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Meo M, Pambrun T, Derval N, Dumas-Pomier C, Puyo S, Duchâteau J, Jaïs P, Hocini M, Haïssaguerre M, Dubois R. Noninvasive Assessment of Atrial Fibrillation Complexity in Relation to Ablation Characteristics and Outcome. Front Physiol 2018; 9:929. [PMID: 30065663 PMCID: PMC6056813 DOI: 10.3389/fphys.2018.00929] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 06/25/2018] [Indexed: 01/01/2023] Open
Abstract
Background: The use of surface recordings to assess atrial fibrillation (AF) complexity is still limited in clinical practice. We propose a noninvasive tool to quantify AF complexity from body surface potential maps (BSPMs) that could be used to choose patients who are eligible for AF ablation and assess therapy impact. Methods: BSPMs (mean duration: 7 ± 4 s) were recorded with a 252-lead vest in 97 persistent AF patients (80 male, 64 ± 11 years, duration 9.6 ± 10.4 months) before undergoing catheter ablation. Baseline cycle length (CL) was measured in the left atrial appendage. The procedural endpoint was AF termination. The ablation strategy impact was defined in terms of number of regions ablated, radiofrequency delivery time to achieve AF termination, and acute outcome. The atrial fibrillatory wave signal extracted from BSPMs was divided in 0.5-s consecutive segments, each projected on a 3D subspace determined through principal component analysis (PCA) in the current frame. We introduced the nondipolar component index (NDI) that quantifies the fraction of energy retained after subtracting an equivalent PCA dipolar approximation of heart electrical activity. AF complexity was assessed by the NDI averaged over the entire recording and compared to ablation strategy. Results: AF terminated in 77 patients (79%), whose baseline AF CL was 177 ± 40 ms, whereas it was 157 ± 26 ms in patients with unsuccessful ablation outcome (p = 0.0586). Mean radiofrequency emission duration was 35 ± 21 min; 4 ± 2 regions were targeted. Long-lasting AF patients (≥12 months) exhibited higher complexity, with higher NDI values (≥12 months: 0.12 ± 0.04 vs. <12 months: 0.09 ± 0.03, p < 0.01) and short CLs (<160 ms: 0.12 ± 0.03 vs. between 160 and 180 ms: 0.10 ± 0.03 vs. >180 ms: 0.09 ± 0.03, p < 0.01). More organized AF as measured by lower NDI was associated with successful ablation outcome (termination: 0.10 ± 0.03 vs. no termination: 0.12 ± 0.04, p < 0.01), shorter procedures (<30 min: 0.09 ± 0.04 vs. ≥30 min: 0.11 ± 0.03, p < 0.001) and fewer ablation targets (<4: 0.09 ± 0.03 vs. ≥4: 0.11 ± 0.04, p < 0.01). Conclusions: AF complexity can be noninvasively quantified by PCA in BSPMs and correlates with ablation outcome and AF pathophysiology.
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Affiliation(s)
- Marianna Meo
- Institute of Electrophysiology and Heart Modeling (IHU Liryc), Foundation Bordeaux University, Pessac-Bordeaux, France.,University of Bordeaux, CRCTB, U1045, Bordeaux, France.,INSERM, CRCTB, U1045, Bordeaux, France
| | - Thomas Pambrun
- Institute of Electrophysiology and Heart Modeling (IHU Liryc), Foundation Bordeaux University, Pessac-Bordeaux, France.,Bordeaux University Hospital Centre Hospitalier Universitaire, Electrophysiology and Ablation Unit, Pessac, France
| | - Nicolas Derval
- Institute of Electrophysiology and Heart Modeling (IHU Liryc), Foundation Bordeaux University, Pessac-Bordeaux, France.,Bordeaux University Hospital Centre Hospitalier Universitaire, Electrophysiology and Ablation Unit, Pessac, France
| | | | - Stéphane Puyo
- Institute of Electrophysiology and Heart Modeling (IHU Liryc), Foundation Bordeaux University, Pessac-Bordeaux, France.,Bordeaux University Hospital Centre Hospitalier Universitaire, Electrophysiology and Ablation Unit, Pessac, France
| | - Josselin Duchâteau
- Institute of Electrophysiology and Heart Modeling (IHU Liryc), Foundation Bordeaux University, Pessac-Bordeaux, France.,University of Bordeaux, CRCTB, U1045, Bordeaux, France.,INSERM, CRCTB, U1045, Bordeaux, France.,Bordeaux University Hospital Centre Hospitalier Universitaire, Electrophysiology and Ablation Unit, Pessac, France
| | - Pierre Jaïs
- Institute of Electrophysiology and Heart Modeling (IHU Liryc), Foundation Bordeaux University, Pessac-Bordeaux, France.,University of Bordeaux, CRCTB, U1045, Bordeaux, France.,INSERM, CRCTB, U1045, Bordeaux, France.,Bordeaux University Hospital Centre Hospitalier Universitaire, Electrophysiology and Ablation Unit, Pessac, France
| | - Mélèze Hocini
- Institute of Electrophysiology and Heart Modeling (IHU Liryc), Foundation Bordeaux University, Pessac-Bordeaux, France.,University of Bordeaux, CRCTB, U1045, Bordeaux, France.,INSERM, CRCTB, U1045, Bordeaux, France.,Bordeaux University Hospital Centre Hospitalier Universitaire, Electrophysiology and Ablation Unit, Pessac, France
| | - Michel Haïssaguerre
- Institute of Electrophysiology and Heart Modeling (IHU Liryc), Foundation Bordeaux University, Pessac-Bordeaux, France.,University of Bordeaux, CRCTB, U1045, Bordeaux, France.,INSERM, CRCTB, U1045, Bordeaux, France.,Bordeaux University Hospital Centre Hospitalier Universitaire, Electrophysiology and Ablation Unit, Pessac, France
| | - Rémi Dubois
- Institute of Electrophysiology and Heart Modeling (IHU Liryc), Foundation Bordeaux University, Pessac-Bordeaux, France.,University of Bordeaux, CRCTB, U1045, Bordeaux, France.,INSERM, CRCTB, U1045, Bordeaux, France
