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Riku S, Inden Y, Yanagisawa S, Fujii A, Tomomatsu T, Nakagomi T, Shimojo M, Okajima T, Furui K, Suga K, Suzuki S, Shibata R, Murohara T. Distributions and number of drivers on real-time phase mapping associated with successful atrial fibrillation termination during catheter ablation for non-paroxysmal atrial fibrillation. J Interv Card Electrophysiol 2024; 67:303-317. [PMID: 37354370 DOI: 10.1007/s10840-023-01588-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 05/31/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Real-time phase mapping (ExTRa™) is useful in determining the strategy of catheter ablation for non-paroxysmal atrial fibrillation (AF). This study aimed to investigate the features of drivers of AF associated with its termination during ablation. METHODS Thirty-six patients who underwent catheter ablation for non-paroxysmal AF using online real-time phase mapping (ExTRa™) were enrolled. A significant AF driver was defined as an area with a non-passively activated ratio of ≥ 50% on mapping analysis in the left atrium (LA). All drivers were simultaneously evaluated using a low-voltage area, complex fractionated atrial electrogram (CFAE), and rotational activity by unipolar electrogram analysis. The electrical characteristics of drivers were compared between patients with and without AF termination during the procedure. RESULTS Twelve patients achieved AF termination during the procedure. The total number of drivers detected on the mapping was significantly lower (4.4 ± 1.6 vs. 7.4 ± 3.8, p = 0.007), and the drivers were more concentrated in limited LA regions (2.8 ± 0.9 vs. 3.9 ± 1.4, p = 0.009) in the termination group than in the non-termination group. The presence of drivers 2-6 with limited (≤ 3) LA regions showed a tenfold increase in the likelihood of AF termination, with 83% specificity and 67% sensitivity. Among 231 AF drivers, the drivers related to termination exhibited a greater overlap of CFAE (56.8 ± 34.1% vs. 39.5 ± 30.4%, p = 0.004) than the non-related drivers. The termination group showed a trend toward a lower recurrence rate after ablation (p = 0.163). CONCLUSIONS Rotors responsible for AF maintenance may be characterized in cases with concentrated regions and fewer drivers on mapping.
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Affiliation(s)
- Shuro Riku
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa-Ku, Nagoya, Aichi, 466-8550, Japan
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa-Ku, Nagoya, Aichi, 466-8550, Japan
| | - Satoshi Yanagisawa
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa-Ku, Nagoya, Aichi, 466-8550, Japan.
| | - Aya Fujii
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa-Ku, Nagoya, Aichi, 466-8550, Japan
| | - Toshiro Tomomatsu
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa-Ku, Nagoya, Aichi, 466-8550, Japan
| | - Toshifumi Nakagomi
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa-Ku, Nagoya, Aichi, 466-8550, Japan
| | - Masafumi Shimojo
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa-Ku, Nagoya, Aichi, 466-8550, Japan
| | - Takashi Okajima
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa-Ku, Nagoya, Aichi, 466-8550, Japan
| | - Koichi Furui
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa-Ku, Nagoya, Aichi, 466-8550, Japan
| | - Kazumasa Suga
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa-Ku, Nagoya, Aichi, 466-8550, Japan
| | - Susumu Suzuki
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa-Ku, Nagoya, Aichi, 466-8550, Japan
| | - Rei Shibata
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa-Ku, Nagoya, Aichi, 466-8550, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa-Ku, Nagoya, Aichi, 466-8550, Japan
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2
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Silva Garcia E, Lobo-Torres I, Fernández-Armenta J, Penela D, Fernandez-Garcia M, Gomez-Lopez A, Soto-Iglesias D, Fernández-Rivero R, Vazquez-Garcia R, Acosta J, Bisbal F, Cano-Calabria L, Berruezo A. Functional mapping to reveal slow conduction and substrate progression in atrial fibrillation. Europace 2023; 25:euad246. [PMID: 37961921 PMCID: PMC10644200 DOI: 10.1093/europace/euad246] [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: 05/11/2023] [Accepted: 08/11/2023] [Indexed: 11/15/2023] Open
Abstract
AIMS The aim of our study was to analyse the response to short-coupled atrial extrastimuli to identify areas of hidden slow conduction (HSC) and their relationship with the atrial fibrillation (AF) phenotype. METHODS AND RESULTS Twenty consecutive patients with paroxysmal AF and persistent AF (10:10) underwent the first pulmonary vein isolation procedure. Triple short-coupled extrastimuli were delivered in sinus rhythm (SR), and the evoked response was analysed: sites exhibiting double or highly fragmented electrograms (EGM) were defined as positive for HSC (HSC+). The delta of the duration of the bipolar EGM was analysed, and bipolar EGM duration maps were built. High-density maps were acquired using a multipolar catheter during AF, SR, and paced rhythm. Spatial co-localization of HSC+ and complex fractionated atrial EGMs (CFAE) during AF was evaluated. Persistent AF showed a higher number and percentage of HSC+ than paroxysmal AF (13.9% vs. 3.3%, P < 0.001). The delta of EGM duration was 53 ± 22 ms for HSC+ compared with 13 ± 11 (10) ms in sites with negative HSC (HSC-) (P < 0.001). The number and density of HSC+ were lower than CFAE during AF (19 vs. 56 per map, P < 0.001). The reproducibility and distribution of HSC+ in repeated maps were superior to CFAE (P = 0.19 vs. P < 0.001). Sites with negative and positive responses showed a similar bipolar voltage in the preceding sinus beat (1.65 ± 1.34 and 1.48 ± 1.47 mV, P = 0.12). CONCLUSION Functional mapping identifies more discrete and reproducible abnormal substrates than mapping during AF. The HSC+ sites in response to triple extrastimuli are more frequent in persistent AF than in paroxysmal AF.
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Affiliation(s)
- Etel Silva Garcia
- Department of Cardiology, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | - Ivan Lobo-Torres
- Department of Cardiology, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | | | - Diego Penela
- Teknon Medical Center, Heart Institute, Barcelona, Spain
| | | | - Andrea Gomez-Lopez
- Department of Cardiology, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | | | | | | | - Juan Acosta
- Department of Cardiology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Felipe Bisbal
- Institut del Cor (iCor), Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
| | - Lucas Cano-Calabria
- Department of Cardiology, Hospital Universitario Puerta del Mar, Cádiz, Spain
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3
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van Staveren LN, Hendriks RC, Taverne YJHJ, de Groot NMS. High Dominant Frequencies and Fractionated Potentials Do Not Indicate Focal or Rotational Activation During AF. JACC Clin Electrophysiol 2023; 9:1082-1096. [PMID: 37495319 DOI: 10.1016/j.jacep.2023.01.013] [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: 03/14/2022] [Revised: 01/19/2023] [Accepted: 01/23/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Dominant frequencies (DFs) or complex fractionated atrial electrograms (CFAEs), indicative of focal sources or rotational activation, are used to identify target sites for atrial fibrillation (AF) ablation in clinical studies, although the relationship among DF, CFAE, and activation patterns remains unclear. OBJECTIVES This study sought to investigate the relationship between patterns of activation underlying DF and CFAE sites during AF. METHODS Epicardial high-resolution mapping of the right and left atrium including Bachmann's bundle was performed in 71 participants. We identified the highest dominant frequency (DFmax) and highest degree of CFAE (CFAEmax) with the use of existing clinical criteria and classified patterns of activation as focal or rotational activation and smooth propagation, conduction block (CB), collision and remnant activity, and fibrillation potentials as single, double, or fractionated potentials containing, respectively, 1, 2, or 3 or more negative deflections. Relationships among activation patterns, DFmax, and potential types were investigated. RESULTS DFmax were primarily located at the left atrioventricular groove and did not harbor focal activation (proportion focal waves: 0% [IQR: 0%-2%]). Compared with non-DFmax sites, DFmax were characterized by more frequent smooth propagation (22% [IQR: 7%-48%] vs 17% [IQR: 11%-24%]; P = 0.001), less frequent conduction block (69% [IQR: 51%-81%] vs 74% [IQR: 69%-78%]; P = 0.006), a higher proportion of single potentials (72% [IQR: 55%-84%] vs 6%1 [IQR: 55%-65%]; P = 0.003), and a lower proportion of fractionated potentials (4% [IQR: 1%-11%] vs 12% [IQR: 9%-15%]; P = 0.004). CFAEmax were mainly found at the pulmonary veins area, and only 1% [IQR: 0%-2%] of all CFAEmax contained focal activation. Compared with non-CFAEmax sites, CFAEmax sites were characterized by less frequent smooth propagation (1% [IQR: 0%-1%] vs 17% [IQR: 12%-24%]; P < 0.001) and more frequent remnant activity (20% [IQR: 12%-29%] vs 8% [IQR: 5%-10%]; P < 0.001), and harbored predominantly fractionated potentials (52% [IQR: 43%-66%] vs 12% [IQR: 9%-14%]; P < 0.001). CONCLUSIONS Focal or rotational patterns of activation were not consistently detected at DFmax domains and CFAEmax sites. These findings do not support the concept of targeting DFmax or CFAEmax according to existing criteria for AF ablation.
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Affiliation(s)
| | | | - Yannick J H J Taverne
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
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4
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Ganesan P, Deb B, Feng R, Rodrigo M, Ruiperez-Campillo S, Rogers AJ, Clopton P, Wang PJ, Zeemering S, Schotten U, Rappel WJ, Narayan SM. Quantifying a spectrum of clinical response in atrial tachyarrhythmias using spatiotemporal synchronization of electrograms. Europace 2023; 25:euad055. [PMID: 36932716 PMCID: PMC10227659 DOI: 10.1093/europace/euad055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 02/09/2023] [Indexed: 03/19/2023] Open
Abstract
AIMS There is a clinical spectrum for atrial tachyarrhythmias wherein most patients with atrial tachycardia (AT) and some with atrial fibrillation (AF) respond to ablation, while others do not. It is undefined if this clinical spectrum has pathophysiological signatures. This study aims to test the hypothesis that the size of spatial regions showing repetitive synchronized electrogram (EGM) shapes over time reveals a spectrum from AT, to AF patients who respond acutely to ablation, to AF patients without acute response. METHODS AND RESULTS We studied n = 160 patients (35% women, 65.0 ± 10.4 years) of whom (i) n = 75 had AF terminated by ablation propensity matched to (ii) n = 75 without AF termination and (iii) n = 10 with AT. All patients had mapping by 64-pole baskets to identify areas of repetitive activity (REACT) to correlate unipolar EGMs in shape over time. Synchronized regions (REACT) were largest in AT, smaller in AF termination, and smallest in non-termination cohorts (0.63 ± 0.15, 0.37 ± 0.22, and 0.22 ± 0.18, P < 0.001). Area under the curve for predicting AF termination in hold-out cohorts was 0.72 ± 0.03. Simulations showed that lower REACT represented greater variability in clinical EGM timing and shape. Unsupervised machine learning of REACT and extensive (50) clinical variables yielded four clusters of increasing risk for AF termination (P < 0.01, χ2), which were more predictive than clinical profiles alone (P < 0.001). CONCLUSION The area of synchronized EGMs within the atrium reveals a spectrum of clinical response in atrial tachyarrhythmias. These fundamental EGM properties, which do not reflect any predetermined mechanism or mapping technology, predict outcome and offer a platform to compare mapping tools and mechanisms between AF patient groups.
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Affiliation(s)
- Prasanth Ganesan
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Brototo Deb
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Ruibin Feng
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Miguel Rodrigo
- Electronic Engineering Department, Universitat de Valencia, Av. de Blasco Ibáñez, 13, 46010 València, Spain
| | - Samuel Ruiperez-Campillo
- Electronic Engineering Department, Universitat de Valencia, Av. de Blasco Ibáñez, 13, 46010 València, Spain
- Department of Bioengineering, University of California, Berkeley, CA 94720, USA
| | - Albert J Rogers
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Paul Clopton
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Paul J Wang
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Stef Zeemering
- Department of Physiology, Maastricht University, 6211 LK Maastricht, 616 6200, Netherlands
| | - Ulrich Schotten
- Department of Physiology, Maastricht University, 6211 LK Maastricht, 616 6200, Netherlands
| | - Wouter-Jan Rappel
- Department of Physics, University of California, 9500 Gilman Dr, La Jolla, CA 92093, USA
| | - Sanjiv M Narayan
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
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5
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Zhu J, Zhuo K, Zhang B, Xie Z, Li W. Sex Differences in Epicardial Adipose Tissue: Association With Atrial Fibrillation Ablation Outcomes. Front Cardiovasc Med 2022; 9:905351. [PMID: 35770221 PMCID: PMC9234200 DOI: 10.3389/fcvm.2022.905351] [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: 03/27/2022] [Accepted: 05/16/2022] [Indexed: 11/24/2022] Open
Abstract
Background There are significant differences in the prevalence and prognosis of atrial fibrillation (AF) between sexes. Epicardial adipose tissue (EAT) has been found as a risk factor for AF. This study aimed to evaluate whether sex-based EAT differences were correlated with AF recurrence and major adverse cardiovascular events (MACE). Methods In this study, postmenopausal women and age, BMI, and type of AF matched men who had received first catheter ablation were included. EAT volume was quantified based on the pre-ablation cardiac computed tomography (CT) images. Clinical, CT, and echocardiographic variables were compared by sex groups. The predictors of AF recurrence and MACE were determined through Cox proportional hazards regression. Results Women were found with significantly lower total EAT volumes (P < 0.001) but higher periatrial/total (P/T) EAT ratios (P = 0.009). The median follow-up duration was 444.5 days. As revealed by the result of the Kaplan-Meier survival analysis, the women were found to have a significantly higher prevalence of AF recurrence (log rank, P = 0.011) but comparable MACE (log rank, P = 0.507) than men. Multivariate analysis demonstrated that female gender (HR: 1.88 [95% CI: 1.03, 4.15], P = 0.032), persistent AF (HR: 2.46 [95% CI: 1.19, 5.05], P = 0.015), left atrial (LA) dimension (HR: 1.47 [95% CI: 1.02, 2.13], P = 0.041), and P/T EAT ratio (HR: 1.73 [95% CI: 1.12, 2.67], P = 0.013) were found as the independent predictors of AF recurrence. Sex-based subgroup multivariable analysis showed that the P/T EAT ratio was an independent predictor of AF recurrence in both men (HR: 1.13 [95% CI: 1.01, 1.46], P = 0.047) and women (HR: 1.37 [95% CI: 1.11, 1.67], P = 0.028). While age (HR: 1.81 [95% CI: 1.18, 2.77], P = 0.007), BMI (HR: 1.44 [95% CI: 1.02, 2.03], P = 0.038), and periatrial EAT volume (HR: 1.31 [95% CI: 1.01, 1.91], P = 0.046) were found to be independent of MACE. Conclusion Women had a higher P/T EAT ratio and AF post-ablation recurrence but similar MACE as compared with men. Female gender and P/T EAT ratio were found to be independent predictors of AF recurrence, whereas age and periatrial EAT volume were found to be independent predictors of MACE.
