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Bates AP, Paisey J, Yue A, Banks P, Roberts PR, Ullah W. Comparison of voltages between atria: differences in sinus rhythm and atrial fibrillation. J Interv Card Electrophysiol 2024; 67:649-656. [PMID: 37875609 PMCID: PMC11016007 DOI: 10.1007/s10840-023-01671-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 10/12/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND Ultra high-density mapping systems allow for comparison of atrial electroanatomical maps in unprecedented detail. Atrial scar determined by voltages and surface area between atria, rhythm and atrial fibrillation (AF) types was assessed. METHODS Left (LA) and right atrial (RA) maps were created using Rhythmia HDx in patients listed for ablation for paroxysmal (PAF, sinus rhythm (SR) maps only) or persistent AF (PeAF, AF and SR maps). Electrograms on corresponding SR/AF maps were paired for direct comparison. Percentage surface area of scar was assigned low- (LVM, ≤ 0.05 mV), intermediate- (IVM, 0.05-0.5 mV) or normal voltage myocardium, (NVM, > 0.5 mV). RESULTS Thirty-eight patients were recruited generating 96 maps using 913,480 electrograms. Paired SR-AF bipolar electrograms showed fair correlation in LA (Spearman's ρ = 0.32) and weak correlation in RA (ρ = 0.19) and were significantly higher in SR in both (LA: 0.61 mV (0.20-1.67) vs 0.31 mV (0.10-0.74), RA: 0.68 mV (0.19-1.88) vs 0.47 mV (0.14-1.07), p < 0.0005 both). Voltages were significantly higher in patients with PAF over PeAF, (LA: 1.13 mV (0.39-2.93) vs 0.52 mV (0.16-1.49); RA: 0.93 mV (0.24-2.46) vs 0.57 mV (0.17-1.69)). Minimal differences were seen in electrogram voltages between atria. Significantly more IVM/LVM surface areas were seen in AF over SR (LA only, p < 0005), and PeAF over PAF (LA: p = 0.01, RA: p = 0.04). There was minimal difference between atria within patients. CONCLUSIONS Ultra high-density mapping shows paired electrograms correlate poorly between SR and AF. SR electrograms are typically (but not always) larger than those in AF. Patients with PeAF have a lower global electrogram voltage than those with PAF. Electrogram voltages are similar between atria within individual patients.
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Affiliation(s)
- Alexander P Bates
- Department of Cardiology, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK.
- Faculty of Medicine, School of Human Development and Health, University of Southampton, Southampton, UK.
| | - John Paisey
- Department of Cardiology, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK
| | - Arthur Yue
- Department of Cardiology, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK
| | - Phil Banks
- Department of Cardiology, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK
| | - Paul R Roberts
- Department of Cardiology, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK
- Faculty of Medicine, School of Human Development and Health, University of Southampton, Southampton, UK
| | - Waqas Ullah
- Department of Cardiology, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK
- Faculty of Medicine, School of Human Development and Health, University of Southampton, Southampton, UK
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2
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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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Rappel WJ, Baykaner T, Zaman J, Ganesan P, Rogers AJ, Narayan SM. Spatially Conserved Spiral Wave Activity During Human Atrial Fibrillation. Circ Arrhythm Electrophysiol 2024; 17:e012041. [PMID: 38348685 PMCID: PMC10950516 DOI: 10.1161/circep.123.012041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 01/17/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND Atrial fibrillation is the most common cardiac arrhythmia in the world and increases the risk for stroke and morbidity. During atrial fibrillation, the electric activation fronts are no longer coherently propagating through the tissue and, instead, show rotational activity, consistent with spiral wave activation, focal activity, collision, or partial versions of these spatial patterns. An unexplained phenomenon is that although simulations of cardiac models abundantly demonstrate spiral waves, clinical recordings often show only intermittent spiral wave activity. METHODS In silico data were generated using simulations in which spiral waves were continuously created and annihilated and in simulations in which a spiral wave was intermittently trapped at a heterogeneity. Clinically, spatio-temporal activation maps were constructed using 60 s recordings from a 64 electrode catheter within the atrium of N=34 patients (n=24 persistent atrial fibrillation). The location of clockwise and counterclockwise rotating spiral waves was quantified and all intervals during which these spiral waves were present were determined. For each interval, the angle of rotation as a function of time was computed and used to determine whether the spiral wave returned in step or changed phase at the start of each interval. RESULTS In both simulations, spiral waves did not come back in phase and were out of step." In contrast, spiral waves returned in step in the majority (68%; P=0.05) of patients. Thus, the intermittently observed rotational activity in these patients is due to a temporally and spatially conserved spiral wave and not due to ones that are newly created at the onset of each interval. CONCLUSIONS Intermittency of spiral wave activity represents conserved spiral wave activity of long, but interrupted duration or transient spiral activity, in the majority of patients. This finding could have important ramifications for identifying clinically important forms of atrial fibrillation and in guiding treatment.
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Affiliation(s)
| | - Tina Baykaner
- Department of Medicine, Stanford University, Palo Alto
| | - Junaid Zaman
- Department of Cardiovascular Medicine, University of Southern California, Los Angeles, CA
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Saha S, Linz D, Saha D, McEwan A, Baumert M. Overcoming Uncertainties in Electrogram-Based Atrial Fibrillation Mapping: A Review. Cardiovasc Eng Technol 2024; 15:52-64. [PMID: 37962813 DOI: 10.1007/s13239-023-00696-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 10/31/2023] [Indexed: 11/15/2023]
Abstract
In clinical rhythmology, intracardiac bipolar electrograms (EGMs) play a critical role in investigating the triggers and substrates inducing and perpetuating atrial fibrillation (AF). However, the interpretation of bipolar EGMs is ambiguous due to several aspects of electrodes, mapping algorithms and wave propagation dynamics, so it requires several variables to describe the effects of these uncertainties on EGM analysis. In this narrative review, we critically evaluate the potential impact of such uncertainties on the design of cardiac mapping tools on AF-related substrate characterization. Literature suggest uncertainties are due to several variables, including the wave propagation vector, the wave's incidence angle, inter-electrode spacing, electrode size and shape, and tissue contact. The preprocessing of the EGM signals and mapping density will impact the electro-anatomical representation and the features extracted from the local electrical activities. The superposition of multiple waves further complicates EGM interpretation. The inclusion of these uncertainties is a nontrivial problem but their consideration will yield a better interpretation of the intra-atrial dynamics in local activation patterns. From a translational perspective, this review provides a concise but complete overview of the critical variables for developing more precise cardiac mapping tools.
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Affiliation(s)
- Simanto Saha
- School of Biomedical Engineering, The University of Sydney, Sydney, NSW, 2008, Australia.
| | - Dominik Linz
- Centre for Heart Rhythm Disorders, The University of Adelaide, Adelaide, SA, 5000, Australia
| | - Dyuti Saha
- Kumudini Women's Medical College, The University of Dhaka, Tangail, 1940, Dhaka, Bangladesh
| | - Alistair McEwan
- School of Biomedical Engineering, The University of Sydney, Sydney, NSW, 2008, Australia
| | - Mathias Baumert
- School of Electrical and Mechanical Engineering, The University of Adelaide, Adelaide, SA, 5000, Australia
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5
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Li TC, Zhong W, Ai BQ, Zhu WJ, Li BW, Panfilov AV, Dierckx H. Reordering and synchronization of electrical turbulence in cardiac tissue through global and partial optogenetical illumination. Phys Rev E 2023; 108:034218. [PMID: 37849154 DOI: 10.1103/physreve.108.034218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 09/06/2023] [Indexed: 10/19/2023]
Abstract
Electrical turbulence in the heart is considered the culprit of cardiac disease, including the fatal ventricular fibrillation. Optogenetics is an emerging technology that has the capability to produce action potentials of cardiomyocytes to affect the electric wave propagation in cardiac tissue, thereby possessing the potential to control the turbulence, by shining a rotating spiral pattern onto the tissue. In this paper, we present a method to reorder and synchronize electrical turbulence through optogenetics. A generic two-variable reaction-diffusion model and a simplified three-variable ionic cardiac model are used. We discuss cases involving either global or partial illumination.
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Affiliation(s)
- Teng-Chao Li
- School of Physics, Hangzhou Normal University, Hangzhou 311121, China and School of Physics and Telecommunication Engineering, South China Normal University, Guangzhou 510006, China
| | - Wei Zhong
- School of Physics and Telecommunication Engineering, South China Normal University, Guangzhou 510006, China
| | - Bao-Quan Ai
- School of Physics and Telecommunication Engineering, South China Normal University, Guangzhou 510006, China
| | - Wei-Jing Zhu
- School of Photoelectric Engineering, Guangdong Polytechnic Normal University, Guangzhou 510665, China
| | - Bing-Wei Li
- School of Physics, Hangzhou Normal University, Hangzhou 311121, China
| | - Alexander V Panfilov
- Ural Federal University, Biomed Laboratory, 620002 Ekaterinburg, Russia; Department of Physics and Astronomy, Ghent University, B-9000 Ghent, Belgium; and World-Class Research Center "Digital biodesign and personalized healthcare", I.M. Sechenov First Moscow State Medical University, 119991 Moscow, Russia
| | - Hans Dierckx
- KU Leuven Campus Kortrijk-Kulak, Department of Mathematics, Etienne Sabbelaan 53 bus 7657, 8500 Kortrijk, Belgium and iSi Health - KU Leuven Institute of Physics-based Modeling for In Silico Health, KU Leuven, Belgium
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Sakata K, Tanaka T, Yamashita S, Kobayashi M, Ito M, Yamashiro K. The spatiotemporal electrogram dispersion ablation targeting rotors is more effective for elderly patients than non-elderly population. J Arrhythm 2023; 39:315-326. [PMID: 37324760 PMCID: PMC10264740 DOI: 10.1002/joa3.12860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/10/2023] [Accepted: 04/16/2023] [Indexed: 06/17/2023] Open
Abstract
Background Modulating atrial fibrillation (AF) drivers has been proposed as one of the effective ablation strategies for non-paroxysmal AF (non-PAF). However, the optimal non-PAF ablation strategy is still under debate because the exact mechanisms of AF persistence including focal activity and/or rotational activity, are not well-understood. Recently, spatiotemporal electrogram dispersion (STED) assumed to indicate rotors in the form of rotational activity is proposed as an effective target for non-PAF ablation. We aimed to clarify the effectiveness of STED ablation for modulating AF drivers. Methods STED ablation plus pulmonary vein isolation was applied in 161 consecutive non-PAF patients not undergoing previous ablation. STED areas within the entire left and right atria were identified and ablated during AF. After the procedures, the STED ablation's acute and long-term outcomes were investigated. Results (1) Despite a more effective acute outcome of the STED ablation for both AF termination and non-inducibility of atrial tachyarrhythmias (ATAs), Kaplan-Meier curves showed that the 24-month freedom ratio from ATAs was 49%, which resulted from the higher recurrence ratio of atrial tachycardia (AT) rather than AF. (2) A multivariate analysis showed that the determinant of ATA recurrences was only a non-elderly age, not long-standing persistent AF, and an enlarged left atrium, which were conventionally considered as key factors. Conclusions STED ablation targeting rotors was effective in elderly non-PAF patients. Therefore, the main mechanism of AF persistency and the component of the fibrillatory conduction might vary between elders and non-elders. However, we should be careful about post-ablation ATs following substrate modification.
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Affiliation(s)
- Kensuke Sakata
- Alliance for Cardiovascular Diagnostic and Treatment InnovationJohns Hopkin UniversityBaltimoreMarylandUSA
| | - Tomomi Tanaka
- Heart Rhythm CenterTakatsuki General HospitalTakatsukiJapan
| | - Soichiro Yamashita
- Department of CardiologyHyogo Prefectural Awaji Medical CenterSumotoJapan
| | - Masanori Kobayashi
- Department of Cardiovascular MedicineMatsumoto Kyoritsu HospitalMatsumotoJapan
| | - Mitsuaki Ito
- Department of Cardiovascular MedicineHyogo Brain and Heart CenterHimejiJapan
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7
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Christie S, Idris S, Bennett RG, Deyell MW, Roston T, Laksman Z. Trigger and Substrate Mapping and Ablation for Ventricular Fibrillation in the Structurally Normal Heart. J Cardiovasc Dev Dis 2023; 10:jcdd10050200. [PMID: 37233167 DOI: 10.3390/jcdd10050200] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 04/28/2023] [Accepted: 04/29/2023] [Indexed: 05/27/2023] Open
Abstract
Sudden cardiac death (SCD) represents approximately 50% of all cardiovascular mortality in the United States. The majority of SCD occurs in individuals with structural heart disease; however, around 5% of individuals have no identifiable cause on autopsy. This proportion is even higher in those <40 years old, where SCD is particularly devastating. Ventricular fibrillation (VF) is often the terminal rhythm leading to SCD. Catheter ablation for VF has emerged as an effective tool to alter the natural history of this disease among high-risk individuals. Important advances have been made in the identification of several mechanisms involved in the initiation and maintenance of VF. Targeting the triggers of VF as well as the underlying substrate that perpetuates these lethal arrhythmias has the potential to eliminate further episodes. Although important gaps remain in our understanding of VF, catheter ablation has become an important option for individuals with refractory arrhythmias. This review outlines a contemporary approach to the mapping and ablation of VF in the structurally normal heart, specifically focusing on the following major conditions: idiopathic ventricular fibrillation, short-coupled ventricular fibrillation, and the J-wave syndromes-Brugada syndrome and early-repolarization syndrome.
