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Vraka A, Moreno-Arribas J, Gracia-Baena JM, Hornero F, Alcaraz R, Rieta JJ. The Relevance of Heart Rate Fluctuation When Evaluating Atrial Substrate Electrical Features in Catheter Ablation of Paroxysmal Atrial Fibrillation. J Cardiovasc Dev Dis 2022; 9:176. [PMID: 35735805 PMCID: PMC9224671 DOI: 10.3390/jcdd9060176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/23/2022] [Accepted: 05/30/2022] [Indexed: 12/10/2022] Open
Abstract
Coronary sinus (CS) catheterization is critical during catheter ablation (CA) of atrial fibrillation (AF). However, the association of CS electrical activity with atrial substrate modification has been barely investigated and mostly limited to analyses during AF. In sinus rhythm (SR), atrial substrate modification is principally assessed at a global level through P-wave analysis. Cross-correlating CS electrograms (EGMs) and P-waves’ features could potentiate the understanding of AF mechanisms. Five-minute surface lead II and bipolar CS recordings before, during, and after CA were acquired from 40 paroxysmal AF patients. Features related to duration, amplitude, and heart-rate variability of atrial activations were evaluated. Heart-rate adjustment (HRA) was applied. Correlations between each P-wave and CS local activation wave (LAW) feature were computed with cross-quadratic sample entropy (CQSE), Pearson correlation (PC), and linear regression (LR) with 10-fold cross-validation. The effect of CA between different ablation steps was compared with PC. Linear correlations: poor to mediocre before HRA for analysis at each P-wave/LAW (PC: max. +18.36%, p = 0.0017, LR: max. +5.33%, p = 0.0002) and comparison between two ablation steps (max. +54.07%, p = 0.0205). HRA significantly enhanced these relationships, especially in duration (P-wave/LAW: +43.82% to +69.91%, p < 0.0001 for PC and +18.97% to +47.25%, p < 0.0001 for LR, CA effect: +53.90% to +85.72%, p < 0.0210). CQSE reported negligent correlations (0.6−1.2). Direct analysis of CS features is unreliable to evaluate atrial substrate modification due to CA. HRA substantially solves this problem, potentiating correlation with P-wave features. Hence, its application is highly recommended.
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Affiliation(s)
- Aikaterini Vraka
- BioMIT.org, Electronic Engineering Department, Universitat Politecnica de Valencia, 46022 Valencia, Spain;
| | - José Moreno-Arribas
- Cardiology Department, Saint John’s University Hospital, 03550 Alicante, Spain;
| | - Juan M. Gracia-Baena
- Cardiovascular Surgery Department, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain; (J.M.G.-B.); (F.H.)
| | - Fernando Hornero
- Cardiovascular Surgery Department, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain; (J.M.G.-B.); (F.H.)
| | - Raúl Alcaraz
- Research Group in Electronic, Biomedical and Telecommunication Engineering, University of Castilla-La Mancha, 16071 Cuenca, Spain;
| | - José J. Rieta
- BioMIT.org, Electronic Engineering Department, Universitat Politecnica de Valencia, 46022 Valencia, Spain;
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Arslan S, Balaban Kocas B, Dogan O, Tanyolac S, Uzunhasan I. The Relationship between Intracardiac Atrial Sensing Values and Atrial High-rate Episodes in Patients With Permanent Pacemakers Implanted due to Sick Sinus Syndrome. HASEKI TIP BÜLTENI 2022. [DOI: 10.4274/haseki.galenos.2021.7732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Koh M, Uemura H, Kada A, Kagisaki K, Hagino I, Yagihara T. Chronologic changes in P-wave characteristics after the Fontan procedure: The effect of surgical modification. J Thorac Cardiovasc Surg 2010; 140:137-43. [DOI: 10.1016/j.jtcvs.2010.03.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2009] [Revised: 01/12/2010] [Accepted: 03/13/2010] [Indexed: 11/16/2022]
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van Diepen S, Siha H, Fu Y, Westerhout CM, Lopes RD, Granger CB, Armstrong PW. Do baseline atrial electrocardiographic and infarction patterns predict new-onset atrial fibrillation after ST-elevation myocardial infarction? Insights from the Assessment of Pexelizumab in Acute Myocardial Infarction Trial. J Electrocardiol 2010; 43:351-8. [DOI: 10.1016/j.jelectrocard.2010.04.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Indexed: 10/19/2022]
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Holmqvist F, Platonov PG, McNitt S, Polonsky S, Carlson J, Zareba W, Moss AJ. Abnormal P-wave morphology is a predictor of atrial fibrillation development and cardiac death in MADIT II patients. Ann Noninvasive Electrocardiol 2010; 15:63-72. [PMID: 20146784 DOI: 10.1111/j.1542-474x.2009.00341.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Several ECG-based approaches have been shown to add value when risk-stratifying patients with congestive heart failure, but little attention has been paid to the prognostic value of abnormal atrial depolarization in this context. The aim of this study was to noninvasively analyze the atrial depolarization phase to identify markers associated with increased risk of mortality, deterioration of heart failure, and development of atrial fibrillation (AF) in a high-risk population with advanced congestive heart failure and a history of acute myocardial infarction. METHODS Patients included in the Multicenter Automatic Defibrillator Implantation Trial II (MADIT II) with sinus rhythm at baseline were studied (n = 802). Unfiltered and band-pass filtered signal-averaged P waves were analyzed to determine orthogonal P-wave morphology (prespecified types 1, 2, and 3/atypical), P-wave duration, and RMS20. The association between P-wave parameters and data on the clinical course and cardiac events during a mean follow-up of 20 months was analyzed. RESULTS P-wave duration was 139 + or - 23 ms and the RMS20 was 1.9 + or - 1.1 microV. None of these parameters was significantly associated with poor cardiac outcome or AF development. After adjustment for clinical covariates, abnormal P-wave morphology was found to be independently predictive of nonsudden cardiac death (HR 2.66; 95% CI 1.41-5.04, P = 0.0027) and AF development (HR 1.75; 95% CI 1.10-2.79, P = 0.019). CONCLUSION Abnormalities in P-wave morphology recorded from orthogonal leads in surface ECG are independently predictive of increased risk of nonsudden cardiac death and AF development in MADIT II patients.