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Affiliation(s)
- Jing Zhu
- Department of Radiology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
- *Correspondence: Jing Zhu
| | - Kaimin Zhuo
- Department of Radiology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Bo Zhang
- Department of Cardiology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Zhen Xie
- Department of Radiology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Wenjia Li
- Department of Radiology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
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6
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Salvador-Montañés Ó, Ramirez RJ, Takemoto Y, Ennis SR, Garcia-Iglesias D, Wang S, Wolfer PJ, Jiang J, Mironov SV, Pandit SV, Jalife J, Berenfeld O. Panoramic Endocardial Optical Mapping Demonstrates Serial Rotors Acceleration and Increasing Complexity of Activity During Onset of Cholinergic Atrial Fibrillation. J Am Heart Assoc 2021; 10:e022300. [PMID: 34726079 PMCID: PMC8751940 DOI: 10.1161/jaha.121.022300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Activation during onset of atrial fibrillation is poorly understood. We aimed at developing a panoramic optical mapping system for the atria and test the hypothesis that sequential rotors underlie acceleration of atrial fibrillation during onset. Methods and Results Five sheep hearts were Langendorff perfused in the presence of 0.25 µmol/L carbachol. Novel optical system recorded activations simultaneously from the entire left and right atrial endocardial surfaces. Twenty sustained (>40 s) atrial fibrillation episodes were induced by a train and premature stimuli protocol. Movies obtained immediately (Initiation stage) and 30 s (Early Stabilization stage) after premature stimulus were analyzed. Serial rotor formation was observed in all sustained inductions and none in nonsustained inductions. In sustained episodes maximal dominant frequency increased from (mean±SD) 11.5±1.74 Hz during Initiation to 14.79±1.30 Hz at Early Stabilization (P<0.0001) and stabilized thereafter. At rotor sites, mean cycle length (CL) during 10 prerotor activations increased every cycle by 0.53% (P=0.0303) during Initiation and 0.34% (P=0.0003) during Early Stabilization. In contrast, CLs at rotor sites showed abrupt decreases after the rotors appearances by a mean of 9.65% (P<0.0001) during both stages. At Initiation, atria‐wide accelerations and decelerations during rotors showed a net acceleration result whereby post‐rotors atria‐wide minimal CL (CLmin) were 95.5±6.8% of the prerotor CLmin (P=0.0042). In contrast, during Early Stabilization, there was no net acceleration in CLmin during accelerating rotors (prerotor=84.9±11.0% versus postrotor=85.8±10.8% of Initiation, P=0.4029). Levels of rotor drift distance and velocity correlated with atria‐wide acceleration. Nonrotor phase singularity points did not accelerate atria‐wide activation but multiplied during Initiation until Early Stabilization. Increasing number of singularity points, indicating increased complexity, correlated with atria‐wide CLmin reduction (P<0.0001). Conclusions Novel panoramic optical mapping of the atria demonstrates shortening CL at rotor sites during cholinergic atrial fibrillation onset. Atrial fibrillation acceleration toward Early Stabilization correlates with the net result of atria‐wide accelerations during drifting rotors activity.
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Affiliation(s)
- Óscar Salvador-Montañés
- Center for Arrhythmia Research Department of Internal Medicine - Cardiology University of Michigan Ann Arbor MI.,Facultad de Medicina Universidad Francisco de Vitoria, Pozuelo de Alarcon Mardid Spain.,Hospital Universitario de Torrejón Mardid Spain
| | - Rafael J Ramirez
- Center for Arrhythmia Research Department of Internal Medicine - Cardiology University of Michigan Ann Arbor MI.,The Department of Physiology and Biophysics Virginia Commonwealth University Richmond VA
| | - Yoshio Takemoto
- Center for Arrhythmia Research Department of Internal Medicine - Cardiology University of Michigan Ann Arbor MI.,Cardiovascular Medicine Gifu Prefectural Tajimi Hospital Tajimi Japan
| | - Steven R Ennis
- Center for Arrhythmia Research Department of Internal Medicine - Cardiology University of Michigan Ann Arbor MI
| | - Daniel Garcia-Iglesias
- Center for Arrhythmia Research Department of Internal Medicine - Cardiology University of Michigan Ann Arbor MI.,Hospital Universitario Central de Asturias Oviedo Spain
| | - Sicong Wang
- Center for Arrhythmia Research Department of Internal Medicine - Cardiology University of Michigan Ann Arbor MI.,Institute for Stem Cell Biology and Regenerative Medicine Stanford University Palo Alto CA
| | - Patrick J Wolfer
- Center for Arrhythmia Research Department of Internal Medicine - Cardiology University of Michigan Ann Arbor MI.,Michigan Technological University Houghton MI
| | - Jiang Jiang
- Center for Arrhythmia Research Department of Internal Medicine - Cardiology University of Michigan Ann Arbor MI
| | - Sergey V Mironov
- Center for Arrhythmia Research Department of Internal Medicine - Cardiology University of Michigan Ann Arbor MI
| | - Sandeep V Pandit
- Center for Arrhythmia Research Department of Internal Medicine - Cardiology University of Michigan Ann Arbor MI
| | - José Jalife
- Center for Arrhythmia Research Department of Internal Medicine - Cardiology University of Michigan Ann Arbor MI.,Centro Nacional de Investigaciones Cardiovasculares Carlos III Madrid Spain
| | - Omer Berenfeld
- Center for Arrhythmia Research Department of Internal Medicine - Cardiology University of Michigan Ann Arbor MI
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7
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Rosa GL, Quintanilla JG, Salgado R, González-Ferrer JJ, Cañadas-Godoy V, Pérez-Villacastín J, Pérez-Castellano N, Jalife J, Filgueiras-Rama D. Mapping Technologies for Catheter Ablation of Atrial Fibrillation Beyond Pulmonary Vein Isolation. Eur Cardiol 2021; 16:e21. [PMID: 34093742 PMCID: PMC8157391 DOI: 10.15420/ecr.2020.39] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 01/25/2021] [Indexed: 11/17/2022] Open
Abstract
Catheter ablation remains the most effective and relatively minimally invasive therapy for rhythm control in patients with AF. Ablation has consistently shown a reduction of arrhythmia-related symptoms and significant improvement in patients’ quality of life compared with medical treatment. The ablation strategy relies on a well-established anatomical approach of effective pulmonary vein isolation. Additional anatomical targets have been reported with the aim of increasing procedure success in complex substrates. However, larger ablated areas with uncertainty of targeting relevant regions for AF initiation or maintenance are not exempt from the potential risk of complications and pro-arrhythmia. Recent developments in mapping tools and computational methods for advanced signal processing during AF have reported novel strategies to identify atrial regions associated with AF maintenance. These novel tools – although mainly limited to research series – represent a significant step forward towards the understanding of complex patterns of propagation during AF and the potential achievement of patient-tailored AF ablation strategies for the near future.
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Affiliation(s)
- Giulio La Rosa
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Myocardial Pathophysiology Area Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute Madrid, Spain
| | - Jorge G Quintanilla
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Myocardial Pathophysiology Area Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV) Madrid, Spain
| | - Ricardo Salgado
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute Madrid, Spain
| | - Juan José González-Ferrer
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV) Madrid, Spain
| | - Victoria Cañadas-Godoy
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV) Madrid, Spain
| | - Julián Pérez-Villacastín
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV) Madrid, Spain.,Fundación Interhospitalaria para la Investigación Cardiovascular (FIC) Madrid, Spain
| | - Nicasio Pérez-Castellano
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV) Madrid, Spain.,Fundación Interhospitalaria para la Investigación Cardiovascular (FIC) Madrid, Spain
| | - José Jalife
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Myocardial Pathophysiology Area Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV) Madrid, Spain
| | - David Filgueiras-Rama
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Myocardial Pathophysiology Area Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV) Madrid, Spain
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8
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The Electrophysiology of Atrial Fibrillation: From Basic Mechanisms to Catheter Ablation. Cardiol Res Pract 2021; 2021:4109269. [PMID: 34194824 PMCID: PMC8203364 DOI: 10.1155/2021/4109269] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 04/11/2021] [Accepted: 05/27/2021] [Indexed: 11/17/2022] Open
Abstract
The electrophysiology of atrial fibrillation (AF) has always been a deep mystery in understanding this complex arrhythmia. The pathophysiological mechanisms of AF are complex and often remain unclear despite extensive research. Therefore, the implementation of basic science knowledge to clinical practice is challenging. After more than 20 years, pulmonary vein isolation (PVI) remains the cornerstone ablation strategy for maintaining the sinus rhythm (SR). However, there is no doubt that, in many cases, especially in persistent and long-standing persistent AF, PVI is not enough, and eventually, the restoration of SR occurs after additional intervention in the rest of the atrial myocardium. Substrate mapping is a modern challenge as it can reveal focal sources or rotational activities that may be responsible for maintaining AF. Whether these areas are actually the cause of the AF maintenance is unknown. If this really happens, then the targeted ablation may be the solution; otherwise, more rough techniques such as atrial compartmentalization may prove to be more effective. In this article, we attempt a broad review of the known pathophysiological mechanisms of AF, and we present the recent efforts of advanced technology initially to reveal the electrical impulse during AF and then to intervene effectively with ablation.
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9
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Sohns C, Marrouche NF. Atrial fibrillation and cardiac fibrosis. Eur Heart J 2021; 41:1123-1131. [PMID: 31713590 DOI: 10.1093/eurheartj/ehz786] [Citation(s) in RCA: 126] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 09/30/2019] [Accepted: 10/23/2019] [Indexed: 12/25/2022] Open
Abstract
The understanding of atrial fibrillation (AF) evolved from a sole rhythm disturbance towards the complex concept of a cardiomyopathy based on arrhythmia substrates. There is evidence that atrial fibrosis can be visualized using late gadolinium enhancement cardiac magnetic resonance imaging and that it is a powerful predictor for the outcome of AF interventions. However, a strategy of an individual and fibrosis guided management of AF looks promising but results from prospective multicentre trials are pending. This review gives an overview about the relationship between cardiac fibrosis and AF focusing on translational aspects, clinical observations, and fibrosis imaging to emphasize the concept of personalized paths in AF management taking into account the individual amount and distribution of fibrosis.
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Affiliation(s)
- Christian Sohns
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Nassir F Marrouche
- Cardiac Electrophysiology, Tulane University School of Medicine, 1430 Tulane Avenue, Box 8548, New Orleans, LA 70112, USA
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10
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Quintanilla JG, Shpun S, Jalife J, Filgueiras-Rama D. Novel approaches to mechanism-based atrial fibrillation ablation. Cardiovasc Res 2021; 117:1662-1681. [PMID: 33744913 PMCID: PMC8208747 DOI: 10.1093/cvr/cvab108] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 02/12/2021] [Accepted: 03/18/2021] [Indexed: 01/23/2023] Open
Abstract
Modern cardiac electrophysiology has reported significant advances in the understanding of mechanisms underlying complex wave propagation patterns during atrial fibrillation (AF), although disagreements remain. One school of thought adheres to the long-held postulate that AF is the result of randomly propagating wavelets that wonder throughout the atria. Another school supports the notion that AF is deterministic in that it depends on a small number of high-frequency rotors generating three-dimensional scroll waves that propagate throughout the atria. The spiralling waves are thought to interact with anatomic and functional obstacles, leading to fragmentation and new wavelet formation associated with the irregular activation patterns documented on AF tracings. The deterministic hypothesis is consistent with demonstrable hierarchical gradients of activation frequency and AF termination on ablation at specific (non-random) atrial regions. During the last decade, data from realistic animal models and pilot clinical series have triggered a new era of novel methodologies to identify and ablate AF drivers outside the pulmonary veins. New generation electroanatomical mapping systems and multielectrode mapping catheters, complimented by powerful mathematical analyses, have generated the necessary platforms and tools for moving these approaches into clinical procedures. Recent clinical data using such platforms have provided encouraging evidence supporting the feasibility of targeting and effectively ablating driver regions in addition to pulmonary vein isolation in persistent AF. Here, we review state-of-the-art technologies and provide a comprehensive historical perspective, characterization, classification, and expected outcomes of current mechanism-based methods for AF ablation. We discuss also the challenges and expected future directions that scientists and clinicians will face in their efforts to understand AF dynamics and successfully implement any novel method into regular clinical practice.
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Affiliation(s)
- Jorge G Quintanilla
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Myocardial Pathophysiology Area, Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | | | - José Jalife
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Myocardial Pathophysiology Area, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Department of Internal Medicine, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI 48109, USA
| | - David Filgueiras-Rama
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Myocardial Pathophysiology Area, Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
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11
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Sánchez de la Nava AM, Atienza F, Bermejo J, Fernández-Avilés F. Artificial intelligence for a personalized diagnosis and treatment of atrial fibrillation. Am J Physiol Heart Circ Physiol 2021; 320:H1337-H1347. [PMID: 33513086 DOI: 10.1152/ajpheart.00764.2020] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Although atrial fibrillation (AF) is the most common cardiac arrhythmia, its early identification, diagnosis, and treatment is still challenging. Due to its heterogeneous mechanisms and risk factors, targeting an individualized treatment of AF demands a large amount of patient data to identify specific patterns. Artificial intelligence (AI) algorithms are particularly well suited for treating high-dimensional data, predicting outcomes, and eventually, optimizing strategies for patient management. The analysis of large patient samples combining different sources of information such as blood biomarkers, electrical signals, and medical images opens a new paradigm for improving diagnostic algorithms. In this review, we summarize suitable AI techniques for this purpose. In particular, we describe potential applications for understanding the structural and functional bases of the disease, as well as for improving early noninvasive diagnosis, developing more efficient therapies, and predicting long-term clinical outcomes of patients with AF.
