PVI had a significantly lower ratio of AF at the final rhythm (28% vs. 56%, p = 0.002) than ostial PVI. Increasing PVI gap numbers correlated with an increased ratio of AF at the final rhythm (p < 0.001). Extra-PV induction yielded a higher ratio of AF at the final rhythm than internal PV induction (77.5% vs. 59.0%, p < 0.001). In conclusion, our human AF digital twin model helped assess AF maintenance mechanisms. Clinical trial registration: https://www.clinicaltrials.gov ; Unique identifier: NCT02138695.
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Affiliation(s)
- Ze Jin
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Taehyun Hwang
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Daehoon Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byounghyun Lim
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Oh-Seok Kwon
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sangbin Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Moon-Hyun Kim
- Division of Cardiology, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea
| | - Je-Wook Park
- Division of Cardiology, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea
| | - Hee Tae Yu
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae-Sun Uhm
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Moon-Hyoung Lee
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Saha S, Linz D, Saha D, McEwan A, Baumert M. Overcoming Uncertainties in Electrogram-Based Atrial Fibrillation Mapping: A Review. Cardiovasc Eng Technol 2024; 15:52-64. [PMID: 37962813 DOI: 10.1007/s13239-023-00696-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 10/31/2023] [Indexed: 11/15/2023]
Abstract
In clinical rhythmology, intracardiac bipolar electrograms (EGMs) play a critical role in investigating the triggers and substrates inducing and perpetuating atrial fibrillation (AF). However, the interpretation of bipolar EGMs is ambiguous due to several aspects of electrodes, mapping algorithms and wave propagation dynamics, so it requires several variables to describe the effects of these uncertainties on EGM analysis. In this narrative review, we critically evaluate the potential impact of such uncertainties on the design of cardiac mapping tools on AF-related substrate characterization. Literature suggest uncertainties are due to several variables, including the wave propagation vector, the wave's incidence angle, inter-electrode spacing, electrode size and shape, and tissue contact. The preprocessing of the EGM signals and mapping density will impact the electro-anatomical representation and the features extracted from the local electrical activities. The superposition of multiple waves further complicates EGM interpretation. The inclusion of these uncertainties is a nontrivial problem but their consideration will yield a better interpretation of the intra-atrial dynamics in local activation patterns. From a translational perspective, this review provides a concise but complete overview of the critical variables for developing more precise cardiac mapping tools.
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Affiliation(s)
- Simanto Saha
- School of Biomedical Engineering, The University of Sydney, Sydney, NSW, 2008, Australia.
| | - Dominik Linz
- Centre for Heart Rhythm Disorders, The University of Adelaide, Adelaide, SA, 5000, Australia
| | - Dyuti Saha
- Kumudini Women's Medical College, The University of Dhaka, Tangail, 1940, Dhaka, Bangladesh
| | - Alistair McEwan
- School of Biomedical Engineering, The University of Sydney, Sydney, NSW, 2008, Australia
| | - Mathias Baumert
- School of Electrical and Mechanical Engineering, The University of Adelaide, Adelaide, SA, 5000, Australia
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7
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Okubo Y, Oguri N, Sakai T, Uotani Y, Furutani M, Miyamoto S, Miyauchi S, Okamura S, Tokuyama T, Nakano Y. Conduction velocity mapping in atrial fibrillation using omnipolar technology. Pacing Clin Electrophysiol 2024; 47:19-27. [PMID: 38041418 DOI: 10.1111/pace.14899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 11/16/2023] [Accepted: 11/24/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Recent studies have shown that atrial slow conduction velocity (CV) is associated with the perpetuation of atrial fibrillation (AF). However, the criteria of CV measurement have not been standardized. The aim of this study was to evaluate the relationship between the slow CV area (SCVA) measured by novel omnipolar technology (OT) and AF recurrence. METHODS This study included 90 patients with AF who underwent initial pulmonary vein isolation (PVI). The segmented surface area of the SCVA was measured by left atrial (LA) electrophysiological mapping using OT before the PVI. The proportion of the SCVA at each cutoff value of CV (from < 0.6 to < 0.9 m/s) was compared between the patients with and without AF recurrence. RESULTS During a mean follow-up period of 516 ± 197 days, the recurrence of AF after the initial PVI was observed in 23 (25.5%) patients. In patients with AF recurrence, the proportion of the SCVA in the LA posterior, LA appendage (LAA), and LA anterior were significantly higher than those without AF recurrence. The multivariate analysis indicated that the proportion of the low voltage area and the SCVA in the LA anterior (local CV < 0.7 m/s) were independent predictors of AF recurrence (hazard ratio [HR], 1.07; 95% confidence interval [CI], 1.01-1.14; p = 0.03; HR, 1.40; 95% CI, 1.07-1.83; p = 0.01, respectively). CONCLUSION By evaluating the local CV using OT, it was indicated that SCVA with CV < 0.7 m/s in the LA anterior is strongly associated with AF recurrence after PVI.
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Affiliation(s)
- Yousaku Okubo
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Naoto Oguri
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Takumi Sakai
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Yukimi Uotani
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Motoki Furutani
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Shogo Miyamoto
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Shunsuke Miyauchi
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Sho Okamura
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Takehito Tokuyama
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Yukiko Nakano
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
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8
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Löbe S, Stellmach P, Darma A, Hilbert S, Paetsch I, Jahnke C, Bollmann A, Hindricks G, Kircher S. Left atrial total emptying fraction measured by cardiovascular magnetic resonance imaging predicts low-voltage areas detected during electroanatomical mapping. Europace 2023; 25:euad307. [PMID: 37960936 PMCID: PMC10643989 DOI: 10.1093/europace/euad307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 10/09/2023] [Indexed: 11/15/2023] Open
Abstract
AIMS Low-voltage areas (LVAs) found during left atrial (LA) electroanatomical mapping are increasingly targeted by radiofrequency catheter ablation (RFCA) on top of pulmonary vein isolation to improve arrhythmia-free survival in patients with atrial fibrillation (AF). However, pre-procedural prediction of LVAs remains challenging. The purpose of the present study was to describe the association between parameters of LA function and dimensions, respectively, derived from pre-procedural cardiovascular magnetic resonance (CMR) imaging, and the presence of LVAs on LA voltage mapping. METHODS AND RESULTS Patients who underwent first-time RFCA for paroxysmal or persistent AF and who were in stable sinus rhythm during pre-procedural CMR imaging were included in this study. Cardiovascular magnetic resonance-derived parameters of LA function and dimensions were calculated. Low-voltage areas were defined as areas with bipolar voltage amplitudes of ≤0.5 mV on electroanatomical mapping. In total, 259 consecutive patients were included in this analysis. Low-voltage areas were found in 25 of 259 patients (9.7%). Compared with those without LVAs, patients with LVAs were significantly older, were more likely to be female, had a higher CHA2DS2-VASc score, had larger LA volumes, and had a lower LA total emptying fraction (TEF). In multivariate analysis, only LA TEF [odds ratio (OR) 0.885, 95% confidence interval (CI) 0.846-0.926, P < 0.001] and the CHA2DS2-VASc score (OR 1.507, 95% CI 1.115-2.038, P = 0.008) remained independently associated with the presence of LVAs. CONCLUSION Left atrial TEF and the CHA2DS2-VASc score were independently associated with the presence of LVAs found during LA electroanatomical mapping. These findings may help to improve pre-procedural prediction of pro-arrhythmogenic LVAs and to improve peri-procedural patient management.
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Affiliation(s)
- Susanne Löbe
- Department of Electrophysiology, HELIOS Heart Center Leipzig—University of Leipzig, Struempellstr. 39, Leipzig 04289, Germany
| | - Pierre Stellmach
- Department of Electrophysiology, HELIOS Heart Center Leipzig—University of Leipzig, Struempellstr. 39, Leipzig 04289, Germany
| | - Angeliki Darma
- Department of Electrophysiology, HELIOS Heart Center Leipzig—University of Leipzig, Struempellstr. 39, Leipzig 04289, Germany
| | - Sebastian Hilbert
- Department of Electrophysiology, HELIOS Heart Center Leipzig—University of Leipzig, Struempellstr. 39, Leipzig 04289, Germany
| | - Ingo Paetsch
- Department of Electrophysiology, HELIOS Heart Center Leipzig—University of Leipzig, Struempellstr. 39, Leipzig 04289, Germany
| | - Cosima Jahnke
- Department of Electrophysiology, HELIOS Heart Center Leipzig—University of Leipzig, Struempellstr. 39, Leipzig 04289, Germany
| | - Andreas Bollmann
- Department of Electrophysiology, HELIOS Heart Center Leipzig—University of Leipzig, Struempellstr. 39, Leipzig 04289, Germany
- Helios Health Institute, Leipzig, Germany
| | - Gerhard Hindricks
- Department of Electrophysiology, HELIOS Heart Center Leipzig—University of Leipzig, Struempellstr. 39, Leipzig 04289, Germany
- Helios Health Institute, Leipzig, Germany
| | - Simon Kircher
- Department of Electrophysiology, HELIOS Heart Center Leipzig—University of Leipzig, Struempellstr. 39, Leipzig 04289, Germany
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9
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Elewa MG, Altoukhy S, Badran HA, El Damanhoury H, Zarif JK. Ablation targets of scar-related ventricular tachycardia identified by dynamic functional substrate mapping. Egypt Heart J 2023; 75:87. [PMID: 37831212 PMCID: PMC10575820 DOI: 10.1186/s43044-023-00414-w] [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: 07/10/2023] [Accepted: 10/03/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Dynamic functional substrate mapping of scar-related ventricular tachycardia offers better identification of ablation targets with limited ablation lesions. Several functional substrate mapping approaches have been proposed, including decrement-evoked potential (DEEP) mapping. The aim of our study was to compare the short- and long-term efficacy of a DEEP-guided versus a fixed-substrate-guided strategy for the ablation of scar-related ventricular tachycardia (VT). RESULTS Forty consecutive patients presenting for ablation of scar-related VT were randomized to either DEEP-guided or substrate-guided ablation. Late potentials were tagged and ablated in the non-DEEP group, while those in the DEEP group were subjected to RV extrastimulation after a drive train. Only potentials showing significant delay were ablated. Patients were followed for a median duration of 12 months. Twenty patients were allocated to the DEEP group, while the other 20 were allocated to the non-DEEP group. Twelve patients (60%) in the DEEP group had ischemic cardiomyopathy versus 10 patients (50%) in the non-DEEP group (P-value 0.525). Intraoperatively, the median percentage of points with LPs was 19% in the DEEP group and 20.6% in the non-DEEP group. The procedural time was longer in the DEEP group, approaching but missing statistical significance (P-value 0.059). VT non-inducibility was successfully accomplished in 16 patients (80%) in the DEEP group versus 17 patients (85%) in the non-DEEP group (P value 0.597). After a median follow-up duration of 12 months, the VT recurrence rate was 65% in both groups (P value 0.311), with a dropout rate of 10% in the DEEP group. As for the secondary endpoints, all-cause mortality rates were 20% and 25% in the DEEP and non-DEEP groups, respectively (P-value 0.342). CONCLUSIONS DEEP-assisted ablation of scar-related ventricular tachycardia is a feasible strategy with comparable short- and long-term outcomes to a fixed-substrate-based strategy with more specific ablation targets, albeit relatively longer but non-significant procedural times and higher procedural deaths. The imbalance between the study groups in terms of epicardial versus endocardial mapping, although non-significant, warrants the prudent interpretation of our results. Further large-scale randomized trials are recommended. TRIAL REGISTRATION clinicaltrials.gov, registration number: NCT05086510, registered on 28th September 2021, record https://classic. CLINICALTRIALS gov/ct2/show/NCT05086510.
