1
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Wesselink R, Vroomen M, Overeinder I, Neefs J, van den Berg NWE, Meulendijks ER, Piersma FR, Al-Shama RFM, de Vries TAC, Verstraelen TE, Luermans J, Maesen B, de Asmundis C, Chierchia GB, La Meir M, Pison L, van Boven WJP, Driessen AHG, de Groot JR. A failed catheter ablation of atrial fibrillation is associated with more advanced remodeling and reduced efficacy of further thoracoscopic ablation. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2023; 76:417-426. [PMID: 36155846 DOI: 10.1016/j.rec.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 09/09/2022] [Indexed: 05/28/2023]
Abstract
INTRODUCTION AND OBJECTIVES Recent observations suggest that patients with a previous failed catheter ablation have an increased risk of atrial fibrillation (AF) recurrence after subsequent thoracoscopic AF ablation. We assessed the risk of AF recurrence in patients with a previous failed catheter ablation undergoing thoracoscopic ablation. METHODS We included patients from 3 medical centers. To correct for potential heterogeneity, we performed propensity matching to compare AF freedom (freedom from any atrial tachyarrhythmia> 30 s during 1-year follow-up). Left atrial appendage tissue was analyzed for collagen distribution. RESULTS A total of 705 patients were included, and 183 had a previous failed catheter ablation. These patients had fewer risk factors for AF recurrence than ablation naïve controls: smaller indexed left atrial volume (40.9± 12.5 vs 43.0±12.5 mL/m2, P=.048), less congestive heart failure (1.5% vs 8.9%, P=.001), and less persistent AF (52.2% vs 60.3%, P=.067). However, AF history duration was longer in patients with a previous failed catheter ablation (6.5 [4-10.5] vs 4 [2-8] years; P<.001). In propensity matched analysis, patients with a failed catheter ablation were at a 68% higher AF recurrence risk (OR, 1.68; 95%CI, 1.20-2.15; P=.034). AF freedom was 61.1% in patients with a previous failed catheter ablation vs 72.5% in ablation naïve matched controls. On histology of the left atrial appendage (n=198), patients with a failed catheter ablation had a higher density of collagen fibers. CONCLUSIONS Patients with a prior failed catheter ablation had fewer risk factors for AF recurrence but more frequently had AF recurrence after thoracoscopic AF ablation than ablation naïve patients. This may in part be explained by more progressed, subclinical, atrial fibrosis formation.
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Affiliation(s)
- Robin Wesselink
- Department of Clinical and Experimental Cardiology and Cardiothoracic Surgery, Heart Center, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Heart Failure and Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Mindy Vroomen
- Department of Cardiac Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Ingrid Overeinder
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussels, Vrije Universiteit Brussel, Brussels, Belgium
| | - Jolien Neefs
- Department of Clinical and Experimental Cardiology and Cardiothoracic Surgery, Heart Center, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Heart Failure and Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Nicoline W E van den Berg
- Department of Clinical and Experimental Cardiology and Cardiothoracic Surgery, Heart Center, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Heart Failure and Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Eva R Meulendijks
- Department of Clinical and Experimental Cardiology and Cardiothoracic Surgery, Heart Center, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Heart Failure and Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Femke R Piersma
- Department of Clinical and Experimental Cardiology and Cardiothoracic Surgery, Heart Center, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Heart Failure and Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Rushd F M Al-Shama
- Department of Clinical and Experimental Cardiology and Cardiothoracic Surgery, Heart Center, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Heart Failure and Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Tim A C de Vries
- Department of Clinical and Experimental Cardiology and Cardiothoracic Surgery, Heart Center, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Heart Failure and Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Tom E Verstraelen
- Department of Clinical and Experimental Cardiology and Cardiothoracic Surgery, Heart Center, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Heart Failure and Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Justin Luermans
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands; Department of Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Bart Maesen
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands; Department of Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussels, Vrije Universiteit Brussel, Brussels, Belgium
| | - Gian-Battista Chierchia
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussels, Vrije Universiteit Brussel, Brussels, Belgium
| | - Mark La Meir
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands; Department of Cardiothoracic Surgery, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Laurent Pison
- Department of Cardiology, Ziekenhuis Oost Limburg, Genk, Belgium
| | - Wim Jan P van Boven
- Department of Clinical and Experimental Cardiology and Cardiothoracic Surgery, Heart Center, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Heart Failure and Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Antoine H G Driessen
- Department of Clinical and Experimental Cardiology and Cardiothoracic Surgery, Heart Center, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Heart Failure and Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Joris R de Groot
- Department of Clinical and Experimental Cardiology and Cardiothoracic Surgery, Heart Center, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Heart Failure and Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.