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Affiliation(s)
- Ana María Sánchez de la Nava
- Department of Cardiology, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBERCV, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain.,Universitat Politècnica de València, València, Spain
| | - Felipe Atienza
- Department of Cardiology, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBERCV, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Javier Bermejo
- Department of Cardiology, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBERCV, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Francisco Fernández-Avilés
- Department of Cardiology, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBERCV, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
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12
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Ciconte G, Vicedomini G, Li W, Mangual JO, McSpadden L, Ryu K, Saviano M, Vitale R, Conti M, Ćalović Ž, Santinelli V, Pappone C. Non-paroxysmal atrial fibrillation mapping: characterization of the electrophysiological substrate using a novel integrated mapping technique. Europace 2020; 21:1193-1202. [PMID: 31056645 DOI: 10.1093/europace/euz123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 04/12/2019] [Indexed: 01/05/2023] Open
Abstract
AIMS Clinical outcomes after radiofrequency catheter ablation (RFCA) remain suboptimal in the treatment of non-paroxysmal atrial fibrillation (AF). Electrophysiological mapping may improve understanding of the underlying mechanisms. To describe the arrhythmia substrate in patients with persistent (Pers) and long-standing persistent (LSPers) AF, undergoing RFCA, using an integrated mechanism mapping technique. METHODS AND RESULTS Patients underwent high-density electroanatomical mapping before and after catheter ablation. Integrated maps characterized electrogram (EGM) cycle length (CL) in regions with repetitive-regular (RR) activations, stable wavefront propagation, fragmentation, and peak-to-peak bipolar voltage. Among 83 patients (72% male, 60 ± 11 years old), RR activations were identified in 376 regions (mean CL 180 ± 31 ms). PersAF patients (n = 43) showed more RR sites per patient (5.3 ± 2.4 vs. 3.7 ± 2.1, P = 0.002) with faster CL (166 ± 29 vs. 190 ± 29 ms; P < 0.001) and smaller surface area of fragmented EGMs (15 ± 14% vs. 27 ± 17%, P < 0.001) compared with LSPersAF. The post-ablation map in 50 patients remaining in AF, documented reduction of the RR activities per patient (1.5 ± 0.7 vs. 3.7 ± 1.4, P < 0.001) and area of fragmentation (22 ± 17% vs. 8 ± 9%, P < 0.001). Atrial fibrillation termination during ablation occurred at RR sites (0.48 ± 0.24 mV; 170.5 ± 20.2 ms CL) in 31/33 patients (94%). At the latest follow-up, arrhythmia freedom was higher among patients receiving ablation >75% of RR sites (Q4 82.6%, Q3 63.1%, Q2 35.1%, and Q1 0%; P < 0.001). CONCLUSION The integrated mapping technique allowed characterization of multiple arrhythmic substrates in non-paroxysmal AF patients. This technique might serve as tool for a substrate-targeted ablation approach.
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Affiliation(s)
- Giuseppe Ciconte
- Department of Arrhythmology, IRCCS Policlinico San Donato, Piazza E. Malan 1, San Donato Milanese, Milano, Italy
| | - Gabriele Vicedomini
- Department of Arrhythmology, IRCCS Policlinico San Donato, Piazza E. Malan 1, San Donato Milanese, Milano, Italy
| | - Wenwen Li
- Applied Research, Abbott, Sylmar, CA, USA
| | | | | | | | - Massimo Saviano
- Department of Arrhythmology, IRCCS Policlinico San Donato, Piazza E. Malan 1, San Donato Milanese, Milano, Italy
| | - Raffaele Vitale
- Department of Arrhythmology, IRCCS Policlinico San Donato, Piazza E. Malan 1, San Donato Milanese, Milano, Italy
| | - Manuel Conti
- Department of Arrhythmology, IRCCS Policlinico San Donato, Piazza E. Malan 1, San Donato Milanese, Milano, Italy
| | - Žarko Ćalović
- Department of Arrhythmology, IRCCS Policlinico San Donato, Piazza E. Malan 1, San Donato Milanese, Milano, Italy
| | - Vincenzo Santinelli
- Department of Arrhythmology, IRCCS Policlinico San Donato, Piazza E. Malan 1, San Donato Milanese, Milano, Italy
| | - Carlo Pappone
- Department of Arrhythmology, IRCCS Policlinico San Donato, Piazza E. Malan 1, San Donato Milanese, Milano, Italy
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13
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Costoya-Sánchez A, Climent AM, Hernández-Romero I, Liberos A, Fernández-Avilés F, Narayan SM, Atienza F, Guillem MS, Rodrigo M. Automatic quality electrogram assessment improves phase-based reentrant activity identification in atrial fibrillation. Comput Biol Med 2020; 117:103593. [PMID: 32072974 PMCID: PMC10984645 DOI: 10.1016/j.compbiomed.2019.103593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 12/20/2019] [Accepted: 12/23/2019] [Indexed: 11/30/2022]
Abstract
Identification of reentrant activity driving atrial fibrillation (AF) is increasingly important to ablative therapies. The goal of this work is to study how the automatically-classified quality of the electrograms (EGMs) affects reentrant AF driver localization. EGMs from 259 AF episodes obtained from 29 AF patients were recorded using 64-poles basket catheters and were manually classified according to their quality. An algorithm capable of identifying signal quality was developed using time and spectral domain parameters. Electrical reentries were identified in 3D phase maps using phase transform and were compared with those obtained with a 2D activation-based method. Effect of EGM quality was studied by discarding 3D phase reentries detected in regions with low-quality EGMs. Removal of reentries identified by 3D phase analysis in regions with low-quality EGMs improved its performance, increasing the area under the ROC curve (AUC) from 0.69 to 0.80. The EGMs quality classification algorithm showed an accurate performance for EGM classification (AUC 0.94) and reentry detection (AUC 0.80). Automatic classification of EGM quality based on time and spectral signal parameters is feasible and accurate, avoiding the manual labelling. Discard of reentries identified in regions with automatically-detected poor-quality EGMs improved the specificity of the 3D phase-based method for AF driver identification.
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Affiliation(s)
| | - Andreu M Climent
- ITACA Institute, Universitat Politècnica de València, Spain; Cardiology Department, Hospital General Universitario Gregorio Marañón, IiSGM, CIBERCV, Spain
| | | | | | | | | | - Felipe Atienza
- Cardiology Department, Hospital General Universitario Gregorio Marañón, IiSGM, CIBERCV, Spain
| | | | - Miguel Rodrigo
- ITACA Institute, Universitat Politècnica de València, Spain.
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14
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Honarbakhsh S, Schilling RJ, Dhillon G, Ullah W, Keating E, Providencia R, Chow A, Earley MJ, Hunter RJ. A Novel Mapping System for Panoramic Mapping of the Left Atrium: Application to Detect and Characterize Localized Sources Maintaining Atrial Fibrillation. JACC Clin Electrophysiol 2019; 4:124-134. [PMID: 29387810 PMCID: PMC5777816 DOI: 10.1016/j.jacep.2017.09.177] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Objectives This study sought to use a novel panoramic mapping system (CARTOFINDER) to detect and characterize drivers in persistent atrial fibrillation (AF). Background Mechanisms sustaining persistent AF remain uncertain. Methods Patients undergoing catheter ablation for persistent AF were included. A 64-pole basket catheter was used to acquire unipolar signals, which were processed by the mapping system to generate wavefront propagation maps. The system was used to identify and characterize potential drivers in AF pre- and post-pulmonary vein (PV) isolation. The effect of ablation on drivers identified post-PV isolation was assessed. Results Twenty patients were included in the study with 112 CARTOFINDER maps created. Potential drivers were mapped in 19 of 20 patients with AF (damage to the basket and noise on electrograms was present in 1 patient). Thirty potential drivers were identified all of which were transient but repetitive; 19 were rotational and 11 focal. Twenty-six drivers were ablated with a predefined response in 22 of 26 drivers: AF terminated with 12 and cycle length slowed (≥30 ms) with 10. Drivers with rotational activation were predominantly mapped to sites of low-voltage zones (81.8%). PV isolation had no remarkable impact on the cycle length at the driver sites (138.4 ± 14.3 ms pre-PV isolation vs. 137.2 ± 15.2 ms post-PV isolation) and drivers that had also been identified on pre-PV isolation maps were more commonly associated with AF termination. Conclusions Drivers were identified in almost all patients in the form of intermittent but repetitive focal or rotational activation patterns. The mechanistic importance of these phenomena was confirmed by the response to ablation.
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Affiliation(s)
- Shohreh Honarbakhsh
- Barts Heart Centre, St. Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Richard J Schilling
- Barts Heart Centre, St. Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Gurpreet Dhillon
- Barts Heart Centre, St. Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Waqas Ullah
- Barts Heart Centre, St. Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Emily Keating
- Barts Heart Centre, St. Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Rui Providencia
- Barts Heart Centre, St. Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Anthony Chow
- Barts Heart Centre, St. Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Mark J Earley
- Barts Heart Centre, St. Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Ross J Hunter
- Barts Heart Centre, St. Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom.
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15
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Ciaccio EJ, Wan EY, Saluja DS, Acharya UR, Peters NS, Garan H. Addressing challenges of quantitative methodologies and event interpretation in the study of atrial fibrillation. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2019; 178:113-122. [PMID: 31416540 PMCID: PMC6748794 DOI: 10.1016/j.cmpb.2019.06.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 05/21/2019] [Accepted: 06/14/2019] [Indexed: 05/06/2023]
Abstract
Atrial fibrillation (AF) is the commonest arrhythmia, yet the mechanisms of its onset and persistence are incompletely known. Although techniques for quantitative assessment have been investigated, there have been few attempts to integrate this information to advance disease treatment protocols. In this review, key quantitative methods for AF analysis are described, and suggestions are provided for the coordination of the available information, and to develop foci and directions for future research efforts. Quantitative biologists may have an interest in this topic in order to develop machine learning and tools for arrhythmia characterization, but they may perhaps have a minimal background in the clinical methodology and in the types of observed events and mechanistic hypotheses that have thus far been developed. We attempt to address these issues via exploration of the published literature. Although no new data is presented in this review, examples are shown of current lines of investigation, and in particular, how electrogram analysis and whole-chamber quantitative modeling of the left atrium may be useful to characterize fibrillatory patterns of activity, so as to propose avenues for more efficacious acquisition and interpretation of AF data.
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Affiliation(s)
- Edward J Ciaccio
- Department of Medicine - Division of Cardiology, Columbia University Medical Center, New York, NY, USA; ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, UK.
| | - Elaine Y Wan
- Department of Medicine - Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Deepak S Saluja
- Department of Medicine - Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - U Rajendra Acharya
- Department of Electronics and Computer Engineering, Ngee Ann Polytechnic, Singapore
| | - Nicholas S Peters
- ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Hasan Garan
- Department of Medicine - Division of Cardiology, Columbia University Medical Center, New York, NY, USA
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16
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Abstract
Optical mapping of electrical activity in the heart is based on voltage-sensitive and lipophilic fluorescence dyes. Optical signals recorded from cardiac cells correlate well with their transmembrane potentials. High spatiotemporal resolution, wide field mapping, and high sensitivity to transmembrane potential enable detailed characterization of action potential initiation and propagation. Optical mapping is used to study complex patterns of excitation propagation, including propagation across the sinoatrial and atrioventricular nodes and during atrial and ventricular arrhythmias.Optical mapping is used to study the role of reentrant activity in atrial and ventricular fibrillation.
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17
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Gianni C, Mohanty S, Trivedi C, Di Biase L, Natale A. Novel concepts and approaches in ablation of atrial fibrillation: the role of non-pulmonary vein triggers. Europace 2019; 20:1566-1576. [PMID: 29697759 DOI: 10.1093/europace/euy034] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 02/26/2018] [Indexed: 12/25/2022] Open
Abstract
Ablation of non-pulmonary vein (PV) triggers is an important step to improve outcomes in atrial fibrillation ablation. Non-pulmonary vein triggers typically originates from predictable sites (such as the left atrial posterior wall, superior vena cava, coronary sinus, interatrial septum, and crest terminalis), and these areas can be ablated either empirically or after observing significant ectopy (with or without drug challenge). In this review, we will focus on ablation of non-PV triggers, summarizing the existing evidence and our current approach for their mapping and ablation.
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Affiliation(s)
- Carola Gianni
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA.,U.O.C. Cardiologia, IRCCS Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Sanghamitra Mohanty
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA.,Dell Medical School, University of Texas, Austin, TX, USA
| | - Chintan Trivedi
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | - Luigi Di Biase
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA.,Department of Biomedical Engineering, University of Texas, Austin, TX, USA.,Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA.,Dell Medical School, University of Texas, Austin, TX, USA.,Department of Biomedical Engineering, University of Texas, Austin, TX, USA.,MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Division of Cardiology, Stanford University, Stanford, CA, USA.,Electrophysiology and Arrhythmia Services, California Pacific Medical Center, San Francisco, CA, USA
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18
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Nakatani Y, Sakamoto T, Yamaguchi Y, Tsujino Y, Kataoka N, Nishida K, Mizumaki K, Kinugawa K. Left atrial posterior wall isolation affects complex fractionated atrial electrograms in persistent atrial fibrillation. J Arrhythm 2019; 35:528-534. [PMID: 31293704 PMCID: PMC6595290 DOI: 10.1002/joa3.12182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 03/11/2019] [Accepted: 03/25/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The impact of left atrial posterior wall isolation (LAPWI) on the complex fractionated atrial electrogram (CFAE) is unknown. METHODS CFAE mapping was performed before and after LAPWI in 46 patients with persistent atrial fibrillation (AF). RESULTS LAPWI decreased both the variable (fractionated index ≤ 120 ms; from 60 ± 4 cm2 to 50 ± 4 cm2, P < 0.001) and continuous (fractionated index ≤ 50 ms; from 4.2 ± 1.0 cm2 to 3.5 ± 0.9 cm2, P = 0.036) CFAE areas. Especially, the CFAE areas on the bottom and roof walls of the left atrium and on the posterior and bottom walls of the right atrium significantly decreased after LAPWI. The distribution of variable CFAE areas was not different between the AF-recurrence (n = 9) and AF-free (n = 37) groups before LAPWI; however, it was larger in the anterior and septal walls of the right atrium in the AF-recurrence group than in the AF-free group after LAPWI (anterior wall, 8% ± 2% vs 5% ± 1%, P = 0.048; septal wall, 23% ± 4% vs 16% ± 1%, P = 0.043). The distribution of continuous CFAE areas on the bottom wall of the right atrium was larger in the AF-recurrence group than in the AF-free group both before LAPWI (30% ± 20% vs 4% ± 2%, P = 0.008) and after LAPWI (25% ± 25% vs 3% ± 1%, P = 0.027). CONCLUSIONS LAPWI decreased the CFAE areas and affected their distribution, which contributed to AF recurrence.