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Rol del sistema autonómico y la fibrilación auricular. REVISTA COLOMBIANA DE CARDIOLOGÍA 2016. [DOI: 10.1016/j.rccar.2016.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Thanigaimani S, Brooks AG, Kuklik P, Twomey DJ, Franklin S, Noschka E, Chapman D, Pathak RK, Mahajan R, Sanders P, Lau DH. Spatiotemporal characteristics of atrial fibrillation electrograms: A novel marker for arrhythmia stability and termination. J Arrhythm 2016; 33:40-48. [PMID: 28217228 PMCID: PMC5300869 DOI: 10.1016/j.joa.2016.05.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 05/26/2016] [Accepted: 05/27/2016] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Sequentially mapped complex fractionated atrial electrograms (CFAE) and dominant frequency (DF) sites have been targeted during catheter ablation for atrial fibrillation (AF). However, these strategies have yielded variable success and have not been shown to correlate consistently with AF dynamics. Here, we evaluated whether the spatiotemporal stability of CFAE and DF may be a better marker of AF sustenance and termination. METHODS Eighteen sheep with 12 weeks of "one-kidney, one-clip" hypertension underwent open-chest studies. A total of 42 self-terminating (28-100 s) and 6 sustained (>15 min) AF episodes were mapped using a custom epicardial plaque and analyzed in 4-s epochs for CFAE, using the NavX CFE-m algorithm, and DF, using a Fast Fourier Transform. The spatiotemporal stability index (STSI) was calculated using the intraclass correlation coefficient of consecutive AF epochs. RESULTS A total of 67,733 AF epochs were analyzed. During AF initiation, mean CFE-m and the STSI of CFE-m/DF were similar between sustained and self-terminating episodes, although median DF was higher in sustained AF (p=0.001). During sustained AF, the STSI of CFE-m increased significantly (p=0.02), whereas mean CFE-m (p=0.5), median DF (p=0.07), and the STSI of DF remained unchanged (p=0.5). Prior to AF termination, the STSI of CFE-m was significantly lower (p<0.001), with a physiologically non-significant decrease in median DF (-0.3 Hz, p=0.006) and no significant changes in mean CFE-m (p=0.14) or the STSI of DF (p=0.06). CONCLUSIONS Spatiotemporal stabilization of CFAE favors AF sustenance and its destabilization heralds AF termination. The STSI of CFE-m is more representative of AF dynamics than are the STSI of DF, sequential mean CFE-m, or median DF.
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Affiliation(s)
- Shivshankar Thanigaimani
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Anthony G Brooks
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Pawel Kuklik
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Darragh J Twomey
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Samantha Franklin
- School of Animal & Veterinary Sciences, University of Adelaide, Roseworthy, South Australia, Australia
| | - Erik Noschka
- School of Animal & Veterinary Sciences, University of Adelaide, Roseworthy, South Australia, Australia
| | - Darius Chapman
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Rajeev K Pathak
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Rajiv Mahajan
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, SA 5000, Australia
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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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Lau DH, Maesen B, Zeemering S, Kuklik P, Hunnik AV, Lankveld TA, Bidar E, Verheule S, Nijs J, Maessen J, Crijns H, Sanders P, Schotten U. Indices of bipolar complex fractionated atrial electrograms correlate poorly with each other and atrial fibrillation substrate complexity. Heart Rhythm 2015; 12:1415-23. [DOI: 10.1016/j.hrthm.2015.03.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Indexed: 10/23/2022]
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Left atrial electrophysiologic feature specific for the genesis of complex fractionated atrial electrogram during atrial fibrillation. Heart Vessels 2015; 31:773-82. [PMID: 25854621 DOI: 10.1007/s00380-015-0672-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 04/01/2015] [Indexed: 10/23/2022]
Abstract
Complex fractionated atrial electrogram (CFAE) has been suggested to contribute to the maintenance of atrial fibrillation (AF). However, electrophysiologic characteristics of the left atrial myocardium responsible for genesis of CFAE have not been clarified. Non-contact mapping of the left atrium was performed at 37 AF onset episodes in 24 AF patients. Electrogram amplitude, width, and conduction velocity were measured during sinus rhythm, premature atrial contraction (PAC) with long- (L-PAC), short- (S-PAC) and very short-coupling intervals (VS-PAC). These parameters were compared between CFAE and non-CFAE regions. Unipolar electrogram amplitude was higher in CFAE than non-CFAE during sinus rhythm, L-, S- and VS-PAC (1.82 ± 0.73 vs. 1.13 ± 0.38, p < 0.001; 1.44 ± 0.54 vs. 0.92 ± 0.35, p < 0.001; 1.09 ± 0.40 vs. 0.70 ± 0.27, p < 0.001; 0.76 ± 0.30 vs. 0.53 ± 0.25 mV, p < 0.001). Laplacian bipolar electrogram amplitude was also higher in CFAE than non-CFAE during sinus rhythm, L-, S- and VS-PAC. Unipolar electrogram width was similar in CFAE and non-CFAE. Laplacian bipolar electrogram width was wider in CFAE than non-CFAE during L-, S- and VS-PAC (85.5 ± 6.8 vs. 79.6 ± 4.5, p < 0.001; 96.1 ± 9.7 vs. 84.5 ± 5.9, p < 0.001; 122.4 ± 16.0 vs. 99.6 ± 9.6 ms, p < 0.001), but not during sinus rhythm. The conduction velocity was slower in CFAE during sinus rhythm, L-, S- and VS-PAC than non-CFAE (1.7 ± 0.3 vs. 2.4 ± 0.4, p < 0.001; 1.4 ± 0.3 vs. 2.0 ± 0.5, p < 0.001; 1.2 ± 0.3 vs. 1.7 ± 0.5, p < 0.001; and 0.9 ± 0.3 vs. 1.4 ± 0.4 m/s, p < 0.001). CFAE was generated in the high amplitude atrial myocardium with slow and non-uniform conduction properties which were pronounced associated with premature activation, suggesting that heterogeneous conduction produced in high amplitude region contributes to the genesis of CFAE.