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Affiliation(s)
- Simon Christie
- Faculty of Medicine, Division of Cardiology, University of British Columbia, Gordon & Leslie Diamond Health Care Centre, 2775 Laurel St., 9th Floor, Vancouver, BC V5Z 1M9, Canada
| | - Sami Idris
- Faculty of Medicine, Division of Cardiology, University of British Columbia, Gordon & Leslie Diamond Health Care Centre, 2775 Laurel St., 9th Floor, Vancouver, BC V5Z 1M9, Canada
| | - Richard G Bennett
- Faculty of Medicine, Division of Cardiology, University of British Columbia, Gordon & Leslie Diamond Health Care Centre, 2775 Laurel St., 9th Floor, Vancouver, BC V5Z 1M9, Canada
| | - Marc W Deyell
- Faculty of Medicine, Division of Cardiology, University of British Columbia, Gordon & Leslie Diamond Health Care Centre, 2775 Laurel St., 9th Floor, Vancouver, BC V5Z 1M9, Canada
| | - Thomas Roston
- Faculty of Medicine, Division of Cardiology, University of British Columbia, Gordon & Leslie Diamond Health Care Centre, 2775 Laurel St., 9th Floor, Vancouver, BC V5Z 1M9, Canada
| | - Zachary Laksman
- Faculty of Medicine, Division of Cardiology, University of British Columbia, Gordon & Leslie Diamond Health Care Centre, 2775 Laurel St., 9th Floor, Vancouver, BC V5Z 1M9, Canada
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Ogbomo-Harmitt S, Muffoletto M, Zeidan A, Qureshi A, King AP, Aslanidi O. Exploring interpretability in deep learning prediction of successful ablation therapy for atrial fibrillation. Front Physiol 2023; 14:1054401. [PMID: 36998987 PMCID: PMC10043207 DOI: 10.3389/fphys.2023.1054401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 02/28/2023] [Indexed: 03/16/2023] Open
Abstract
Background: Radiofrequency catheter ablation (RFCA) therapy is the first-line treatment for atrial fibrillation (AF), the most common type of cardiac arrhythmia globally. However, the procedure currently has low success rates in dealing with persistent AF, with a reoccurrence rate of ∼50% post-ablation. Therefore, deep learning (DL) has increasingly been applied to improve RFCA treatment for AF. However, for a clinician to trust the prediction of a DL model, its decision process needs to be interpretable and have biomedical relevance.Aim: This study explores interpretability in DL prediction of successful RFCA therapy for AF and evaluates if pro-arrhythmogenic regions in the left atrium (LA) were used in its decision process.Methods: AF and its termination by RFCA have been simulated in MRI-derived 2D LA tissue models with segmented fibrotic regions (n = 187). Three ablation strategies were applied for each LA model: pulmonary vein isolation (PVI), fibrosis-based ablation (FIBRO) and a rotor-based ablation (ROTOR). The DL model was trained to predict the success of each RFCA strategy for each LA model. Three feature attribution (FA) map methods were then used to investigate interpretability of the DL model: GradCAM, Occlusions and LIME.Results: The developed DL model had an AUC (area under the receiver operating characteristic curve) of 0.78 ± 0.04 for predicting the success of the PVI strategy, 0.92 ± 0.02 for FIBRO and 0.77 ± 0.02 for ROTOR. GradCAM had the highest percentage of informative regions in the FA maps (62% for FIBRO and 71% for ROTOR) that coincided with the successful RFCA lesions known from the 2D LA simulations, but unseen by the DL model. Moreover, GradCAM had the smallest coincidence of informative regions of the FA maps with non-arrhythmogenic regions (25% for FIBRO and 27% for ROTOR).Conclusion: The most informative regions of the FA maps coincided with pro-arrhythmogenic regions, suggesting that the DL model leveraged structural features of MRI images to identify such regions and make its prediction. In the future, this technique could provide a clinician with a trustworthy decision support tool.
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Abstract
The global burden caused by cardiovascular disease is substantial, with heart disease representing the most common cause of death around the world. There remains a need to develop better mechanistic models of cardiac function in order to combat this health concern. Heart rhythm disorders, or arrhythmias, are one particular type of disease which has been amenable to quantitative investigation. Here we review the application of quantitative methodologies to explore dynamical questions pertaining to arrhythmias. We begin by describing single-cell models of cardiac myocytes, from which two and three dimensional models can be constructed. Special focus is placed on results relating to pattern formation across these spatially-distributed systems, especially the formation of spiral waves of activation. Next, we discuss mechanisms which can lead to the initiation of arrhythmias, focusing on the dynamical state of spatially discordant alternans, and outline proposed mechanisms perpetuating arrhythmias such as fibrillation. We then review experimental and clinical results related to the spatio-temporal mapping of heart rhythm disorders. Finally, we describe treatment options for heart rhythm disorders and demonstrate how statistical physics tools can provide insights into the dynamics of heart rhythm disorders.
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Affiliation(s)
- Wouter-Jan Rappel
- Department of Physics, University of California San Diego, La Jolla, CA 92037
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10
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Atrial conduction velocity mapping: clinical tools, algorithms and approaches for understanding the arrhythmogenic substrate. Med Biol Eng Comput 2022; 60:2463-2478. [PMID: 35867323 PMCID: PMC9365755 DOI: 10.1007/s11517-022-02621-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 06/07/2022] [Indexed: 11/02/2022]
Abstract
Characterizing patient-specific atrial conduction properties is important for understanding arrhythmia drivers, for predicting potential arrhythmia pathways, and for personalising treatment approaches. One metric that characterizes the health of the myocardial substrate is atrial conduction velocity, which describes the speed and direction of propagation of the electrical wavefront through the myocardium. Atrial conduction velocity mapping algorithms are under continuous development in research laboratories and in industry. In this review article, we give a broad overview of different categories of currently published methods for calculating CV, and give insight into their different advantages and disadvantages overall. We classify techniques into local, global, and inverse methods, and discuss these techniques with respect to their faithfulness to the biophysics, incorporation of uncertainty quantification, and their ability to take account of the atrial manifold.
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11
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Deisenhofer I. Electrogram-based AF ablation -finally, reproducibility! J Cardiovasc Electrophysiol 2022; 33:2261-2262. [PMID: 35989539 DOI: 10.1111/jce.15660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 08/01/2022] [Indexed: 11/29/2022]
Abstract
After several years with sobering experiences with electrogram-based AF ablation approaches, Seitz et al present with the VX1 software a reliable tool to map and ablate spatio-temporal dispersion. The presented multicenter study in persistent AF patients was conducted in 1 expert and 7 satellite centers with a total of 17 operators, using the VX1 software to detect and subsequently ablate spatiotemporal dispersion. While the AF termination rate (88%) and the freedom from AF in 12 months FU (82%) was very encouraging, the VX1 software, using AI enhanced electrogram adjudication, achieved very similar results in all centers, regardless of the centre`s or the operator`s experience. Thus, the biggest criticism of electrogram-based ablation strategies, i.e. the lack of reproducibility in "non-expert" centers, seems to be finally addressed. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM), Munich, Germany
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Ezzeddine FM, Ward RC, Jiang Z, Tri JA, Agboola K, Hu T, Lodhi F, Tan NY, Ladas TP, Christopoulos G, Sugrue AM, Tolkacheva EG, Munoz FDC, McLeod CJ, Asirvatham SJ, DeSimone CV. Novel insights into the substrate involved in maintenance of ventricular fibrillation: results from continuous multipolar mapping in a canine model. J Interv Card Electrophysiol 2022:10.1007/s10840-022-01333-7. [PMID: 35948726 DOI: 10.1007/s10840-022-01333-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/01/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND While the triggers for ventricular fibrillation (VF) are well-known, the substrate required for its maintenance remains elusive. We have previously demonstrated dynamic spatiotemporal changes across VF from electrical induction of VF to asystole. Those data suggested that VF drivers seemed to reside in the distal RV and LV. However, signals from these areas were not recorded continuously. The aim of this study was to map these regions of significance with stationary basket electrodes from induction to asystole to provide further insights into the critical substrate for VF rhythm sustenance in canines. METHODS In six healthy canines, three multipolar basket catheters were positioned in the distal right ventricle (RV), RV outflow tract, and distal left ventricle (LV), and remained in place throughout the study. VF was induced via direct current application from an electrophysiologic catheter. Surface and intracardiac electrograms were recorded simultaneously and continuously from baseline, throughout VF, and until asystole, in order to get a complete electrophysiologic analysis of VF. Focused data analysis was also performed via two defined stages of VF: early VF (immediately after induction of VF to 10 min) and late VF (after 10 min up to VF termination and asystole). RESULTS VF was continuously mapped for a mean duration of 54 ± 9 min (range 42-70 min). Immediately after initiation of VF in the early phase, the distal LV region appeared to drive the maintenance of VF. Towards the terminal stage of VF, the distal RV region appeared to be responsible for VF persistence. In all canines, we noted local termination of VF in the LV, while VF on surface ECG continued; conversely, subsequent spontaneous termination of VF in the RV was associated with termination of VF on surface ECG into a ventricular escape rhythm. Continuous mapping of VF showed trends towards an increase in peak-to-peak ventricular electrogram cycle length (p = 0.06) and a decrease in the ventricular electrogram amplitude (p = 0.06) after 40 min. Once we could no longer discern surface QRS activity, we demonstrated local ventricular myocardial capture in both the RV and LV but could not reinitiate sustained VF despite aggressive ventricular burst pacing. CONCLUSIONS This study describes the evolution of VF from electrical initiation to spontaneous VF termination without hemodynamic support in healthy canines. These data are hypothesis-generating and suggest that critical substrate for VF maintenance may reside in both the distal RV and LV depending on stage of VF. Further studies are needed to replicate these findings with hemodynamic support and to translate such findings into clinical practice. Ventricular fibrillation maintenance may be dependent on critical structures in the distal RV. ECG: electrocardiogram; LV: left ventricle; RV: right ventricle; RVOT: right ventricular outflow tract; VF: ventricular fibrillation.
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Affiliation(s)
- Fatima M Ezzeddine
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Robert C Ward
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Zhi Jiang
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Jason A Tri
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Kolade Agboola
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Tiffany Hu
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Fahad Lodhi
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Nicholas Y Tan
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Thomas P Ladas
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Georgios Christopoulos
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Alan M Sugrue
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Elena G Tolkacheva
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, USA
| | - Freddy Del-Carpio Munoz
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | - Samuel J Asirvatham
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
- Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Christopher V DeSimone
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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13
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Osorio D, Vraka A, Quesada A, Hornero F, Alcaraz R, Rieta JJ. An Efficient Hybrid Methodology for Local Activation Waves Detection under Complex Fractionated Atrial Electrograms of Atrial Fibrillation. SENSORS (BASEL, SWITZERLAND) 2022; 22:s22145345. [PMID: 35891025 PMCID: PMC9316244 DOI: 10.3390/s22145345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/06/2022] [Accepted: 07/15/2022] [Indexed: 05/04/2023]
Abstract
Local activation waves (LAWs) detection in complex fractionated atrial electrograms (CFAEs) during catheter ablation (CA) of atrial fibrillation (AF), the commonest cardiac arrhythmia, is a complicated task due to their extreme variability and heterogeneity in amplitude and morphology. There are few published works on reliable LAWs detectors, which are efficient for regular or low fractionated bipolar electrograms (EGMs) but lack satisfactory results when CFAEs are analyzed. The aim of the present work is the development of a novel optimized method for LAWs detection in CFAEs in order to assist cardiac mapping and catheter ablation (CA) guidance. The database consists of 119 bipolar EGMs classified by AF types according to Wells' classification. The proposed method introduces an alternative Botteron's preprocessing technique targeting the slow and small-ampitude activations. The lower band-pass filter cut-off frequency is modified to 20 Hz, and a hyperbolic tangent function is applied over CFAEs. Detection is firstly performed through an amplitude-based threshold and an escalating cycle-length (CL) analysis. Activation time is calculated at each LAW's barycenter. Analysis is applied in five-second overlapping segments. LAWs were manually annotated by two experts and compared with algorithm-annotated LAWs. AF types I and II showed 100% accuracy and sensitivity. AF type III showed 92.77% accuracy and 95.30% sensitivity. The results of this study highlight the efficiency of the developed method in precisely detecting LAWs in CFAEs. Hence, it could be implemented on real-time mapping devices and used during CA, providing robust detection results regardless of the fractionation degree of the analyzed recordings.
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Affiliation(s)
- Diego Osorio
- BioMIT.org, Electronic Engineering Department, Universitat Politecnica de Valencia, 46022 Valencia, Spain; (D.O.); (A.V.)
| | - Aikaterini Vraka
- BioMIT.org, Electronic Engineering Department, Universitat Politecnica de Valencia, 46022 Valencia, Spain; (D.O.); (A.V.)
| | - Aurelio Quesada
- Arrhythmia Unit, Cardiology Department, General University Hospital Consortium of Valencia, 46014 Valencia, Spain;
| | - Fernando Hornero
- Cardiovascular Surgery Department, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain;
| | - 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; (D.O.); (A.V.)