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Affiliation(s)
- Yosuke Nakatani
- Second Department of Internal MedicineUniversity of ToyamaToyamaJapan
| | - Tamotsu Sakamoto
- Second Department of Internal MedicineUniversity of ToyamaToyamaJapan
| | | | - Yasushi Tsujino
- Second Department of Internal MedicineUniversity of ToyamaToyamaJapan
| | - Naoya Kataoka
- Second Department of Internal MedicineUniversity of ToyamaToyamaJapan
| | | | | | - Koichiro Kinugawa
- Second Department of Internal MedicineUniversity of ToyamaToyamaJapan
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19
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20
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Song JS, Kim J, Lim B, Lee YS, Hwang M, Joung B, Shim EB, Pak HN. Pro-Arrhythmogenic Effects of Heterogeneous Tissue Curvature - A Suggestion for Role of Left Atrial Appendage in Atrial Fibrillation. Circ J 2018; 83:32-40. [PMID: 30429429 DOI: 10.1253/circj.cj-18-0615] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The arrhythmogenic role of complex atrial morphology has not yet been clearly elucidated. We hypothesized that bumpy tissue geometry can induce action potential duration (APD) dispersion and wavebreak in atrial fibrillation (AF). Methods and Results: We simulated a 2D-bumpy atrial model by varying the degree of bumpiness, and 3D-left atrial (LA) models integrated by LA computed tomographic (CT) images taken from 14 patients with persistent AF. We also analyzed wave-dynamic parameters with bipolar electrograms during AF and compared them with LA-CT geometry in 30 patients with persistent AF. In the 2D-bumpy model, APD dispersion increased (P<0.001) and wavebreak occurred spontaneously when the surface bumpiness was greater, showing phase transition-like behavior (P<0.001). The bumpiness gradient 2D-model showed that spiral wave drifted in the direction of higher bumpiness, and phase singularity (PS) points were mostly located in areas with higher bumpiness. In the 3D-LA model, PS density was higher in the LA appendage (LAA) compared with other parts of the LA (P<0.05). In 30 persistent-AF patients, the surface bumpiness of LAA was 5.8-fold that of other LA parts (P<0.001), and exceeded critical bumpiness to induce wavebreak. Wave dynamics complexity parameters were consistently dominant in the LAA (P<0.001). CONCLUSIONS Bumpy tissue geometry promoted APD dispersion, wavebreak, and spiral wave drift in in-silico human atrial tissue, and corresponded to clinical electroanatomical maps.
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21
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Stiles MK, Sanders P, Lau DH. Targeting the Substrate in Ablation of Persistent Atrial Fibrillation: Recent Lessons and Future Directions. Front Physiol 2018; 9:1158. [PMID: 30279660 PMCID: PMC6154526 DOI: 10.3389/fphys.2018.01158] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 08/02/2018] [Indexed: 12/16/2022] Open
Abstract
While isolation of the pulmonary veins is firmly established as effective treatment for the majority of paroxysmal atrial fibrillation (AF) patients, there is recognition that patients with persistent AF have substrate for perpetuation of arrhythmia existing outside of the pulmonary veins. Various computational approaches have been used to identify targets for effective ablation of persistent AF. This paper aims to discuss the clinical aspects of computational approaches that aim to identify critical sites for treatment. Various analyses of electrogram characteristics have been performed with this aim. Leading techniques for electrogram analysis are Complex Fractionated Atrial Electrograms (CFAE) and Dominant Frequency (DF). These techniques have been the subject of clinical trials of which the results are discussed. Evaluation of the activation patterns of atria in AF has been another avenue of research. Focal Impulse and Rotor Modulation (FIRM) mapping and forms of Body Surface Mapping aim to characterize multiple atrial wavelets, macro-reentry and focal sources which have been proposed as basic mechanisms perpetuating AF. Both invasive and non-invasive activation mapping techniques are reviewed. The presence of atrial fibrosis causes non-uniform anisotropic impulse propagation. Therefore, identification of fibrosis by imaging techniques is an avenue of potential research. The leading contender for imaging-based techniques is Cardiac Magnetic Resonance (CMR). As this technology advances, improvements in resolution and scar identification have positioned CMR as the mode of choice for analysis of atrial structure. AF has been demonstrated to be associated with obesity, inactivity and diseases of modern life. An opportunity exists for detailed computational analysis of the impact of risk factor modification on atrial substrate. This ranges from microstructural investigation through to examination at a population level via registries and public health interventions. Computational analysis of atrial substrate has moved from basic science toward clinical application. Future directions and potential limitations of such analyses are examined in this review.
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Affiliation(s)
- Martin K Stiles
- Waikato Clinical School, University of Auckland, Hamilton, New Zealand.,Department of Cardiology, Waikato District Health Board, Hamilton, New Zealand
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders (CHRD), South Australian Health and Medical Research Institute (SAHMRI), The University of Adelaide and Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders (CHRD), South Australian Health and Medical Research Institute (SAHMRI), The University of Adelaide and Royal Adelaide Hospital, Adelaide, SA, Australia
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22
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Rubenstein DS, Yin H, Azami SA. Compass Mapping, Double Potentials, Activation Patterns Can Identify and Track Rotational Activity Sites in the Left Atrium of Humans with Persistent Atrial Fibrillation. J Atr Fibrillation 2018; 11:2053. [PMID: 30505380 PMCID: PMC6244311 DOI: 10.4022/jafib.2053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 06/28/2018] [Accepted: 07/25/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND Rotational circuits that occur between bipolar electrodes exhibit double potentials (DPs). It had been previously surmised that rotors could not be electrically tracked directly. PURPOSE Our purpose was twofold; first, to show that the use of compass mapping, one can regionally identify rotational activity; and second, to show that by combining simultaneous compass map recordings, standard narrow-adjacent bipolar, and unipolar recordings, that specific signature recording patterns emerge that allow one to identify the accurate time, location, and path of a rotational mechanism. METHODS This was an observational study in 20 patients with persistent atrial fibrillation in which the electrode configuration of a circular mapping catheter was changed to wide cross-circle electrode pairing (compass mapping). DPs were recorded and analyzed from 12 left atrial (LA) sites and identified electrical wavefront patterns and direction. A substudy analyzed transitions patterns with simultaneous narrow-adjacent bipolar and unipolar recordings. RESULTS Four wavefront patterns were identified: DPs, peripheral waves (PWs), distal peripheral waves and fibrillatory activity. DP wavefront patterns exhibited significantly shorter cycle lengths than PWs in 8 of 12 LA sites. Patients had 2.9± 2.1 regions that exhibited DPs. DPs of varying duration were found, few (25%) were of stable duration and location. Detailed electrical examination at the transition between a PW to a DP identified a highly consistent pattern of simultaneous reversal of activation sequence, a special form of Doppler effect for spiral waves as a rotor passes between 2 electrodes, and a ½ cycle drop-off of activation signals along the line of electrodes. CONCLUSION DP recordings in compass mode can provide a regional assessment for the existence of rotational activity. Simultaneous DP recordings in compass mode, narrow-adjacent bipolar, and unipolar recording provide an accurate assessment of the time, location, and path that a rotational mechanism breaches a perimeter of electrodes. Accurate time, location and path of perimeter breaches can be used to electrically track rotational mechanisms during atrial fibrillation.
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Affiliation(s)
- Donald S Rubenstein
- Greenville Health System, Greenville Health System, 701 Grove Road, Greenville, SC 29605
| | - Hang Yin
- Provident Sacred Heart Medical Center, 101 W 8th Ave, Spokane, WA 99204
| | - Sana A Azami
- Greenville Health System, 701 Grove Road, Greenville, SC 29605
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23
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Honarbakhsh S, Schilling RJ, Providencia R, Keating E, Chow A, Sporton S, Lowe M, Earley MJ, Lambiase PD, Hunter RJ. Characterization of drivers maintaining atrial fibrillation: Correlation with markers of rapidity and organization on spectral analysis. Heart Rhythm 2018; 15:1296-1303. [PMID: 29753943 DOI: 10.1016/j.hrthm.2018.04.020] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Better characterization of drivers in atrial fibrillation (AF) may facilitate their identification. OBJECTIVE The purpose of this study was to demonstrate that certain driver characteristics are associated with greater mechanistic importance in maintaining AF. METHODS Persistent AF was mapped in patients using the CARTOFINDER system with a 64-pole basket catheter to identify and ablate drivers with rotational or focal activity after pulmonary vein isolation. An ablation response was defined as cycle length (CL) slowing ≥30 ms or AF termination. Driver sites with an ablation response were correlated to sites of fastest CL, highest dominant frequency (DF), and greatest organization (lowest cycle length variability [CLV] and highest regularity index [RI]). Parameters predicting AF termination with driver ablation were evaluated. RESULTS All 29 patients had ≥1 driver identified. Forty-four potential drivers were identified. The predefined ablation response occurred with 39 drivers (89%): 23 rotational and 16 focal. During a 30-second recording, each driver occurred 8.7 ± 5.4 times and completed 3.1 ± 0.9 consecutive repetitions per occurrence. Driver sites correlated best with markers of organization, corresponding to the site of lowest CLV (29/39 [74%]) and highest RI (26/39 [67%]). Correlation with sites of fastest CL and highest DF was poor (17/39 and 15/39, respectively) and depended on driver temporal stability. Greater temporal stability (3.4 ± 0.9 vs 2.7 ± 0.6; P = .001) and driver correlation with sites of lowest CLV and highest RI (both P <.001) predicted AF termination with ablation. CONCLUSION Intermittent focal or rotational drivers were identified in all patients. Drivers consistently correlated to organization markers. Greater temporal stability and organization predicted AF termination with driver ablation.
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Affiliation(s)
- Shohreh Honarbakhsh
- Barts Heart Centre, Barts Health NHS Trust, Department of Arrhythmia Management, London, United Kingdom
| | - Richard J Schilling
- Barts Heart Centre, Barts Health NHS Trust, Department of Arrhythmia Management, London, United Kingdom
| | - Rui Providencia
- Barts Heart Centre, Barts Health NHS Trust, Department of Arrhythmia Management, London, United Kingdom
| | - Emily Keating
- Barts Heart Centre, Barts Health NHS Trust, Department of Arrhythmia Management, London, United Kingdom
| | - Anthony Chow
- Barts Heart Centre, Barts Health NHS Trust, Department of Arrhythmia Management, London, United Kingdom
| | - Simon Sporton
- Barts Heart Centre, Barts Health NHS Trust, Department of Arrhythmia Management, London, United Kingdom
| | - Martin Lowe
- Barts Heart Centre, Barts Health NHS Trust, Department of Arrhythmia Management, London, United Kingdom
| | - Mark J Earley
- Barts Heart Centre, Barts Health NHS Trust, Department of Arrhythmia Management, London, United Kingdom
| | - Pier D Lambiase
- Barts Heart Centre, Barts Health NHS Trust, Department of Arrhythmia Management, London, United Kingdom
| | - Ross J Hunter
- Barts Heart Centre, Barts Health NHS Trust, Department of Arrhythmia Management, London, United Kingdom.
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Rodrigo M, Climent AM, Liberos A, Hernandez-Romero I, Arenal A, Bermejo J, Fernandez-Aviles F, Atienza F, Guillem MS. Solving Inaccuracies in Anatomical Models for Electrocardiographic Inverse Problem Resolution by Maximizing Reconstruction Quality. IEEE TRANSACTIONS ON MEDICAL IMAGING 2018; 37:733-740. [PMID: 28541896 DOI: 10.1109/tmi.2017.2707413] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Electrocardiographic Imaging has become an increasingly used technique for non-invasive diagnosis of cardiac arrhythmias, although the need for medical imaging technology to determine the anatomy hinders its introduction in the clinical practice. This paper explores the ability of a new metric based on the inverse reconstruction quality for the location and orientation of the atrial surface inside the torso. Body surface electrical signals from 31 realistic mathematical models and four AF patients were used to estimate the optimal position of the atria inside the torso. The curvature of the L-curve from the Tikhonov method, which was found to be related to the inverse reconstruction quality, was measured after application of deviations in atrial position and orientation. Independent deviations in the atrial position were solved by finding the maximal L-curve curvature with an error of 1.7 ± 2.4 mm in mathematical models and 9.1 ± 11.5 mm in patients. For the case of independent angular deviations, the error in location by using the L-curve was 5.8±7.1° in mathematical models and 12.4° ± 13.2° in patients. The ability of the L-curve curvature was tested also under superimposed uncertainties in the three axis of translation and in the three axis of rotation, and the error in location was of 2.3 ± 3.2 mm and 6.4° ± 7.1° in mathematical models, and 7.9±10.7 mm and 12.1°±15.5° in patients. The curvature of L-curve is a useful marker for the atrial position and would allow emending the inaccuracies in its location.