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Sairaku A, Yoshida Y, Hirayama H, Nakano Y, Kihara Y. Impact of pulmonary vein isolation on fractionated atrial potentials and ganglionated plexi in patients with persistent atrial fibrillation. Int Heart J 2014; 55:494-8. [PMID: 25310931 DOI: 10.1536/ihj.14-147] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Some patients with persistent atrial fibrillation (AF) acquire long-term freedom from AF by pulmonary vein (PV) isolation alone. The aim of the present study was to evaluate the characteristics of their atrial substrate.We studied 20 patients with persistent AF to examine the distribution of fractionated atrial potentials (FAP) and that of the anatomic sites of ganglionated plexi (GPs) with vagal reflexes elicited by high frequency stimulation (HFS) with the use of the CARTO system before and after the PV isolation.Both the %FAP area defined as a proportion of the FAP area to the total left atrial area (34.3 ± 10.3 to 21.5 ± 10.2%; P < 0.0001) and number of GP sites with vagal reflexes (4.0 [3.0, 5.0] to 2.0 [1.0, 2.8]; P < 0.0001) were markedly decreased after the PV isolation. Seven (35%) patients had AF recurrences, and they had a greater %FAP area after the PV isolation than those without (32.8 [22.1, 37.3] versus 13.8 [10.9, 19.9]%; P = 0.0049). A %FAP area after the PV isolation of > 20% was significantly associated with an AF recurrence (odds ratio 20.0, 95% confidence interval 2.26470.34; P = 0.018). No significant difference was found between the patients with and without AF recurrence in the reduction rate of anatomic sites of GPs with a vagal reflex induced by the HFS.A more marked reduction in the FAP area by the PV isolation was significantly associated with a better outcome in patients with persistent AF.
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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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Ciaccio EJ, Biviano AB, Garan H. The dominant morphology of fractionated atrial electrograms has greater temporal stability in persistent as compared with paroxysmal atrial fibrillation. Comput Biol Med 2013; 43:2127-35. [PMID: 24290930 DOI: 10.1016/j.compbiomed.2013.08.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 08/03/2013] [Accepted: 08/16/2013] [Indexed: 10/26/2022]
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Seitz J, Horvilleur J, Lacotte J, Mouhoub Y, Salerno F, Moynagh A, O H-Ici D, Monchi M, Curel L, Pisapia A. Automated Detection of Complex Fractionated Atrial Electrograms In Substrate-Based Atrial Fibrillation Ablation: Better Discrimination with a New Setting of CARTO® Algorithm. J Atr Fibrillation 2013; 6:673. [PMID: 28496868 DOI: 10.4022/jafib.673] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Revised: 05/14/2013] [Accepted: 06/24/2013] [Indexed: 11/10/2022]
Abstract
Background and purpose: Up until recently complex fractionated atrial electrogram (CFAE) ablation has been considered as time consuming and its achievement as challenging, especially for non experimented operators. Moreover, results of substrate ablation based on CFAE detection in atrial fibrillation (AF) are very disparate, mainly because of the operator's subjective electrogram visual analysis and the difficult distinction between CFAEs really involved in AF perpetuation from other CFAE. Automatic detection provided by 3D mapping system (CARTO® algorithm) can be helpful but is not selective enough, drawing too wide CFAE areas. We sought to demonstrate a better selectivity of a new CFAE algorithm setting in order to better discriminate CFAEs really involved in AF perpetuation from other CFAE. Methods and subjects: A population of 32 patients (60.4±12.7 years) with paroxysmal (n=3) AF (PAF), persistent (n=16) AF (PeAF) or long-standing persistent (n=13) AF (LSPeAF), and AF history =56±65 months, underwent CFAE ablation based on visual analysis. Before ablation, left atrium CFAE mapping was performed on CARTO® shortest complex interval (SCI) algorithm and reanalyzed after ablation with the two different settings: nominal (SCI 60-120ms/0.05-0.15mV) vs. customized setting (SCI 30-40ms/0,04-0.15mV). CFAE areas automatically detected by both settings (CFAE-CARTO® areas) were respectively measured. The decision to ablate CFAE was only based upon the operator's electrogram visual analysis taken as reference because of high AF termination rate (93.7%) due to operator's CFAE selection experience. These ablation points drawn reference-CFAE areas involved in AF perpetuation (ablation point=60mm2) allowing to compare the selectivity of the two previous automatic maps. Results: With the customized CARTO® SCI setting, we observed a significant reduction of CFAE areas detected by CARTO® (CFAE-CARTO® areas) and of the ablated CFAE surface inside non-CFAE CARTO® areas, (30.6±20.5cm2 vs. 68.8±24.5cm2, p<0.0001, and 1.86±1.82% vs. 3±3%, p=0.003). Furthermore the proportion of ablated areas/detected CFAE-CARTO® areas were higher with customized setting (38.2±19.6% vs. 20.4±17.5%, p=0.008). Conclusions: This new customized CFAE algorithm setting is significantly more selective than the nominal one and allows an automated detection of CFAE really involved in AF perpetuation truer to an efficient experienced operator's electrogram visual analysis.