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Affiliation(s)
- Mohammad Gamal Elewa
- Cardiology Department, Ain Shams University Hospital, Faculty of Medicine, Ain Shams University, 5B - Swiss Project B, PO 11826, Nasr City, Cairo, Egypt.
| | - Sherif Altoukhy
- Cardiology Department, Ain Shams University Hospital, Faculty of Medicine, Ain Shams University, 5B - Swiss Project B, PO 11826, Nasr City, Cairo, Egypt
| | - Haitham Abdelfattah Badran
- Cardiology Department, Ain Shams University Hospital, Faculty of Medicine, Ain Shams University, 5B - Swiss Project B, PO 11826, Nasr City, Cairo, Egypt
| | - Hayam El Damanhoury
- Cardiology Department, Ain Shams University Hospital, Faculty of Medicine, Ain Shams University, 5B - Swiss Project B, PO 11826, Nasr City, Cairo, Egypt
| | - John Kamel Zarif
- Cardiology Department, Ain Shams University Hospital, Faculty of Medicine, Ain Shams University, 5B - Swiss Project B, PO 11826, Nasr City, Cairo, Egypt
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10
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Butcher C, Roney C, Wharmby A, Ahluwalia N, Chow A, Lambiase PD, Hunter RJ, Honarbakhsh S. In Atrial Fibrillation, Omnipolar Voltage Maps More Accurately Delineate Scar Than Bipolar Voltage Maps. JACC Clin Electrophysiol 2023; 9:1500-1512. [PMID: 37204357 DOI: 10.1016/j.jacep.2023.03.010] [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: 01/27/2023] [Revised: 03/20/2023] [Accepted: 03/22/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Optimal method for voltage assessment in AF remains unclear. OBJECTIVES This study evaluated different methods for assessing atrial voltage and their accuracy in identifying pulmonary vein reconnection sites (PVRSs) in atrial fibrillation (AF). METHODS Patients with persistent AF undergoing ablation were included. De novo procedures: voltage assessment in AF with omnipolar voltage (OV) and bipolar voltage (BV) methodology and BV assessment in sinus rhythm (SR). Activation vector and fractionation maps were reviewed at voltage discrepancy sites on OV and BV maps in AF. AF voltage maps were compared with SR BV maps. Repeat ablation procedures: OV and BV maps in AF were compared to detect gaps in wide area circumferential ablation (WACA) lines that correlated with PVRS. RESULTS Forty patients were included: 20 de novo and 20 repeat procedures. De novo procedure: OV vs BV maps in AF; average voltage 0.55 ± 0.18 mV vs 0.38 ± 0.12 mV; P = 0.002, voltage difference of 0.20 ± 0.07 mV; P = 0.003 at coregistered points and proportion of left atrium (LA) area occupied by low-voltage zones (LVZs) was smaller on OV maps (42.4% ± 12.8% OV vs 66.7% ± 12.7% BV; P < 0.001). LVZs identified on BV maps and not on OV maps correlated frequently to wavefront collision and fractionation sites (94.7%). OV AF maps agreed better with BV SR maps (voltage difference at coregistered points 0.09 ± 0.03 mV; P = 0.24) unlike BV AF maps (0.17 ± 0.07 mV, P = 0.002). Repeat ablation procedure: OV was superior in identifying WACA line gaps that correlated with PVRS than BV maps (area under the curve = 0.89, P < 0.001). CONCLUSIONS OV AF maps improve voltage assessment by overcoming the impact of wavefront collision and fractionation. OV AF maps correlate better with BV maps in SR and more accurately delineate gaps on WACA lines at PVRS.
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Affiliation(s)
- Charles Butcher
- Electrophysiology Department, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Caroline Roney
- Queen Mary's University of London, London, United Kingdom
| | - Amy Wharmby
- Electrophysiology Department, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Nikhil Ahluwalia
- Electrophysiology Department, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Anthony Chow
- Electrophysiology Department, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Pier D Lambiase
- Electrophysiology Department, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Ross J Hunter
- Electrophysiology Department, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Shohreh Honarbakhsh
- Electrophysiology Department, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Queen Mary's University of London, London, United Kingdom.
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11
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Okabe T, Bhuta S, Afzal MR, Savona SJ, Kalbfleisch SJ, Houmsse M, Augostini RS, Daoud EG, Hummel JD. Delayed bipolar voltage changes in the left atrium after vein of Marshall ethanol infusion. Pacing Clin Electrophysiol 2023; 46:948-950. [PMID: 37436707 DOI: 10.1111/pace.14786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 06/28/2023] [Accepted: 07/01/2023] [Indexed: 07/13/2023]
Affiliation(s)
- Toshimasa Okabe
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sapan Bhuta
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Muhammad R Afzal
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Salvatore J Savona
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Steven J Kalbfleisch
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Mahmoud Houmsse
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ralph S Augostini
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Emile G Daoud
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - John D Hummel
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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12
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High-resolution mapping of reentrant atrial tachycardias: Relevance of low bipolar voltage. Heart Rhythm 2023; 20:430-437. [PMID: 36368515 DOI: 10.1016/j.hrthm.2022.11.003] [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: 05/18/2022] [Revised: 10/26/2022] [Accepted: 11/02/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Bipolar voltage is widely used to characterize the atrial substrate but has been poorly validated, particularly during clinical tachycardias. OBJECTIVE The purpose of this study was to evaluate the diagnostic performance of voltage thresholds for identifying regions of slow conduction during reentrant atrial tachycardias (ATs). METHODS Thirty bipolar voltage and activation maps created during reentrant ATs were analyzed to (1) examine the relationship between voltage amplitude and conduction velocity (CV), (2) measure the diagnostic ability of voltage thresholds to predict CV, and (3) identify determinants of AT circuit dimensions. Voltage amplitude was categorized as "normal" (>0.50 mV), "abnormal" (0.05-0.50 mV), or "scar" (<0.05 mV); slow conduction was defined as <30 cm/s. RESULTS A total of 266,457 corresponding voltage and CV data points were included for analysis. Voltage and CV were moderately correlated (r = 0.407; P < .001). Bipolar voltage predicted regions of slow conduction with an area under the receiver operating characteristic curve of 0.733 (95% confidence interval 0.731-0.735). A threshold of 0.50 mV had 91% sensitivity and 35% specificity for identifying slow conduction, whereas 0.05 mV had 36% sensitivity and 87% specificity, with an optimal voltage threshold of 0.15 mV. Analyses restricted to the AT circuits identified weaker associations between voltage and CV and an optimal voltage threshold of 0.25 mV. CONCLUSION Widely used bipolar voltage amplitude thresholds to define "abnormal" and "scar" tissue in the atria are, respectively, sensitive and specific for identifying regions of slow conduction during reentrant ATs. However, overall, the association of voltage with CV is modest. No clinical predictors of AT circuit dimensions were identified.
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13
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Shah CD, Everett TH. Revisiting bipolar voltage mapping-Does the amplitude correlate to conduction velocity? Heart Rhythm 2023; 20:438-439. [PMID: 36464127 DOI: 10.1016/j.hrthm.2022.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 11/29/2022] [Indexed: 12/03/2022]
Affiliation(s)
- Chirag Dipak Shah
- Division of Cardiovascular Medicine, Krannert Cardiovascular Research Center, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Thomas H Everett
- Division of Cardiovascular Medicine, Krannert Cardiovascular Research Center, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.
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14
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Yavin H, Younis A, Zilberman I, Krywanczyk A, Bubar ZP, Higuchi K, Barkagan M, Anter E. Atrial Endocardial Unipolar Voltage Mapping for Detection of Viable Intramural Myocardium: A Proof-of-Concept Study. Circ Arrhythm Electrophysiol 2023; 16:e011321. [PMID: 36595639 DOI: 10.1161/circep.122.011321] [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] [Indexed: 01/05/2023]
Abstract
BACKGROUND Endocardial bipolar voltage amplitude is largely derived from endocardial and subendocardial wall layers. This may result in situations of low bipolar voltage amplitude despite the presence of mid-myocardial including epicardial (ie, intramural-epicardial) viable myocardium. This study examined the utility of endocardial unipolar voltage mapping for detection of viable intramural-epicardial atrial myocardium. METHODS In 15 swine, an atrial intercaval ablation line with an intentional gap was created. Animals survived for 6 to 8 weeks before electroanatomical mapping followed by sacrifice. Gaps were determined by the presence of electrical conduction and classified based on the histopathologiclly layer(s) of viable myocardium into the following: (1) transmural, (2) endocardial, and (3) intramural-epicardial. Voltage data from healthy, scar, and gap points were exported into excel. The sensitivity and specificity of bipolar and unipolar voltage amplitude to detect intramural-epicardial gaps were compared using receiver operating characteristic analysis. RESULTS In 9 of 15 (60%) swine, a focal ablation gap was detected in the intercaval line, while in the remainder 6 of 15 (40%), the line was complete without gaps. Gaps were classified into transmural (n=3), endocardial (n=3), or intramural-epicardial (n=3). Intramural-epicardial gaps were characterized by very low bipolar voltage amplitude that was similar to areas with transmural scar (P=0.91). In comparison, unipolar voltage amplitude in intramural-epicardial gaps was significantly higher compared to transmural scar (P<0.001). Unipolar voltage amplitude had higher sensitivity (93% versus 14%, respectively) and similar specificity (95% versus 98%, respectively) to bipolar voltage for detection of intramural-epicardial gaps. CONCLUSIONS Atrial unipolar voltage mapping may be a useful technique for identifying viable intramural-epicardial myocardium in patients with endocardial scar.
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Affiliation(s)
- Hagai Yavin
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine (H.Y., A.Y., I.Z., K.H., E.A.), Cleveland Clinic, OH
| | - Arwa Younis
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine (H.Y., A.Y., I.Z., K.H., E.A.), Cleveland Clinic, OH
| | - Israel Zilberman
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine (H.Y., A.Y., I.Z., K.H., E.A.), Cleveland Clinic, OH
| | - Alison Krywanczyk
- Department of Pathology and Laboratory Medicine (A.K.), Cleveland Clinic, OH
| | | | - Koji Higuchi
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine (H.Y., A.Y., I.Z., K.H., E.A.), Cleveland Clinic, OH
| | - Michael Barkagan
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Shamir Medical Center, Be'er Ya'akov, Israel (M.B., E.A.)
| | - Elad Anter
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine (H.Y., A.Y., I.Z., K.H., E.A.), Cleveland Clinic, OH.,Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Shamir Medical Center, Be'er Ya'akov, Israel (M.B., E.A.)
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15
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Gu W, Liu W, Li J, Shen J, Pan J, Wu B, Shi H, Luo X, Xiong N. Anatomy-based characteristics of far-field SVC electrograms in right superior pulmonary veins after isolation. SCAND CARDIOVASC J 2022; 56:224-230. [PMID: 35792722 DOI: 10.1080/14017431.2022.2095015] [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] [Indexed: 10/17/2022]
Abstract
Background. Far-field electrograms from superior vena cava (SVC) can be present in right superior pulmonary vein (RSPV) after pulmonary vein (PV) isolation. Objectives. To analyze the characteristics of far-field SVC potentials in RSPV after PV isolation and the local anatomy difference between patients with and without the potentials. Methods. Patients undergoing PV isolation were retrospectively reviewed, contrast-enhanced computed tomography (CT) was performed before procedure for observing the anatomical relationship between RSPV and SVC. The prevalence and characteristics of far-field SVC electrograms were described and compared to far-field left atrial potentials at the nearest point along the linear ablation lesion. The anatomical proximity of RSPV and SVC on a 2-dimensional horizontal CT view was compared between patients with and without far-field SVC potentials. Results. Far-field SVC electrograms were observed in 35/92(38%) patients with an amplitude of 0.24 ± 0.11 mV and a major deflection slope of 0.051 ± 0.036 mV, both significantly higher than far-field left atrial electrograms (p < .001). In patients with far-field SVC electrograms, 83% had connected RSPV-SVC, defined as distance between RSPV and SVC endocardium less than 3 mm at the layer of RSPV ostium roof, while in patients without far-field SVC electrograms, 70% had disconnected RSPV-SVC. Conclusions. Far-field SVC electrograms appeared in RSPV had a prevalence higher than previously reported and a sharper major deflection compared to far-field left atrial electrograms. Connected RSPV-SVC on CT was associated with the presence of far-field SVC electrograms.
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Affiliation(s)
- Wentao Gu
- Department of Cardiology, Huashan Hospital Fudan University, Shanghai, China
| | - Weizhuo Liu
- Department of Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Jian Li
- Department of Cardiology, Huashan Hospital Fudan University, Shanghai, China
| | - Jun Shen
- Department of Cardiology, Huashan Hospital Fudan University, Shanghai, China
| | - Jiawei Pan
- Department of Radiology, Huashan Hospital Fudan University, Shanghai, China
| | - Bangwei Wu
- Department of Cardiology, Huashan Hospital Fudan University, Shanghai, China
| | - Haiming Shi
- Department of Cardiology, Huashan Hospital Fudan University, Shanghai, China
| | - Xinping Luo
- Department of Cardiology, Huashan Hospital Fudan University, Shanghai, China
| | - Nanqing Xiong
- Department of Cardiology, Huashan Hospital Fudan University, Shanghai, China
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16
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Vázquez-Calvo S, Roca-Luque I, Porta-Sánchez A. Ventricular Tachycardia Ablation Guided by Functional Substrate Mapping: Practices and Outcomes. J Cardiovasc Dev Dis 2022; 9:jcdd9090288. [PMID: 36135433 PMCID: PMC9501404 DOI: 10.3390/jcdd9090288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/23/2022] [Accepted: 08/24/2022] [Indexed: 11/16/2022] Open
Abstract
Catheter ablation of ventricular tachycardia has demonstrated its important role in the treatment of ventricular tachycardia in patients with structural cardiomyopathy. Conventional mapping techniques used to define the critical isthmus, such as activation mapping and entrainment, are limited by the non-inducibility of the clinical tachycardia or its poor hemodynamic tolerance. To overcome these limitations, a voltage mapping strategy based on bipolar electrograms peak to peak analysis was developed, but a low specificity (30%) for VT isthmus has been described with this approach. Functional mapping strategy relies on the analysis of the characteristics of the electrograms but also their propagation patterns and their response to extra-stimulus or alternative pacing wavefronts to define the targets for ablation. With this review, we aim to summarize the different functional mapping strategies described to date to identify ventricular arrhythmic substrate in patients with structural heart disease.