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25
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Lim B, Hwang M, Song JS, Ryu AJ, Joung B, Shim EB, Ryu H, Pak HN. Effectiveness of atrial fibrillation rotor ablation is dependent on conduction velocity: An in-silico 3-dimensional modeling study. PLoS One 2017; 12:e0190398. [PMID: 29287119 PMCID: PMC5747478 DOI: 10.1371/journal.pone.0190398] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 12/14/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND We previously reported that stable rotors are observed in in-silico human atrial fibrillation (AF) models, and are well represented by a dominant frequency (DF). In the current study, we hypothesized that the outcome of DF ablation is affected by conduction velocity (CV) conditions and examined this hypothesis using in-silico 3D-AF modeling. METHODS We integrated 3D CT images of left atrium obtained from 10 patients with persistent AF (80% male, 61.8±13.5 years old) into in-silico AF model. We compared AF maintenance durations (max 300s), spatiotemporal stabilities of DF, phase singularity (PS) number, life-span of PS, and AF termination or defragmentation rates after virtual DF ablation with 5 different CV conditions (0.2, 0.3, 0.4, 0.5, and 0.6m/s). RESULTS 1. AF maintenance duration (p<0.001), spatiotemporal mean variance of DF (p<0.001), and the number of PS (p = 0.023) showed CV dependent bimodal patterns (highest at CV0.4m/s and lowest at CV0.6m/s) consistently. 2. After 10% highest DF ablation, AF defragmentation rates were the lowest at CV0.4m/s (37.8%), but highest at CV0.5 and 0.6m/s (all 100%, p<0.001). 3. In the episodes with AF termination or defragmentation followed by 10% highest DF ablation, baseline AF maintenance duration was shorter (p<0.001), spatiotemporal mean variance of DF was lower (p = 0.014), and the number of PS was lower (p = 0.004) than those with failed AF defragmentation after DF ablation. CONCLUSION Virtual ablation of DF, which may indicate AF driver, was more likely to terminate or defragment AF with spatiotemporally stable DF, but not likely to do so in long-lasting and sustained AF conditions, depending on CV.
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Affiliation(s)
- Byounghyun Lim
- Yonsei University Health System, Seoul, Republic of Korea
| | - Minki Hwang
- Yonsei University Health System, Seoul, Republic of Korea
| | - Jun-Seop Song
- Yonsei University Health System, Seoul, Republic of Korea
| | - Ah-Jin Ryu
- Department of Mechanical and Biomedical Engineering, Kangwon National University, Chuncheon, Ganwon-do, Republic of Korea
| | - Boyoung Joung
- Yonsei University Health System, Seoul, Republic of Korea
| | - Eun Bo Shim
- Department of Mechanical and Biomedical Engineering, Kangwon National University, Chuncheon, Ganwon-do, Republic of Korea
| | - Hyungon Ryu
- NVIDIA, Yonsei University, Department of Mathematics, Seoul, Republic of Korea
| | - Hui-Nam Pak
- Yonsei University Health System, Seoul, Republic of Korea
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26
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Seitz J, Bars C, Théodore G, Beurtheret S, Lellouche N, Bremondy M, Ferracci A, Faure J, Penaranda G, Yamazaki M, Avula UMR, Curel L, Siame S, Berenfeld O, Pisapia A, Kalifa J. AF Ablation Guided by Spatiotemporal Electrogram Dispersion Without Pulmonary Vein Isolation: A Wholly Patient-Tailored Approach. J Am Coll Cardiol 2017; 69:303-321. [PMID: 28104073 DOI: 10.1016/j.jacc.2016.10.065] [Citation(s) in RCA: 149] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 09/29/2016] [Accepted: 10/18/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND The use of intracardiac electrograms to guide atrial fibrillation (AF) ablation has yielded conflicting results. OBJECTIVES The authors evaluated the usefulness of spatiotemporal dispersion, a visually recognizable electric footprint of AF drivers, for the ablation of all forms of AF. METHODS The authors prospectively enrolled 105 patients admitted for AF ablation. AF was sequentially mapped in both atria with a 20-pole PentaRay catheter. The authors tagged and ablated only regions displaying electrogram dispersion during AF. Results were compared to a validation set in which a conventional ablation approach was used (pulmonary vein isolation/stepwise approach). To establish the mechanism underlying spatiotemporal dispersion of AF electrograms, the authors conducted realistic numerical simulations of AF drivers in a 2-dimensional model and optical mapping of ovine atrial scar-related AF. RESULTS Ablation at dispersion areas terminated AF in 95% of the 105 patients. After ablation of 17 ± 10% of the left atrial surface and 18 months of follow-up, the atrial arrhythmia recurrence rate was 15% after 1.4 ± 0.5 procedures per patient versus 41% in the validation set after 1.5 ± 0.5 procedures per patient (arrhythmia free-survival: 85% vs. 59%; log-rank p < 0.001). Compared with the validation set, radiofrequency times (49 ± 21 min vs. 85 ± 34.5 min; p = 0.001) and procedure times (168 ± 42 min vs. 230 ± 67 min; p < 0.0001) were shorter. In simulations and optical mapping experiments, virtual PentaRay recordings demonstrated that electrogram dispersion is mostly recorded in the vicinity of a driver. CONCLUSIONS The clustering of intracardiac electrograms exhibiting spatiotemporal dispersion is indicative of AF drivers. Their ablation allows for a nonextensive and patient-tailored approach to AF ablation. (Substrate Ablation Guided by High Density Mapping in Atrial Fibrillation [SUBSTRATE HD]; NCT02093949).
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Affiliation(s)
- Julien Seitz
- Unité de Rythmologie Interventionnelle, Hôpital Saint Joseph Marseille, France.
| | - Clément Bars
- Unité de Rythmologie Interventionnelle, Hôpital Saint Joseph Marseille, France; Service de Cardiologie, Institut Mutualiste Montsouris, Paris, France
| | | | - Sylvain Beurtheret
- Unité de Rythmologie Interventionnelle, Hôpital Saint Joseph Marseille, France
| | | | - Michel Bremondy
- Unité de Rythmologie Interventionnelle, Hôpital Saint Joseph Marseille, France
| | - Ange Ferracci
- Unité de Rythmologie Interventionnelle, Hôpital Saint Joseph Marseille, France
| | - Jacques Faure
- Unité de Rythmologie Interventionnelle, Hôpital Saint Joseph Marseille, France
| | | | - Masatoshi Yamazaki
- Center for Arrhythmia Research, Cardiovascular Research Center, Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Uma Mahesh R Avula
- Center for Arrhythmia Research, Cardiovascular Research Center, Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Laurence Curel
- Unité de Rythmologie Interventionnelle, Hôpital Saint Joseph Marseille, France
| | - Sabrina Siame
- Unité de Rythmologie Interventionnelle, Hôpital Saint Joseph Marseille, France
| | - Omer Berenfeld
- Center for Arrhythmia Research, Cardiovascular Research Center, Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - André Pisapia
- Unité de Rythmologie Interventionnelle, Hôpital Saint Joseph Marseille, France
| | - Jérôme Kalifa
- Center for Arrhythmia Research, Cardiovascular Research Center, Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor, Michigan
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27
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Gaborit B, Sengenes C, Ancel P, Jacquier A, Dutour A. Role of Epicardial Adipose Tissue in Health and Disease: A Matter of Fat? Compr Physiol 2017. [PMID: 28640452 DOI: 10.1002/cphy.c160034] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Epicardial adipose tissue (EAT) is a small but very biologically active ectopic fat depot that surrounds the heart. Given its rapid metabolism, thermogenic capacity, unique transcriptome, secretory profile, and simply measurability, epicardial fat has drawn increasing attention among researchers attempting to elucidate its putative role in health and cardiovascular diseases. The cellular crosstalk between epicardial adipocytes and cells of the vascular wall or myocytes is high and suggests a local role for this tissue. The balance between protective and proinflammatory/profibrotic cytokines, chemokines, and adipokines released by EAT seem to be a key element in atherogenesis and could represent a future therapeutic target. EAT amount has been found to predict clinical coronary outcomes. EAT can also modulate cardiac structure and function. Its amount has been associated with atrial fibrillation, coronary artery disease, and sleep apnea syndrome. Conversely, a beiging fat profile of EAT has been identified. In this review, we describe the current state of knowledge regarding the anatomy, physiology and pathophysiological role of EAT, and the factors more globally leading to ectopic fat development. We will also highlight the most recent findings on the origin of this ectopic tissue, and its association with cardiac diseases. © 2017 American Physiological Society. Compr Physiol 7:1051-1082, 2017.
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Affiliation(s)
- Bénédicte Gaborit
- NORT, Aix Marseille Univ, INSERM, INRA, NORT, Marseille, France.,Endocrinology Metabolic Diseases, and Nutrition Department, Pole ENDO, APHM, Aix-Marseille Univ, Marseille, France
| | - Coralie Sengenes
- STROMALab, Université de Toulouse, EFS, ENVT, Inserm U1031, ERL CNRS 5311, CHU Rangueil, Toulouse, France
| | - Patricia Ancel
- NORT, Aix Marseille Univ, INSERM, INRA, NORT, Marseille, France
| | - Alexis Jacquier
- CNRS UMR 7339, Centre de Résonance Magnétique Biologique et Médicale (CRMBM), Marseille, France.,Radiology department, CHU La Timone, Marseille, France
| | - Anne Dutour
- NORT, Aix Marseille Univ, INSERM, INRA, NORT, Marseille, France.,Endocrinology Metabolic Diseases, and Nutrition Department, Pole ENDO, APHM, Aix-Marseille Univ, Marseille, France
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28
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Gadenz L, Hashemi J, Shariat MH, Gula L, Redfearn DP. Clinical Role of Dominant Frequency Measurements in Atrial Fibrillation Ablation - A Systematic Review. J Atr Fibrillation 2017; 9:1548. [PMID: 29250291 DOI: 10.4022/jafib.1548] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 02/19/2017] [Accepted: 02/26/2017] [Indexed: 11/10/2022]
Abstract
Introduction Experimental data strongly supports a role for high-frequency sources in the perpetuation of atrial fibrillation, it follows that identification of areas exhibiting spectra containing high dominant frequencies (DF) may represent perpetuating sources and targeted elimination might terminate AF. The aim of this review is to present and critically appraise the literature on DF studied in association with AF ablation. Methods And Results A systematic review was done including the PubMed (MEDLINE), Cochrane Central Register of Controlled Trials (Central), Scientific Electronic Library Online (SciELO), and HighWire Press databases. The searches were made by combining the terms "Dominant Frequency", "Atrial Fibrillation", and "Catheter Ablation" and their translations for the English and non-English based databases. Ten articles were selected from a total of 327 articles found after the initial search. The ablation strategy varied, most studies performed pulmonary vein isolation alone or associated with complex fractionated atrial electrogram ablation with or without an additional intervention. The use or not of DF sites as ablation target was distinguishable between the articles. Four articles ablated DF sites as a major intervention or in addition to a traditional approach. The remaining 6 articles assessed DF sites pre and post ablation and associated these data with clinical outcome. Conclusion No prior study has systematically comprised information for clinical use of DF. The current literature supports global DF as a useful marker of ablation outcome; however direct intervention targeting DF appears premature with mixed results and too few studies.
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Affiliation(s)
| | | | | | - Lorne Gula
- London Health Sciences, London, Ontario, Canada
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29
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Yin X, Zhao Z, Gao L, Chang D, Xiao X, Zhang R, Chen Q, Cheng J, Yang Y, Xi Y, Xia Y. Frequency Gradient Within Coronary Sinus Predicts the Long-Term Outcome of Persistent Atrial Fibrillation Catheter Ablation. J Am Heart Assoc 2017; 6:JAHA.116.004869. [PMID: 28255079 PMCID: PMC5524018 DOI: 10.1161/jaha.116.004869] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background The coronary sinus (CS), as a junction of the atria, contributes to atrial fibrillation (AF) by developing unstable reentry, and isolating the atria by ablation at the CS could terminate AF. The present study evaluated whether AF activities at the CS in a subset of patients contributed to AF maintenance and predicted clinical outcome of ablation. Methods and Results We studied 122 consecutive patients who had a first‐time radiofrequency ablation for persistent AF. Bipolar electrograms were obtained from multiple regions of the left atrium by a Lasso mapping catheter before ablation. Pulmonary vein isolation terminated AF in 12 patients (9.8%). Sequential stepwise ablation was conducted in pulmonary vein isolation nontermination patients and succeeded in 22 patients (18%). In the stepwise termination group, AF frequency in the proximal CS (CSp) was significantly higher (10.2±2.1 Hz versus 8.3±1.8 Hz, P<0.001), and the ratio of distal CS (CSd) to proximal CS (CSd/CSp ratio, 56.6%±10.11% versus 70.7%±9.8%, P<0.001) was significantly lower than that in the nontermination group. The stepwise logistic regression analysis indicated that the CSd/CSp ratio was an independent predictor with an odds ratio of 1.131 (95%CI 1.053‐1.214; P=0.001). With a cutoff of 67%, the patients with lower CSd/CSp ratios had significantly better index and long‐term outcomes than those with higher ratios during a follow‐up of 46±18 months. Conclusions Rapid repetitive activities in the musculature of the proximal CS may contribute to maintenance of AF after pulmonary vein isolation alone in persistent AF. A cutoff at 67%, of the CSd/CSp frequency ratio might be an indicator to stratify the subset of patients who might benefit from CS ablation.
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Affiliation(s)
- Xiaomeng Yin
- First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Ziming Zhao
- First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Lianjun Gao
- First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Dong Chang
- First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Xianjie Xiao
- First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Rongfeng Zhang
- First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Qi Chen
- Texas Heart Institute, Houston, TX
| | | | - Yanzong Yang
- First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Yutao Xi
- Texas Heart Institute, Houston, TX
| | - Yunlong Xia
- First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
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30
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Grandi E, Maleckar MM. Anti-arrhythmic strategies for atrial fibrillation: The role of computational modeling in discovery, development, and optimization. Pharmacol Ther 2016; 168:126-142. [PMID: 27612549 DOI: 10.1016/j.pharmthera.2016.09.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Atrial fibrillation (AF), the most common cardiac arrhythmia, is associated with increased risk of cerebrovascular stroke, and with several other pathologies, including heart failure. Current therapies for AF are targeted at reducing risk of stroke (anticoagulation) and tachycardia-induced cardiomyopathy (rate or rhythm control). Rate control, typically achieved by atrioventricular nodal blocking drugs, is often insufficient to alleviate symptoms. Rhythm control approaches include antiarrhythmic drugs, electrical cardioversion, and ablation strategies. Here, we offer several examples of how computational modeling can provide a quantitative framework for integrating multiscale data to: (a) gain insight into multiscale mechanisms of AF; (b) identify and test pharmacological and electrical therapy and interventions; and (c) support clinical decisions. We review how modeling approaches have evolved and contributed to the research pipeline and preclinical development and discuss future directions and challenges in the field.