- Correspondence:
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14
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Meng S, Chamorro-Servent J, Sunderland N, Zhao J, Bear LR, Lever NA, Sands GB, LeGrice IJ, Gillis AM, Budgett DM, Smaill BH. Non-Contact Intracardiac Potential Mapping Using Mesh-Based and Meshless Inverse Solvers. Front Physiol 2022; 13:873630. [PMID: 35874529 PMCID: PMC9301455 DOI: 10.3389/fphys.2022.873630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 06/07/2022] [Indexed: 11/13/2022] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac dysrhythmia and percutaneous catheter ablation is widely used to treat it. Panoramic mapping with multi-electrode catheters has been used to identify ablation targets in persistent AF but is limited by poor contact and inadequate coverage of the left atrial cavity. In this paper, we investigate the accuracy with which atrial endocardial surface potentials can be reconstructed from electrograms recorded with non-contact catheters. An in-silico approach was employed in which “ground-truth” surface potentials from experimental contact mapping studies and computer models were compared with inverse potential maps constructed by sampling the corresponding intracardiac field using virtual basket catheters. We demonstrate that it is possible to 1) specify the mixed boundary conditions required for mesh-based formulations of the potential inverse problem fully, and 2) reconstruct accurate inverse potential maps from recordings made with appropriately designed catheters. Accuracy improved when catheter dimensions were increased but was relatively stable when the catheter occupied >30% of atrial cavity volume. Independent of this, the capacity of non-contact catheters to resolve the complex atrial potential fields seen in reentrant atrial arrhythmia depended on the spatial distribution of electrodes on the surface bounding the catheter. Finally, we have shown that reliable inverse potential mapping is possible in near real-time with meshless methods that use the Method of Fundamental Solutions.
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Affiliation(s)
- Shu Meng
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
- *Correspondence: Shu Meng,
| | | | - Nicholas Sunderland
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Jichao Zhao
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Laura R. Bear
- HU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, Université Bordeaux, Bordeaux, France
- INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Nigel A. Lever
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
- Auckland City Hospital, Auckland, New Zealand
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Gregory B. Sands
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Ian J. LeGrice
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Anne M. Gillis
- Libin Cardiovascular Research Institute, Calgary University, Calgary, AB, Canada
| | - David M. Budgett
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Bruce H. Smaill
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
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15
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Cunha PS, Laranjo S, Heijman J, Oliveira MM. The Atrium in Atrial Fibrillation - A Clinical Review on How to Manage Atrial Fibrotic Substrates. Front Cardiovasc Med 2022; 9:879984. [PMID: 35859594 PMCID: PMC9289204 DOI: 10.3389/fcvm.2022.879984] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 06/03/2022] [Indexed: 12/27/2022] Open
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia in the population and is associated with a significant clinical and economic burden. Rigorous assessment of the presence and degree of an atrial arrhythmic substrate is essential for determining treatment options, predicting long-term success after catheter ablation, and as a substrate critical in the pathophysiology of atrial thrombogenesis. Catheter ablation of AF has developed into an essential rhythm-control strategy. Nowadays is one of the most common cardiac ablation procedures performed worldwide, with its success inversely related to the extent of atrial structural disease. Although atrial substrate evaluation remains complex, several diagnostic resources allow for a more comprehensive assessment and quantification of the extent of left atrial structural remodeling and the presence of atrial fibrosis. In this review, we summarize the current knowledge on the pathophysiology, etiology, and electrophysiological aspects of atrial substrates promoting the development of AF. We also describe the risk factors for its development and how to diagnose its presence using imaging, electrocardiograms, and electroanatomic voltage mapping. Finally, we discuss recent data regarding fibrosis biomarkers that could help diagnose atrial fibrotic substrates.
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Affiliation(s)
- Pedro Silva Cunha
- Arrhythmology, Pacing and Electrophysiology Unit, Cardiology Service, Santa Marta Hospital, Central Lisbon Hospital University Center, Lisbon, Portugal
- Lisbon School of Medicine, Universidade de Lisboa, Lisbon, Portugal
- Comprehensive Health Research Center, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Sérgio Laranjo
- Arrhythmology, Pacing and Electrophysiology Unit, Cardiology Service, Santa Marta Hospital, Central Lisbon Hospital University Center, Lisbon, Portugal
- Lisbon School of Medicine, Universidade de Lisboa, Lisbon, Portugal
- Comprehensive Health Research Center, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Jordi Heijman
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Mário Martins Oliveira
- Arrhythmology, Pacing and Electrophysiology Unit, Cardiology Service, Santa Marta Hospital, Central Lisbon Hospital University Center, Lisbon, Portugal
- Lisbon School of Medicine, Universidade de Lisboa, Lisbon, Portugal
- Comprehensive Health Research Center, Universidade NOVA de Lisboa, Lisbon, Portugal
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16
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Meng S, Sunderland N, Chamorro-Servent J, Bear LR, Lever NA, Sands GB, LeGrice IJ, Gillis AM, Zhao J, Budgett DM, Smaill BH. Intracardiac Inverse Potential Mapping Using the Method of Fundamental Solutions. Front Physiol 2022; 13:873049. [PMID: 35651876 PMCID: PMC9149204 DOI: 10.3389/fphys.2022.873049] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/19/2022] [Indexed: 12/31/2022] Open
Abstract
Introduction: Atrial fibrillation (AF) is the most prevalent cardiac dysrhythmia and percutaneous catheter ablation is widely used to treat it. Panoramic mapping with multi-electrode catheters can identify ablation targets in persistent AF, but is limited by poor contact and inadequate coverage. Objective: To investigate the accuracy of inverse mapping of endocardial surface potentials from electrograms sampled with noncontact basket catheters. Methods: Our group has developed a computationally efficient inverse 3D mapping technique using a meshless method that employs the Method of Fundamental Solutions (MFS). An in-silico test bed was used to compare ground-truth surface potentials with corresponding inverse maps reconstructed from noncontact potentials sampled with virtual catheters. Ground-truth surface potentials were derived from high-density clinical contact mapping data and computer models. Results: Solutions of the intracardiac potential inverse problem with the MFS are robust, fast and accurate. Endocardial surface potentials can be faithfully reconstructed from noncontact recordings in real-time if the geometry of cardiac surface and the location of electrodes relative to it are known. Larger catheters with appropriate electrode density are needed to resolve complex reentrant atrial rhythms. Conclusion: Real-time panoramic potential mapping is feasible with noncontact intracardiac catheters using the MFS. Significance: Accurate endocardial potential maps can be reconstructed in AF with appropriately designed noncontact multi-electrode catheters.
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Affiliation(s)
- Shu Meng
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Nicholas Sunderland
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | | | - Laura R. Bear
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, Univ. Bordeaux, Bordeaux, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM, Bordeaux, France
| | - Nigel A. Lever
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
- Auckland City Hospital, Auckland, New Zealand
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Gregory B. Sands
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Ian J. LeGrice
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Anne M. Gillis
- Libin Cardiovascular Research Institute, Calgary University, Calgary, AB, Canada
| | - Jichao Zhao
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - David M. Budgett
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Bruce H. Smaill
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
- *Correspondence: Bruce H. Smaill,
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17
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Kawaji T, Aizawa T, Hojo S, Yaku H, Nakatsuma K, Kaneda K, Kato M, Yokomatsu T, Miki S. Instability of rotational activation as atrial fibrillation drivers: assessment by ExTRa Mapping system. Pacing Clin Electrophysiol 2022; 45:688-695. [PMID: 35415846 DOI: 10.1111/pace.14502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 03/10/2022] [Accepted: 04/01/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND ExTRa Mapping™ has developed to visualize rotational activation as atrial fibrillation(AF) drivers. The current study was sought to evaluate the instability of AF drivers by ExTRa Mapping™. METHODS Variation of non-passively activated ratio(%NP) among 3-time repetitive recordings before and after pulmonary vein isolation(PVI) in left atrium was assessed in 26 persistent AF patients. The recoding time was set at 5 seconds or 8 seconds for the respective patients. The outcome measures included %NP at each recording, mean value of the 3-time recordings, and the instability index, which was defined as maximum difference per mean %NP×100 (%). RESULTS Total 683 sites 2049 recordings were assessed. Mean %NP was 33.3(23.3-42.7)%, and higher in sites with severe(≥50%) and patchy low voltage area than those without, but not in those with severe complex fractionated atrial electrogram area. There was significant correlation between actual and mean %NP (R = 0.86, P<0.001), but maximum difference among the repetitive recordings was 16(10-24) %. The instability index of %NP was 55.9(30.9-83.6)%, and significantly lower at the recordings of 8 seconds compared with 5 seconds (50.6[28.6-78.4]% versus 60.4[35.0-90.0]%, P = 0.004). Furthermore, it was higher at sites with lower reliability of the recordings. After PVI, mean %NP significantly decreased (28.7[18.3-36.7]% versus 37.7[28.7-45.7]%, P<0.001), but the instability index significantly increased compared with those before PVI (60.0[35.0-92.7]% versus 48.9[29.1-75.0]%, P = 0.001). CONCLUSION Rotational activation as AF drivers assessed by ExTRa Mapping™ is unstable, and repetitive and longer recording is required for the reliable assessment even after PVI. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Tetsuma Kawaji
- Department of Cardiology, Mitsubishi Kyoto Hospital, Kyoto.,Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto
| | - Takanori Aizawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto
| | - Shun Hojo
- Department of Cardiology, Mitsubishi Kyoto Hospital, Kyoto
| | - Hidenori Yaku
- Department of Cardiology, Mitsubishi Kyoto Hospital, Kyoto.,Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto
| | | | | | - Masashi Kato
- Department of Cardiology, Mitsubishi Kyoto Hospital, Kyoto
| | | | - Shinji Miki
- Department of Cardiology, Mitsubishi Kyoto Hospital, Kyoto
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18
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Convolutional Neural Networks for Mechanistic Driver Detection in Atrial Fibrillation. Int J Mol Sci 2022; 23:ijms23084216. [PMID: 35457044 PMCID: PMC9032062 DOI: 10.3390/ijms23084216] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 04/04/2022] [Accepted: 04/04/2022] [Indexed: 02/04/2023] Open
Abstract
The maintaining and initiating mechanisms of atrial fibrillation (AF) remain controversial. Deep learning is emerging as a powerful tool to better understand AF and improve its treatment, which remains suboptimal. This paper aims to provide a solution to automatically identify rotational activity drivers in endocardial electrograms (EGMs) with convolutional recurrent neural networks (CRNNs). The CRNN model was compared with two other state-of-the-art methods (SimpleCNN and attention-based time-incremental convolutional neural network (ATI-CNN)) for different input signals (unipolar EGMs, bipolar EGMs, and unipolar local activation times), sampling frequencies, and signal lengths. The proposed CRNN obtained a detection score based on the Matthews correlation coefficient of 0.680, an ATI-CNN score of 0.401, and a SimpleCNN score of 0.118, with bipolar EGMs as input signals exhibiting better overall performance. In terms of signal length and sampling frequency, no significant differences were found. The proposed architecture opens the way for new ablation strategies and driver detection methods to better understand the AF problem and its treatment.
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19
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Ríos-Muñoz GR, Soto N, Ávila P, Carta A, Atienza F, Datino T, González-Torrecilla E, Fernández-Avilés F, Arenal Á. Structural Remodeling and Rotational Activity in Persistent/Long-Lasting Atrial Fibrillation: Gender-Effect Differences and Impact on Post-ablation Outcome. Front Cardiovasc Med 2022; 9:819429. [PMID: 35387439 PMCID: PMC8977980 DOI: 10.3389/fcvm.2022.819429] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 02/02/2022] [Indexed: 11/13/2022] Open
Abstract
Background Structural and post-ablation gender differences are reported in atrial fibrillation (AF). We analyzed the gender differences in structural remodeling and AF mechanisms in patients with persistent/long-lasting AF who underwent wide area circumferential pulmonary vein isolation (WACPVI). Materials and Methods Ultra-high-density mapping was used to study atrial remodeling and AF drivers in 85 consecutive patients. Focal and rotational activity (RAc) were identified with the CartoFinder system and activation sequence analysis. The impact of RAc location on post-ablation outcomes was analyzed. Results This study included 64 men and 21 women. RAc was detected in 73.4% of men and 38.1% of women (p = 0.003). RAc patients had higher left atrium (LA) voltage (0.64 ± 0.3 vs. 0.50 ± 0.2 mV; p = 0.01), RAc sites had higher voltage than non-RAc sites 0.77 ± 0.46 vs. 0.53 ± 0.37 mV (p < 0.001). Women had lower LA voltage than men (0.42 vs. 0.64 mV; p < 0.001), including pulmonary vein (PV) antra (0.16 vs. 0.30 mV; p < 0.001) and posterior wall (0.34 vs. 0.51 mV; p < 0.001). RAc in the posterior atrium was recorded in few women (23.8 vs. 54.7% in men; p = 0.014). AF recurrence rate was higher in patients with RAc outside WACPVI than those with all RAc inside WACPVI or no RAc (63.4 vs. 11.1 and 31.0%; p = 0.008 and p = 0.01). Comparison of selected patients using propensity score matching confirmed lower atrial voltage (0.4 ± 0.2 vs. 0.7 ± 0.3 mV; p = 0.007) and less RAc (38 vs. 75%; p = 0.02) in women. Conclusion Women have shown more advanced structural remodeling at ablation, which is associated with a lower incidence of RAc (usually located outside the WACPVI). These findings could explain post-ablation gender differences.