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17
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Vázquez-Calvo S, Garre P, Sanchez-Somonte P, Borras R, Quinto L, Caixal G, Pujol-Lopez M, Althoff T, Guasch E, Arbelo E, Tolosana JM, Brugada J, Mont L, Roca-Luque I. Orthogonal high-density mapping with ventricular tachycardia isthmus analysis vs. pure substrate ventricular tachycardia ablation: A case-control study. Front Cardiovasc Med 2022; 9:912335. [PMID: 35979023 PMCID: PMC9376368 DOI: 10.3389/fcvm.2022.912335] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 07/04/2022] [Indexed: 11/29/2022] Open
Abstract
Background Substrate-based ablation has become a successful technique for ventricular tachycardia (VT) ablation. High-density (HD) mapping catheters provide high-resolution electroanatomical maps and better discrimination of local abnormal electrograms. The HD Grid Mapping Catheter is an HD catheter with the ability to map orthogonal signals on top of conventional bipolar signals, which could provide better discrimination of the arrhythmic substrate. On the other hand, conventional mapping techniques, such as activation mapping, when possible, help to identify the isthmus of the tachycardia. Aim The purpose of this study was to compare clinical outcomes after using two different VT ablation strategies: one based on extensive mapping with the HD Grid Mapping Catheter, including VT isthmus analysis, and the other based on pure substrate ablation. Methods Forty consecutive patients undergoing VT ablation with extensive HD mapping method in the hospital clinic (November 2018–November 2019) were included. Clinical outcomes were compared with a historical cohort of 26 consecutive patients who underwent ablation using a scar dechanneling technique before 2018. Results The density of mapping points was higher in the extensive mapping group (2370.24 ± 920.78 vs. 576.45 ± 294.46; p < 0.001). After 1 year of follow-up, VT recurred in 18.4% of patients in the extensive mapping group vs. 34.6% of patients in the historical control group (p = 0.14), with a significantly greater reduction of VT burden: VT episodes (81.7 ± 7.79 vs. 43.4 ± 19.9%, p < 0.05), antitachycardia pacing (99.45 ± 2.29 vs. 33.9 ± 102.5%, p < 0.001), and implantable cardioverter defibrillator (ICD) shocks (99 ± 4.5 vs. 64.7 ± 59.9%, p = 0.02). Conclusion The use of a method based on extensive mapping with the HD Grid Mapping Catheter and VT isthmus analysis allows better discrimination of the arrhythmic substrate and could be associated with a greater decrease in VT burden.
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Affiliation(s)
- Sara Vázquez-Calvo
- Department of Cardiology, Cardiovascular Clinical Institute, Arrythmia Section, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Paz Garre
- Department of Cardiology, Cardiovascular Clinical Institute, Arrythmia Section, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Paula Sanchez-Somonte
- Department of Cardiology, Cardiovascular Clinical Institute, Arrythmia Section, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Roger Borras
- Department of Cardiology, Cardiovascular Clinical Institute, Arrythmia Section, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Levio Quinto
- Department of Cardiology, Cardiovascular Clinical Institute, Arrythmia Section, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Gala Caixal
- Department of Cardiology, Cardiovascular Clinical Institute, Arrythmia Section, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Margarida Pujol-Lopez
- Department of Cardiology, Cardiovascular Clinical Institute, Arrythmia Section, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Till Althoff
- Department of Cardiology, Cardiovascular Clinical Institute, Arrythmia Section, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Eduard Guasch
- Department of Cardiology, Cardiovascular Clinical Institute, Arrythmia Section, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Elena Arbelo
- Department of Cardiology, Cardiovascular Clinical Institute, Arrythmia Section, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - José Maria Tolosana
- Department of Cardiology, Cardiovascular Clinical Institute, Arrythmia Section, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Josep Brugada
- Department of Cardiology, Cardiovascular Clinical Institute, Arrythmia Section, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Lluís Mont
- Department of Cardiology, Cardiovascular Clinical Institute, Arrythmia Section, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Ivo Roca-Luque
- Department of Cardiology, Cardiovascular Clinical Institute, Arrythmia Section, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
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18
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Parreira L, Carmo P, Marinheiro R, Chambel D, Mesquita D, Amador P, Pinho J, Marques L, Reis RP, Adragao P. A simplified approach to radiofrequency catheter ablation of idiopathic ventricular outflow tract premature ventricular contractions. J Cardiovasc Electrophysiol 2022; 33:2308-2321. [PMID: 35938385 DOI: 10.1111/jce.15652] [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: 06/24/2022] [Revised: 07/14/2022] [Accepted: 08/01/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Frequently, low voltage areas (LVAs) and diastolic potentials (DPs) are present at ablation site in sinus rhythm in patients with idiopathic premature ventricular contractions (PVCs). OBJECTIVE Validate these findings as substrate for PVCs and evaluate the feasibility of a simplified substrate approach based on LVAs and DPs for ablation of idiopathic outflow tract PVCs, in patients with a low PVC burden during the procedure. METHODS Prospective single-arm clinical trial at two centers with comparison with a historical group, matched to age and gender. The study group consisted of consecutive patients referred for ablation of frequent idiopathic PVCs with inferior axis, that presented with less than 2 PVCs/min in first 5 minutes of the procedure. The ablation was based on fast mapping of the RVOT in sinus rhythm looking for LVAs and DPs, defined as isolated small amplitude potentials occurring after the T wave of the surface ECG. The area with LVAs and DPs was tagged, and a simplified activation mapping of the PVCs was done in that area. The procedure time, success rate and recurrence rate were compared with the historical group in whom ablation was performed based on activation and pace mapping only. A validation group without PVCs was also studied to assess the prevalence of LVAs and DPs in the general population. RESULTS The study (n=38), historical (n=38) and validation (n=38) groups did not differ in relation to age or gender. Prevalence of LVAs and DPs was significantly higher in the study group in comparison with the validation group, respectively, 71% vs 11%, p<0.0001 and 87% vs 8%, p<0.0001. Procedure time was significantly lower in the study group when comparing to the historical group, 130 (100-164) vs 183 (160-203) min, p<0.0001 and the success rate was significantly higher, 90% vs 64%, p=0.013. The recurrence rate in patients with a successful ablation was not significantly different between both groups, Log-Rank=0.125. CONCLUSION Prevalence of LVAs and DPs was significantly higher in the study group than in the validation group. The proposed approach proved to be feasible, faster and more efficient than the historical approach. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Leonor Parreira
- Setubal Hospital Centre, R. Camilo Castelo Branco 175, 2910-549, Setubal.,Luz Hospital Lisbon, Av. Lusiada 100, 1500-650, Lisboa
| | - Pedro Carmo
- Luz Hospital Lisbon, Av. Lusiada 100, 1500-650, Lisboa
| | - Rita Marinheiro
- Setubal Hospital Centre, R. Camilo Castelo Branco 175, 2910-549, Setubal
| | - Duarte Chambel
- Setubal Hospital Centre, R. Camilo Castelo Branco 175, 2910-549, Setubal
| | - Dinis Mesquita
- Setubal Hospital Centre, R. Camilo Castelo Branco 175, 2910-549, Setubal
| | - Pedro Amador
- Setubal Hospital Centre, R. Camilo Castelo Branco 175, 2910-549, Setubal
| | - Joana Pinho
- Luz Hospital Lisbon, Av. Lusiada 100, 1500-650, Lisboa
| | - Lia Marques
- Setubal Hospital Centre, R. Camilo Castelo Branco 175, 2910-549, Setubal
| | | | - Pedro Adragao
- Luz Hospital Lisbon, Av. Lusiada 100, 1500-650, Lisboa
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19
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Impact of device length on electrogram sensing in miniaturized insertable cardiac monitors. J Electrocardiol 2022; 73:42-48. [DOI: 10.1016/j.jelectrocard.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/24/2022] [Accepted: 05/15/2022] [Indexed: 11/23/2022]
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20
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Multielectrode Unipolar Voltage Mapping and Electrogram Morphology to Identify Post-Infarct Scar Geometry: Validation by Histology. JACC Clin Electrophysiol 2022; 8:437-449. [PMID: 35450598 DOI: 10.1016/j.jacep.2021.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 10/27/2021] [Accepted: 11/17/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES This study sought to evaluate the ability of uni- and bipolar electrograms collected with a multielectrode catheter with smaller electrodes to: 1) delineate scar; and 2) determine local scar complexity. BACKGROUND Early reperfusion results in variable endocardial scar, often overlaid with surviving viable myocardium. Although bipolar voltage (BV) mapping is considered the pillar of substrate-based ablation, the role of unipolar voltage (UV) mapping has not been sufficiently explored. It has been suggested that bipolar electrograms collected with small electrode catheters can better identify complex scar geometries. METHODS Twelve swine with early reperfusion infarctions were mapped with the 48-electrode OctaRay catheter and a conventional catheter during sinus rhythm. BV electrograms with double components were identified. Transmural (n = 933) biopsy specimens corresponding to mapping points were obtained, histologically assessed, and classified by scar geometry. RESULTS OctaRay UV (UVOcta) and BV (BVOcta) amplitude were associated with the amount of viable myocardium at a given location, with a stronger association for UVOcta (R2 = 0.767 vs 0.473). Cutoff values of 3.7 mV and 1.0 mV could delineate scar (area under the curve: 0.803 and 0.728 for UVOcta and BVOcta, respectively). The morphology of bipolar electrograms collected with the OctaRay catheter more frequently identified areas with 2 layers of surviving myocardium than electrograms collected with the conventional catheter (84% vs 71%). CONCLUSIONS UV mapping can generate a map to delineate the area of interest when using a multielectrode catheter. Within this area of interest, the morphology of bipolar electrograms can identify areas in which a surviving epicardial layer may overlay a poorly coupled, potentially arrhythmogenic, endocardium.
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21
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Vlachos K, Gkalapis C, Efremidis M, Bazoukis G, Gouziouta A, Jaïs P, Letsas KP. Left Inferior Pulmonary Vein-related Reentry Identified Using High-density Activation and Voltage Mapping in Combination with Entrainment Mapping. J Innov Card Rhythm Manag 2022; 13:4852-4855. [PMID: 35127239 PMCID: PMC8812704 DOI: 10.19102/icrm.2022.130103] [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: 12/03/2020] [Accepted: 07/16/2021] [Indexed: 11/10/2022] Open
Abstract
A 61-year-old man with highly symptomatic palpitations presented 13 months after undergoing pulmonary vein isolation for paroxysmal atrial fibrillation. A 12-lead electrocardiogram revealed atrial tachycardia, and the patient was scheduled for mapping, which revealed two regions of reconnection along the posterior part of the region of the left inferior pulmonary vein.