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Affiliation(s)
- Eleonora Grandi
- Department of Pharmacology, University of California Davis, Davis, USA.
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31
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Song JS, Lee YS, Hwang M, Lee JK, Li C, Joung B, Lee MH, Shim EB, Pak HN. Spatial reproducibility of complex fractionated atrial electrogram depending on the direction and configuration of bipolar electrodes: an in-silico modeling study. THE KOREAN JOURNAL OF PHYSIOLOGY & PHARMACOLOGY : OFFICIAL JOURNAL OF THE KOREAN PHYSIOLOGICAL SOCIETY AND THE KOREAN SOCIETY OF PHARMACOLOGY 2016; 20:507-14. [PMID: 27610037 PMCID: PMC5014997 DOI: 10.4196/kjpp.2016.20.5.507] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 07/08/2016] [Accepted: 07/11/2016] [Indexed: 12/02/2022]
Abstract
Although 3D-complex fractionated atrial electrogram (CFAE) mapping is useful in radiofrequency catheter ablation for persistent atrial fibrillation (AF), the directions and configuration of the bipolar electrodes may affect the electrogram. This study aimed to compare the spatial reproducibility of CFAE by changing the catheter orientations and electrode distance in an in-silico left atrium (LA). We conducted this study by importing the heart CT image of a patient with AF into a 3D-homogeneous human LA model. Electrogram morphology, CFAE-cycle lengths (CLs) were compared for 16 different orientations of a virtual bipolar conventional catheter (conv-cath: size 3.5 mm, inter-electrode distance 4.75 mm). Additionally, the spatial correlations of CFAE-CLs and the percentage of consistent sites with CFAE-CL<120 ms were analyzed. The results from the conv-cath were compared with that obtained using a mini catheter (mini-cath: size 1 mm, inter-electrode distance 2.5 mm). Depending on the catheter orientation, the electrogram morphology and CFAE-CLs varied (conv-cath: 11.5±0.7% variation, mini-cath: 7.1±1.2% variation), however the mini-cath produced less variation of CFAE-CL than conv-cath (p<0.001). There were moderate spatial correlations among CFAE-CL measured at 16 orientations (conv-cath: r=0.3055±0.2194 vs. mini-cath: 0.6074±0.0733, p<0.001). Additionally, the ratio of consistent CFAE sites was higher for mini catheter than conventional one (38.3±4.6% vs. 22.3±1.4%, p<0.05). Electrograms and CFAE distribution are affected by catheter orientation and electrode configuration in the in-silico LA model. However, there was moderate spatial consistency of CFAE areas, and narrowly spaced bipolar catheters were less influenced by catheter direction than conventional catheters.
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Affiliation(s)
- Jun-Seop Song
- Division of Cardiology, Yonsei University Health System, Seoul 03722, Korea
| | - Young-Seon Lee
- Division of Cardiology, Yonsei University Health System, Seoul 03722, Korea
| | - Minki Hwang
- Division of Cardiology, Yonsei University Health System, Seoul 03722, Korea
| | - Jung-Kee Lee
- Division of Cardiology, Yonsei University Health System, Seoul 03722, Korea
| | - Changyong Li
- Division of Cardiology, Yonsei University Health System, Seoul 03722, Korea
| | - Boyoung Joung
- Division of Cardiology, Yonsei University Health System, Seoul 03722, Korea
| | - Moon-Hyoung Lee
- Division of Cardiology, Yonsei University Health System, Seoul 03722, Korea
| | - Eun Bo Shim
- Department of Mechanical and Biomedical Engineering, Kangwon National University, Chuncheon 24341, Korea
| | - Hui-Nam Pak
- Division of Cardiology, Yonsei University Health System, Seoul 03722, Korea
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32
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Electrogram Fractionation-Guided Ablation in the Left Atrium Decreases the Frequency of Activation in the Pulmonary Veins and Leads to Atrial Fibrillation Termination: Pulmonary Vein Modulation Rather Than Isolation. JACC Clin Electrophysiol 2016; 2:732-742. [PMID: 29759752 DOI: 10.1016/j.jacep.2016.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 04/04/2016] [Accepted: 04/14/2016] [Indexed: 01/03/2023]
Abstract
OBJECTIVES This study sought to evaluate the impact of a complex fractionated atrial electrogram (CFAE)-guided ablation strategy on atrial fibrillation (AF) dynamics in patients with persistent AF. BACKGROUND It is still unclear whether complete pulmonary vein isolation (PVI) is required or if the ablation of well-delineated pulmonary vein (PV) subregions could achieve similar outcomes in persistent AF. METHODS CFAE-guided ablations were performed in 76 patients (65.2 ± 10 years of age) with persistent AF. In 47 patients, we measured mean PVs and left atrial appendage (LAA) cycle length (CL) values (PV-CL and LAA-CL), before ablation and before AF termination. We defined "active" PVs as PV-CL ≤ LAA-CL, "rapid fires" as PV-CL ≤80% of LAA-CL, and "PV-LAA CL gradient" as a significant CL difference between the 2 regions. RESULTS AF termination (sinus rhythm [SR] or atrial tachycardia [AT] conversion) occurred in 92% and SR conversion in 75%. The radiofrequency time for AF termination and total radiofrequency time were 26 ± 25 min and 61.1 ± 21.6 min, respectively. Thirty of 47 patients had active PV (with 19 PV "rapid fires"). Ablation significantly increased median CL, both at PVs and LAA from 188 ms (interquartile range [IQR]: 161 to 210 ms) to 227.5 ms (IQR: 200 to 256 ms) (p < 0.0001) and from 197 ms (IQR: 168 to 220 ms) to 224 ms (IQR: 193 to 250 ms) (p < 0001), respectively. After ablation, PV-LAA CL gradients were withdrawn and all PV "rapid fires" were extinguished (without PVI). After 17.2 ± 10 months of follow-up and 1.61 ± 0.75 procedures, 86.3% and 73% of the patients were free from AF and from any arrhythmia (AF/AT), respectively. CONCLUSIONS CFAE-guided ablation leads to a large decrease in PV frequency of activation, preceding AF termination. A PV modulation approach, rather than complete PVI, may be preferable for persistent AF.
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Quintanilla JG, Pérez-Villacastín J, Pérez-Castellano N, Pandit SV, Berenfeld O, Jalife J, Filgueiras-Rama D. Mechanistic Approaches to Detect, Target, and Ablate the Drivers of Atrial Fibrillation. Circ Arrhythm Electrophysiol 2016; 9:e002481. [PMID: 26729850 DOI: 10.1161/circep.115.002481] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jorge G Quintanilla
- From the Advanced Development in Arrhythmia Mechanisms and Therapy Laboratory, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (J.G.Q., J.J., D.F.R.); Arrhythmia Unit, Cardiovascular Institute, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain (J.G.Q., J.P.V., N.P.C, D.F.R.); and Center for Arrhythmia Research, Department of Internal Medicine-Cardiology, University of Michigan, Ann Arbor (S.V.P., O.B., J.J.)
| | - Julián Pérez-Villacastín
- From the Advanced Development in Arrhythmia Mechanisms and Therapy Laboratory, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (J.G.Q., J.J., D.F.R.); Arrhythmia Unit, Cardiovascular Institute, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain (J.G.Q., J.P.V., N.P.C, D.F.R.); and Center for Arrhythmia Research, Department of Internal Medicine-Cardiology, University of Michigan, Ann Arbor (S.V.P., O.B., J.J.)
| | - Nicasio Pérez-Castellano
- From the Advanced Development in Arrhythmia Mechanisms and Therapy Laboratory, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (J.G.Q., J.J., D.F.R.); Arrhythmia Unit, Cardiovascular Institute, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain (J.G.Q., J.P.V., N.P.C, D.F.R.); and Center for Arrhythmia Research, Department of Internal Medicine-Cardiology, University of Michigan, Ann Arbor (S.V.P., O.B., J.J.)
| | - Sandeep V Pandit
- From the Advanced Development in Arrhythmia Mechanisms and Therapy Laboratory, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (J.G.Q., J.J., D.F.R.); Arrhythmia Unit, Cardiovascular Institute, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain (J.G.Q., J.P.V., N.P.C, D.F.R.); and Center for Arrhythmia Research, Department of Internal Medicine-Cardiology, University of Michigan, Ann Arbor (S.V.P., O.B., J.J.)
| | - Omer Berenfeld
- From the Advanced Development in Arrhythmia Mechanisms and Therapy Laboratory, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (J.G.Q., J.J., D.F.R.); Arrhythmia Unit, Cardiovascular Institute, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain (J.G.Q., J.P.V., N.P.C, D.F.R.); and Center for Arrhythmia Research, Department of Internal Medicine-Cardiology, University of Michigan, Ann Arbor (S.V.P., O.B., J.J.)
| | - José Jalife
- From the Advanced Development in Arrhythmia Mechanisms and Therapy Laboratory, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (J.G.Q., J.J., D.F.R.); Arrhythmia Unit, Cardiovascular Institute, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain (J.G.Q., J.P.V., N.P.C, D.F.R.); and Center for Arrhythmia Research, Department of Internal Medicine-Cardiology, University of Michigan, Ann Arbor (S.V.P., O.B., J.J.).
| | - David Filgueiras-Rama
- From the Advanced Development in Arrhythmia Mechanisms and Therapy Laboratory, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (J.G.Q., J.J., D.F.R.); Arrhythmia Unit, Cardiovascular Institute, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain (J.G.Q., J.P.V., N.P.C, D.F.R.); and Center for Arrhythmia Research, Department of Internal Medicine-Cardiology, University of Michigan, Ann Arbor (S.V.P., O.B., J.J.)
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Nitta T, Ishii Y, Fujii M, Miyagi Y, Sakamoto SI, Hiromoto A, Imura H. Restoration of sinus rhythm and atrial transport function after the maze procedure: U lesion set versus box lesion set. J Thorac Cardiovasc Surg 2016; 151:1062-9. [DOI: 10.1016/j.jtcvs.2015.10.108] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 10/21/2015] [Accepted: 10/29/2015] [Indexed: 11/16/2022]
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Guillem MS, Climent AM, Rodrigo M, Fernández-Avilés F, Atienza F, Berenfeld O. Presence and stability of rotors in atrial fibrillation: evidence and therapeutic implications. Cardiovasc Res 2016; 109:480-92. [PMID: 26786157 PMCID: PMC4777913 DOI: 10.1093/cvr/cvw011] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 12/30/2015] [Accepted: 01/15/2016] [Indexed: 01/08/2023] Open
Abstract
Rotor-guided ablation has opened new perspectives into the therapy of atrial fibrillation (AF). Analysis of the spatio-temporal cardiac excitation patterns in the frequency and phase domains has demonstrated the importance of rotors in research models of AF, however, the dynamics and role of rotors in human AF are still controversial. In this review, the current knowledge gained through research models and patient data that support the notion that rotors are key players in AF maintenance is summarized. We report and discuss discrepancies regarding rotor prevalence and stability in various studies, which can be attributed in part to methodological differences among mapping systems. Future research for validation and improvement of current clinical electrophysiology mapping technologies will be crucial for developing mechanistic-based selection and application of the best therapeutic strategy for individual AF patient, being it, pharmaceutical, ablative, or other approach.
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Affiliation(s)
- María S Guillem
- ITACA, Universitat Politèscnica de València, Valencia, Spain
| | - Andreu M Climent
- Hospital General Universitario Gregorio Marañón, Madrid, Spain Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Miguel Rodrigo
- ITACA, Universitat Politèscnica de València, Valencia, Spain
| | - Francisco Fernández-Avilés
- Hospital General Universitario Gregorio Marañón, Madrid, Spain Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain Facultad de Medicina, Universidad Complutense de Madrid, Spain
| | - Felipe Atienza
- Hospital General Universitario Gregorio Marañón, Madrid, Spain Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain Facultad de Medicina, Universidad Complutense de Madrid, Spain
| | - Omer Berenfeld
- Center for Arrhythmia Research, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI 48109, USA
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Pedrón-Torrecilla J, Rodrigo M, Climent AM, Liberos A, Pérez-David E, Bermejo J, Arenal Á, Millet J, Fernández-Avilés F, Berenfeld O, Atienza F, Guillem MS. Noninvasive Estimation of Epicardial Dominant High-Frequency Regions During Atrial Fibrillation. J Cardiovasc Electrophysiol 2016; 27:435-42. [PMID: 26776725 DOI: 10.1111/jce.12931] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 12/02/2015] [Accepted: 12/11/2015] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Ablation of high dominant frequency (DF) sources in patients with atrial fibrillation (AF) is an effective treatment option for paroxysmal AF. The aim of this study was to evaluate the accuracy of noninvasive estimation of DF and electrical patterns determination by solving the inverse problem of the electrocardiography. METHODS Four representative AF patients with left-to-right and right-to-left atrial DF patterns were included in the study. For each patient, intracardiac electrograms from both atria were recorded simultaneously together with 67-lead body surface recordings. In addition to clinical recordings, realistic mathematical models of atria and torso anatomy with different DF patterns of AF were used. For both mathematical models and clinical recordings, inverse-computed electrograms were compared to intracardiac electrograms in terms of voltage, phase, and frequency spectrum relative errors. RESULTS Comparison between intracardiac and inverse computed electrograms for AF patients showed 8.8 ± 4.4% errors for DF, 32 ± 4% for voltage, and 65 ± 4% for phase determination. These results were corroborated by mathematical simulations showing that the inverse problem solution was able to reconstruct the frequency spectrum and the DF maps with relative errors of 5.5 ± 4.1%, whereas the reconstruction of the electrograms or the instantaneous phase presented larger relative errors (i.e., 38 ± 15% and 48 ± 14 % respectively, P < 0.01). CONCLUSIONS Noninvasive reconstruction of atrial frequency maps can be achieved by solving the inverse problem of electrocardiography with a higher accuracy than temporal distribution patterns.