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Affiliation(s)
- Gonzalo R Ríos-Muñoz
- Department of Cardiology, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Center for Biomedical Research in Cardiovascular Disease Network (CIBERCV), Madrid, Spain.,Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Madrid, Spain
| | - Nina Soto
- Department of Cardiology, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Pablo Ávila
- Department of Cardiology, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Center for Biomedical Research in Cardiovascular Disease Network (CIBERCV), Madrid, Spain
| | - Alejandro Carta
- Department of Cardiology, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Center for Biomedical Research in Cardiovascular Disease Network (CIBERCV), Madrid, Spain
| | - Felipe Atienza
- Department of Cardiology, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Center for Biomedical Research in Cardiovascular Disease Network (CIBERCV), Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Tomás Datino
- Department of Cardiology, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Center for Biomedical Research in Cardiovascular Disease Network (CIBERCV), Madrid, Spain
| | - Esteban González-Torrecilla
- Department of Cardiology, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Center for Biomedical Research in Cardiovascular Disease Network (CIBERCV), 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.,Center for Biomedical Research in Cardiovascular Disease Network (CIBERCV), Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Ángel Arenal
- Department of Cardiology, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Center for Biomedical Research in Cardiovascular Disease Network (CIBERCV), Madrid, Spain
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20
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Li QH, Xia YX, Xu SX, Song Z, Pan JT, Panfilov AV, Zhang H. Control of spiral waves in optogenetically modified cardiac tissue by periodic optical stimulation. Phys Rev E 2022; 105:044210. [PMID: 35590553 DOI: 10.1103/physreve.105.044210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 03/30/2022] [Indexed: 06/15/2023]
Abstract
Resonant drift of nonlinear spiral waves occurs in various types of excitable media under periodic stimulation. Recently a novel methodology of optogenetics has emerged, which allows to affect excitability of cardiac cells and tissues by optical stimuli. In this paper we study if resonant drift of spiral waves in the heart can be induced by a homogeneous weak periodic optical stimulation of cardiac tissue. We use a two-variable and a detailed model of cardiac tissue and add description of depolarizing and hyperpolarizing optogenetic ionic currents. We show that weak periodic optical stimulation at a frequency equal to the natural rotation frequency of the spiral wave induces resonant drift for both depolarizing and hyperpolarizing optogenetic currents. We quantify these effects and study how the speed of the drift and its direction depend on the initial conditions. We also derive analytical formulas based on the response function theory which correctly predict the drift velocity and its trajectory. We conclude that optogenetic methodology can be used for control of spiral waves in cardiac tissue and discuss its possible applications.
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Affiliation(s)
- Qi-Hao Li
- Zhejiang Institute of Modern Physics and Department of Physics, Zhejiang University, Hangzhou 310027, China
- Department of Mathematics and Theories, Peng Cheng Laboratory, Shenzhen 518066, China
| | - Yuan-Xun Xia
- Zhejiang Institute of Modern Physics and Department of Physics, Zhejiang University, Hangzhou 310027, China
| | - Shu-Xiao Xu
- Zhejiang Institute of Modern Physics and Department of Physics, Zhejiang University, Hangzhou 310027, China
| | - Zhen Song
- Department of Mathematics and Theories, Peng Cheng Laboratory, Shenzhen 518066, China
| | - Jun-Ting Pan
- Ocean College, Zhejiang University, Zhoushan 316021, China
| | - Alexander V Panfilov
- Department of Physics and Astronomy, Ghent University, Ghent 9000, Belgium
- Laboratory of Computational Biology and Medicine, Ural Federal University, Ekaterinburg 620002, Russia
- World-Class Research Center "Digital biodesign and personalized healthcare," Sechenov University, Moscow 119146, Russia
| | - Hong Zhang
- Zhejiang Institute of Modern Physics and Department of Physics, Zhejiang University, Hangzhou 310027, China
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21
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Zaman JAB, Grace AA, Narayan SM. Future Directions for Mapping Atrial Fibrillation. Arrhythm Electrophysiol Rev 2022; 11:e08. [PMID: 35734143 PMCID: PMC9194915 DOI: 10.15420/aer.2021.52] [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] [Received: 08/30/2021] [Accepted: 11/08/2021] [Indexed: 01/14/2023] Open
Abstract
Mapping for AF focuses on the identification of regions of interest that may guide management and - in particular - ablation therapy. Mapping may point to specific mechanisms associated with localised scar or fibrosis, or electrical features, such as localised repetitive, rotational or focal activation. In patients in whom AF is caused by disorganised waves with no spatial predilection, as proposed in the multiwavelet theory for AF, mapping would be of less benefit. The role of AF mapping is controversial at the current time in view of the debate over the underlying mechanisms. However, recent clinical expansions of mapping technologies confirm the importance of understanding the state of the art, including limitations of current approaches and potential areas of future development.
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Affiliation(s)
- Junaid AB Zaman
- Keck School of Medicine, University of Southern California, Los Angeles, CA, US
| | - Andrew A Grace
- Department of Biochemistry, University of Cambridge, Cambridge, UK
| | - Sanjiv M Narayan
- Cardiovascular Institute and Department of Medicine, Stanford University, CA, US
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22
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Nonlinear interdependence of electrograms as a tool to characterize propagation patterns in atrial fibrillation. Biomed Signal Process Control 2022. [DOI: 10.1016/j.bspc.2021.103282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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23
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Utility of Simultaneous Biatrial Atrial Anti-Tachycardia Pacing for the Termination of Atrial Fibrillation during Catheter Ablation of Atrial Fibrillation. J Clin Med 2022; 11:jcm11030575. [PMID: 35160027 PMCID: PMC8837084 DOI: 10.3390/jcm11030575] [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: 12/15/2021] [Revised: 01/19/2022] [Accepted: 01/22/2022] [Indexed: 02/01/2023] Open
Abstract
Background: Atrial anti-tachycardia pacing (A-ATP) of the right atrium (RA) has been shown to decrease the burden of atrial fibrillation (AF) in patients with dual-chamber pacemakers. The aim of this study is to identify the novel predictors of effective A-ATP for terminating AF in patients with AF undergoing catheter ablation. Methods: This study included 41 consecutive patients undergoing a first ablation procedure for paroxysmal (PAF: n = 21) or persistent (PEF: n = 20) AF. We prospectively evaluated predictors of AF termination after A-ATP. The coefficient of variation (CoV = SD/mean × 100) of the dominant frequencies (DFs) was calculated to evaluate the variability in atrial activation. Results: AF was terminated by A-ATP in 29% of PAF and 5% of PEF patients. In these patients, simultaneous high-rate pacing from the RA and the coronary sinus (CS) terminated AF in 71% of patients, in whom the mean AF cycle length (CL) before A-ATP was longer (214 ± 23 vs. 177 ± 35 ms, p = 0.02) and became slower after A-ATP (234 ± 37 vs. 176 ± 32 ms, p < 0.01), compared to unsuccessful patients. The CoV of the DFs before A-ATP were lower in both RA (6.2 ± 2.0 vs. 15.3 ± 7.9, p = 0.02) and CS (11.0 ± 7.9 vs. 24.3 ± 9.3, p < 0.01) in successful patients. Conclusions: Simultaneous biatrial A-ATP from the RA and CS could terminate AF in patients with PAF. The predictors for successful termination include longer AF CL and higher AF stability.
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24
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Beyond pulmonary vein isolation for persistent atrial fibrillation: sequential high-resolution mapping to guide ablation. J Interv Card Electrophysiol 2022; 65:53-62. [PMID: 35000099 PMCID: PMC9550675 DOI: 10.1007/s10840-021-01115-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 12/27/2021] [Indexed: 11/16/2022]
Abstract
Purpose We aimed to evaluate whether outcomes with ablation in persistent (PsAF) and long-standing persistent (LsPsAF) AF can be improved beyond what can be achieved with pulmonary vein isolation (PVI) alone, using individualized mapping to guide ablation. Methods We studied 20 pts (15 M, 68 ± 11y) with PsAF (14) or LsPsAF (6) referred for first-time AF ablation. Following antral PVI, individualized mapping (IM) was performed using a high-density mapping catheter stably and fully deployed for 30 s at each of 23 ± 9 sites per patient. Activation data were reviewed, and an ablation strategy designed to intersect areas of focal and rotational activity. Mean follow-up was 429 ± 131 days. The study population was compared to a matched contemporary control cohort (CC) of 20 consecutive patients undergoing conventional ablation. Results Despite the IM group having a higher median comorbidities score, 3.5 vs. 2.5 in the CC group, indicating potentially more complex patients and more advanced substrate, cumulative freedom from AF after a single procedure was achieved in 94% of patients in the IM group vs. 75% in the CC group at 1 year and remained the same in both groups at the conclusion of the study (p = 0.02). There was a similar trend in atrial arrhythmia-free survival between both groups (84% vs. 67% at 1 year) that did not reach statistical significance. The procedure duration was longer in the IM group by a median of 31.5 min (p = 0.004). Conclusions Individualized mapping to guide AF ablation appears to achieve significantly greater AF-free survival compared to conventional PVI when applied as a primary ablation treatment. The results of this pilot study need to be confirmed in a larger, randomized trial. Supplementary Information The online version contains supplementary material available at 10.1007/s10840-021-01115-7.
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25
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Zheng Z, Li H, Liu S, Gao G, Yu C, Lin H, Meng Y. Box lesion or bi-atrial lesion set for atrial fibrillation during thoracoscopic epicardial ablation. Interact Cardiovasc Thorac Surg 2022; 34:1-8. [PMID: 34999802 PMCID: PMC8923398 DOI: 10.1093/icvts/ivab211] [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: 04/28/2021] [Revised: 05/27/2021] [Accepted: 07/07/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Thoracoscopic epicardial ablation with a limited lesion set led to suboptimal results for advanced paroxysmal atrial fibrillation (AF) or persistent AF. Whether additional right atrial lesions improve the result is unclear. METHODS We conducted a retrospective study involving 80 consecutive patients with paroxysmal or persistent AF, left atrial (LA) dilation (LA diameter >40 mm) and failed prior interventional ablation (40 patients, 50%) who underwent thoracoscopic epicardial ablation with box lesions (36 patients) or bi-atrial (BA) lesion (44 patients) in our institution. Freedom from atrial tachyarrhythmias after the procedures was compared between the box lesion group and BA lesion group. RESULTS Baseline differences included more patients with persistent AF (86.4% vs 47.2%) and larger left atrium [48.00 (44.00-50.75) vs 42.00 (41.25-44.00) mm] in the BA lesion group. There was no difference in procedural complications between the 2 groups. After a mean follow-up of 32 months, the freedom from atrial tachyarrhythmias off antiarrhythmic drugs at 6, 12 and 24 months was 77.2%, 77.2% and 77.2% in the BA lesion group and 69.4%, 50.0% and 40.6% in the box lesion group, respectively (P = 0.006). After adjustment for sex, age, body mass index, LA diameter, AF type, history of AF, and previous interventional ablation, BA lesion was an independent predictor of lower atrial tachyarrhythmia recurrence (hazard ratio 0.447, 95% confidential interval 0.208-0.963; P = 0.040). CONCLUSIONS Compared with the box lesion set, thoracoscopic epicardial ablation with BA lesion sets might provide better freedom from atrial tachyarrhythmias for paroxysmal or persistent AF with LA dilation. Randomized control trials are warranted to confirm the benefit of BA lesion sets in these patients.
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Affiliation(s)
- Zhe Zheng
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Haojie Li
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Sheng Liu
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ge Gao
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chunyu Yu
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hengqiang Lin
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ying Meng
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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26
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Rappel WJ, Krummen DE, Baykaner T, Zaman J, Donsky A, Swarup V, Miller JM, Narayan SM. Stochastic termination of spiral wave dynamics in cardiac tissue. FRONTIERS IN NETWORK PHYSIOLOGY 2022; 2:809532. [PMID: 36187938 PMCID: PMC9524168 DOI: 10.3389/fnetp.2022.809532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Rotating spiral waves are self-organized features in spatially extended excitable media and may play an important role in cardiac arrhythmias including atrial fibrillation (AF). In homogeneous media, spiral wave dynamics are perpetuated through spiral wave breakup, leading to the continuous birth and death of spiral waves, but have a finite probability of termination. In non-homogeneous media, however, heterogeneities can act as anchoring sources that result in sustained spiral wave activity. It is thus unclear how and if AF may terminate following the removal of putative spiral wave sources in patients. Here, we address this question using computer simulations in which a stable spiral wave is trapped by an heterogeneity and is surrounded by spiral wave breakup. We show that, following ablation of spatial heterogeneity to render that region of the medium unexcitable, termination of spiral wave dynamics is stochastic and Poisson-distributed. Furthermore, we show that the dynamics can be accurately described by a master equation using birth and death rates. To validate these predictions in vivo, we mapped spiral wave activity in patients with AF and targeted the locations of spiral wave sources using radiofrequency ablation. Targeted ablation was indeed able to terminate AF, but only after a variable delay of up to several minutes. Furthermore, and consistent with numerical simulations, termination was not accompanied by gradual temporal or spatial organization. Our results suggest that spiral wave sources and tissue heterogeneities play a critical role in the maintenance of AF and that the removal of sources results in spiral wave dynamics with a finite termination time, which could have important clinical implications.