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Affiliation(s)
| | - Charis Gkalapis
- Department of Electrophysiology-Cardiology, Klinikum Vest, Recklinghausen, Germany
| | | | - George Bazoukis
- Arrhythmia Unit, Onassis Cardiac Surgery Centre, Athens, Greece
| | | | - Pierre Jaïs
- LIRYC, University of Bordeaux, CHU de Bordeaux, Bordeaux, France.,Service de Rhythmologie, Hôpital Cardiologique du Haut-Lévêque, Pessac, France
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22
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Kumagai K, Sato T, Kurose Y, Sumiyoshi T, Hasegawa K, Sekiguchi Y, Yambe M, Komaru T. Predictors of recurrence of atrial tachyarrhythmias after pulmonary vein isolation by functional and structural mapping of nonparoxysmal atrial fibrillation. J Arrhythm 2022; 38:86-96. [PMID: 35222754 PMCID: PMC8851591 DOI: 10.1002/joa3.12670] [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: 09/21/2021] [Revised: 12/09/2021] [Accepted: 12/12/2021] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND This study aimed to evaluate the predictors of recurrence of atrial tachyarrhythmias by structural and functional mapping: voltage, dominant frequency (DF), and rotor mapping after a pulmonary vein isolation (PVI) in nonparoxysmal atrial fibrillation (AF) patients. METHODS A total of 66 nonparoxysmal AF patients were prospectively investigated. After the PVI, an online real-time phase mapping system was used to detect the location of rotors with critical nonpassively activated ratios (%NPs) of ≧50% in each left atrial (LA) segment, and high-DFs of ≧7 Hz were simultaneously mapped. After restoring sinus rhythm, low-voltage areas (LVAs < 0.5 mV) were mapped using the Advisor HD grid catheter (HDG). RESULTS Sixty-four of 66 (97%) AF patients had minimum to mild LVAs regardless of an enlarged LAD and LA volume (45 ± 6.0 mm and 141 ± 29 ml). There were no significant differences in the max and mean DF values and %NPs between the patients with and without recurrent atrial tachyarrhythmias. However, there was a significant difference in the LVA/LA surface area between the patients with and without recurrent atrial tachyarrhythmias (p = .004). Atrial tachyarrhythmia freedom was significantly greater in those with LVAs of ≤3.3% than in those >3.3% after one procedure over 11.6 ± 0.8 months of follow-up (77.1% vs. 33.3%, p < .001). In a multivariate analysis, the LVA/LA surface area after the PVI (HR 1.079; CI, 1.025-1.135, p = .003) was an independent predictor of AF recurrence. CONCLUSIONS The predictor of atrial tachyarrhythmia recurrence after the PVI was LVAs rather than DFs and rotors in nonparoxysmal AF patients.
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Affiliation(s)
- Koji Kumagai
- Department of Cardiovascular MedicineTohoku Medical and Pharmaceutical UniversityMiyagiJapan
| | - Tsukasa Sato
- Department of Cardiovascular MedicineTohoku Medical and Pharmaceutical UniversityMiyagiJapan
| | - Yuki Kurose
- Department of Cardiovascular MedicineTohoku Medical and Pharmaceutical UniversityMiyagiJapan
| | - Takenori Sumiyoshi
- Department of Cardiovascular MedicineTohoku Medical and Pharmaceutical UniversityMiyagiJapan
| | - Kaoru Hasegawa
- Department of Cardiovascular MedicineTohoku Medical and Pharmaceutical UniversityMiyagiJapan
| | - Yuko Sekiguchi
- Department of Cardiovascular MedicineTohoku Medical and Pharmaceutical UniversityMiyagiJapan
| | - Minoru Yambe
- Department of Cardiovascular MedicineTohoku Medical and Pharmaceutical UniversityMiyagiJapan
| | - Tatsuya Komaru
- Department of Cardiovascular MedicineTohoku Medical and Pharmaceutical UniversityMiyagiJapan
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23
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Therapeutic implications of galectin-3 in patients with atrial fibrillation. Sci Rep 2022; 12:784. [PMID: 35039576 PMCID: PMC8764095 DOI: 10.1038/s41598-022-04894-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 12/20/2021] [Indexed: 11/09/2022] Open
Abstract
Atrial fibrosis can present as an arrhythmogenic substrate that is correlated with higher recurrence after catheter ablation for atrial fibrillation. Galectin-3, a beta-galactoside-binding lectin, is highly expressed and secreted from macrophages and is important in inflammation and fibrosis. We assessed the clinical implications of serum galectin-3 in patients with atrial fibrillation. This was a prospective cohort study of consecutive patients who underwent radiofrequency catheter ablation in a tertiary referral center from February 2017 to September 2017. Intracardiac blood sampling, echocardiographic measurements, magnetic resonance imaging with late gadolinium enhancement, electrophysiologic testing, and endocardial voltage mapping were consistently implemented in 75 patients before the ablation. Serum galectin-3 level was higher in patients with diabetes mellitus and was correlated with values that indicated the left atrial size. During a median 14 months of follow-up, atrial tachyarrhythmia recurred in 27% of patients. In multivariable Cox regression analysis, non-paroxysmal atrial fibrillation (hazard ratio 6.8; 95% confidence interval 1.6–28.9) and higher galectin-3 levels (hazard ratio 1.3; 95% confidence interval 1.0–1.7) were associated with increased risk of recurrence. Serum galectin-3 may be a prognostic biomarker for risk stratification in patients with atrial fibrillation planned catheter ablation.
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24
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Ciaccio EJ, Anter E, Coromilas J, Wan EY, Yarmohammadi H, Wit AL, Peters NS, Garan H. Structure and function of the ventricular tachycardia isthmus. Heart Rhythm 2022; 19:137-153. [PMID: 34371192 DOI: 10.1016/j.hrthm.2021.08.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/22/2021] [Accepted: 08/01/2021] [Indexed: 12/24/2022]
Abstract
Catheter ablation of postinfarction reentrant ventricular tachycardia (VT) has received renewed interest owing to the increased availability of high-resolution electroanatomic mapping systems that can describe the VT circuits in greater detail, and the emergence and need to target noninvasive external beam radioablation. These recent advancements provide optimism for improving the clinical outcome of VT ablation in patients with postinfarction and potentially other scar-related VTs. The combination of analyses gleaned from studies in swine and canine models of postinfarction reentrant VT, and in human studies, suggests the existence of common electroanatomic properties for reentrant VT circuits. Characterizing these properties may be useful for increasing the specificity of substrate mapping techniques and for noninvasive identification to guide ablation. Herein, we describe properties of reentrant VT circuits that may assist in elucidating the mechanisms of onset and maintenance, as well as a means to localize and delineate optimal catheter ablation targets.
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Affiliation(s)
- Edward J Ciaccio
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York; ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, United Kingdom.
| | - Elad Anter
- Department of Cardiovascular Medicine, Cardiac Electrophysiology, Cleveland Clinic, Cleveland, Ohio
| | - James Coromilas
- Department of Medicine, Division of Cardiovascular Disease and Hypertension, Rutgers University, New Brunswick, New Jersey
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Hirad Yarmohammadi
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Andrew L Wit
- Department of Pharmacology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Nicholas S Peters
- ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, United Kingdom
| | - Hasan Garan
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York
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25
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Im SI, Park KM. What Is Better Predictor of Late Recurrence after Radiofrequency Catheter Ablation for Atrial Fibrillation? Korean Circ J 2022; 52:379-381. [PMID: 35502568 PMCID: PMC9064699 DOI: 10.4070/kcj.2022.0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/16/2022] [Accepted: 03/24/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Sung Il Im
- Division of Cardiology, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Korea
| | - Kyoung-Min Park
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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26
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Miao Y, Xu M, Yang L, Zhang C, Liu H, Shao X. Investigating the association between P wave duration and atrial fibrillation recurrence after radiofrequency ablation in early persistent atrial fibrillation patients. Int J Cardiol 2021; 351:48-54. [PMID: 34954277 DOI: 10.1016/j.ijcard.2021.12.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 12/11/2021] [Accepted: 12/20/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND In the present study, we aimed to explore the association between P wave duration, as the measured time from the start point of the P wave to the end point, and atrial fibrillation recurrence after transcatheter radiofrequency ablation in patients with early persistent atrial fibrillation. METHODS Patients with early persistent atrial fibrillation who underwent the first radiofrequency ablation procedure were retrospectively analyzed. The electrocardiographic, echocardiographic and clinical data of the enrolled patients before and after operation were collected and recorded. After adjusting confounding factors and performing stratified analysis, the association between the P wave duration and the atrial fibrillation recurrence of patients with early persistent atrial fibrillation after radiofrequency ablation was explored. RESULTS The proportions of atrial fibrillation recurrence of the low, medium, and high P wave duration groups were 6.4%, 19.7%, and 47.0%, respectively. After potential confounding factors were adjusted, the risk of atrial fibrillation recurrence gradually increased with the increase of P wave duration (odds ratio: 1.093, 95% confidence interval: 1.063-1.124, p < 0.001). This trend was statistically significant (odds ratio: 1.099, 95% confidence interval: 1.052-1.149, p < 0.001), especially in comparison of high vs. low (odds ratio: 16.99, 95% confidence interval: 4.75-60.78, p < 0.001). Curve fitting showed that there was a linear and positive association between the P wave duration and the risk of atrial fibrillation recurrence. This association was consistent in different subgroups based on gender, drinking, history of smoking, hypertension, diabetes mellitus, peripheral artery disease, stroke or transient ischemia attack, hyperlipidemia, heart failure, and heart rate, suggesting that there was no significant interaction between different grouping parameters and the association (p for interaction range = 0.217-0.965). CONCLUSIONS In patients with early persistent atrial fibrillation who underwent radiofrequency ablation procedure for the first time and converted to sinus rhythm, the P wave duration within 72 h after the procedure was independently associated with the risk of atrial fibrillation recurrence, and such association was linear and positive.
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Affiliation(s)
- Yuxia Miao
- Department of Cardiovascular Division of The Third Affiliated Hospital of Soochow University, Chang Zhou City 213000, Jiangsu Province, China
| | - Min Xu
- Department of Cardiovascular Division of The Third Affiliated Hospital of Soochow University, Chang Zhou City 213000, Jiangsu Province, China.
| | - Ling Yang
- Department of Cardiovascular Division of The Third Affiliated Hospital of Soochow University, Chang Zhou City 213000, Jiangsu Province, China.
| | - Chunxu Zhang
- Department of Cardiovascular Division of Changzhou Municipal Hospital of Traditional Chinese Medicine, Chang Zhou City 213000, Jiangsu Province, China
| | - Huannian Liu
- Department of Cardiovascular Division of Changzhou Cancer Hospital Affiliated to Soochow University, Chang Zhou City 213000, Jiangsu Province, China.
| | - Xiaoliang Shao
- Department of Nuclear Medicine of The Third Affiliated Hospital of Soochow University, Chang Zhou City 213000, Jiangsu Province, China
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27
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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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28
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Yavin HD, Sroubek J, Yarnitsky J, Bubar ZP, Higuchi K, Zilberman I, Basu S, Anter E. Direction-aware mapping algorithms have minimal impact on bipolar voltage maps created using high-resolution multielectrode catheters. J Cardiovasc Electrophysiol 2021; 33:73-80. [PMID: 34822200 DOI: 10.1111/jce.15299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/11/2021] [Accepted: 10/27/2021] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Direction-aware mapping algorithms improve the accuracy of voltage mapping by measuring the maximal voltage amplitude recorded in the direction of wavefront propagation. While beneficial for stationary catheters, its utility for roving catheters collecting electrograms (EGMs) at multiple angles is unknown. OBJECTIVE To compare the directional dependence of bipolar voltage amplitude between stationary and roving catheters. METHODS In 10 swine, a transcaval ablation line with a gap was created. The gap was mapped using an array catheter (Optrell™; Biosense Webster). In Step 1, the array was kept stationary over the gap, and four voltage maps were created during activation of the gap from superior, inferior, septal, and lateral directions. In Step 2, four additional maps were created; however, the catheter was allowed to move with points acquired at multiple angles. In Step 3, the gap was remapped; however, bipoles were computed using a direction-aware mapping algorithm. RESULTS In a stationary catheter position, bipolar voltage distribution was influenced by the direction of activation with maximal differences obtained between orthogonal directions 32% (13%-53%). However, roving the catheter produced similar bipolar voltage maps irrespective of the direction of activation 11% (5%-18%). A direction-aware mapping algorithm was beneficial for reducing the directional dependence of voltage maps created by stationary catheters but not by roving catheters. CONCLUSION The directional dependency of bipolar voltage amplitude is greatest when the catheter is stationary. However, when the catheter is allowed to rove and collect EGMs at multiple angles as occurs clinically, the directional dependence of bipolar voltage is minimal.