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Affiliation(s)
- Julien Seitz
- The Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300 Massy, France.,Hôpital Saint Joseph, 26 Bd de Louvain, 13008 Marseille, France
| | - Jérôme Horvilleur
- The Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300 Massy, France
| | - Jérôme Lacotte
- The Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300 Massy, France
| | - Yamina Mouhoub
- The Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300 Massy, France
| | - Fiorella Salerno
- The Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300 Massy, France
| | - Anouska Moynagh
- The Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300 Massy, France
| | - Darach O H-Ici
- The Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300 Massy, France
| | - Mehran Monchi
- The Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300 Massy, France
| | - Laurence Curel
- Hôpital Saint Joseph, 26 Bd de Louvain, 13008 Marseille, France
| | - Andre Pisapia
- Hôpital Saint Joseph, 26 Bd de Louvain, 13008 Marseille, France
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Feasibility of TEE-guided stroke risk assessment in atrial fibrillation-background, aims, design and baseline data of the TIARA pilot study. Neth Heart J 2013; 19:214-22. [PMID: 21541835 PMCID: PMC3087029 DOI: 10.1007/s12471-011-0095-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Antithrombotic management in atrial fibrillation (AF) is currently based on clinical characteristics, despite evidence of potential fine-tuning with transoesophageal echocardiography (TEE). This open, randomised, multicentre study addresses the hypothesis that a comprehensive strategy of TEE-based aspirin treatment in AF patients is feasible and safe. Methods Between 2005 and 2009, ten large hospitals in the Netherlands enrolled AF patients with a moderate risk of stroke. Patients without thrombogenic TEE characteristics were randomised to aspirin or vitamin K antagonists (VKA). The primary objective is to show that TEE-based aspirin treatment is safe compared with VKA therapy. The secondary objective tests feasibility of TEE as a tool to detect echocardiographic features of high stroke risk. This report compares randomised to non-randomised patients and describes the feasibility of a TEE-based approach. Results In total, 310 patients were included. Sixty-nine patients were not randomised because of non-visualisation (n = 6) or TEE risk factors (n = 63). Compared with non-randomised patients, randomised patients (n = 241) were younger (65 ± 11 vs. 69 ± 9 years, p = 0.004), had less coronary artery disease (9 vs. 20%, p = 0.018), previous TIA (1.7 vs. 7.2%, p = 0.029), AF during TEE (25 vs. 54%, p < 0.001), mitral incompetence (55 vs. 70%, p = 0.038), VKA use (69 vs. 82%, p = 0.032), had a lower mean CHADS2 score (1.2 ± 0.6 vs. 1.6 ± 1.0, p = 0.004), and left ventricular ejection fraction (59 ± 8 vs. 56 ± 8%, p = 0.016). Conclusions This study shows that a TEE-based approach for fine-tuning stroke risk in AF patients with a moderate risk for stroke is feasible. Follow-up data will address the safety of this TEE-based approach.
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Roten L, Derval N, Pascale P, Scherr D, Komatsu Y, Shah A, Ramoul K, Denis A, Sacher F, Hocini M, Haïssaguerre M, Jaïs P. Current hot potatoes in atrial fibrillation ablation. Curr Cardiol Rev 2013; 8:327-46. [PMID: 22920482 PMCID: PMC3492816 DOI: 10.2174/157340312803760802] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Revised: 05/11/2012] [Accepted: 05/11/2012] [Indexed: 12/30/2022] Open
Abstract
Atrial fibrillation (AF) ablation has evolved to the treatment of choice for patients with drug-resistant and symptomatic AF. Pulmonary vein isolation at the ostial or antral level usually is sufficient for treatment of true paroxysmal AF. For persistent AF ablation, drivers and perpetuators outside of the pulmonary veins are responsible for AF maintenance and have to be targeted to achieve satisfying arrhythmia-free success rate. Both complex fractionated atrial electrogram (CFAE) ablation and linear ablation are added to pulmonary vein isolation for persistent AF ablation. Nevertheless, ablation failure and necessity of repeat ablations are still frequent, especially after persistent AF ablation. Pulmonary vein reconduction is the main reason for arrhythmia recurrence after paroxysmal and to a lesser extent after persistent AF ablation. Failure of persistent AF ablation mostly is a consequence of inadequate trigger ablation, substrate modification or incompletely ablated or reconducting linear lesions. In this review we will discuss these points responsible for AF recurrence after ablation and review current possibilities on how to overcome these limitations.