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Affiliation(s)
| | - Miguel Rodrigo
- ITACA, Universitat Politècnica de València, Valencia, Spain
| | - Andreu M Climent
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain and Facultad de Medicina, Universidad Complutense de Madrid, Spain
| | | | - Esther Pérez-David
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain and Facultad de Medicina, Universidad Complutense de Madrid, Spain
| | - Javier Bermejo
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain and Facultad de Medicina, Universidad Complutense de Madrid, Spain
| | - Ángel Arenal
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain and Facultad de Medicina, Universidad Complutense de Madrid, Spain
| | - José Millet
- ITACA, Universitat Politècnica de València, Valencia, Spain
| | - Francisco Fernández-Avilés
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain and Facultad de Medicina, Universidad Complutense de Madrid, Spain
| | - Omer Berenfeld
- Facultad de Medicina, Universidad Complutense de Madrid, Spain Center for Arrhythmia Research, University of Michigan, Ann Arbor, Michigan, U.S.A
| | - Felipe Atienza
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain and Facultad de Medicina, Universidad Complutense de Madrid, Spain
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Almeida TP, Chu GS, Salinet JL, Vanheusden FJ, Li X, Tuan JH, Stafford PJ, Ng GA, Schlindwein FS. Minimizing discordances in automated classification of fractionated electrograms in human persistent atrial fibrillation. Med Biol Eng Comput 2016; 54:1695-1706. [PMID: 26914407 PMCID: PMC5069340 DOI: 10.1007/s11517-016-1456-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 01/29/2016] [Indexed: 11/26/2022]
Abstract
Ablation of persistent atrial fibrillation (persAF) targeting complex fractionated atrial electrograms (CFAEs) detected by automated algorithms has produced conflicting outcomes in previous electrophysiological studies. We hypothesize that the differences in these algorithms could lead to discordant CFAE classifications by the available mapping systems, giving rise to potential disparities in CFAE-guided ablation. This study reports the results of a head-to-head comparison of CFAE detection performed by NavX (St. Jude Medical) versus CARTO (Biosense Webster) on the same bipolar electrogram data (797 electrograms) from 18 persAF patients. We propose revised thresholds for both primary and complementary indices to minimize the differences in CFAE classification performed by either system. Using the default thresholds [NavX: CFE-Mean ≤ 120 ms; CARTO: ICL ≥ 7], NavX classified 70 % of the electrograms as CFAEs, while CARTO detected 36 % (Cohen’s kappa κ ≈ 0.3, P < 0.0001). Using revised thresholds found using receiver operating characteristic curves [NavX: CFE-Mean ≤ 84 ms, CFE-SD ≤ 47 ms; CARTO: ICL ≥ 4, ACI ≤ 82 ms, SCI ≤ 58 ms], NavX classified 45 %, while CARTO detected 42 % (κ ≈ 0.5, P < 0.0001). Our results show that CFAE target identification is dependent on the system and thresholds used by the electrophysiological study. The thresholds found in this work counterbalance the differences in automated CFAE classification performed by each system. This could facilitate comparisons of CFAE ablation outcomes guided by either NavX or CARTO in future works.
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Affiliation(s)
- Tiago P Almeida
- Department of Engineering, University of Leicester, University Road, Leicester, LE1 7RH, UK
| | - Gavin S Chu
- Department of Cardiovascular Science, University of Leicester, Leicester, UK
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - João L Salinet
- Department of Engineering, University of Leicester, University Road, Leicester, LE1 7RH, UK
- Biomedical Engineering, Engineering, Modelling and Applied Social Sciences Centre, Federal ABC University, Santo André, Brazil
| | | | - Xin Li
- Department of Engineering, University of Leicester, University Road, Leicester, LE1 7RH, UK
| | - Jiun H Tuan
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - G André Ng
- Department of Cardiovascular Science, University of Leicester, Leicester, UK
- University Hospitals of Leicester NHS Trust, Leicester, UK
- National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK
| | - Fernando S Schlindwein
- Department of Engineering, University of Leicester, University Road, Leicester, LE1 7RH, UK.
- National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK.
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Rodrigo M, Climent AM, Liberos A, Calvo D, Fernández-Avilés F, Berenfeld O, Atienza F, Guillem MS. Identification of Dominant Excitation Patterns and Sources of Atrial Fibrillation by Causality Analysis. Ann Biomed Eng 2016; 44:2364-2376. [PMID: 26850022 DOI: 10.1007/s10439-015-1534-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 12/11/2015] [Indexed: 01/18/2023]
Abstract
Burden of atrial fibrillation (AF) can be reduced by ablation of sources of electrical impulses driving AF but driver identification is still challenging. This study presents a new methodology based on causality analysis that allows identifying the hierarchically dominant areas driving AF. Identification of dominant propagation patterns was achieved by computing causal relations between intracardiac multi-electrode catheter recordings of four paroxysmal AF patients during sinus rhythm, pacing and AF. In addition, realistic mathematical models of the atria during AF were used to validate the methodology both in the presence and absence of dominant frequency (DF) gradients. During electrical pacing, sources of propagation patterns detected by causality analysis were consistent with the location of the stimulating catheter. During AF, propagation patterns presented temporal variability, but a dominant direction accounted for significantly more propagations than other directions (49 ± 15% vs. 14 ± 13% or less, p < 0.01). Both in patients with a DF gradient and in mathematical models, causal maps allowed the identification of sites responsible for maintenance of AF. Causal maps allowed the identification of atrial dominant sites. In particular, causality analysis resulted in stable dominant cause-effect propagation directions during AF and could serve as a guide for performing ablation procedures in AF patients.
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Affiliation(s)
- Miguel Rodrigo
- ITACA, Universitat Politècnica de Valencia, 1ªplanta, Edificio 8G, Ciudad Politécnica de la Innovación, Camino de Vera s/n, 46022, Valencia, Spain
| | - Andreu M Climent
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Calle Dr Esquerdo 46, 28007, Madrid, Spain
| | - Alejandro Liberos
- ITACA, Universitat Politècnica de Valencia, 1ªplanta, Edificio 8G, Ciudad Politécnica de la Innovación, Camino de Vera s/n, 46022, Valencia, Spain
| | - David Calvo
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Calle Dr Esquerdo 46, 28007, Madrid, Spain
- Hospital Universitario Central de Asturias, Avd de Roma sn, 33006, Oviedo, Spain
| | - Francisco Fernández-Avilés
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Calle Dr Esquerdo 46, 28007, Madrid, Spain
- Facultad de Medicina, Universidad Complutense de Madrid, Pza. Ramón y Cajal, s/n, Ciudad Universitaria, 28040, Madrid, Spain
| | - Omer Berenfeld
- Center for Arrhythmia Research, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA
| | - Felipe Atienza
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Calle Dr Esquerdo 46, 28007, Madrid, Spain
- Facultad de Medicina, Universidad Complutense de Madrid, Pza. Ramón y Cajal, s/n, Ciudad Universitaria, 28040, Madrid, Spain
| | - Maria S Guillem
- ITACA, Universitat Politècnica de Valencia, 1ªplanta, Edificio 8G, Ciudad Politécnica de la Innovación, Camino de Vera s/n, 46022, Valencia, Spain.
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Kogawa R, Okumura Y, Watanabe I, Kofune M, Nagashima K, Mano H, Sonoda K, Sasaki N, Iso K, Takahashi K, Ohkubo K, Nakai T, Hirayama A. Effect of adenosine triphosphate on left atrial electrogram interval and dominant frequency in human atrial fibrillation. J Arrhythm 2015; 31:381-7. [PMID: 26702319 PMCID: PMC4672075 DOI: 10.1016/j.joa.2015.07.001] [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: 05/20/2015] [Revised: 06/28/2015] [Accepted: 07/02/2015] [Indexed: 11/26/2022] Open
Abstract
Background Complex fractionated atrial electrograms (CFAEs) and high dominant frequency (DF) are targets for atrial fibrillation (AF) ablation. Although adenosine triphosphate (ATP) is known to promote AF by shortening the atrial refractory period, its role in the pathogenesis of CFAEs and DF during AF is not fully understood. Methods We recorded electrical activity from a 64-electrode basket catheter placed in the left atrium (LA) of patients with paroxysmal AF (PAF, n=18) or persistent AF (PerAF, n=19) before ablation. Atrial electrogram fractionation intervals (FIs) and DFs were measured from bipolar electrograms of each adjacent electrode pair. Offline mean atrial FIs and DFs were obtained before bolus injection of 30 mg ATP. Peak effect was defined as an R–R interval >3 s. Results With ATP, the mean FI decreased (from 110.4±29.1 ms to 90.5±24.7 ms, P<0.0001) and DF increased (from 6.4±0.6 Hz to 7.1±0.8 Hz, P<0.0001) in all patients. There was no difference in the FI decrease between the two groups (−20.3±20.5 ms vs. −19.6±14.5 ms, P=0.6032), but the increase in DF was significantly greater in PAF patients (1.1±0.8 Hz vs. 0.3±0.6 Hz, P=0.0051). Conclusions ATP shortens atrial FIs and increases DFs in both PAF and PerAF patients. The significant increase in DF in PAF patients suggests that pathophysiologic characteristics related to the frequency of atrial fractionation change as atrial remodeling progresses.
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Affiliation(s)
- Rikitake Kogawa
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Ichiro Watanabe
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Masayoshi Kofune
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Koichi Nagashima
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Hiroaki Mano
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Kazumasa Sonoda
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Naoko Sasaki
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Kazuki Iso
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Keiko Takahashi
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Kimie Ohkubo
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Toshiko Nakai
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Atsushi Hirayama
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
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Biviano AB, Ciaccio EJ, Knotts R, Fleitman J, Lawrence J, Iyer V, Whang W, Garan H. Atrial electrogram discordance during baseline vs reinduced atrial fibrillation: Potential ramifications for ablation procedures. Heart Rhythm 2015; 12:1448-55. [PMID: 25818256 PMCID: PMC4485587 DOI: 10.1016/j.hrthm.2015.03.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Indexed: 11/20/2022]
Abstract
BACKGROUND There are scant data comparing the electrogram (EGM) signal characteristics of atrial fibrillation (AF) at baseline vs electrically induced states during ablation procedures. OBJECTIVE The purpose of this study was to use novel intracardiac signal analysis techniques to gain insights into the effects of catheter ablation and AF reinduction on AF EGMs in patients with persistent AF. METHODS We collected left atrial EGMs in patients undergoing first ablation for persistent AF at 3 time intervals: (1) AF at baseline; (2) AF after pulmonary vein isolation (PVI); and (3) AF after post-PVI cardioversion and subsequent reinduction. We analyzed 2 EGM spectral characteristics: (1) dominant frequency and (2) spectral complexity; and 2 EGM morphologic characteristics: (1) morphology variation and (2) pattern repetitiveness. RESULTS There were no differences in AF dominant frequency, dominant amplitude, spectral complexity, or metrics of EGM morphology or repetitiveness at baseline vs after PVI. However, dominant frequency, dominant amplitude, and spectral complexity differed significantly after direct current cardioversion and reinduction of AF. CONCLUSION The frequency, spectral complexity, and local EGM morphologies of AF do not significantly change over the course of a PVI procedure in patients with persistent AF. However, reinduction of AF after direct current cardioversion results in different dominant frequency and spectral complexity, consistent with a change in the characteristics of the perpetuating source(s) of the newly induced AF. These data suggest that AF properties can vary significantly between baseline and reinduced AF, with potential clinical ramifications for outcomes of catheter ablation procedures.
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Affiliation(s)
- Angelo B Biviano
- Department of Medicine, Cardiology Division, Columbia University College of Physicians and Surgeons, New York, New York.
| | - Edward J Ciaccio
- Department of Medicine, Cardiology Division, Columbia University College of Physicians and Surgeons, New York, New York
| | - Robert Knotts
- Department of Medicine, Cardiology Division, Columbia University College of Physicians and Surgeons, New York, New York
| | - Jessica Fleitman
- Department of Medicine, Cardiology Division, Columbia University College of Physicians and Surgeons, New York, New York
| | - John Lawrence
- Department of Medicine, Cardiology Division, Columbia University College of Physicians and Surgeons, New York, New York
| | - Vivek Iyer
- Department of Medicine, Cardiology Division, Columbia University College of Physicians and Surgeons, New York, New York
| | - William Whang
- Department of Medicine, Cardiology Division, Columbia University College of Physicians and Surgeons, New York, New York
| | - Hasan Garan
- Department of Medicine, Cardiology Division, Columbia University College of Physicians and Surgeons, New York, New York
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Okumura Y, Watanabe I, Nagashima K, Sonoda K, Sasaki N, Kogawa R, Takahashi K, Iso K, Ohkubo K, Nakai T, Takahashi R, Taniguchi Y, Mitsumata M, Nikaido M, Hirayama A. Effects of a high-fat diet on the electrical properties of porcine atria. J Arrhythm 2015; 31:352-8. [PMID: 26702314 PMCID: PMC4672030 DOI: 10.1016/j.joa.2015.05.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 04/06/2015] [Accepted: 05/11/2015] [Indexed: 11/10/2022] Open
Abstract
Background Because obesity is an important risk factor for atrial fibrillation (AF), we conducted an animal study to examine the effect of a high-fat diet (HFD) on atrial properties and AF inducibility. Methods Ten 8-week-old pigs (weight, 18–23 kg) were divided into two groups. For 18 weeks, five pigs were fed a HFD (HFD group) and five were fed a normal diet (control group). Maps of atrial activation and voltages during sinus rhythm were created for all pigs using the EnSite NavX system. Effective refractory period (ERP) and AF inducibility were also determined. When AF was induced, complex fractionated atrial electrogram (CFAE) mapping was performed. At 18 weeks, hearts were removed for comparing the results of histological analysis between the two groups. Body weight, lipid levels, hemodynamics, cardiac structures, and electrophysiological properties were also compared. Results Total cholesterol levels were significantly higher (347 [191–434] vs. 81 [67–88] mg/dL, P=0.0088), and left atrium pressure was higher (34.5 [25.6–39.5] vs. 24.5 [21.3–27.8] mmHg, P=0.0833) in the HFD group than in the control group, although body weight only increased marginally (89 [78–101] vs. 70 [66–91] kg, P=0.3472). ERPs of the pulmonary vein (PV) were shorter (P<0.05) and AF lasted longer in the HFD group than in the control group (80 [45–1350] vs. 22 [3–30] s, P=0.0212). Neither CFAE site distribution nor histopathological characteristics differed between the two groups. Conclusions The shorter ERPs for the PV observed in response to the HFD increased vulnerability to AF, and these electrophysiological characteristics may underlie obesity-related AF.