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Affiliation(s)
- Hagai D Yavin
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Cardiovascular and Metabolic Sciences, Mark-Josephson and Andrew Wit Research Laboratory, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jakub Sroubek
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Cardiovascular and Metabolic Sciences, Mark-Josephson and Andrew Wit Research Laboratory, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Zachary P Bubar
- Department of Cardiovascular and Metabolic Sciences, Mark-Josephson and Andrew Wit Research Laboratory, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Biosense Webster of Johnson & Johnson, Irvine, California, USA
| | - Koji Higuchi
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Cardiovascular and Metabolic Sciences, Mark-Josephson and Andrew Wit Research Laboratory, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Israel Zilberman
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Cardiovascular and Metabolic Sciences, Mark-Josephson and Andrew Wit Research Laboratory, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shubhayu Basu
- Biosense Webster of Johnson & Johnson, Irvine, California, USA
| | - Elad Anter
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Cardiovascular and Metabolic Sciences, Mark-Josephson and Andrew Wit Research Laboratory, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
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29
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Han B, Trew ML, Zgierski-Johnston CM. Cardiac Conduction Velocity, Remodeling and Arrhythmogenesis. Cells 2021; 10:cells10112923. [PMID: 34831145 PMCID: PMC8616078 DOI: 10.3390/cells10112923] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 10/14/2021] [Accepted: 10/22/2021] [Indexed: 02/06/2023] Open
Abstract
Cardiac electrophysiological disorders, in particular arrhythmias, are a key cause of morbidity and mortality throughout the world. There are two basic requirements for arrhythmogenesis: an underlying substrate and a trigger. Altered conduction velocity (CV) provides a key substrate for arrhythmogenesis, with slowed CV increasing the probability of re-entrant arrhythmias by reducing the length scale over which re-entry can occur. In this review, we examine methods to measure cardiac CV in vivo and ex vivo, discuss underlying determinants of CV, and address how pathological variations alter CV, potentially increasing arrhythmogenic risk. Finally, we will highlight future directions both for methodologies to measure CV and for possible treatments to restore normal CV.
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Affiliation(s)
- Bo Han
- Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg-Bad Krozingen, 79110 Freiburg im Breisgau, Germany;
- Faculty of Medicine, University of Freiburg, 79110 Freiburg im Breisgau, Germany
- Spemann Graduate School of Biology and Medicine (SGBM), University of Freiburg, 79104 Freiburg im Breisgau, Germany
- Department of Cardiovascular Surgery, The Fourth People’s Hospital of Jinan, 250031 Jinan, China
| | - Mark L. Trew
- Auckland Bioengineering Institute, University of Auckland, Auckland 1010, New Zealand;
| | - Callum M. Zgierski-Johnston
- Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg-Bad Krozingen, 79110 Freiburg im Breisgau, Germany;
- Faculty of Medicine, University of Freiburg, 79110 Freiburg im Breisgau, Germany
- Correspondence:
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Atrial substrate characterization in patients with atrial fibrillation and hypertrophic cardiomyopathy: Evidence for an extensive fibrotic disease. J Electrocardiol 2021; 69:87-92. [PMID: 34619440 DOI: 10.1016/j.jelectrocard.2021.06.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 05/27/2021] [Accepted: 06/03/2021] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Data regarding the left atrial (LA) electroanatomical substrate in patients with hypertrophic cardiomyopathy (HCM) and atrial fibrillation (AF) are missing. In this electroanatomical mapping (EAM) study, we evaluated the extent of LA fibrosis and its impact on catheter ablation outcomes in patients with HCM and AF. MATERIALS AND METHODS High-density LA EAM was performed during AF in 28 consecutive patients with obstructive HCM and AF (42.9% displayed paroxysmal AF and 57.1% persistent AF). Propensity score (PS) matching analysis was performed to reduce the impact of potential confounding factors. PS were derived to match patients at a 1:1 ratio. Patients were matched according to age, sex and LA diameter. After PS, 28 non-HCM patients with AF were selected, and served as controls. Two different cut-off values of bipolar signal amplitude were investigated for fibrosis characterization (≤0.25 mV and ≤ 0.4 mV). HCM patients underwent pulmonary vein antral isolation (PVAI) and roof line, while non-HCM patients PVAI only. RESULTS After the 3-month blanking period, 10 HCM patients (35.7%) displayed atrial arrhythmia recurrence. HCM patients with arrhythmia recurrence showed significantly greater low voltage areas defined as either bipolar voltage ≤0.25 mV (22.5 ± 10% vs. 5.5 ± 6.4%, p = 0.001) or ≤ 0.4 mV (32 ± 13.9% vs. 5.9 ± 5.1%, p < 0.001). The presence of low voltage areas ≤0.4 mV greater than 14.1% of the total LA area also predicted arrhythmia recurrence with excellent sensitivity (100%) and specificity (100%). Univariate analysis revealed that the extent of LA fibrosis was the only predictor of AF recurrence. After PS matching with non-HCM patients, patients with HCM exhibited wider fibrotic regions ≤0.25 mV compared to non-HCM patients (p = 0.016). CONCLUSIONS High-density EAM reveals extensive LA fibrotic disease in patients with HCM, an event with certain implications in catheter ablation outcomes.
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Letsas KP, Vlachos K, Conte G, Efremidis M, Nakashima T, Duchateau J, Bazoukis G, Frontera A, Mililis P, Tse G, Cheniti G, Takigawa M, Pambrun T, Prappa E, Sacher F, Derval N, Sideris A, Auricchio A, Jais P, Haissaguerre M, Hocini M. Right ventricular outflow tract electroanatomical abnormalities in asymptomatic and high-risk symptomatic patients with Brugada syndrome: Evidence for a new risk stratification tool? J Cardiovasc Electrophysiol 2021; 32:2997-3007. [PMID: 34596938 DOI: 10.1111/jce.15262] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 08/30/2021] [Accepted: 09/06/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Microstructural abnormalities at the epicardium of the right ventricular outflow tract (RVOT) may provide the arrhythmia substrate in Brugada syndrome (BrS). Endocardial unipolar electroanatomical mapping allows the identification of epicardial abnormalities. We evaluated the clinical implications of an abnormal endocardial substrate as perceived by high-density electroanatomical mapping (HDEAM) in patients with BrS. METHODS Fourteen high-risk BrS patients with aborted sudden cardiac death (SCD) (12 males, mean age: 41.9 ± 11.8 years) underwent combined endocardial-epicardial HDEAM of the right ventricle/RVOT, while 40 asymptomatic patients (33 males, mean age: 42 ± 10.7 years) underwent endocardial HDEAM. Based on combined endocardial-epicardial procedures, endocardial HDEAM was considered abnormal in the presence of low voltage areas (LVAs) more than 1 cm2 with bipolar signals less than 1 mV and unipolar signals less than 5.3 mV. Programmed ventricular stimulation (PVS) was performed in all patients. RESULTS The endocardial unipolar LVAs were colocalized with epicardial bipolar LVAs (p = .0027). Patients with aborted SCD exhibited significantly wider endocardial unipolar (p < .01) and bipolar LVAs (p < .01) compared with asymptomatic individuals. A substrate size of unipolar LVAs more than 14.5 cm2 (area under the curve [AUC]: 0.92, p < .001] and bipolar LVAs more than 3.68 cm2 (AUC: 0.82, p = .001) distinguished symptomatic from asymptomatic patients. Patients with ventricular fibrillation inducibility (23/54) demonstrated broader endocardial unipolar (p < .001) and bipolar LVAs (p < .001) than noninducible patients. The presence of unipolar LVAs more than 13.5 cm2 (AUC: 0.95, p < .001) and bipolar LVAs more than 2.97 cm2 (AUC: 0.78, p < .001) predicted a positive PVS. CONCLUSION Extensive endocardial electroanatomical abnormalities identify high-risk patients with BrS. Endocardial HDEAM may allow risk stratification of asymptomatic patients referred for PVS.
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Affiliation(s)
- Konstantinos P Letsas
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Athens, Greece
| | - Konstantinos Vlachos
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Athens, Greece.,Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | | | - Michael Efremidis
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Athens, Greece
| | - Takashi Nakashima
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Josselin Duchateau
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Athens, Greece
| | - George Bazoukis
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Athens, Greece
| | - Antonio Frontera
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Panagiotis Mililis
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Athens, Greece
| | - Gary Tse
- Xiamen Cardiovascular Hospital, Xiamen University, Xiamen, China
| | - Ghassen Cheniti
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Masateru Takigawa
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Thomas Pambrun
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Efstathia Prappa
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Athens, Greece
| | - Frederic Sacher
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Nicolas Derval
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Antonios Sideris
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Athens, Greece
| | | | - Pierre Jais
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Michel Haissaguerre
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Meleze Hocini
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et Modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
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Zoppo F, Gagno G, Perazza L, Cocciolo A, Mugnai G, Vaccari D, Calzolari V. Electroanatomic voltage mapping for tissue characterization beyond arrhythmia definition: A systematic review. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1432-1448. [PMID: 34096635 DOI: 10.1111/pace.14288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 05/17/2021] [Accepted: 05/30/2021] [Indexed: 11/28/2022]
Abstract
Three-dimensional (3D) reconstruction by means of electroanatomic mapping (EAM) systems, allows for the understanding of the mechanism of focal or re-entrant arrhythmic circuits, which can be identified by means of dynamic (activation and propagation) and static (voltage) color-coded maps. However, besides this conventional use, EAM may offer helpful anatomical and functional information for tissue characterisation in several clinical settings. Today, data regarding electromechanical myocardial viability, scar detection in ischaemic and nonischaemic cardiomyopathy and arrhythmogenic right ventricle dysplasia (ARVC/D) definition are mostly consolidated, while emerging results are becoming available in contexts such as Brugada syndrome and cardiac resynchronisation therapy (CRT) implant procedures. As part of an invasive procedure, EAM has not yet been widely adopted as a stand-alone tool in the diagnostic path. We aim to review the data in the current literature regarding the use of 3D EAM systems beyond the definition of arrhythmia.
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Affiliation(s)
- Franco Zoppo
- Elettrofisiologia, U.O.C. di Cardiologia, Ospedale Civile Gorizia, Gorizia, Italy
| | - Giulia Gagno
- Dipartimento di Cardiologia, Azienda Sanitaria Universitaria Giuliano Isontina, ed Università degli Studi di Trieste, Trieste, Italy
| | - Luca Perazza
- Elettrofisiologia, U.O.C. di Cardiologia, Ospedale Civile Gorizia, Gorizia, Italy
| | - Andrea Cocciolo
- Elettrofisiologia, U.O.C. di Cardiologia, Ospedale Civile Gorizia, Gorizia, Italy
| | - Giacomo Mugnai
- Elettrofisiologia, U.O.C di Cardiologia, Ospedale Civile Arzignano, Vicenza, Italy
| | - Diego Vaccari
- Elettrofisiologia, U.O.C di Cardiologia, Ospedale Civile Feltre, Belluno, Italy
| | - Vittorio Calzolari
- Elettrofisiologia, U.O.C di Cardiologia, Ospedale Civile Treviso, Treviso, Italy
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Berte B, Zeppenfeld K, Tung R. Impact of Micro-, Mini- and Multi-Electrode Mapping on Ventricular Substrate Characterisation. Arrhythm Electrophysiol Rev 2020; 9:128-135. [PMID: 33240508 PMCID: PMC7675146 DOI: 10.15420/aer.2020.24] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/23/2020] [Indexed: 12/29/2022] Open
Abstract
Accurate substrate characterisation may improve the evolving understanding and treatment of cardiac arrhythmias. During substrate-based ablation techniques, wide practice variations exist with mapping via dedicated multi-electrode catheter or conventional ablation catheters. Recently, newer ablation catheter technology with embedded mapping electrodes have been introduced. This article focuses on the general misconceptions of voltage mapping and more specific differences in unipolar and bipolar signal morphology, field of view, signal-to-noise ratio, mapping capabilities (density and resolution), catheter-specific voltage thresholds and impact of micro-, mini- and multi-electrodes for substrate mapping. Efficiency and cost-effectiveness of different catheter types are discussed. Increasing sampling density with smaller electrodes allows for higher resolution with a greater likelihood to record near-field electrical information. These advances may help to further improve our mechanistic understanding of the correlation between substrate and ventricular tachycardia, as well as macro-reentry arrhythmia in humans.