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Affiliation(s)
- Fredrik Holmqvist
- Department of Cardiology, Lund University Hospital, SE-221 85 Lund, Sweden.
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Roberts-Thomson KC, Sanders P, Kalman JM. Sinus Node Disease: An Idiopathic Right Atrial Myopathy. Trends Cardiovasc Med 2007; 17:211-4. [PMID: 17662917 DOI: 10.1016/j.tcm.2007.06.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2007] [Revised: 06/05/2007] [Accepted: 06/12/2007] [Indexed: 11/30/2022]
Abstract
Sinus node disease was previously thought to be a disease limited to the sinus node and its atrial connections. However, recent reports have demonstrated sinus node disease as a disease of the entire right atrial myocardium. These patients have widespread electrophysiological abnormalities of their atria, including prolonged refractory periods and slowed conduction. In addition to these electrical changes, there are significant structural changes, such as fibrosis and fatty infiltration, which can be detected endocardially as regions of fractionated signals, low-voltage electrograms, and electrically silent areas. In most cases, the etiology of these changes is unknown. These changes may contribute to the high prevalence of atrial fibrillation seen in patients with sinus node disease.
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Ozmen N, Cebeci BS, Yiginer O, Muhcu M, Kardesoglu E, Dincturk M. P-wave dispersion is increased in pregnancy due to shortening of minimum duration of P: does this have clinical significance? J Int Med Res 2007; 34:468-74. [PMID: 17133775 DOI: 10.1177/147323000603400503] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Most pregnant women complain of palpitation, and various kinds of arrhythmias can be observed during pregnancy. We investigated P-wave and QT dispersion during pregnancy. Healthy pregnant women (n=162) and healthy age-matched, non-pregnant women (n=150) were included. We performed electrocardiography and transthoracic echocardiography and determined serum oestradiol levels in both groups, and performed Holter monitoring in the pregnant group only. Resting heart rate, P-wave dispersion, left ventricular diastolic diameter, left atrial diameter and serum oestradiol levels in the pregnant group were significantly higher than in the control group. Minimum P-wave duration was shorter in the control group than in the pregnant group; however, there was no statistically significant difference in maximum P wavelength and corrected QT dispersion between the groups. No atrial fibrillation was detected in the pregnant group during Holter monitoring. Shortening of the minimum P-wave duration leads to increased P-wave dispersion during pregnancy. In contrast to other pathologies with increased P-wave dispersion, paroxysmal atrial fibrillation is absent in pregnant women; this may be a result of the stable maximum P wavelength that is present during pregnancy.
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Affiliation(s)
- N Ozmen
- Department of Cardiology, Gulhane Military Medical Academy, Haydarpasa Teaching Hospital, Istanbul, Turkey.
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Husser D, Stridh M, Sornmo L, Platonov P, Olsson SB, Bollmann A. Analysis of the surface electrocardiogram for monitoring and predicting antiarrhythmic drug effects in atrial fibrillation. Cardiovasc Drugs Ther 2005; 18:377-86. [PMID: 15717140 DOI: 10.1007/s10557-005-5062-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Specific antiarrhythmic therapy with class I and III drugs for atrial fibrillation (AF) conversion and prevention of its recurrence is frequently utilized in clinical practice. Besides being only moderate effective, the utilization of antiarrhythmic drugs may be associated with serious side effects. In the clinical setting it is difficult to directly evaluate the effects of antiarrhythmic drugs on the individual patient's atrial electrophysiology, thereby predicting their efficacy in restoring and maintaining sinus rhythm. Analysis of the surface electrocardiogram in terms of P-wave signal averaged ECG during sinus rhythm and spectral characterization of fibrillatory waves during AF for evaluation of atrial antiarrhythmic drug effects is a new field of investigation. Both techniques provide reproducible parameters for characterizing atrial electrical abnormalities and seem to contain prognostic information regarding antiarrhythmic drug efficacy. Further research is needed which elucidates the most challenging clinical questions in AF management whom to place on antiarrhythmic drug treatment and what antiarrhythmic drug to prescribe. Analysis of the surface ECG might have the potential to answer these questions.