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Affiliation(s)
| | | | - Tina Baykaner
- Department of Medicine and Cardiovascular Institute, Stanford University, Palo Alto, California
| | - Junaid Zaman
- Department of Medicine, Division of Cardiology, University of Southern California, Los Angeles, California
| | | | - Vijay Swarup
- Arizona Heart Rhythm Institute, Phoenix, Arizona
| | - John M Miller
- Krannert Institute, Indiana University, Indianapolis, Indiana
| | - Sanjiv M Narayan
- Department of Medicine and Cardiovascular Institute, Stanford University, Palo Alto, California
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27
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Kumagai K, Sato T, Kurose Y, Sumiyoshi T, Hasegawa K, Sekiguchi Y, Yambe M, Komaru T. Predictors of recurrence of atrial tachyarrhythmias after pulmonary vein isolation by functional and structural mapping of nonparoxysmal atrial fibrillation. J Arrhythm 2021; 38:86-96. [PMID: 35222754 PMCID: PMC8851591 DOI: 10.1002/joa3.12670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 12/09/2021] [Accepted: 12/12/2021] [Indexed: 11/07/2022] Open
Abstract
Background This study aimed to evaluate the predictors of recurrence of atrial tachyarrhythmias by structural and functional mapping: voltage, dominant frequency (DF), and rotor mapping after a pulmonary vein isolation (PVI) in nonparoxysmal atrial fibrillation (AF) patients. Methods A total of 66 nonparoxysmal AF patients were prospectively investigated. After the PVI, an online real‐time phase mapping system was used to detect the location of rotors with critical nonpassively activated ratios (%NPs) of ≧50% in each left atrial (LA) segment, and high‐DFs of ≧7 Hz were simultaneously mapped. After restoring sinus rhythm, low‐voltage areas (LVAs < 0.5 mV) were mapped using the Advisor HD grid catheter (HDG). Results Sixty‐four of 66 (97%) AF patients had minimum to mild LVAs regardless of an enlarged LAD and LA volume (45 ± 6.0 mm and 141 ± 29 ml). There were no significant differences in the max and mean DF values and %NPs between the patients with and without recurrent atrial tachyarrhythmias. However, there was a significant difference in the LVA/LA surface area between the patients with and without recurrent atrial tachyarrhythmias (p = .004). Atrial tachyarrhythmia freedom was significantly greater in those with LVAs of ≤3.3% than in those >3.3% after one procedure over 11.6 ± 0.8 months of follow‐up (77.1% vs. 33.3%, p < .001). In a multivariate analysis, the LVA/LA surface area after the PVI (HR 1.079; CI, 1.025–1.135, p = .003) was an independent predictor of AF recurrence. Conclusions The predictor of atrial tachyarrhythmia recurrence after the PVI was LVAs rather than DFs and rotors in nonparoxysmal AF patients.
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Affiliation(s)
- Koji Kumagai
- Department of Cardiovascular Medicine Tohoku Medical and Pharmaceutical University Miyagi Japan
| | - Tsukasa Sato
- Department of Cardiovascular Medicine Tohoku Medical and Pharmaceutical University Miyagi Japan
| | - Yuki Kurose
- Department of Cardiovascular Medicine Tohoku Medical and Pharmaceutical University Miyagi Japan
| | - Takenori Sumiyoshi
- Department of Cardiovascular Medicine Tohoku Medical and Pharmaceutical University Miyagi Japan
| | - Kaoru Hasegawa
- Department of Cardiovascular Medicine Tohoku Medical and Pharmaceutical University Miyagi Japan
| | - Yuko Sekiguchi
- Department of Cardiovascular Medicine Tohoku Medical and Pharmaceutical University Miyagi Japan
| | - Minoru Yambe
- Department of Cardiovascular Medicine Tohoku Medical and Pharmaceutical University Miyagi Japan
| | - Tatsuya Komaru
- Department of Cardiovascular Medicine Tohoku Medical and Pharmaceutical University Miyagi Japan
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28
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Tan NY, Christopoulos G, Ladas TP, Jiang Z, Sugrue AM, Tri JA, Tolkacheva EG, Del-Carpio Munoz F, McLeod CJ, Asirvatham SJ, DeSimone CV. Regional and Temporal Variation of Ventricular and Conduction Tissue Activity During Ventricular Fibrillation in Canines. Circ Arrhythm Electrophysiol 2021; 14:e010281. [PMID: 34665643 DOI: 10.1161/circep.121.010281] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Nicholas Y Tan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester (N.T., G.C., T.P.L., Z.J., A.M.S., J.A.T., F.D.-C.M., S.J.A., C.V.D.)
| | - Georgios Christopoulos
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester (N.T., G.C., T.P.L., Z.J., A.M.S., J.A.T., F.D.-C.M., S.J.A., C.V.D.)
| | - Thomas P Ladas
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester (N.T., G.C., T.P.L., Z.J., A.M.S., J.A.T., F.D.-C.M., S.J.A., C.V.D.)
| | - Zhi Jiang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester (N.T., G.C., T.P.L., Z.J., A.M.S., J.A.T., F.D.-C.M., S.J.A., C.V.D.)
| | - Alan M Sugrue
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester (N.T., G.C., T.P.L., Z.J., A.M.S., J.A.T., F.D.-C.M., S.J.A., C.V.D.)
| | - Jason A Tri
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester (N.T., G.C., T.P.L., Z.J., A.M.S., J.A.T., F.D.-C.M., S.J.A., C.V.D.)
| | - Elena G Tolkacheva
- Department of Biomedical Engineering, University of Minnesota, Minneapolis (E.G.T.)
| | - Freddy Del-Carpio Munoz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester (N.T., G.C., T.P.L., Z.J., A.M.S., J.A.T., F.D.-C.M., S.J.A., C.V.D.)
| | | | - Samuel J Asirvatham
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester (N.T., G.C., T.P.L., Z.J., A.M.S., J.A.T., F.D.-C.M., S.J.A., C.V.D.)
| | - Christopher V DeSimone
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester (N.T., G.C., T.P.L., Z.J., A.M.S., J.A.T., F.D.-C.M., S.J.A., C.V.D.)
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29
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He YJ, Li QH, Zhou K, Jiang R, Jiang C, Pan JT, Zheng D, Zheng B, Zhang H. Topological charge-density method of identifying phase singularities in cardiac fibrillation. Phys Rev E 2021; 104:014213. [PMID: 34412332 DOI: 10.1103/physreve.104.014213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 06/28/2021] [Indexed: 11/07/2022]
Abstract
Spiral waves represent the key motifs of typical self-sustained dynamical patterns in excitable systems such as cardiac tissue. The motion of phase singularities (PSs) that lies at the center of spiral waves captures many qualitative and, in some cases, quantitative features of their complex dynamics. Recent clinical studies suggested that ablating the tissue at PS locations may cure atrial fibrillation. Here, we propose a different method to determine the location of PSs. Starting from the definition of the topological charge of spiral waves, we obtain the expression of the topological charge density in a discrete case. With this expression, we can calculate the topological charge at each grid in the space directly, so as to accurately identify the position of PSs.
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Affiliation(s)
- Yin-Jie He
- Zhejiang Institute of Modern Physics and Department of Physics, Zhejiang University, Hangzhou 310027, China
| | - Qi-Hao Li
- Zhejiang Institute of Modern Physics and Department of Physics, Zhejiang University, Hangzhou 310027, China
| | - Kuangshi Zhou
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Ruhong Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Chenyang Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China
| | - Jun-Ting Pan
- Ocean College, Zhejiang University, Zhoushan 316021, China
| | - Dafang Zheng
- Zhejiang Institute of Modern Physics and Department of Physics, Zhejiang University, Hangzhou 310027, China
| | - Bo Zheng
- Zhejiang Institute of Modern Physics and Department of Physics, Zhejiang University, Hangzhou 310027, China.,School of Physics and Astronomy, Yunnan University, Kunming 650091, China
| | - Hong Zhang
- Zhejiang Institute of Modern Physics and Department of Physics, Zhejiang University, Hangzhou 310027, China
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30
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Maesen B, Luermans JGLM, Bidar E, Chaldoupi SM, Gelsomino S, Maessen JG, Pison L, Meir ML. A hybrid approach to complex arrhythmias. Europace 2021; 23:ii28-ii33. [PMID: 33837755 DOI: 10.1093/europace/euab027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 01/20/2021] [Indexed: 12/16/2022] Open
Abstract
Despite many years of research, the different aspects of the mechanism of atrial fibrillation (AF) are still incompletely understood. And although the latest guidelines recommend catheter ablation with pulmonary vein isolation as a rhythm control strategy, long-term results in persistent and long-standing persistent AF are suboptimal. Historically, a mechanistic-based patient-tailored approach for the treatment of AF was impossible because of the lack real-time mapping techniques and advanced ablation tools. Therefore, surgeons created lesion sets based upon the anatomy of both atria and the safety of the incisions made by the knife. These complex open-heart procedures had to be performed through a sternotomy on the arrested heart and where therefore not generally adopted. The use of controlled energy sources such as cryothermy and radiofrequency where the first step to make the creation of these lesions less complex. With the development and improvement of electrophysiology techniques and catheters, this invasive and solely anatomical approach could again be partially redesigned. Now less invasive, it prepared the way for collaboration between electrophysiologists working on the endocardial side of the heart and cardiac surgeons providing epicardial access. The introduction of video-assisted technology and hybrid procedures has further increased the possibilities of new successful therapies. Now more than 40 years since the beginning of this exciting maze of AF procedures and still working towards a less aggressive and more comprehensive approach we give an overview of the history of the different minimally invasive surgical solutions and of the hybrid approach.
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Affiliation(s)
- Bart Maesen
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, the Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Justin G L M Luermans
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands.,Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Elham Bidar
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, the Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Sevasti-Maria Chaldoupi
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands.,Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Sandro Gelsomino
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, the Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | | | - Mark La Meir
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, the Netherlands.,Department of Cardiothoracic Surgery, UZ Brussels, Brussels, Belgium
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31
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van Rosmalen F, Maesen B, van Hunnik A, Hermans BJM, Bonizzi P, Bidar E, Nijs J, Maessen JG, Verheule S, Delhaas T, Schotten U, Zeemering S. Incidence, prevalence, and trajectories of repetitive conduction patterns in human atrial fibrillation. Europace 2021; 23:i123-i132. [PMID: 33751087 DOI: 10.1093/europace/euaa403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/11/2020] [Indexed: 11/12/2022] Open
Abstract
AIMS Repetitive conduction patterns in atrial fibrillation (AF) may reflect anatomical structures harbouring preferential conduction paths and indicate the presence of stationary sources for AF. Recently, we demonstrated a novel technique to detect repetitive patterns in high-density contact mapping of AF. As a first step towards repetitive pattern mapping to guide AF ablation, we determined the incidence, prevalence, and trajectories of repetitive conduction patterns in epicardial contact mapping of paroxysmal and persistent AF patients. METHODS AND RESULTS A 256-channel mapping array was used to record epicardial left and right AF electrograms in persistent AF (persAF, n = 9) and paroxysmal AF (pAF, n = 11) patients. Intervals containing repetitive conduction patterns were detected using recurrence plots. Activation movies, preferential conduction direction, and average activation sequence were used to characterize and classify conduction patterns. Repetitive patterns were identified in 33/40 recordings. Repetitive patterns were more prevalent in pAF compared with persAF [pAF: median 59%, inter-quartile range (41-72) vs. persAF: 39% (0-51), P < 0.01], larger [pAF: = 1.54 (1.15-1.96) vs. persAF: 1.16 (0.74-1.56) cm2, P < 0.001), and more stable [normalized preferentiality (0-1) pAF: 0.38 (0.25-0.50) vs. persAF: 0.23 (0-0.33), P < 0.01]. Most repetitive patterns were peripheral waves (87%), often with conduction block (69%), while breakthroughs (9%) and re-entries (2%) occurred less frequently. CONCLUSION High-density epicardial contact mapping in AF patients reveals frequent repetitive conduction patterns. In persistent AF patients, repetitive patterns were less frequent, smaller, and more variable than in paroxysmal AF patients. Future research should elucidate whether these patterns can help in finding AF ablation targets.