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Affiliation(s)
- Benjamin Berte
- Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Roderick Tung
- Center for Arrhythmia Care, Pritzker School of Medicine University of Chicago Medicine, Chicago, IL, US
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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: 11] [Impact Index Per Article: 2.8] [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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Porta-Sánchez A, Magtibay K, Nayyar S, Bhaskaran A, Lai PFH, Massé S, Labos C, Qiang B, Romagnuolo R, Masoudpour H, Biswas L, Ghugre N, Laflamme M, Deno DC, Nanthakumar K. Omnipolarity applied to equi-spaced electrode array for ventricular tachycardia substrate mapping. Europace 2020; 21:813-821. [PMID: 30726937 PMCID: PMC6479413 DOI: 10.1093/europace/euy304] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 12/04/2018] [Indexed: 11/17/2022] Open
Abstract
Aims Bipolar electrogram (BiEGM)-based substrate maps are heavily influenced by direction of a wavefront to the mapping bipole. In this study, we evaluate high-resolution, orientation-independent peak-to-peak voltage (Vpp) maps obtained with an equi-spaced electrode array and omnipolar EGMs (OTEGMs), measure its beat-to-beat consistency, and assess its ability to delineate diseased areas within the myocardium compared against traditional BiEGMs on two orientations: along (AL) and across (AC) array splines. Methods and results The endocardium of the left ventricle of 10 pigs (three healthy and seven infarcted) were each mapped using an Advisor™ HD grid with a research EnSite Precision™ system. Cardiac magnetic resonance images with late gadolinium enhancement were registered with electroanatomical maps and were used for gross scar delineation. Over healthy areas, OTEGM Vpp values are larger than AL bipoles by 27% and AC bipoles by 26%, and over infarcted areas OTEGM Vpp values are 23% larger than AL bipoles and 27% larger than AC bipoles (P < 0.05). Omnipolar EGM voltage maps were 37% denser than BiEGM maps. In addition, OTEGM Vpp values are more consistent than bipolar Vpps showing less beat-by-beat variation than BiEGM by 39% and 47% over both infarcted and healthy areas, respectively (P < 0.01). Omnipolar EGM better delineate infarcted areas than traditional BiEGMs from both orientations. Conclusion An equi-spaced electrode grid when combined with omnipolar methodology yielded the largest detectable bipolar-like voltage and is void of directional influences, providing reliable voltage assessment within infarcted and non-infarcted regions of the heart.
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Affiliation(s)
- Andreu Porta-Sánchez
- Dept de Medicina, Universitat de Barcelona, Barcelona and Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain.,Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Karl Magtibay
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Sachin Nayyar
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Abhishek Bhaskaran
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Patrick F H Lai
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Stéphane Massé
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Christopher Labos
- Office for Science and Society, McGill University, Montreal, Quebec, Canada
| | - Beiping Qiang
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Rocco Romagnuolo
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Hassan Masoudpour
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | | | - Nilesh Ghugre
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Michael Laflamme
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | | | - Kumaraswamy Nanthakumar
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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Almeida TP, Soriano DC, Mase M, Ravelli F, Bezerra AS, Li X, Chu GS, Salinet J, Stafford PJ, Andre Ng G, Schlindwein FS, Yoneyama T. Unsupervised Classification of Atrial Electrograms for Electroanatomic Mapping of Human Persistent Atrial Fibrillation. IEEE Trans Biomed Eng 2020; 68:1131-1141. [PMID: 32881680 DOI: 10.1109/tbme.2020.3021480] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Ablation treatment for persistent atrial fibrillation (persAF) remains challenging due to the absence of a 'ground truth' for atrial substrate characterization and the presence of multiple mechanisms driving the arrhythmia. We implemented an unsupervised classification to identify clusters of atrial electrograms (AEGs) with similar patterns, which were then validated by AEG-derived markers. METHODS 956 bipolar AEGs were collected from 11 persAF patients. CARTO variables (Biosense Webster; ICL, ACI and SCI) were used to create a 3D space, and subsequently used to perform an unsupervised classification with k-means. The characteristics of the identified groups were investigated using nine AEG-derived markers: sample entropy (SampEn), dominant frequency, organization index (OI), determinism, laminarity, recurrence rate (RR), peak-to-peak (PP) amplitude, cycle length (CL), and wave similarity (WS). RESULTS Five AEG classes with distinct characteristics were identified (F = 582, P<0.0001). The presence of fractionation increased from class 1 to 5, as reflected by the nine markers. Class 1 (25%) included organized AEGs with high WS, determinism, laminarity, and RR, and low SampEn. Class 5 (20%) comprised fractionated AEGs with in low WS, OI, determinism, laminarity, and RR, and in high SampEn. Classes 2 (12%), 3 (13%) and 4 (30%) suggested different degrees of AEG organization. CONCLUSIONS Our results expand and reinterpret the criteria used for automated AEG classification. The nine markers highlighted electrophysiological differences among the five classes found by the k-means, which could provide a more complete characterization of persAF substrate during ablation target identification in future clinical studies.
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Left Atrial Electroanatomical Voltage Mapping to Characterize Substrate and Guide Ablation. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00833-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Parreira L, Marinheiro R, Carmo P, Mesquita D, Farinha J, Amador P, Ferreira A, Fonseca M, Costa F, Cavaco D, Caria R, Adragão P. Idiopathic Premature Ventricular Contractions From the Outflow Tract Display an Underlying Substrate That Can Be Unmasked by a Type 2 Brugada Electrocardiographic Pattern at High Right Precordial Leads. Front Physiol 2020; 11:969. [PMID: 32848884 PMCID: PMC7426514 DOI: 10.3389/fphys.2020.00969] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 07/16/2020] [Indexed: 01/12/2023] Open
Abstract
Background: Patients with premature ventricular contractions (PVCs) from the right ventricular outflow tract (RVOT) and apparently normal hearts, can have ST elevation similar to type 2 or type 3 Brugada pattern in the electrocardiographic (ECG) performed at a higher position. Cardiac magnetic resonance (CMR), has shown conflicting data regarding existence of structural abnormalities in patients with idiopathic PVCs from the RVOT. Objective: Our aim was to evaluate the prevalence of low voltage areas (LVAs) in the RVOT of patients with PVCS from the outflow tract, and in a control group. Secondly, assess for the presence of a non-invasive ECG marker. Methods: A 56 consecutive patients, 45 with frequent PVCs (>10000/24 h) LBBB, vertical axis, negative in aVL and 11 subjects without PVCs. Arrhythmogenic right ventricular cardiomyopathy was ruled out in all patients. An ECG was performed with V1-V2 at the level of the second intercostal space and the presence of ST-segment elevation with a Type 2 or 3 Brugada pattern (Type 2 BrP) was assessed. Bipolar voltage map of the RVOT was performed in sinus rhythm (0.5-1.5 mV color display). Areas with electrograms <1.5 mV represented the LVA. The area adjacent to the pulmonary valve usually displays voltage between 0.5 and 1.5 mV and is classified as transitional-voltage zone. Presence of LVAs outside this transitional-voltage zone were estimated. We compared two groups with and without ST-segment elevation and tested for the association between ECG pattern and LVAs. Results: None of the patients in the control group had ST-segment elevation or LVAs. In the PVC group, no patient had type 1 Brugada pattern, 29 patients (64%) had type 2 or 3 ST-segment elevation (Type 2 BrP), and 28 (62%) had LVAs outside the transitional-voltage zone. LVAs were more frequent in patients with Type 2 BrP; 93% versus 4%, p < 0.0001. The ECG pattern was associated with the presence of LVAs, OR (95% CI): 202.50 (16.92-2423), p < 0.0001. Conclusion: Low voltage areas were frequently present in the RVOT of patients with idiopathic PVCs. They were absent in controls and can be unmasked by the presence of Type 2 BrP in high right precordial leads.
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Affiliation(s)
- Leonor Parreira
- Department of Cardiology, Hospital da Luz Lisboa, Lisbon, Portugal
- Department of Cardiology, Hospital Center of Setúbal, Setúbal, Portugal
| | - Rita Marinheiro
- Department of Cardiology, Hospital Center of Setúbal, Setúbal, Portugal
| | - Pedro Carmo
- Department of Cardiology, Hospital da Luz Lisboa, Lisbon, Portugal
| | - Dinis Mesquita
- Department of Cardiology, Hospital Center of Setúbal, Setúbal, Portugal
| | - José Farinha
- Department of Cardiology, Hospital Center of Setúbal, Setúbal, Portugal
| | - Pedro Amador
- Department of Cardiology, Hospital Center of Setúbal, Setúbal, Portugal
| | - António Ferreira
- Department of Cardiology, Hospital da Luz Lisboa, Lisbon, Portugal
| | - Marta Fonseca
- Department of Cardiology, Hospital Center of Setúbal, Setúbal, Portugal
| | - Francisco Costa
- Department of Cardiology, Hospital da Luz Lisboa, Lisbon, Portugal
| | - Diogo Cavaco
- Department of Cardiology, Hospital da Luz Lisboa, Lisbon, Portugal
| | - Rui Caria
- Department of Cardiology, Hospital Center of Setúbal, Setúbal, Portugal
| | - Pedro Adragão
- Department of Cardiology, Hospital da Luz Lisboa, Lisbon, Portugal
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39
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Porterfield C, J Gora P, Wystrach A, Rossi P, Rillo M, A Sebag F, Giuggia M, Mantica M, Dorszewski A, Eldadah Z, Volpicelli M, Bottoni N, Jøns C, T Hollis Z, Dekker L, Mathew S, Schmitt J, Nilsson K. Confirmation of Pulmonary Vein Isolation with High-Density Mapping: Comparison to Traditional Workflows. J Atr Fibrillation 2020; 12:2361. [PMID: 33024494 DOI: 10.4022/jafib.2361] [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: 08/01/2019] [Revised: 09/11/2019] [Accepted: 10/12/2019] [Indexed: 02/03/2023]
Abstract
Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. Yet tools and techniques used for confirmation of PVI vary greatly, and it is unclear whether the use of any particular combination of tools and techniques provides greater sensitivity for identifying gaps periprocedurally. It has been suggested the use of a high-density mapping catheter, which enables simultaneous recording of adjacent bipolar EGMs in two directions, may provide improved sensitivity for gap identification. Anonymized, acute procedural data was prospectively collected in AF ablation cases utilizing various workflows for confirmation of PVI. Post-hoc analysis was performed to evaluate the incidence of gaps detected by different diagnostic catheter technologies, including a high-density mapping catheter and circular mapping catheters (CMCs), and common techniques such as pacing the ablation lines. A total of 139 cases were included across three subgroup analyses: 99 cases were included in an indirect comparison of three mapping catheter technologies, revealing gaps in 36.7%, 38.9%, and 81.8% of cases utilizing a 10-pole CMC, 20-pole CMC, and a high-density mapping catheter, respectively; a direct comparison of diagnostic catheter technologies in 18 cryoballoon ablation cases revealed residual gaps in 22.2% of patients identified by high-density mapping which were missed previously with the use of a 3.3F CMC; in 22 cases utilizing a technique of pacing the ablation lines, high-density mapping identified residual gaps in 68.2% of patients. This proof of concept analysis demonstrated that the use of a high-density catheter which records orthogonal bipoles simultaneously, appears to improve acute detection of gaps in PVI lines relative to other commonly utilized techniques and technologies. The long-term impact of ablating these concealed gaps remains unclear. Further study, including direct comparison of diagnostic catheter technologies in a randomized setting with long-term followup, is warranted.
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Affiliation(s)
| | | | | | - Pietro Rossi
- S. Giovanni Calibita FateBeneFratelli - Isola Tiberina, Rome, Italy
| | | | - Frederic A Sebag
- Institut Mutualiste Montsouris, Departement de Cardiologie, Paris, France
| | | | | | | | - Zayd Eldadah
- Medstar Washington Hospital Center, Washington D.C., USA
| | | | | | | | | | - Lukas Dekker
- Catharina Ziekenhuis Eindhoven, Eindhoven, Netherlands
| | | | | | - Kent Nilsson
- Piedmont Athens Regional Medical Center, Athens, GA, USA
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40
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Saha S, Linz D, Sanders P, Baumert M. Beamforming-inspired Spatial Filtering Technique for Intracardiac Electrograms. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2019:4254-4257. [PMID: 31946808 DOI: 10.1109/embc.2019.8857194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Bipolar electrograms (EGM) are widely used to assess intracardiac electrical activity and to find the atrial fibrillation-related sources. However, the interpretation of bipolar EGM is not straightforward. Variables including bipolar lead (vector) orientation relative to the wave propagation dynamics significantly impact the EGM and EGM-derived measures, which are clinically used to select target sources for catheter ablation. In this study, left atrial unipolar EGM were recorded using a 4 × 4 grid of 16 unipolar electrodes. A set (node) of 4 unipolar EGM were used to construct possible 6 bipolar EGM to evaluate the measurement uncertainty within a particular node. A novel beamforming-inspired spatial filtering (BiSF) method is proposed to reduce the potential measurement uncertainty inevitable in bipolar EGM. A set of three bipolar lead orientations that were constructed using a common unipolar electrode towards three different directions at 45°s, were added to form beamforming EGM. Finally, two beamforming EGM were intertwined to acquire BiSF EGM for a node. Results show greater signal power gain (at least around 10dB) for all BiSF EGM with better or similar signal-to-noise ratio as compared to their respective bipolar counterparts. In conclusion, reduced uncertainty in BiSF EGM improve the interpretation of EGM and EGM-derived measures used in clinical practice after further validation on a larger dataset.