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Affiliation(s)
- Daniela Husser
- Los Angeles Biomedical Research Institute at Harbor-UCLA, Los Angeles, CA, USA
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Kristensen L, Nielsen JC, Mortensen PT, Christensen PD, Vesterlund T, Pedersen AK, Andersen HR. Sinus and Paced P Wave Duration and Dispersion as Predictors of Atrial Fibrillation After Pacemaker Implantation in Patients with Isolated Sick Sinus Syndrome. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2004; 27:606-14. [PMID: 15125716 DOI: 10.1111/j.1540-8159.2004.00494.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The aim of this study was to prospectively evaluate the sinus and the paced P wave duration and dispersion as predictors of AF after pacemaker implantation in patients with isolated sick sinus syndrome (SSS). The study included 109 (69 women, mean age 72 +/- 11 years) patients with SSS, 59 with bradycardia-tachycardia syndrome (BTS). A 12-lead ECG was recorded before pacemaker implantation and during high right atrial and septal right atrial pacing at 70 and 100 beats/min. The ECGs were scanned into a computer and analyzed on screen. The patients were treated with AAIR (n = 52) or DDDR pacing. The P wave duration was measured in each lead and mean P wave duration and P wave dispersion were calculated for each ECG. AF during follow-up was defined as: AF in an ECG at or between follow-up visits; an atrial high rate episode with a rate of > or =220 beats/min for > or =5 minutes, atrial sensing with a rate of > or =170 beats/min in > or =5% of total counted beats, mode-switching in >/=5% of total time recorded, or a mode switching episode of > or =5 minutes recorded by the pacemaker telemetry. The ECG parameters were correlated to AF during follow-up. Mean follow-up was 1.5 +/- 0.9 years. None of the ECG parameters differed between patients with AF and patients without AF during follow-up, nor was there any difference between groups after correction for BTS and age. BTS was the strongest predictor of AF during follow-up (P < 0.001). P wave duration and dispersion measured before and during pacemaker implantation were not predictive of AF after pacemaker implantation in patients with isolated SSS.
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Affiliation(s)
- Lene Kristensen
- Department of Cardiology, Skejby Hospital, Aarhus University Hospital, Aarhus, Denmark
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Sanders P, Morton JB, Kistler PM, Spence SJ, Davidson NC, Hussin A, Vohra JK, Sparks PB, Kalman JM. Electrophysiological and electroanatomic characterization of the atria in sinus node disease: evidence of diffuse atrial remodeling. Circulation 2004; 109:1514-22. [PMID: 15007004 DOI: 10.1161/01.cir.0000121734.47409.aa] [Citation(s) in RCA: 211] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The normal sinus pacemaker complex is an extensive structure within the right atrium. We hypothesized that patients with sinus node disease (SND) would have evidence of diffuse atrial abnormalities. METHODS AND RESULTS Sixteen patients with symptomatic SND and 16 age-matched controls were studied. The following were evaluated: effective refractory periods (ERPs) from the high and low lateral right atrium (RA), high septal RA, and distal coronary sinus (CS); conduction time along the CS and lateral RA; P-wave duration; and conduction at the crista terminalis. Electroanatomic mapping was performed to define the sinus node complex and determine regional conduction velocity, double potentials, fractionated electrograms, regional voltage, and areas of electrical silence. Patients with SND demonstrated significant increase in atrial ERP at all right atrial sites, increased atrial conduction time along the lateral RA and CS, prolongation of the P-wave duration, and greater number and duration of double potentials along the crista terminalis. Electroanatomic mapping demonstrated the sinus node complex in SND to be more often unicentric, localized to the low crista terminalis at the site of the largest residual voltage amplitude. There was significant regional conduction slowing with double potentials and fractionation associated with areas of low voltage and electrical silence (or scar). CONCLUSIONS SND is associated with diffuse atrial remodeling characterized by structural change, conduction abnormalities, and increased right atrial refractoriness. There was a change in the nature of sinus pacemaker activity with loss of the normal multicentric pattern of activation, caudal shift of the pacemaker complex, and abnormal and circuitous conduction around lines of conduction block.
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Affiliation(s)
- Prashanthan Sanders
- Department of Cardiology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
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