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Affiliation(s)
- Frank van Rosmalen
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Bart Maesen
- Department of Cardiothoracic Surgery, Maastricht University, Medical Center & Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Arne van Hunnik
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Ben J M Hermans
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Pietro Bonizzi
- Department of Data Science and Knowledge Engineering, Maastricht University, Maastricht, The Netherlands
| | - Elham Bidar
- Department of Cardiothoracic Surgery, Maastricht University, Medical Center & Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Jan Nijs
- Department of Cardiac Surgery, UZ Brussel, Brussels, Belgium
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University, Medical Center & Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Sander Verheule
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Tammo Delhaas
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Ulrich Schotten
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Stef Zeemering
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
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Pope MT, Kuklik P, Briosa E Gala A, Leo M, Mahmoudi M, Paisey J, Betts TR. Spatial and temporal variability of rotational, focal, and irregular activity: Practical implications for mapping of atrial fibrillation. J Cardiovasc Electrophysiol 2021; 32:2393-2403. [PMID: 34260134 PMCID: PMC9290790 DOI: 10.1111/jce.15170] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 05/06/2021] [Accepted: 05/25/2021] [Indexed: 01/24/2023]
Abstract
BACKGROUND Charge density mapping of atrial fibrillation (AF) reveals dynamic localized rotational activation (LRA), irregular activation (LIA) and focal firing (FF). Their spatial stability, conduction characteristics and the optimal duration of mapping required to reveal these phenomena and has not been explored. METHODS Bi-atrial mapping of AF propagation was undertaken using AcQMap (Acutus Medical) and variability of activation patterns quantified up to a duration of 30 s. The frequency of each pattern was quantified at each unique point of the chamber over two separate 30-s recordings before ablation and R2 calculated to quantify spatial stability. Regions with the highest frequency were identified at increasing time durations and compared to the result over 30 s using Cohen's kappa. Properties of regions with the most stable patterns were assessed during sinus rhythm and extrastimulus pacing. RESULTS In 21 patients, 62 paired LA and RA maps were obtained. LIA was highly spatially stable with R2 between maps of 0.83 (0.71-0.88) compared to 0.39 (0.24-0.57), and 0.64 (0.54-0.73) for LRA and FF, respectively. LIA was most temporally stable with a kappa of >0.8 reached by 12 s. LRA showed greatest variability with kappa >0.8 only after 22 s. Regions of LIA were of normal voltage amplitude (1.09 mv) but showed increased conduction heterogeneity during extrastimulus pacing (p = .0480). CONCLUSION Irregular activation patterns characterized by changing wavefront direction are temporally and spatially stable in contrast with LRA that is transient with least spatial stability. Focal activation appears of intermediate stability. Regions of LIA show increased heterogeneity following extrastimulus pacing and may represent fixed anatomical substrate.
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Affiliation(s)
- Michael Tb Pope
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Faculty of Medicine, University of Southampton, Southampton, UK
| | - Pawel Kuklik
- Department of Cardiology, Asklepios Clinic St. Georg, Hamburg, Germany
| | - Andre Briosa E Gala
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Faculty of Medicine, University of Southampton, Southampton, UK
| | - Milena Leo
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - John Paisey
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Timothy R Betts
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,University of Oxford Biomedical Research Center, Oxford, UK
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33
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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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Mann I, Linton NWF, Coyle C, Howard JP, Fudge M, Lim E, Qureshi N, Koa-Wing M, Whinnett Z, Lim PB, Ng FS, Peters NS, Francis DP, Kanagaratnam P. RETRO-MAPPING: A New Approach to Activation Mapping in Persistent Atrial Fibrillation Reveals Evidence of Spatiotemporal Stability. Circ Arrhythm Electrophysiol 2021; 14:e009602. [PMID: 33999670 DOI: 10.1161/circep.121.009602] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Ian Mann
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Nick W F Linton
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Clare Coyle
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - James P Howard
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Michael Fudge
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Elaine Lim
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Norman Qureshi
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | | | | | - Phang Boon Lim
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Fu Siong Ng
- Imperial College Healthcare NHS Trust, London, United Kingdom
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Abad R, Collart O, Ganesan P, Rogers AJ, Alhusseini MI, Rodrigo M, Narayan SM, Rappel WJ. Three dimensional reconstruction to visualize atrial fibrillation activation patterns on curved atrial geometry. PLoS One 2021; 16:e0249873. [PMID: 33836026 PMCID: PMC8034734 DOI: 10.1371/journal.pone.0249873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 03/26/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The rotational activation created by spiral waves may be a mechanism for atrial fibrillation (AF), yet it is unclear how activation patterns obtained from endocardial baskets are influenced by the 3D geometric curvature of the atrium or 'unfolding' into 2D maps. We develop algorithms that can visualize spiral waves and their tip locations on curved atrial geometries. We use these algorithms to quantify differences in AF maps and spiral tip locations between 3D basket reconstructions, projection onto 3D anatomical shells and unfolded 2D surfaces. METHODS We tested our algorithms in N = 20 patients in whom AF was recorded from 64-pole baskets (Abbott, CA). Phase maps were generated by non-proprietary software to identify the tips of spiral waves, indicated by phase singularities. The number and density of spiral tips were compared in patient-specific 3D shells constructed from the basket, as well as 3D maps from clinical electroanatomic mapping systems and 2D maps. RESULTS Patients (59.4±12.7 yrs, 60% M) showed 1.7±0.8 phase singularities/patient, in whom ablation terminated AF in 11/20 patients (55%). There was no difference in the location of phase singularities, between 3D curved surfaces and 2D unfolded surfaces, with a median correlation coefficient between phase singularity density maps of 0.985 (0.978-0.990). No significant impact was noted by phase singularities location in more curved regions or relative to the basket location (p>0.1). CONCLUSIONS AF maps and phase singularities mapped by endocardial baskets are qualitatively and quantitatively similar whether calculated by 3D phase maps on patient-specific curved atrial geometries or in 2D. Phase maps on patient-specific geometries may be easier to interpret relative to critical structures for ablation planning.
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Affiliation(s)
- Ricardo Abad
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, United States of America
| | - Orvil Collart
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, United States of America
| | - Prasanth Ganesan
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, United States of America
| | - A. J. Rogers
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, United States of America
| | - Mahmood I. Alhusseini
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, United States of America
| | - Miguel Rodrigo
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, United States of America
- Universitat Politècnica de València, Valencia, Spain
| | - Sanjiv M. Narayan
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, United States of America
- * E-mail: (SMN); (WJR)
| | - Wouter-Jan Rappel
- Department of Physics, UC San Diego, La Jolla, California, United States of America
- * E-mail: (SMN); (WJR)
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36
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Carrick RT, Benson BE, Bates ORJ, Spector PS. Competitive Drivers of Atrial Fibrillation: The Interplay Between Focal Drivers and Multiwavelet Reentry. Front Physiol 2021; 12:633643. [PMID: 33796028 PMCID: PMC8007783 DOI: 10.3389/fphys.2021.633643] [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: 11/25/2020] [Accepted: 02/22/2021] [Indexed: 11/15/2022] Open
Abstract
Background There is debate whether human atrial fibrillation is driven by focal drivers or multiwavelet reentry. We propose that the changing activation sequences surrounding a focal driver can at times self-sustain in the absence of that driver. Further, the relationship between focal drivers and surrounding chaotic activation is bidirectional; focal drivers can generate chaotic activation, which may affect the dynamics of focal drivers. Methods and Results In a propagation model, we generated tissues that support structural micro-reentry and moving functional reentrant circuits. We qualitatively assessed (1) the tissue’s ability to support self-sustaining fibrillation after elimination of the focal driver, (2) the impact that structural-reentrant substrate has on the duration of fibrillation, the impact that micro-reentrant (3) frequency, (4) excitable gap, and (5) exposure to surrounding fibrillation have on micro-reentry in the setting of chaotic activation, and finally the likelihood fibrillation will end in structural reentry based on (6) the distance between and (7) the relative lengths of an ablated tissue’s inner and outer boundaries. We found (1) focal drivers produced chaotic activation when waves encountered heterogeneous refractoriness; chaotic activation could then repeatedly initiate and terminate micro-reentry. Perpetuation of fibrillation following elimination of micro-reentry was predicted by tissue properties. (2) Duration of fibrillation was increased by the presence of a structural micro-reentrant substrate only when surrounding tissue had a low propensity to support self-sustaining chaotic activation. Likelihood of micro-reentry around the structural reentrant substrate increased as (3) the frequency of structural reentry increased relative to the frequency of fibrillation in the surrounding tissue, (4) the excitable gap of micro-reentry increased, and (5) the exposure of the structural circuit to the surrounding tissue decreased. Likelihood of organized tachycardia following termination of fibrillation increased with (6) decreasing distance and (7) disparity of size between focal obstacle and external boundary. Conclusion Focal drivers such as structural micro-reentry and the chaotic activation they produce are continuously interacting with one another. In order to accurately describe cardiac tissue’s propensity to support fibrillation, the relative characteristics of both stationary and moving drivers must be taken into account.
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Affiliation(s)
- Richard T Carrick
- College of Medicine, University of Vermont, Burlington, VT, United States.,College of Engineering and Mathematical Sciences, University of Vermont, Burlington, VT, United States
| | - Bryce E Benson
- College of Engineering and Mathematical Sciences, University of Vermont, Burlington, VT, United States
| | - Oliver R J Bates
- College of Engineering, Boston University, Boston, MA, United States
| | - Peter S Spector
- College of Medicine, University of Vermont, Burlington, VT, United States.,College of Engineering and Mathematical Sciences, University of Vermont, Burlington, VT, United States
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37
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Luongo G, Azzolin L, Schuler S, Rivolta MW, Almeida TP, Martínez JP, Soriano DC, Luik A, Müller-Edenborn B, Jadidi A, Dössel O, Sassi R, Laguna P, Loewe A. Machine learning enables noninvasive prediction of atrial fibrillation driver location and acute pulmonary vein ablation success using the 12-lead ECG. CARDIOVASCULAR DIGITAL HEALTH JOURNAL 2021; 2:126-136. [PMID: 33899043 PMCID: PMC8053175 DOI: 10.1016/j.cvdhj.2021.03.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common supraventricular arrhythmia, characterized by disorganized atrial electrical activity, maintained by localized arrhythmogenic atrial drivers. Pulmonary vein isolation (PVI) allows to exclude PV-related drivers. However, PVI is less effective in patients with additional extra-PV arrhythmogenic drivers. OBJECTIVES To discriminate whether AF drivers are located near the PVs vs extra-PV regions using the noninvasive 12-lead electrocardiogram (ECG) in a computational and clinical framework, and to computationally predict the acute success of PVI in these cohorts of data. METHODS AF drivers were induced in 2 computerized atrial models and combined with 8 torso models, resulting in 1128 12-lead ECGs (80 ECGs with AF drivers located in the PVs and 1048 in extra-PV areas). A total of 103 features were extracted from the signals. Binary decision tree classifier was trained on the simulated data and evaluated using hold-out cross-validation. The PVs were subsequently isolated in the models to assess PVI success. Finally, the classifier was tested on a clinical dataset (46 patients: 23 PV-dependent AF and 23 with additional extra-PV sources). RESULTS The classifier yielded 82.6% specificity and 73.9% sensitivity for detecting PV drivers on the clinical data. Consistency analysis on the 46 patients resulted in 93.5% results match. Applying PVI on the simulated AF cases terminated AF in 100% of the cases in the PV class. CONCLUSION Machine learning-based classification of 12-lead-ECG allows discrimination between patients with PV drivers vs those with extra-PV drivers of AF. The novel algorithm may aid to identify patients with high acute success rates to PVI.
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Affiliation(s)
- Giorgio Luongo
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology, Karlsruhe, Germany
- Address reprint requests and correspondence: Mr Giorgio Luongo, Fritz-Haber-Weg 1, 76131 Karlsruhe, Germany.
| | - Luca Azzolin
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology, Karlsruhe, Germany
| | - Steffen Schuler
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology, Karlsruhe, Germany
| | - Massimo W. Rivolta
- Dipartimento di Informatica, Università degli Studi di Milano, Milan, Italy
| | - Tiago P. Almeida
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | | | - Diogo C. Soriano
- Engineering, Modelling and Applied Social Sciences Centre, ABC Federal University, São Bernardo do Campo, Brazil
| | - Armin Luik
- Medizinische Klinik IV, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - Björn Müller-Edenborn
- Department of Electrophysiology, University-Heart-Center Freiburg-Bad Krozingen, Bad Krozingen Campus, Bad Krozingen, Germany
| | - Amir Jadidi
- Department of Electrophysiology, University-Heart-Center Freiburg-Bad Krozingen, Bad Krozingen Campus, Bad Krozingen, Germany
| | - Olaf Dössel
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology, Karlsruhe, Germany
| | - Roberto Sassi
- Dipartimento di Informatica, Università degli Studi di Milano, Milan, Italy
| | - Pablo Laguna
- I3A, Universidad de Zaragoza, and CIBER-BNN, Zaragoza, Spain
| | - Axel Loewe
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology, Karlsruhe, Germany
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38
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Ho G, Lin AY, Krummen DE. Linking Electrical Drivers With Atrial Cardiomyopathy for the Targeted Treatment of Atrial Fibrillation. Front Physiol 2020; 11:570740. [PMID: 33281614 PMCID: PMC7689158 DOI: 10.3389/fphys.2020.570740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/22/2020] [Indexed: 12/19/2022] Open
Abstract
The relationship between atrial fibrillation (AF) and underlying functional and structural abnormalities has received substantial attention in the research literature over the past decade. Significant progress has been made in identifying these changes using non-invasive imaging, voltage mapping, and electrical recordings. Advances in computed tomography and cardiac magnetic resonance imaging can now provide insight regarding the presence and extent of cardiac fibrosis. Additionally, multiple technologies able to identify electrical targets during AF have emerged. However, an organized strategy to employ these resources in the targeted treatment of AF remains elusive. In this work, we will discuss the basis for mechanistic importance of atrial fibrosis and scar as potential sites promoting AF and emerging technologies to identify and target these structural and functional substrates in the electrophysiology laboratory. We also propose an approach to the use of such technologies to serve as a basis for ongoing work in the field.