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41
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Trayanova NA, Doshi AN, Prakosa A. How personalized heart modeling can help treatment of lethal arrhythmias: A focus on ventricular tachycardia ablation strategies in post-infarction patients. WILEY INTERDISCIPLINARY REVIEWS-SYSTEMS BIOLOGY AND MEDICINE 2020; 12:e1477. [PMID: 31917524 DOI: 10.1002/wsbm.1477] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 12/18/2022]
Abstract
Precision Cardiology is a targeted strategy for cardiovascular disease prevention and treatment that accounts for individual variability. Computational heart modeling is one of the novel approaches that have been developed under the umbrella of Precision Cardiology. Personalized computational modeling of patient hearts has made strides in the development of models that incorporate the individual geometry and structure of the heart as well as other patient-specific information. Of these developments, one of the potentially most impactful is the research aimed at noninvasively predicting the targets of ablation of lethal arrhythmia, ventricular tachycardia (VT), using patient-specific models. The approach has been successfully applied to patients with ischemic cardiomyopathy in proof-of-concept studies. The goal of this paper is to review the strategies for computational VT ablation guidance in ischemic cardiomyopathy patients, from model developments to the intricacies of the actual clinical application. To provide context in describing the road these computational modeling applications have undertaken, we first review the state of the art in VT ablation in the clinic, emphasizing the benefits that personalized computational prediction of ablation targets could bring to the clinical electrophysiology practice. This article is characterized under: Analytical and Computational Methods > Computational Methods Models of Systems Properties and Processes > Organ, Tissue, and Physiological Models Translational, Genomic, and Systems Medicine > Translational Medicine.
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Affiliation(s)
- Natalia A Trayanova
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland.,Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Ashish N Doshi
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland
| | - Adityo Prakosa
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland
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42
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Lee A, Walters TE, Alhede C, Vittinghoff E, Sievers R, Gerstenfeld EP. Standard peak-to-peak bipolar voltage amplitude criteria underestimate myocardial scar during substrate mapping with a novel microelectrode catheter. Heart Rhythm 2019; 17:476-484. [PMID: 31606463 DOI: 10.1016/j.hrthm.2019.10.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Ventricular bipolar voltage values <0.5 and <1.0/1.5 mV (epi- and endocardium) correlating with dense scar and border zone, respectively, were established using a 3.5-mm tip catheter. Novel microelectrode catheters promise improved mapping resolution; however, whether standard voltage criteria apply to catheters with smaller electrode size and interelectrode distance remains unclear. OBJECTIVE The purpose of this study was to determine whether traditional bipolar voltage criteria for scar apply during substrate mapping with a microelectrode catheter. METHODS Paired bipolar and microbipolar voltage values were acquired from control swine (n = 2) using the microelectrode catheter and assessed for systemic differences. In a postinfarction swine model (n = 6), scar characteristics were compared between the bipolar maps and microbipolar maps using both standard and adjusted voltage criteria derived from the control animals. RESULTS In control swine, although 5th percentile values for bipolar and microbipolar voltage were similar (1.12 vs 1.22 mV [left ventricular (LV) endo]; 0.88 mV vs 0.98 mV [epi]), median values were significantly greater when acquired by microbipolar electrodes (3.60 vs 6.76 mV, P = .002 [LV endo]; 2.61 vs 2.72 mV, P = .02 [epi]). Microbipolar values were systematically larger by 2.0× and 1.4× in the LV endocardium and epicardium, respectively. Application of standard voltage values to microbipolar maps in postinfarct swine underestimated scar area by approximately 41% in the LV endocardium (13.7 vs 33.4 cm2, P = .004). CONCLUSION Bipolar voltage values acquired from microelectrodes are systemically larger than those acquired from standard catheters. New reference values should be established for these novel catheters.
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Affiliation(s)
- Adam Lee
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Tomos E Walters
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Christina Alhede
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Eric Vittinghoff
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Richard Sievers
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California.
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43
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Letsas KP, Efremidis M, Vlachos K, Asvestas D, Takigawa M, Bazoukis G, Frontera A, Giannopoulos G, Saplaouras A, Sakellaropoulou A, Mililis P, Dragasis S, Megarisiotou A, Valkanas K, Tse G, Liu T, Deftereos S, Sideris A, Baranchuk A, Jais P. Right ventricular outflow tract low‐voltage areas identify the site of origin of idiopathic ventricular arrhythmias: A high‐density mapping study. J Cardiovasc Electrophysiol 2019; 30:2362-2369. [PMID: 31502366 DOI: 10.1111/jce.14155] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 07/30/2019] [Accepted: 08/23/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Konstantinos P. Letsas
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology “Evangelismos” General Hospital of Athens Athens Greece
| | - Michael Efremidis
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology “Evangelismos” General Hospital of Athens Athens Greece
| | - Konstantinos Vlachos
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology “Evangelismos” General Hospital of Athens Athens Greece
- Hôpital Cardiologique du Haut‐Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC) Université Bordeaux Bordeaux France
| | - Dimitrios Asvestas
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology “Evangelismos” General Hospital of Athens Athens Greece
| | - Masateru Takigawa
- Hôpital Cardiologique du Haut‐Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC) Université Bordeaux Bordeaux France
| | - George Bazoukis
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology “Evangelismos” General Hospital of Athens Athens Greece
| | - Antonio Frontera
- Hôpital Cardiologique du Haut‐Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC) Université Bordeaux Bordeaux France
| | - George Giannopoulos
- Department of Cardiology “G. Gennimatas” General Hospital of Athens Athens Greece
| | - Athanasios Saplaouras
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology “Evangelismos” General Hospital of Athens Athens Greece
| | - Antigoni Sakellaropoulou
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology “Evangelismos” General Hospital of Athens Athens Greece
| | - Panagiotis Mililis
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology “Evangelismos” General Hospital of Athens Athens Greece
| | - Stylianos Dragasis
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology “Evangelismos” General Hospital of Athens Athens Greece
| | - Athanasia Megarisiotou
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology “Evangelismos” General Hospital of Athens Athens Greece
| | - Kosmas Valkanas
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology “Evangelismos” General Hospital of Athens Athens Greece
| | - Gary Tse
- Department of Medicine and Therapeutics, Faculty of Medicine Chinese University of Hong Kong Hong Kong, SAR China
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine Chinese University of Hong Kong Hong Kong, SAR China
| | - Tong Liu
- Department of Cardiology, Tianjin Institute of Cardiology Second Hospital of Tianjin Medical University Tianjin China
| | - Spyridon Deftereos
- Department of Cardiology “G. Gennimatas” General Hospital of Athens Athens Greece
| | - Antonios Sideris
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology “Evangelismos” General Hospital of Athens Athens Greece
| | - Adrian Baranchuk
- Division of Cardiology Queen's University, Kingston General Hospital Ontario Canada
| | - Pierre Jais
- Hôpital Cardiologique du Haut‐Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC) Université Bordeaux Bordeaux France
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44
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Okubo K, Frontera A, Bisceglia C, Paglino G, Radinovic A, Foppoli L, Calore F, Della Bella P. Grid Mapping Catheter for Ventricular Tachycardia Ablation. Circ Arrhythm Electrophysiol 2019; 12:e007500. [DOI: 10.1161/circep.119.007500] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
A new grid mapping catheter (GMC)—allowing for bipolar recordings of the electrograms in each orthogonal direction—became available. The aim of the current study is to evaluate the utility of the GMC in creating substrate and ventricular tachycardia (VT) activation maps during VT ablation procedures.
Methods:
From December 2017 to July 2018, 41 consecutive patients undergoing a VT ablation procedure using a GMC were studied. During the substrate mapping, 3 different maps were created using the 3 GMC bipolar configurations (along the spline, across the spline, HD wave solution); the low voltage area and late potential areas were compared. In case of inducible VTs, the GMC was used to create the VT activation maps focusing on the diastolic interval. The relation between diastolic activities during VT and substrate abnormality during sinus rhythm was also investigated.
Results:
The median low-voltage area drawn by the HD wave configuration was 28.9 cm
2
, 13% and 15% smaller than the low-voltage areas identified by the along and across configuration, respectively (33.1 and 33.9 cm
2
;
P
<0.0001). The late potential areas obtained with the 3 GMC configuration did not differ (
P
>0.05). VT activation mappings using the GMC were performed in 40 VTs, visualizing the full diastolic pathway in 22 (55%) of them. While the latest late potential areas were included in VT diastolic pathway in 17 VTs, the other 6 VTs showed mismatching of them. Identifying the full diastolic pathway led to a higher ongoing VT termination rate during the ablation than in case of partial recordings (88% versus 45%;
P
=0.03); furthermore, in the former situation, the noninducibility of the targeted VTs was achieved in all cases.
Conclusions:
The GMC is a useful tool for performing substrate and VT activation mappings during the VT ablation procedure, precisely identifying the low-voltage areas and quickly visualizing the diastolic pathways.
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Affiliation(s)
- Kenji Okubo
- Arrhythmology Unit, San Raffaele Hospital, Milan, Italy (K.O, A.F., C.B., G.P., A.R., L.F., P.D.B.)
| | - Antonio Frontera
- Arrhythmology Unit, San Raffaele Hospital, Milan, Italy (K.O, A.F., C.B., G.P., A.R., L.F., P.D.B.)
| | - Caterina Bisceglia
- Arrhythmology Unit, San Raffaele Hospital, Milan, Italy (K.O, A.F., C.B., G.P., A.R., L.F., P.D.B.)
| | - Gabriele Paglino
- Arrhythmology Unit, San Raffaele Hospital, Milan, Italy (K.O, A.F., C.B., G.P., A.R., L.F., P.D.B.)
| | - Andrea Radinovic
- Arrhythmology Unit, San Raffaele Hospital, Milan, Italy (K.O, A.F., C.B., G.P., A.R., L.F., P.D.B.)
| | - Luca Foppoli
- Arrhythmology Unit, San Raffaele Hospital, Milan, Italy (K.O, A.F., C.B., G.P., A.R., L.F., P.D.B.)
| | - Federico Calore
- Abbott Medical Italy, Sesto San Giovanni, Milano, Italy (F.C)
| | - Paolo Della Bella
- Arrhythmology Unit, San Raffaele Hospital, Milan, Italy (K.O, A.F., C.B., G.P., A.R., L.F., P.D.B.)
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45
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Pandozi C, Lavalle C, Russo M, Galeazzi M, Ficili S, Malacrida M, Centurion Aznaran C, Colivicchi F. Mapping of ventricular tachycardia in patients with ischemic cardiomyopathy: Current approaches and future perspectives. Clin Cardiol 2019; 42:1041-1050. [PMID: 31411347 PMCID: PMC6788471 DOI: 10.1002/clc.23245] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/12/2019] [Accepted: 07/30/2019] [Indexed: 01/03/2023] Open
Abstract
Despite the technical improvements made in recent years, the overall long-term success rate of ventricular tachycardia (VT) ablation in patients with ischemic cardiomyopathy remains disappointing. This unsatisfactory situation has persisted even though several approaches to VT substrate ablation allow mapping and ablation of noninducible/nontolerated arrhythmias. The current substrate mapping methods present some shortcomings regarding the accurate definition of the true scar, the modality of detection in sinus rhythm of abnormal electrograms that identify sites of critical channels during VT and the possibility to determine the boundaries of functional re-entrant circuits during sinus or paced rhythms. In this review, we focus on current and proposed ablation strategies for VT to provide an overview of the potential/real application (and results) of several ablation approaches and future perspectives.
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Affiliation(s)
- Claudio Pandozi
- Division of Cardiology, San Filippo Neri Hospital, Rome, Italy
| | - Carlo Lavalle
- Division of Cardiology, San Filippo Neri Hospital, Rome, Italy
| | - Maurizio Russo
- Division of Cardiology, San Filippo Neri Hospital, Rome, Italy
| | - Marco Galeazzi
- Division of Cardiology, San Filippo Neri Hospital, Rome, Italy
| | - Sabina Ficili
- Division of Cardiology, San Filippo Neri Hospital, Rome, Italy
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46
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Magtibay K, Porta-Sánchez A, Haldar SK, Deno DC, Massé S, Nanthakumar K. Reinserting Physiology into Cardiac Mapping Using Omnipolar Electrograms. Card Electrophysiol Clin 2019; 11:525-536. [PMID: 31400876 DOI: 10.1016/j.ccep.2019.05.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Omnipolar electrograms (EGMs) make use of biophysical electric fields that accompany activation along the surface of the myocardium. A grid-like electrode array provides bipolar signals in orthogonal directions to deliver catheter-orientation-independent assessments of cardiac electrophysiology. Studies with myocyte monolayers, isolated animal and human hearts, and anesthetized animals validated the tenets of omnipolar EGMs. The combination of information from omnipolar-based activation vectors and voltages may aid in localizing areas of scar, lesion gaps, wavefront disorganization, and fractionation or collision during arrhythmias. The goal of omnipolar EGMs is to better characterize myocardium through reintroducing electrogram direction related fundamentals of cardiac electrophysiology.