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Affiliation(s)
- Laurent Roten
- Hôpital Cardiologique du Haut-Lévêque and the Université Victor Segalen Bordeaux II, Bordeaux, France.
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Pantos I, Katritsis G, Zografos T, Camm AJ, Katritsis DG. Temporal stability of atrial electrogram fractionation in patients with paroxysmal atrial fibrillation. Am J Cardiol 2013; 111:863-8. [PMID: 23276474 DOI: 10.1016/j.amjcard.2012.11.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2012] [Revised: 11/27/2012] [Accepted: 11/27/2012] [Indexed: 11/19/2022]
Abstract
The atrial sites associated with fractionated activity and/or high-frequency signals are commonly considered as targets of ablation for atrial fibrillation (AF); however, their temporal stability has not been established. A total of 21 patients with paroxysmal AF were studied. Left atrial (LA) ganglionated plexi (GP) were identified by high-frequency stimulation, and prolonged (3-minute) electrogram sampling from the GP and the posterior wall of the left atrium during AF was acquired. Fast Fourier transformation was used to determine the dominant frequencies (DFs) of the recorded electrogram signals and to study their temporal variability. The DF at the identified GP was 5.34 ± 0.78 Hz and at the posterior LA wall was 5.58 ± 0.87 Hz. Fractionation, expressed as electrograms exhibiting consecutive DFs deferring >20%, was detected at 21 of the studied GP (84%) and 7 of the posterior LA wall sites (44%). Fractionation, expressed as electrograms exhibiting DFs >8 Hz, was detected at 6 GP (24%) and 1 posterior LA wall site (6%). During the 3-minute recordings, the derived DFs were temporally variable, exhibiting an average coefficient of variation of 15.2 ± 12.0%. Fractionation, expressed by significant consecutive DF variability (>20%), was detected only for 18.0 ± 19.0% of the recording period at GP and for 12.7 ± 13.4% at the posterior LA wall. In conclusion, atrial electrograms are temporarily variable, and fractionation is transient at atrial sites associated with fractionated electrical activity during AF. Our results question the clinical validity of fractionated atrial electrograms for ablation purposes.
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Tsai WC, Wang JH, Lin YJ, Tsao HM, Chang SL, Lo LW, Hu YF, Chang CJ, Tang WH, Huang SY, Suenari K, Tuan TC, Chen SA. Consistency of the automatic algorithm in detecting complex fractionated electrograms using an electroanatomical navigation system. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 35:980-9. [PMID: 22816370 DOI: 10.1111/j.1540-8159.2012.03444.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The different settings of the automatic algorithm in the Carto system (Carto XP, Biosense Webster, Diamond Bar, CA, USA) used for detecting complex fractionated electrograms (CFEs) during atrial fibrillation (AF) may influence the identification of the fragmented electrograms. OBJECTIVES We aimed to evaluate the impact of the different parameters on the detection of CFEs and the efficacy of the substrate modification after pulmonary vein isolation (PVI). METHODS A total of 1,159 electrograms were analyzed from 11 consecutive patients (age = 56 ± 12 years). The effect of the different algorithm factors, such as the high-voltage thresholds (0.12, 0.25, 0.5, 20 mV), detection algorithms (average complex interval [ACI] vs interval confidence level), and recording duration (2.5 seconds vs 5 seconds), on the disparities of the CFEs was investigated. RESULTS The proportion of the different grades of CFEs depended on the detection algorithm and recording duration. The high-voltage threshold would not affect the consistency of the CFEs irrespective of the different settings of the detection algorithm or recording duration. High-grade CFEs were most consistent with an ACI algorithm and recording duration of 5 seconds (Cronbach's alpha = 0.952). Ablation consisting of a PVI and high-grade CFE sites converted AF directly to sinus rhythm in eight of 11 patients or into atrial tachycardia in one of 11. CONCLUSIONS The distribution and consistency of the CFE detection depended on the detection algorithm and recording duration, but not on the high-voltage threshold. Under the ACI algorithm and a recording duration of 5 seconds, high-grade CFE sites remained highest consistency.
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Affiliation(s)
- Wen-Chin Tsai
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. J Interv Card Electrophysiol 2012; 33:171-257. [PMID: 22382715 DOI: 10.1007/s10840-012-9672-7] [Citation(s) in RCA: 256] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
This is a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation, developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology and the European Cardiac Arrhythmia Society (ECAS), and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). This is endorsed by the governing bodies of the ACC Foundation, the AHA, the ECAS, the EHRA, the STS, the APHRS, and the HRS.