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Affiliation(s)
- Gordon Ho
- Division of Cardiology, Department of Medicine, University of California, San Diego, San Diego, CA, United States
- Division of Cardiology, Veterans Affairs San Diego Medical Center, San Diego, CA, United States
| | - Andrew Y. Lin
- Division of Cardiology, Department of Medicine, University of California, San Diego, San Diego, CA, United States
- Division of Cardiology, Veterans Affairs San Diego Medical Center, San Diego, CA, United States
| | - David E. Krummen
- Division of Cardiology, Department of Medicine, University of California, San Diego, San Diego, CA, United States
- Division of Cardiology, Veterans Affairs San Diego Medical Center, San Diego, CA, United States
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39
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Spitzer SG, Károlyi L, Rämmler C, Zieschank M, Langbein A. Retrospective analysis of FIRM-guided ablation in patients with recurrent atrial fibrillation: a single-center study. Herzschrittmacherther Elektrophysiol 2020; 31:417-425. [PMID: 33052485 DOI: 10.1007/s00399-020-00724-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 09/22/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Ablation of recurrent atrial fibrillation (AF) is common. Studies indicate that AF recurrence is primarily due to pulmonary vein (PV) re-conduction. This retrospective analysis characterized and evaluated recurrent AF patients using focal impulse and rotor mapping (FIRM) plus PV re-isolation, with follow up at 3, 6, 12, and 24 months after the repeat ablation. METHODS AND RESULTS Patients (consecutive, n = 100) underwent FIRM-guided ablation followed by conventional PV re-isolation for recurrent AF treatment. All FIRM patients had failed one or more conventional ablation procedures (1.4 ± 0.08) for paroxysmal (14%), persistent (15%), and long-standing persistent (71%) AF. Stable rotors were identified in 97/100 patients: 60% in the right atrium (RA) and 82% in left atrium (LA) (mean 1.5 ± 0.8 and 2.1 ± 1.2 per patient, respectively). No correlation was noted between the previous number of ablations, AF duration, or LA diameter to the number of rotors (R2 = 0.0039, R2 = 0.0017, and R2 = 0.006, respectively). In this limited observation, only 22% of identified rotors were associated with proximity to low voltage areas. The 12- and 24-month arrhythmia free rate was 93% (13/14) and 92% (12/13) for paroxysmal AF, 60% (9/15) and 47% (7/15) for persistent AF, and 70% (48/69) and 64% (43/67) for long-standing persistent AF, respectively, after a single FIRM procedure and re-isolation of the veins. CONCLUSIONS The data show a benefit for FIRM-guided ablation in recurrent AF at 12 months. No correlation was found between rotors and tissue characterization, AF duration, or previous number of ablations, suggesting that rotors may play an independent role in maintaining recurrent AF after prior failed ablation.
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Affiliation(s)
- Stefan Georg Spitzer
- Praxisklinik Herz und Gefäße Dresden, Kardiologie-Angiologie-Radiologie, Nuklearmedizin, Akademische Lehrpraxisklinik der TU Dresden, Forststr. 3, 01099, Dresden, Germany.
- Institut für Medizintechnologie, Campus Senftenberg, Brandenburgische Technische Universität Cottbus-Senftenberg, Universitätsplatz 1, 01968, Senftenberg, Germany.
| | - László Károlyi
- Praxisklinik Herz und Gefäße Dresden, Kardiologie-Angiologie-Radiologie, Nuklearmedizin, Akademische Lehrpraxisklinik der TU Dresden, Forststr. 3, 01099, Dresden, Germany
| | - Carola Rämmler
- Praxisklinik Herz und Gefäße Dresden, Kardiologie-Angiologie-Radiologie, Nuklearmedizin, Akademische Lehrpraxisklinik der TU Dresden, Forststr. 3, 01099, Dresden, Germany
| | - Mirko Zieschank
- Praxisklinik Herz und Gefäße Dresden, Kardiologie-Angiologie-Radiologie, Nuklearmedizin, Akademische Lehrpraxisklinik der TU Dresden, Forststr. 3, 01099, Dresden, Germany
| | - Anke Langbein
- Praxisklinik Herz und Gefäße Dresden, Kardiologie-Angiologie-Radiologie, Nuklearmedizin, Akademische Lehrpraxisklinik der TU Dresden, Forststr. 3, 01099, Dresden, Germany
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40
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Nazarian S, Markman TM. Mapping Endocardial-Epicardial Dissociation: Significance for Atrial Fibrillation Ablation. JACC Clin Electrophysiol 2020; 6:846-848. [PMID: 32703567 DOI: 10.1016/j.jacep.2020.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 04/22/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Saman Nazarian
- Section for Cardiac Electrophysiology, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Timothy M Markman
- Section for Cardiac Electrophysiology, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Site-Specific Epicardium-to-Endocardium Dissociation of Electrical Activation in a Swine Model of Atrial Fibrillation. JACC Clin Electrophysiol 2020; 6:830-845. [PMID: 32703566 DOI: 10.1016/j.jacep.2020.04.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 03/24/2020] [Accepted: 04/08/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVES This study sought to define the extent and spatial distribution of endocardial-epicardial dissociation (EED) in a swine model. BACKGROUND The mechanisms underlying persistent atrial fibrillation (AF) remain unclear. METHODS Sixteen swine underwent simultaneous endocardial and epicardial mapping using 32-electrode grid catheters. This included 6 swine with rapid atrial pacing-induced atrial remodeling. Three right atrial (RA) and 3 left atrial (LA) regions were mapped during sinus rhythm, atrial pacing, acute or persistent AF, and AF in the presence of pericardial acetylcholine. Unipolar electrogram recordings over 10-s epochs underwent offline phase analysis using customized software. Regional activation patterns on paired surfaces and the instantaneous phase at each matched electrode location were analyzed. EED was defined as paired electrodes out of phase by ≥20 ms. RESULTS The mean distance between matched endocardial-epicardial electrode pairs was 4.4 ± 1.8 mm. During episodes of AF, rotational activations with ≥3 full rotations were not seen. EED was seen during 34.4 ± 16.4% of mapped time periods: LA > RA, persistent > acute AF in the LA, and acetylcholine-induced > acute AF in both atria (p < 0.05 for each). Most marked EED in persistent AF was in the LA appendage (47.2 ± 3.7%) and the LA posterior wall (50.3 ± 4.7%). CONCLUSIONS Marked EED was seen in a swine model of AF, particularly during persistent AF. There was significantly more EED in the LA than the RA and, particularly, in the LA PW and LAA. Mapping approaches limited to the endocardium may not sufficiently characterize the complexity of AF.
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42
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Li X, Almeida TP, Dastagir N, Guillem MS, Salinet J, Chu GS, Stafford PJ, Schlindwein FS, Ng GA. Standardizing Single-Frame Phase Singularity Identification Algorithms and Parameters in Phase Mapping During Human Atrial Fibrillation. Front Physiol 2020; 11:869. [PMID: 32792983 PMCID: PMC7386053 DOI: 10.3389/fphys.2020.00869] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/29/2020] [Indexed: 12/03/2022] Open
Abstract
PURPOSE Recent investigations failed to reproduce the positive rotor-guided ablation outcomes shown by initial studies for treating persistent atrial fibrillation (persAF). Phase singularity (PS) is an important feature for AF driver detection, but algorithms for automated PS identification differ. We aim to investigate the performance of four different techniques for automated PS detection. METHODS 2048-channel virtual electrogram (VEGM) and electrocardiogram signals were collected for 30 s from 10 patients undergoing persAF ablation. QRST-subtraction was performed and VEGMs were processed using sinusoidal wavelet reconstruction. The phase was obtained using Hilbert transform. PSs were detected using four algorithms: (1) 2D image processing based and neighbor-indexing algorithm; (2) 3D neighbor-indexing algorithm; (3) 2D kernel convolutional algorithm estimating topological charge; (4) topological charge estimation on 3D mesh. PS annotations were compared using the structural similarity index (SSIM) and Pearson's correlation coefficient (CORR). Optimized parameters to improve detection accuracy were found for all four algorithms using F β score and 10-fold cross-validation compared with manual annotation. Local clustering with density-based spatial clustering of applications with noise (DBSCAN) was proposed to improve algorithms 3 and 4. RESULTS The PS density maps created by each algorithm with default parameters were poorly correlated. Phase gradient threshold and search radius (or kernels) were shown to affect PS detections. The processing times for the algorithms were significantly different (p < 0.0001). The F β scores for algorithms 1, 2, 3, 3 + DBSCAN, 4 and 4 + DBSCAN were 0.547, 0.645, 0.742, 0.828, 0.656, and 0.831. Algorithm 4 + DBSCAN achieved the best classification performance with acceptable processing time (2.0 ± 0.3 s). CONCLUSION AF driver identification is dependent on the PS detection algorithms and their parameters, which could explain some of the inconsistencies in rotor-guided ablation outcomes in different studies. For 3D triangulated meshes, algorithm 4 + DBSCAN with optimal parameters was the best solution for real-time, automated PS detection due to accuracy and speed. Similarly, algorithm 3 + DBSCAN with optimal parameters is preferred for uniform 2D meshes. Such algorithms - and parameters - should be preferred in future clinical studies for identifying AF drivers and minimizing methodological heterogeneities. This would facilitate comparisons in rotor-guided ablation outcomes in future works.
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Affiliation(s)
- Xin Li
- Department of Cardiovascular Science, University of Leicester, Leicester, United Kingdom
- School of Engineering, University of Leicester, Leicester, United Kingdom
| | - Tiago P. Almeida
- Department of Cardiovascular Science, University of Leicester, Leicester, United Kingdom
- School of Engineering, University of Leicester, Leicester, United Kingdom
- Aeronautics Institute of Technology, ITA, São José dos Campos, Brazil
| | - Nawshin Dastagir
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | | | - João Salinet
- Centre for Engineering, Modelling and Applied Social Sciences, Federal University of ABC, Santo André, Brazil
| | - Gavin S. Chu
- Department of Cardiovascular Science, University of Leicester, Leicester, United Kingdom
| | - Peter J. Stafford
- National Institute for Health Research Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - Fernando S. Schlindwein
- School of Engineering, University of Leicester, Leicester, United Kingdom
- National Institute for Health Research Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - G. André Ng
- Department of Cardiovascular Science, University of Leicester, Leicester, United Kingdom
- National Institute for Health Research Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
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Ali RL, Hakim JB, Boyle PM, Zahid S, Sivasambu B, Marine JE, Calkins H, Trayanova NA, Spragg DD. Arrhythmogenic propensity of the fibrotic substrate after atrial fibrillation ablation: a longitudinal study using magnetic resonance imaging-based atrial models. Cardiovasc Res 2020; 115:1757-1765. [PMID: 30977811 DOI: 10.1093/cvr/cvz083] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 01/31/2019] [Accepted: 04/08/2019] [Indexed: 12/19/2022] Open
Abstract
AIMS Inadequate modification of the atrial fibrotic substrate necessary to sustain re-entrant drivers (RDs) may explain atrial fibrillation (AF) recurrence following failed pulmonary vein isolation (PVI). Personalized computational models of the fibrotic atrial substrate derived from late gadolinium enhanced (LGE)-magnetic resonance imaging (MRI) can be used to non-invasively determine the presence of RDs. The objective of this study is to assess the changes of the arrhythmogenic propensity of the fibrotic substrate after PVI. METHODS AND RESULTS Pre- and post-ablation individualized left atrial models were constructed from 12 AF patients who underwent pre- and post-PVI LGE-MRI, in six of whom PVI failed. Pre-ablation AF sustained by RDs was induced in 10 models. RDs in the post-ablation models were classified as either preserved or emergent. Pre-ablation models derived from patients for whom the procedure failed exhibited a higher number of RDs and larger areas defined as promoting RD formation when compared with atrial models from patients who had successful ablation, 2.6 ± 0.9 vs. 1.8 ± 0.2 and 18.9 ± 1.6% vs. 13.8 ± 1.5%, respectively. In cases of successful ablation, PVI eliminated completely the RDs sustaining AF. Preserved RDs unaffected by ablation were documented only in post-ablation models of patients who experienced recurrent AF (2/5 models); all of these models had also one or more emergent RDs at locations distinct from those of pre-ablation RDs. Emergent RDs occurred in regions that had the same characteristics of the fibrosis spatial distribution (entropy and density) as regions that harboured RDs in pre-ablation models. CONCLUSION Recurrent AF after PVI in the fibrotic atria may be attributable to both preserved RDs that sustain AF pre- and post-ablation, and the emergence of new RDs following ablation. The same levels of fibrosis entropy and density underlie the pro-RD propensity in both pre- and post-ablation substrates.