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Affiliation(s)
- Karl Magtibay
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, University Health Network, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Andreu Porta-Sánchez
- Hospital Universitario Quironsalud Madrid, Calle Diego de Velázquez, 1, 28223 Pozuelo de Alarcón, Madrid, Spain; Fundacion Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Melchor Fernández Almagro, 3, Madrid 28029, Spain
| | - Shouvik K Haldar
- Royal Brompton & Harefield NHS Foundation Trust, Harefield Hospital, Hill End Road, Harefield, Uxbridge UB9 6JH, UK
| | - Don Curtis Deno
- Abbott Laboratories, One St. Jude Medical Drive, St. Paul, MN 55117, USA
| | - Stéphane Massé
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, University Health Network, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
| | - Kumaraswamy Nanthakumar
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, University Health Network, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada.
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47
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Martinez-Mateu L, Romero L, Saiz J, Berenfeld O. Far-field contributions in multi-electrodes atrial recordings blur distinction between anatomical and functional reentries and may cause imaginary phase singularities - A computational study. Comput Biol Med 2019; 108:276-287. [PMID: 31015048 DOI: 10.1016/j.compbiomed.2019.02.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 02/14/2019] [Accepted: 02/21/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common cardiac arrhythmia and the most important cause of embolic stroke, requiring new technologies for its better understanding and therapies. Recent approaches to map the electrical activity during AF with multi-electrode systems aim at localizing patient-specific ablation targets of reentrant patterns. However, there is a critical need to determine the accuracy of those mapping systems. We performed computer simulations as a numerical approach of systematically evaluating the influence of far-field sources on the electrical recordings and detection of rotors. METHODS We constructed 2 computer models of atrial tissue: (i) a 2D sheet model with varying non-active cells area in its center, and (ii) a whole realistic 3D atrial model. Phase maps were built based on the Hilbert transform of the unipolar electrograms recorded by virtual 2D and 3D multi-electrode systems and rotors were tracked through phase singularities detections. RESULTS Analysis of electrograms recorded away from the 2D atrial model shows that the larger the distance between an electrode and the tissue model, the stronger the far-field sources contribution to the electrogram is. Importantly, even if an electrode is positioned in contact with the tissue, the electrogram contains significant contributions from distal sources that blur the distinction between anatomical and functional reentries. Moreover, when mapping the 3D atrial model, remote activity generated false phase singularities at locations without local reentrant excitation patterns. CONCLUSIONS Far-field contributions to electrograms during AF reduce the accuracy of detecting and interpreting reentrant activity.
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Affiliation(s)
- Laura Martinez-Mateu
- Centro de Investigación e Innovación en Bioingeniería, Universitat Politècnica de València, Valencia, Spain.
| | - Lucia Romero
- Centro de Investigación e Innovación en Bioingeniería, Universitat Politècnica de València, Valencia, Spain
| | - Javier Saiz
- Centro de Investigación e Innovación en Bioingeniería, Universitat Politècnica de València, Valencia, Spain
| | - Omer Berenfeld
- Center for Arrhythmia Research, University of Michigan, Ann Arbor, MI, USA
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48
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Yamaguchi T, Fukui A, Node K. Bipolar Voltage Mapping for the Evaluation of Atrial Substrate: Can We Overcome the Challenge of Directionality? J Atr Fibrillation 2019; 11:2116. [PMID: 31139298 PMCID: PMC6533827 DOI: 10.4022/jafib.2116] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 07/25/2018] [Accepted: 12/08/2018] [Indexed: 01/15/2023]
Abstract
The relationship between atrial fibrosis and atrial fibrillation (AF) has been proven. Patient specific substrate ablation targeting fibrotic tissue estimated by bipolar voltage mapping has emerged as an alternative strategy for additional substrate modification beyond pulmonary vein isolation. The primary mechanism of a low-voltage electrogram has been suggested to be atrial fibrosis, however, no direct correlation between histological fibrosis and low-voltage zone has been confirmed. Furthermore, the definition of low-voltage zone is still controversial, and bipolar voltage amplitudes depend on multiple variables including electrodes orientation relative to direction of wavefront, electrode length, interelectrode spacing, and tissue contact. The aim of this article is to review the role and limitation of voltage mapping, and to share our initial experience of a newly released grid-pattern designed mapping catheter to make the voltage mapping more reliable to guide patient specific AF ablation.
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Affiliation(s)
| | - Akira Fukui
- Department of Cardiovascular medicine, Saga University
| | - Koichi Node
- Department of Cardiovascular medicine, Saga University
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49
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Bazan V, Frankel DS, Santangeli P, Garcia FC, Tschabrunn CM, Marchlinski FE. Three-dimensional myocardial scar characterization from the endocardium: Usefulness of endocardial unipolar electroanatomic mapping. J Cardiovasc Electrophysiol 2019; 30:427-437. [PMID: 30614100 DOI: 10.1111/jce.13842] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 12/26/2018] [Accepted: 12/30/2018] [Indexed: 11/29/2022]
Abstract
Epicardial ablation may be required to eliminate ventricular tachycardia (VT) in patients with underlying structural heart disease. The decision to gain epicardial access is frequently based on the suspicion of an epicardial origin for the VT and/or presence of an arrhythmogenic substrate. Epicardial pathology and VT is frequently present in patients with nonischemic right and/or left cardiomyopathies even in the setting of modest or no endocardial bipolar voltage substrate. In this setting, unipolar voltage mapping from the endocardium serves to help identify midmyocardial and/or epicardial VT substrate. The additional value of endocardial unipolar mapping includes its usefulness to predict the clinical outcome after VT ablation, to determine the irreversibility of myocardial disease, and to guide endomyocardial biopsy procedures to specific areas of intramural scarring. In this review, we aim to provide a guide to the use of endocardial unipolar mapping and its appropriate interpretation in a variety of clinical situations.
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Affiliation(s)
| | - David S Frankel
- Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pasquale Santangeli
- Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fermin C Garcia
- Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cory M Tschabrunn
- Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Francis E Marchlinski
- Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Takigawa M, Relan J, Martin R, Kim S, Kitamura T, Cheniti G, Vlachos K, Pillois X, Frontera A, Massoullié G, Thompson N, Martin CA, Bourier F, Lam A, Wolf M, Duchateau J, Klotz N, Pambrun T, Denis A, Derval N, Magat J, Naulin J, Merle M, Collot F, Quesson B, Cochet H, Hocini M, Haïssaguerre M, Sacher F, Jaïs P. Detailed Analysis of the Relation Between Bipolar Electrode Spacing and Far- and Near-Field Electrograms. JACC Clin Electrophysiol 2018; 5:66-77. [PMID: 30678788 DOI: 10.1016/j.jacep.2018.08.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 08/28/2018] [Accepted: 08/29/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES This study sought to evaluate the relation between bipolar electrode spacing and far- and near-field electrograms. BACKGROUND The detailed effects of bipolar spacing on electrograms (EGMs) is not well described. METHODS With a HD-Grid catheter, EGMs from different bipole pairs could be created in each acquisition. This study analyzed the effect of bipolar spacing on EGMs in 7 infarcted sheep. A segment was defined as a 2-mm center-to-center bipole. In total, 4,768 segments (2,020 healthy, 1,542 scar, and 1,206 in border areas, as defined by magnetic resonance imaging [MRI]) were covered with an electrode pair of spacing of 2 mm (Bi-2), 4 mm (Bi-4), and 8 mm (Bi-8). RESULTS A total of 3,591 segments in Bi-2 were free from local abnormal ventricular activities (LAVAs); 1,630 segments were within the MRI-defined scar and/or border area. Among them, 172 (10.6%) segments in Bi-4 and 219 (13.4%) segments in Bi-8 showed LAVAs. In contrast, LAVAs were identified in 1,177 segments in Bi-2; 1,118 segments were within the MRI-defined scar and/or border area. Among them, LAVAs were missed in 161 (14.4%) segments in Bi-4 and in 409 (36.6%) segments in Bi-8. In segments with LAVAs, median far-field voltage increased from 0.09 mV (25th to 75th percentile: 0.06 to 0.14 mV) in Bi-2, to 0.16 mV (25th to 75th percentile: 0.10 to 0.24 mV) in Bi-4, and to 0.28 mV (25th to 75th percentile: 0.20 to 0.42 mV) in Bi-8 (p < 0.0001). Median near-field voltage increased from 0.14 mV (25th to 75th percentile: 0.08 to 0.25 mV) in Bi-2, to 0.21 mV (25th to 75th percentile: 0.12 to 0.35 mV) in Bi-4, and to 0.32 mV (25th to 75th percentile: 0.17 to 0.48 mV) in Bi-8 (p < 0.0001). The median near-/far-field voltage ratio decreased from 1.67 in Bi-2, to 1.43 in Bi-4, and 1.23 in Bi-8 (p < 0.0001). CONCLUSIONS Closer spacing better discriminates surviving tissue from dead scar area. Although far-field voltage systematically increases with spacing, near-field voltages were more variable, depending on local surviving muscular bundles. Near-field EGMs are more easily observed with smaller spacing, largely due to the reduction of the far-field effect.
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Affiliation(s)
- Masateru Takigawa
- CHU Bordeaux, IHU Lyric, Université de Bordeaux, Bordeaux, France; Heart Rhythm Center, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Jatin Relan
- CHU Bordeaux, IHU Lyric, Université de Bordeaux, Bordeaux, France; Abbott, St. Paul, Minnesota
| | - Ruairidh Martin
- CHU Bordeaux, IHU Lyric, Université de Bordeaux, Bordeaux, France; Institute of Genetic Medicine, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | | | - Takeshi Kitamura
- CHU Bordeaux, IHU Lyric, Université de Bordeaux, Bordeaux, France
| | - Ghassen Cheniti
- CHU Bordeaux, IHU Lyric, Université de Bordeaux, Bordeaux, France
| | | | - Xavier Pillois
- CHU Bordeaux, IHU Lyric, Université de Bordeaux, Bordeaux, France
| | - Antonio Frontera
- CHU Bordeaux, IHU Lyric, Université de Bordeaux, Bordeaux, France
| | | | | | - Claire A Martin
- CHU Bordeaux, IHU Lyric, Université de Bordeaux, Bordeaux, France
| | - Felix Bourier
- CHU Bordeaux, IHU Lyric, Université de Bordeaux, Bordeaux, France
| | - Anna Lam
- CHU Bordeaux, IHU Lyric, Université de Bordeaux, Bordeaux, France
| | - Michael Wolf
- CHU Bordeaux, IHU Lyric, Université de Bordeaux, Bordeaux, France
| | | | - Nicolas Klotz
- CHU Bordeaux, IHU Lyric, Université de Bordeaux, Bordeaux, France
| | - Thomas Pambrun
- CHU Bordeaux, IHU Lyric, Université de Bordeaux, Bordeaux, France
| | - Arnaud Denis
- CHU Bordeaux, IHU Lyric, Université de Bordeaux, Bordeaux, France
| | - Nicolas Derval
- CHU Bordeaux, IHU Lyric, Université de Bordeaux, Bordeaux, France
| | - Julie Magat
- CHU Bordeaux, IHU Lyric, Université de Bordeaux, Bordeaux, France
| | - Jérôme Naulin
- CHU Bordeaux, IHU Lyric, Université de Bordeaux, Bordeaux, France
| | - Mathilde Merle
- CHU Bordeaux, IHU Lyric, Université de Bordeaux, Bordeaux, France
| | - Florent Collot
- CHU Bordeaux, IHU Lyric, Université de Bordeaux, Bordeaux, France
| | - Bruno Quesson
- CHU Bordeaux, IHU Lyric, Université de Bordeaux, Bordeaux, France
| | - Hubert Cochet
- CHU Bordeaux, IHU Lyric, Université de Bordeaux, Bordeaux, France
| | - Mélèze Hocini
- CHU Bordeaux, IHU Lyric, Université de Bordeaux, Bordeaux, France
| | | | - Frédéric Sacher
- CHU Bordeaux, IHU Lyric, Université de Bordeaux, Bordeaux, France
| | - Pierre Jaïs
- CHU Bordeaux, IHU Lyric, Université de Bordeaux, Bordeaux, France
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