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Lau DH, Maesen B, Zeemering S, Verheule S, Crijns HJ, Schotten U. Stability of Complex Fractionated Atrial Electrograms: A Systematic Review. J Cardiovasc Electrophysiol 2012; 23:980-7. [PMID: 22554025 DOI: 10.1111/j.1540-8167.2012.02335.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Dennis H Lau
- Department of Physiology, Maastricht University, Maastricht, The Netherlands
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Calkins H, Kuck KH, Cappato R, Brugada J, Camm AJ, Chen SA, Crijns HJG, Damiano RJ, Davies DW, DiMarco J, Edgerton J, Ellenbogen K, Ezekowitz MD, Haines DE, Haissaguerre M, Hindricks G, Iesaka Y, Jackman W, Jalife J, Jais P, Kalman J, Keane D, Kim YH, Kirchhof P, Klein G, Kottkamp H, Kumagai K, Lindsay BD, Mansour M, Marchlinski FE, McCarthy PM, Mont JL, Morady F, Nademanee K, Nakagawa H, Natale A, Nattel S, Packer DL, Pappone C, Prystowsky E, Raviele A, Reddy V, Ruskin JN, Shemin RJ, Tsao HM, Wilber D. 2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. Europace 2012; 14:528-606. [PMID: 22389422 DOI: 10.1093/europace/eus027] [Citation(s) in RCA: 1144] [Impact Index Per Article: 95.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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Calkins H, Kuck KH, Cappato R, Brugada J, Camm AJ, Chen SA, Crijns HJG, Damiano RJ, Davies DW, DiMarco J, Edgerton J, Ellenbogen K, Ezekowitz MD, Haines DE, Haissaguerre M, Hindricks G, Iesaka Y, Jackman W, Jalife J, Jais P, Kalman J, Keane D, Kim YH, Kirchhof P, Klein G, Kottkamp H, Kumagai K, Lindsay BD, Mansour M, Marchlinski FE, McCarthy PM, Mont JL, Morady F, Nademanee K, Nakagawa H, Natale A, Nattel S, Packer DL, Pappone C, Prystowsky E, Raviele A, Reddy V, Ruskin JN, Shemin RJ, Tsao HM, Wilber D. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design: a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology (ESC) and the European Cardiac Arrhythmia Society (ECAS); and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). Endorsed by the governing bodies of the American College of Cardiology Foundation, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, the Asia Pacific Heart Rhythm Society, and the Heart Rhythm Society. Heart Rhythm 2012; 9:632-696.e21. [PMID: 22386883 DOI: 10.1016/j.hrthm.2011.12.016] [Citation(s) in RCA: 1299] [Impact Index Per Article: 108.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Indexed: 12/20/2022]
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Correa de Sa DD, Thompson N, Stinnett-Donnelly J, Znojkiewicz P, Habel N, Müller JG, Bates JHT, Buzas JS, Spector PS. Electrogram fractionation: the relationship between spatiotemporal variation of tissue excitation and electrode spatial resolution. Circ Arrhythm Electrophysiol 2011; 4:909-16. [PMID: 21984446 DOI: 10.1161/circep.111.965145] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Fractionated electrograms are used by some as targets for ablation in atrial and ventricular arrhythmias. Fractionation has been demonstrated to result when there is repetitive or asynchronous activation of separate groups of cells within the recording region of a mapping electrode(s). METHODS AND RESULTS Using a computer model, we generated tissue activation patterns with increasing spatiotemporal variation and calculated virtual electrograms from electrodes with decreasing resolution. We then quantified electrogram fractionation. In addition, we recorded unipolar electrograms during atrial fibrillation in 20 patients undergoing atrial fibrillation ablation. From these we constructed bipolar electrograms with increasing interelectrode spacing and quantified fractionation. During modeling of spatiotemporal variation, fractionation varied directly with electrode length, diameter, height, and interelectrode spacing. When resolution was held constant, fractionation increased with increasing spatiotemporal variation. In the absence of spatial variation, fractionation was independent of resolution and proportional to excitation frequency. In patients with atrial fibrillation, fractionation increased as interelectrode spacing increased. CONCLUSIONS We created a model for distinguishing the roles of spatial and temporal electric variation and electrode resolution in producing electrogram fractionation. Spatial resolution affects fractionation attributable to spatiotemporal variation but not temporal variation alone. Electrogram fractionation was directly proportional to spatiotemporal variation and inversely proportional to spatial resolution. Spatial resolution limits the ability to distinguish high-frequency excitation from overcounting. In patients with atrial fibrillation, complex fractionated atrial electrogram detection varies with spatial resolution. Electrode resolution must therefore be considered when interpreting and comparing studies of fractionation.
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Affiliation(s)
- Daniel D Correa de Sa
- Department of Medicine, University of Vermont College of Medicine, Burlington, VT, USA
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Chaldoupi SM, Linnenbank AC, Wittkampf FH, Boldt LH, VAN Wessel H, VAN Driel VJ, Doevendans PA, Hauer RN, DE Bakker JM, Loh P. Complex fractionated electrograms in the right atrial free wall and the superior/posterior wall of the left atrium are affected by activity of the autonomic nervous system. J Cardiovasc Electrophysiol 2011; 23:26-33. [PMID: 21815962 DOI: 10.1111/j.1540-8167.2011.02145.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Complex fractionated atrial electrograms (CFAEs) are supposed to be related to structural and electrical remodeling. Animal studies suggest a role of the autonomic nervous system (ANS). However, this has never been studied in humans. OBJECTIVE The goal of this study was to investigate the influence of ANS on CFAEs in patients with idiopathic atrial fibrillation (AF). METHODS Thirty-six patients (28 men, 55 ± 9 years) were included before undergoing catheter ablation. In the 24 hours preceding the procedure, 20 patients were in AF (group 1) and 16 were in sinus rhythm (SR, group 2). With 2 decapolar catheters, 1 in the right atrium (RA) and 1 in the left atrium (LA), 20 unipolar electrograms were simultaneously recorded during a 100-second AF-period (in group 2 after induction of AF). After atropine and metoprolol administration, a second 100-second AF-period was recorded 30 minutes later. Five patients of group 2 served as controls and did not receive atropine and metoprolol prior to the second recording. CFAEs were assessed and the prevalence of CFAEs was expressed as percentage of the recording time. RESULTS The prevalence of CFAEs was greater in group 1 than in group 2 in both RA and LA (P = 0.026, P < 0.001, respectively). Atropine and metoprolol significantly reduced CFAEs in group 1 (P < 0.001) and prevented the time-dependent increase of CFAEs in group 2. CONCLUSION The prevalence of CFAEs is greater in long-lasting AF episodes. Atropine and metoprolol administration reduces CFAEs in both atria. Thus, CFAEs are at least partly influenced by the ANS.