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Affiliation(s)
- Rheeda L Ali
- Institute for Computational Medicine, Johns Hopkins University, 3400 N Charles Street, 208 Hackerman, Baltimore, MD, USA
| | - Joe B Hakim
- Institute for Computational Medicine, Johns Hopkins University, 3400 N Charles Street, 208 Hackerman, Baltimore, MD, USA
| | - Patrick M Boyle
- Institute for Computational Medicine, Johns Hopkins University, 3400 N Charles Street, 208 Hackerman, Baltimore, MD, USA.,Department of Biomedical Engineering, Johns Hopkins University, 3400 N Charles Street, 208 Hackerman, Baltimore, MD, USA.,Department of Bioengineering, University of Washington, Seattle, WA, USA
| | - Sohail Zahid
- Department of Biomedical Engineering, Johns Hopkins University, 3400 N Charles Street, 208 Hackerman, Baltimore, MD, USA
| | - Bhradeev Sivasambu
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph E Marine
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hugh Calkins
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Natalia A Trayanova
- Institute for Computational Medicine, Johns Hopkins University, 3400 N Charles Street, 208 Hackerman, Baltimore, MD, USA.,Department of Biomedical Engineering, Johns Hopkins University, 3400 N Charles Street, 208 Hackerman, Baltimore, MD, USA.,Department of Medicine, Johns Hopkins University School of Medicine, USA
| | - David D Spragg
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Lozier MR, Pachon RE, Lee JJ, Sanchez AM, Donath EM, Osman AF. Long-term clinical outcomes and prognostic indicators for focal impulse and rotor modulation guided ablation: A single-center observational study. J Electrocardiol 2020; 61:153-159. [PMID: 32623257 DOI: 10.1016/j.jelectrocard.2020.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 05/20/2020] [Accepted: 06/04/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Electrophysiologists have developed a computational mapping approach to localize sources that may perpetuate persistent atrial fibrillation (AF). Focal impulse and rotor modulation (FIRM)-guided ablation of these sources have produced variable results. The current study further assesses single-procedure success rates of FIRM-guided ablation for preventing AF or atrial tachyarrhythmia recurrence and analyzes different baseline characteristics as prognostic indicators for individuals experiencing these undesired outcomes. METHODS Seventy-one consecutive patients (mean age 64.58 ± 9.05 years and 36.6% female) with drug-refractory persistent AF with and without prior history of pulmonary vein antral isolation (PVAI) underwent FIRM-guided ablation. Patients without prior history of PVAI underwent FIRM-guided ablation in addition to de novo PVAI. Patients with prior history of PVAI had the pulmonary veins reassessed at the time of FIRM-guided ablation for reconnection as well as re-isolation, when necessary. These patients were then prospectively followed for AF and atrial tachyarrhythmia recurrence. RESULTS FIRM analysis revealed rotors in the right atrium in 66.2% (1.77 ± 1.53 mean rotors per patient) and in the left atrium in 85.9% (2.65 ± 1.52 mean rotors per patient) of patients analyzed in the current study. After a single FIRM-guided ablation procedure, AF and atrial tachyarrhythmia recurrence was demonstrated in 21.1% (15/71) and 33.8% (24/71) of patients, respectively. The entire cohort of patients were followed for a mean duration of 23.20 ± 8.38 months with the mean time to AF recurrence found to be 12.35 ± 10.44 months. Furthermore, valvular heart disease (i.e. moderate mitral or tricuspid regurgitation) was found to be a statistically significant independent predictor for AF recurrence following FIRM-guided ablation (p = .033). CONCLUSIONS FIRM-guided ablation in combination with PVAI is a suitable and effective approach for symptomatic individuals with drug-refractory persistent AF with and without prior history of PVAI. Randomized controlled studies are warranted.
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Affiliation(s)
- Matthew R Lozier
- University of Miami at Holy Cross Hospital, Department of Internal Medicine, Fort Lauderdale, FL, USA.
| | - Ronald E Pachon
- Broward General Medical Center, Department of Cardiology, Fort Lauderdale, FL, USA.
| | - John J Lee
- Columbia University at Mount Sinai Medical Center, Department of Cardiology, Miami Beach, FL, USA.
| | - Alexandra M Sanchez
- University of Miami at Holy Cross Hospital, Department of Internal Medicine, Fort Lauderdale, FL, USA.
| | - Elie M Donath
- McGill University, Department of Statistics, Montreal, Quebec, Canada
| | - Ahmed F Osman
- Broward General Medical Center, Department of Cardiology, Fort Lauderdale, FL, USA
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Aryana A, Chierchia GB, de Asmundis C. Recurrent Atrial Fibrillation After Cryoballoon Ablation: What to Expect! Card Electrophysiol Clin 2020; 12:199-208. [PMID: 32451104 DOI: 10.1016/j.ccep.2020.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Atrial fibrillation (AF) recurrence following cryoballoon ablation may occur as a consequence of pulmonary vein (PV) reconnection, which can be treated effectively by performing repeat PV isolation. Alternatively, AF recurrence can manifest in presence of bilateral antral PV isolation. In such circumstances, one may pursue catheter ablation of AF triggers, if present, or proceed with empiric posterior left atrial wall ablation. Although traditionally, focal radiofrequency ablation has been used for this, cryoballoon ablation, itself, may also be used for ablation/isolation of certain structures such as the superior vena cava, the left atrial appendage and even the posterior left atrial wall.
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Affiliation(s)
- Arash Aryana
- Mercy General Hospital and Dignity Health Heart and Vascular Institute, Suite #350, 3941 J Street, Sacramento, CA 95819, USA.
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Ganesan P, Cherry EM, Huang DT, Pertsov AM, Ghoraani B. Atrial fibrillation source area probability mapping using electrogram patterns of multipole catheters. Biomed Eng Online 2020; 19:27. [PMID: 32370754 PMCID: PMC7201756 DOI: 10.1186/s12938-020-00769-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 04/15/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Catheter ablation therapy involving isolation of pulmonary veins (PVs) from the left atrium is performed to terminate atrial fibrillation (AF). Unfortunately, standalone PV isolation procedure has shown to be a suboptimal success with AF continuation or recurrence. One reason, especially in patients with persistent or high-burden paroxysmal AF, is known to be due to the formation of repeating-pattern AF sources with a meandering core inside the atria. However, there is a need for accurate mapping and localization of these sources during catheter ablation. METHODS A novel AF source area probability (ASAP) mapping algorithm was developed and evaluated in 2D and 3D atrial simulated tissues with various arrhythmia scenarios and a retrospective study with three cases of clinical human AF. The ASAP mapping analyzes the electrograms collected from a multipole diagnostic catheter that is commonly used during catheter ablation procedure to intelligently sample the atria and delineate the trajectory path of a meandering repeating-pattern AF source. ASAP starts by placing the diagnostic catheter at an arbitrary location in the atria. It analyzes the recorded bipolar electrograms to build an ASAP map over the atrium anatomy and suggests an optimal location for the subsequent catheter location. ASAP then determines from the constructed ASAP map if an AF source has been delineated. If so, the catheter navigation is stopped and the algorithm provides the area of the AF source. Otherwise, the catheter is navigated to the suggested location, and the process is continued until an AF-source area is delineated. RESULTS ASAP delineated the AF source in over 95% of the simulated human AF cases within less than eight catheter placements regardless of the initial catheter placement. The success of ASAP in the clinical AF was confirmed by the ablation outcomes and the electrogram patterns at the delineated area. CONCLUSION Our analysis indicates the potential of the ASAP mapping to provide accurate information about the area of the meandering repeating-pattern AF sources as AF ablation targets for effective AF termination. Our algorithm could improve the success of AF catheter ablation therapy by locating and subsequently targeting patient-specific and repeating-pattern AF sources inside the atria.
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Affiliation(s)
- Prasanth Ganesan
- Department of Computer and Electrical Engineering, Florida Atlantic University, Boca Raton, FL, USA
| | - Elizabeth M Cherry
- School of Computational Science and Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - David T Huang
- Department of Cardiology, University of Rochester Medical Center, Rochester, NY, USA
| | - Arkady M Pertsov
- Department of Pharmacology, SUNY Upstate Medical Center, Syracuse, NY, USA
| | - Behnaz Ghoraani
- Department of Computer and Electrical Engineering, Florida Atlantic University, Boca Raton, FL, USA.
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47
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El Moheb M, Refaat MM. FIRM-guided ablation for recurrent atrial fibrillation with pulmonary vein reconnection: Lessons learned. J Cardiovasc Electrophysiol 2020; 31:1038-1039. [PMID: 32115789 DOI: 10.1111/jce.14427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 02/26/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Mohamad El Moheb
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Marwan M Refaat
- Division of Cardiology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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48
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Borlich M, Sommer P. Cardiac Mapping Systems: Rhythmia, Topera, EnSite Precision, and CARTO. Card Electrophysiol Clin 2020; 11:449-458. [PMID: 31400869 DOI: 10.1016/j.ccep.2019.05.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Novel cardiac mapping systems allow a safe and highly accurate 3-D reconstruction of cardiac structures as well as fast and accurate visualization of cardiac arrhythmias. In addition, they are increasingly reducing the need for fluoroscopy in these procedures. The current state of the art, as well as the presentation of possible uses of individual systems and their limitations, is presented in this article. Cardiac mapping systems can significantly contribute to an optimal therapeutic decision making in invasive electrophysiology. This article introduces new developments of Rhythmia, Topera, EnSite Precision, and CARTO systems and provides a look ahead to the future.
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Affiliation(s)
- Martin Borlich
- Heart Center, Segeberger Kliniken (Academic Teaching Hospital of the Universities of Kiel, Lübeck and Hamburg), Am Kurpark 1, Bad Segeberg, Schleswig-Holstein 23795, Germany.
| | - Philipp Sommer
- Clinic of Electrophysiology, Heart and Diabetes Center NRW, University Hospital of Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, Nordrhein-Westfalen 32545, Germany
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49
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Zaman J, Baykaner T, Narayan SM. Mapping and Ablation of Rotational and Focal Drivers in Atrial Fibrillation. Card Electrophysiol Clin 2020; 11:583-595. [PMID: 31706467 DOI: 10.1016/j.ccep.2019.08.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Drivers are increasingly studied ablation targets for atrial fibrillation (AF). However, results from ablation remain controversial. First, outcomes vary between centers and patients. Second, it is unclear how best to perform driver ablation. Third, there is a lack of practical guidance on how to identify critical from secondary sites using different AF mapping methods. This article addresses each of these issues.
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Affiliation(s)
- Junaid Zaman
- Stanford University, 780 Welch Road, Suite CJ250F, Stanford, CA 94305, USA; Imperial College London, London, UK
| | - Tina Baykaner
- Department of Medicine/Cardiovascular Medicine, Stanford University, 780 Welch Road, Suite CJ250F, Stanford, CA 94305, USA
| | - Sanjiv M Narayan
- Department of Medicine/Cardiovascular Medicine and Cardiovascular Institute, Stanford University, 780 Welch Road, Suite CJ250F, MC 5773, Stanford, CA 94305, USA.
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50
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Vraka A, Hornero F, Bertomeu-González V, Osca J, Alcaraz R, Rieta JJ. Short-Time Estimation of Fractionation in Atrial Fibrillation with Coarse-Grained Correlation Dimension for Mapping the Atrial Substrate. ENTROPY 2020; 22:e22020232. [PMID: 33286006 PMCID: PMC7516661 DOI: 10.3390/e22020232] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/14/2020] [Accepted: 02/15/2020] [Indexed: 11/16/2022]
Abstract
Atrial fibrillation (AF) is currently the most common cardiac arrhythmia, with catheter ablation (CA) of the pulmonary veins (PV) being its first line therapy. Ablation of complex fractionated atrial electrograms (CFAEs) outside the PVs has demonstrated improved long-term results, but their identification requires a reliable electrogram (EGM) fractionation estimator. This study proposes a technique aimed to assist CA procedures under real-time settings. The method has been tested on three groups of recordings: Group 1 consisted of 24 highly representative EGMs, eight of each belonging to a different AF Type. Group 2 contained the entire dataset of 119 EGMs, whereas Group 3 contained 20 pseudo-real EGMs of the special Type IV AF. Coarse-grained correlation dimension (CGCD) was computed at epochs of 1 s duration, obtaining a classification accuracy of 100% in Group 1 and 84.0–85.7% in Group 2, using 10-fold cross-validation. The receiver operating characteristics (ROC) analysis for highly fractionated EGMs, showed 100% specificity and sensitivity in Group 1 and 87.5% specificity and 93.6% sensitivity in Group 2. In addition, 100% of the pseudo-real EGMs were correctly identified as Type IV AF. This method can consistently express the fractionation level of AF EGMs and provides better performance than previous works. Its ability to compute fractionation in short-time can agilely detect sudden changes of AF Types and could be used for mapping the atrial substrate, thus assisting CA procedures under real-time settings for atrial substrate modification.
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Affiliation(s)
- Aikaterini Vraka
- BioMIT.org, Electronic Engineering Department, Universitat Politecnica de Valencia, 46022 Valencia, Spain;
| | - Fernando Hornero
- Cardiac Surgery Department, Hospital Universitari i Politecnic La Fe, 46026 Valencia, Spain;
| | | | - Joaquín Osca
- Electrophysiology Section, Hospital Universitari i Politecnic La Fe, 46026 Valencia, Spain;
| | - 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;
- Correspondence:
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