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Affiliation(s)
- Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Ichiro Watanabe
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Koichi Nagashima
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Kazumasa Sonoda
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Naoko Sasaki
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Rikitake Kogawa
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Keiko Takahashi
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Kazuki Iso
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Kimie Ohkubo
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Toshiko Nakai
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Rie Takahashi
- Department of Advanced Cardiovascular Imaging, Nihon University School of Medicine, Tokyo, Japan
| | - Yoshiki Taniguchi
- Institute of Medical Science, Medical Research Support Center, Section of Laboratory for Animal Experiments, Nihon University School of Medicine, Tokyo, Japan
| | - Masako Mitsumata
- Department of Pathology, Nihon University School of Medicine, Tokyo, Japan
| | | | - Atsushi Hirayama
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
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Hwang SH, Oh YW, Lee DI, Shim J, Park SW, Kim YH. Relation between left atrial wall composition by late gadolinium enhancement and complex fractionated atrial electrograms in patients with persistent atrial fibrillation: influence of non-fibrotic substrate in the left atrium. Int J Cardiovasc Imaging 2015; 31:1191-9. [DOI: 10.1007/s10554-015-0675-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Accepted: 05/06/2015] [Indexed: 02/05/2023]
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43
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Gal P, Linnenbank AC, Adiyaman A, Smit JJJ, Ramdat Misier AR, Delnoy PPH, de Bakker JM, Elvan A. Correlation of atrial fibrillation cycle length and fractionation is associated with atrial fibrillation free survival. Int J Cardiol 2015; 187:208-15. [DOI: 10.1016/j.ijcard.2015.03.284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 01/06/2015] [Accepted: 03/03/2015] [Indexed: 10/23/2022]
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Atienza F, Climent AM, Guillem MS, Berenfeld O. Frontiers in Non-invasive Cardiac Mapping: Rotors in Atrial Fibrillation-Body Surface Frequency-Phase Mapping. Card Electrophysiol Clin 2015; 7:59-69. [PMID: 25729463 DOI: 10.1016/j.ccep.2014.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Experimental and clinical data demonstrate that atrial fibrillation (AF) maintenance in animals and groups of patients depends on localized reentrant sources localized primarily to the pulmonary veins (PVs) and the left atrium(LA) posterior wall in paroxysmal AF but elsewhere, including the right atrium (RA), in persistent AF. Moreover, AF can be eliminated by directly ablating AF-driving sources or "rotors," that exhibit high-frequency, periodic activity. The RADAR-AF randomized trial demonstrated that an ablation procedure based on a more target-specific strategy aimed at eliminating high frequency sites responsible for AF maintenance is as efficacious as and safer than empirically isolating all the PVs. In contrast to the standard ECG, global atrial noninvasive frequency analysis allows non-invasive identification of high-frequency sources before the arrival at the electrophysiology laboratory for ablation. Body surface potential map (BSPM) replicates the endocardial distribution of DFs with localization of the highest DF (HDF) and can identify small areas containing the high-frequency sources. Overall, BSPM had a sensitivity of 75% and specificity of 100% for capturing intracardiac EGMs as having LARA DF gradient. However, raw BSPM data analysis of AF patterns of activity showed incomplete and instable reentrant patterns of activation. Thus, we developed an analysis approach whereby a narrow band-pass filtering allowed selecting the electrical activity projected on the torso at the HDF, which stabilized the projection of rotors that potentially drive AF on the surface. Consequently, driving reentrant patterns ("rotors") with spatiotemporal stability during >70% of the AF time could be observed noninvasibly after HDF-filtering. Moreover, computer simulations found that the combination of BSPM phase mapping with DF analysis enabled the discrimination of true rotational patterns even during the most complex AF. Altogether, these studies show that the combination of DF analysis with phase maps of HDF-filtered surface ECG recordings allows noninvasive localization of atrial reentries during AF and further a physiologically-based rationale for personalized diagnosis and treatment of patients with AF.
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Affiliation(s)
- Felipe Atienza
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - María S Guillem
- Bio-ITACA, Universitat Politécnica de Valencia, Valencia, Spain
| | - Omer Berenfeld
- Center for Arrhythmia Research, University of Michigan, Ann Arbor, Michigan
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Park J, Pak HN. Elimination Of Triggers Without An Additional Substrate Modification Is Not Sufficient In Patients With Persistent Atrial Fibrillation. J Atr Fibrillation 2015; 7:1207. [PMID: 27957155 DOI: 10.4022/jafib.1207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 01/30/2015] [Accepted: 01/30/2015] [Indexed: 11/10/2022]
Abstract
Atrial fibrillation (AF) is a multifactorial disease with complex pathophysiology. Although restoring sinus rhythm delays the progression of atrial remodeling, non-pharmacologic intervention, such as radiofrequency catheter ablation (RFCA), should be done based on the background pathophysiology of the disease. While circumferential pulmonary vein isolation (CPVI) has been known to be the cornerstone of AF catheter ablation, a clinical recurrence rate after CPVI is high in patients with persistent AF (PeAF). Step-wise linear ablation, complex fractionate atrial electrogram (CFAE)-guided ablation, rotor ablation, ganglionate plexus ablation, and left atrial appendage isolation may improve the ablation success rate after CPVI. But, there are still substantial AF recurrences after such liberal atrial substrate ablation, and current ablation techniques regarding substrate modification still have limitations. Therefore, more understanding about AF pathophysiology and early precise intervention may improve clinical outcome of AF management. Keeping in mind "more touch, more scar," operators should generate most efficient substrate modification to achieve better long-term clinical outcome.
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Affiliation(s)
- Junbeom Park
- Yonsei University Health System, Seoul, Republic of Korea
| | - Hui-Nam Pak
- Yonsei University Health System, Seoul, Republic of Korea
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Location of epicardial adipose tissue affects the efficacy of a combined dominant frequency and complex fractionated atrial electrogram ablation of atrial fibrillation. Heart Rhythm 2015; 12:257-65. [DOI: 10.1016/j.hrthm.2014.10.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Indexed: 11/13/2022]
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Comparison of Radiofrequency Catheter Ablation of Drivers and Circumferential Pulmonary Vein Isolation in Atrial Fibrillation. J Am Coll Cardiol 2014; 64:2455-67. [DOI: 10.1016/j.jacc.2014.09.053] [Citation(s) in RCA: 172] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 08/31/2014] [Accepted: 09/05/2014] [Indexed: 12/22/2022]
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Rodrigo M, Pedrón-Torecilla J, Hernández I, Liberos A, Climent AM, Guillem MS. Data analysis in cardiac arrhythmias. Methods Mol Biol 2014; 1246:217-35. [PMID: 25417089 DOI: 10.1007/978-1-4939-1985-7_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Cardiac arrhythmias are an increasingly present in developed countries and represent a major health and economic burden. The occurrence of cardiac arrhythmias is closely linked to the electrical function of the heart. Consequently, the analysis of the electrical signal generated by the heart tissue, either recorded invasively or noninvasively, provides valuable information for the study of cardiac arrhythmias. In this chapter, novel cardiac signal analysis techniques that allow the study and diagnosis of cardiac arrhythmias are described, with emphasis on cardiac mapping which allows for spatiotemporal analysis of cardiac signals.Cardiac mapping can serve as a diagnostic tool by recording cardiac signals either in close contact to the heart tissue or noninvasively from the body surface, and allows the identification of cardiac sites responsible of the development or maintenance of arrhythmias. Cardiac mapping can also be used for research in cardiac arrhythmias in order to understand their mechanisms. For this purpose, both synthetic signals generated by computer simulations and animal experimental models allow for more controlled physiological conditions and complete access to the organ.
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Affiliation(s)
- Miguel Rodrigo
- BIO-ITACA, Universitat Politècnica de València, Edificio 8G, Camino de Vera, S/N, 46022, Valencia, Spain
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Kogawa R, Okumura Y, Watanabe I, Kofune M, Nagashima K, Mano H, Sonoda K, Sasaki N, Ohkubo K, Nakai T, Hirayama A. Spatial and temporal variability of the complex fractionated atrial electrogram activity and dominant frequency in human atrial fibrillation. J Arrhythm 2014; 31:101-7. [PMID: 26336540 DOI: 10.1016/j.joa.2014.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 07/30/2014] [Accepted: 08/05/2014] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND The presence of complex fractionated atrial electrograms (CFAEs) and high dominant frequencies (DFs) during atrial fibrillation (AF) have been demonstrated to be related to AF maintenance. Therefore, sequential mapping of CFAEs and DFs have been used for target sites of AF ablation. However, such mapping strategies are valid only if the CFAEs and DFs are spatiotemporally stable during the mapping procedure. We obtained spatially stable multi-electrode recordings to assess the spatiotemporal stability of CFAEs and DFs. METHODS We recorded electrical activity during AF for 10 min with a 64-electrode basket catheter (48 bipole electrode pairs) placed in the left atrium in 36 patients with AF (paroxysmal AF [PAF], n=16; persistent AF [PerAF], n=20). The spatial and temporal distribution of the CFAEs (fractionation interval <120 ms) and high DFs (>8 Hz) at 1-min intervals for 10 min were compared for each of the 48 bipoles. RESULTS The baseline CFAEs were located at 68.5±14.0% (32.9±6.7) of the 48 bipoles; however, the high DF sites were fewer (9.6±8.6% [4.6±4.1 bipoles]). The CFAEs sites did not change significantly during the 10-min recording period (kappa statistic: 0.71±0.24); however, the high DF sites changed significantly (kappa statistic: 0.07±0.19). These spatiotemporal changes in the CFAEs and high DFs did not differ between patients with PAF and PerAF. CONCLUSIONS Regardless of the AF type, CFAEs sites, but not high DF sites, showed a high degree of spatial and temporal stability.
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Key Words
- 3D, 3-dimensional
- AF, atrial fibrillation
- Atrial fibrillation
- Basket catheter
- CFAE, complex fractionated atrial electrogram
- Complex fractionated atrial electrogram
- DF, dominant frequency
- Dominant frequency
- FI, fractionation interval
- LA, left atrium
- LAA, left atrial appendage
- LV, left ventricle
- MAP, monophasic action potential
- PV, pulmonary vein
- PVI, pulmonary vein isolation
- PerAF, persistent AF
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Affiliation(s)
- Rikitake Kogawa
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Ichiro Watanabe
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Masayoshi Kofune
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Koichi Nagashima
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Hiroaki Mano
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Kazumasa Sonoda
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Naoko Sasaki
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Kimie Ohkubo
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Toshiko Nakai
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | - Atsushi Hirayama
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
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Abramic A, Martínez-Alzamora N, González Del Rio Rams J, Barrachina T, Polo JF. New methodology for analysing and increasing the cost-efficiency of environmental monitoring networks. MARINE POLLUTION BULLETIN 2014; 86:161-173. [PMID: 25107342 DOI: 10.1016/j.marpolbul.2014.07.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2013] [Revised: 07/17/2014] [Accepted: 07/20/2014] [Indexed: 06/03/2023]
Abstract
This study focuses on the coastal monitoring network established in the scope of WFD implementation. The objective of this network was to provide an ecological assessment of Valencian coastal waters. After three years, sufficient data had been collected to enable us to analyse and explore ways to increase the network's efficiency. A methodology was developed to select the best subset of sampling stations to be surveyed. This method was approached from the perspective of an inter-observer variability problem. In order to compare the concordance between the k-observers and the reference observer, two measures were considered: euclidean distance, and interclass correlation coefficient. The obtained results confirm that the current network can be reduced by over 50% and still guarantee accurate results. This methodology (not limited by indicators, geographically, or by type of water body) could be applied to different environmental monitoring networks and could significantly decrease the efforts and costs required by the WFD.
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Affiliation(s)
- Andrej Abramic
- Department of Hydraulic Engineering and the Environment, Universitat Politècnica de València, Camino de Vera s/n, 46022 Valencia, Spain; Institute for Industrial, Radiophysical, and Environmental Safety, Universitat Politècnica de València, Camino de Vera s/n, 46022 Valencia, Spain.
| | - Nieves Martínez-Alzamora
- Department of Applied Statistics, Operational Research, and Quality, Universitat Politècnica de València, Camino de Vera s/n, 46022 Valencia, Spain; Institute for Industrial, Radiophysical, and Environmental Safety, Universitat Politècnica de València, Camino de Vera s/n, 46022 Valencia, Spain.
| | - Julio González Del Rio Rams
- Water and Environmental Engineering Research Institute, Universitat Politècnica de València, Camino de Vera s/n, 46022 Valencia, Spain; Institute for Industrial, Radiophysical, and Environmental Safety, Universitat Politècnica de València, Camino de Vera s/n, 46022 Valencia, Spain
| | - Teresa Barrachina
- Water and Environmental Engineering Research Institute, Universitat Politècnica de València, Camino de Vera s/n, 46022 Valencia, Spain; Institute for Industrial, Radiophysical, and Environmental Safety, Universitat Politècnica de València, Camino de Vera s/n, 46022 Valencia, Spain
| | - José Ferrer Polo
- Water and Environmental Engineering Research Institute, Universitat Politècnica de València, Camino de Vera s/n, 46022 Valencia, Spain; Institute for Industrial, Radiophysical, and Environmental Safety, Universitat Politècnica de València, Camino de Vera s/n, 46022 Valencia, Spain
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