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Affiliation(s)
- Sevasti-Maria Chaldoupi
- Department of Cardiology, Division of Heart & Lungs, University Medical Center Utrecht, Utrecht, The Netherlands
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Teh AW, Kistler PM, Lee G, Medi C, Heck PM, Spence SJ, Sparks PB, Morton JB, Sanders P, Kalman JM. The relationship between complex fractionated electrograms and atrial low-voltage zones during atrial fibrillation and paced rhythm. Europace 2011; 13:1709-16. [DOI: 10.1093/europace/eur197] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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Katritsis DG, Pantos I, Efstathopoulos EP. Catheter ablation of atrial fibrillation guided by electrogram fractionation and dominant frequency analysis. Expert Rev Cardiovasc Ther 2011; 9:631-6. [PMID: 21615326 DOI: 10.1586/erc.11.36] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Catheter ablation is an established therapeutic option for certain patients with atrial fibrillation (AF), but the reported success rates of anatomically oriented ablation techniques are low compared with those for other ablation indications, particularly for persistent AF. Electrophysiologically oriented ablation techniques have emerged over the last decade that aim at modifying the arrhythmogenic substrate to the extent that it cannot maintain fibrillatory activity. Electrogram-guided ablation procedures are the most common substrate-targeted ablation approaches and can be broadly divided into procedures that target atrial sites with particular electrogram characteristics in either the time domain (complex fractionated electrograms) or frequency components in the frequency domain (dominant frequencies). The concept of electrogram-based catheter ablation of AF by identifying complex fractionated electrograms and dominant frequency sites is valid only if these sites are temporally stable.
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Schotten U, Verheule S, Kirchhof P, Goette A. Pathophysiological mechanisms of atrial fibrillation: a translational appraisal. Physiol Rev 2011; 91:265-325. [PMID: 21248168 DOI: 10.1152/physrev.00031.2009] [Citation(s) in RCA: 863] [Impact Index Per Article: 66.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Atrial fibrillation (AF) is an arrhythmia that can occur as the result of numerous different pathophysiological processes in the atria. Some aspects of the morphological and electrophysiological alterations promoting AF have been studied extensively in animal models. Atrial tachycardia or AF itself shortens atrial refractoriness and causes loss of atrial contractility. Aging, neurohumoral activation, and chronic atrial stretch due to structural heart disease activate a variety of signaling pathways leading to histological changes in the atria including myocyte hypertrophy, fibroblast proliferation, and complex alterations of the extracellular matrix including tissue fibrosis. These changes in electrical, contractile, and structural properties of the atria have been called "atrial remodeling." The resulting electrophysiological substrate is characterized by shortening of atrial refractoriness and reentrant wavelength or by local conduction heterogeneities caused by disruption of electrical interconnections between muscle bundles. Under these conditions, ectopic activity originating from the pulmonary veins or other sites is more likely to occur and to trigger longer episodes of AF. Many of these alterations also occur in patients with or at risk for AF, although the direct demonstration of these mechanisms is sometimes challenging. The diversity of etiological factors and electrophysiological mechanisms promoting AF in humans hampers the development of more effective therapy of AF. This review aims to give a translational overview on the biological basis of atrial remodeling and the proarrhythmic mechanisms involved in the fibrillation process. We pay attention to translation of pathophysiological insights gained from in vitro experiments and animal models to patients. Also, suggestions for future research objectives and therapeutical implications are discussed.
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Affiliation(s)
- Ulrich Schotten
- Department of Physiology, University Maastricht, Maastricht, The Netherlands.
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Houben RPM, de Groot NMS, Allessie MA. Analysis of Fractionated Atrial Fibrillation Electrograms by Wavelet Decomposition. IEEE Trans Biomed Eng 2010; 57:1388-98. [DOI: 10.1109/tbme.2009.2037974] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Wilber DJ. DeCFAEnating atrial fibrillation: narrowing the targets. J Cardiovasc Electrophysiol 2010; 21:617-9. [PMID: 20455971 DOI: 10.1111/j.1540-8167.2010.01776.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Biviano A. Mapping of dominant frequency and complex fractionated electrograms in atrial fibrillation patients: Caveat medicus. Heart Rhythm 2010; 7:594-5. [DOI: 10.1016/j.hrthm.2010.01.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2010] [Accepted: 01/14/2010] [Indexed: 11/17/2022]
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Characteristics and distribution of complex fractionated atrial electrograms in patients with paroxysmal and persistent atrial fibrillation. J Interv Card Electrophysiol 2010; 28:87-93. [PMID: 20386973 DOI: 10.1007/s10840-010-9479-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2009] [Accepted: 02/12/2010] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Substrate-based radiofrequency ablation for treatment of atrial fibrillation (AF) is still under development. The purpose of this study was to investigate the different characteristics and distribution of complex fractionated atrial electrograms (CFAE) in both atria in patients with paroxysmal and persistent AF. METHODS AND RESULTS The NavX system was used to map the left and right atria and the coronary sinus in 20 AF patients (ten persistent). An automated algorithm calculates the average time interval between consecutive deflections (complex fractionated electrogram (CFE) mean). All recordings were visually inspected off-line and interpreted either as continuous, fragmented, mixed CFAE, or non-CFAE, and their locations were determined. Electrograms with intermittent CFAE characteristics were also regarded as non-CFAEs. There were more CFAEs in persistent AF than in paroxysmal AF (52% vs. 44% of total registrations, p < 0.05), and CFAEs were more widespread in both atria in persistent AF patients. There were also more continuous CFAEs (70% vs. 59% of total CFAEs, p < 0.05), and less mixed and intermittent CFAEs (22% vs. 30% and 16% vs. 21% of total CFAEs, respectively, p < 0.05) in persistent AF. Fragmented CFAEs had more high-voltage signals than other groups. Employing the automated algorithm for CFAE mapping, a CFE mean cut-off value of < or =80 ms provides a sensitivity and specificity of 87.4% and 81.2%, respectively. CONCLUSIONS CFAEs distribute in preferential areas and arrange in different patterns in both atria. Patients with persistent AF have more continuous CFAEs and higher temporal signal stability than patients with paroxysmal AF.
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Hunter RJ, Diab I, Thomas G, Duncan E, Abrams D, Dhinoja M, Sporton S, Earley MJ, Schilling RJ. Validation of a classification system to grade fractionation in atrial fibrillation and correlation with automated detection systems. Europace 2009; 11:1587-96. [PMID: 19897499 DOI: 10.1093/europace/eup351] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AIMS We tested application of a grading system describing complex fractionated electrograms (CFE) in atrial fibrillation (AF) and used it to validate automated CFE detection (AUTO). METHODS AND RESULTS Ten seconds bipolar electrograms were classified by visual inspection (VI) during ablation of persistent AF and the result compared with offline manual measurement (MM) by a second blinded operator: Grade 1 uninterrupted fractionated activity (defined as segments > or =70 ms) for > or =70% of recording and uninterrupted > or =1 s; Grade 2 interrupted fractionated activity > or =70% of recording; Grade 3 intermittent fractionated activity 30-70%; Grade 4 discrete (<70 ms) complex electrogram (> or =5 direction changes); Grade 5 discrete simple electrograms (< or =4 direction changes); Grade 6 scar. Grade by VI and MM for 100 electrograms agreed in 89%. Five hundred electrograms were graded on Carto and NavX by VI to validate AUTO in (i) detection of CFE (grades 1-4 considered CFE), and (ii) assessing degree of fractionation by correlating grade and score by AUTO (data shown as sensitivity, specificity, r): NavX 'CFE mean' 92%, 91%, 0.56; Carto 'interval confidence level' using factory settings 89%, 62%, -0.72, and other published settings 80%, 74%, -0.65; Carto 'shortest confidence interval' 74%, 70%, 0.43; Carto 'average confidence interval' 86%, 66%, 0.53. CONCLUSION Grading CFE by VI is accurate and correlates with AUTO.
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Affiliation(s)
- Ross J Hunter
- Cardiology Research Department, Barts and The London NHS Trust and QMUL, St Bartholomew's Hospital, First Floor Dominion House, 60 Bartholomew Close, West Smithfield, London, UK
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Krummen DE, Peng KA, Bullinga JR, Narayan SM. Centrifugal gradients of rate and organization in human atrial fibrillation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2009; 32:1366-78. [PMID: 19744279 DOI: 10.1111/j.1540-8159.2009.02525.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Animal studies show that atrial fibrillation (AF) may emanate from sites of high rate and regularity, with fibrillatory conduction to adjacent areas. We used simultaneous mapping to find evidence for potential drivers in human AF defined as sites with higher rate and regularity than surrounding tissue. MATERIALS AND METHODS In 24 patients (age 61+/-10 years; 12 persistent), we recorded AF simultaneously from 32 left atrial bipolar basket electrodes in addition to pulmonary veins (PV), coronary sinus, and right atrial electrodes. We measured AF cycle length (CL) by Fourier transform and electrogram regularity at each electrode, referenced to patient-specific atrial anatomy. RESULTS We analyzed 10,298 electrode-periods. Evidence for potential AF drivers was found in 11 patients (five persistent). In persistent AF, these sites lay at the coronary sinus and left atrial roof but not PVs, while in paroxysmal AF six of nine sites lay at PVs (P<0.05). During ablation, a subset of patients experienced AF CL prolongation or termination with a focal lesion; in each case this lesion mapped to potential driver sites on blinded analysis. Conversely, sequential mapping failed to reveal these sites, possibly due to fluctuations in dominant frequency at driver locations in the context of migratory AF. CONCLUSIONS Simultaneous multisite recordings in human AF reveal evidence for drivers that lie near PVs in paroxysmal but not persistent AF, and were sites where ablation slowed or terminated AF in a subset of patients. The future work should determine if real-time ablation of AF-maintaining regions defined in this fashion eliminates AF.
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Affiliation(s)
- David E Krummen
- University of California San Diego and VA San Diego Healthcare System, San Diego, California 92161, USA.
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