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2
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van Schie MS, Ramdat Misier NL, Razavi Ebrahimi P, Heida A, Kharbanda RK, Taverne YJHJ, de Groot NMS. Premature atrial contractions promote local directional heterogeneities in conduction velocity vectors. Europace 2023; 25:1162-1171. [PMID: 36637110 PMCID: PMC10062298 DOI: 10.1093/europace/euac283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 12/15/2022] [Indexed: 01/14/2023] Open
Abstract
AIMS Loss of cell-to-cell communication results in local conduction disorders and directional heterogeneity (LDH) in conduction velocity (CV) vectors, which may be unmasked by premature atrial contractions (PACs). We quantified LDH and examined differences between sinus rhythm (SR) and spontaneous PACs in patients with and without atrial fibrillation (AF). METHODS AND RESULTS Intra-operative epicardial mapping of the right and left atrium (RA, LA), Bachmann's bundle (BB) and pulmonary vein area (PVA) was performed in 228 patients (54 with AF). Conduction velocity vectors were computed at each electrode using discrete velocity vectors. Directions and magnitudes of individual vectors were compared with surrounding vectors to identify LDH. Five hundred and three PACs [2 (1-3) per patient; prematurity index of 45 ± 12%] were included. During SR, most LDH were found at BB and LA [11.9 (8.3-14.9) % and 11.3 (8.0-15.2) %] and CV was lowest at BB [83.5 (72.4-94.3) cm/s, all P < 0.05]. Compared with SR, the largest increase in LDH during PAC was found at BB and PVA [+13.0 (7.7, 18.3) % and +12.5 (10.8, 14.2) %, P < 0.001]; CV decreased particularly at BB, PVA and LA [-10.0 (-13.2, -6.9) cm/s, -9.3 (-12.5, -6.2) cm/s and -9.1 (-11.7, -6.6) cm/s, P < 0.001]. Comparing patients with and without AF, more LDH were found during SR in AF patients at PVA and BB, although the increase in LDH during PACs was similar for all sites. CONCLUSION Local directional heterogeneity is a novel methodology to quantify local heterogeneity in CV as a possible indicator of electropathology. Intra-operative high-resolution mapping indeed revealed that LDH increased during PACs particularly at BB and PVA. Also, patients with AF already have more LDH during SR, which becomes more pronounced during PACs.
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Affiliation(s)
- Mathijs S van Schie
- Department of Cardiology, Erasmus Medical Center, Dr. Molewaterplein 40, 3015GD Rotterdam, the Netherlands
| | - Nawin L Ramdat Misier
- Department of Cardiology, Erasmus Medical Center, Dr. Molewaterplein 40, 3015GD Rotterdam, the Netherlands
| | - Payam Razavi Ebrahimi
- Department of Cardiology, Erasmus Medical Center, Dr. Molewaterplein 40, 3015GD Rotterdam, the Netherlands
| | - Annejet Heida
- Department of Cardiology, Erasmus Medical Center, Dr. Molewaterplein 40, 3015GD Rotterdam, the Netherlands
| | - Rohit K Kharbanda
- Department of Cardiology, Erasmus Medical Center, Dr. Molewaterplein 40, 3015GD Rotterdam, the Netherlands
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Dr. Molewaterplein 40, 3015GD Rotterdam, the Netherlands
| | - Yannick J H J Taverne
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Dr. Molewaterplein 40, 3015GD Rotterdam, the Netherlands
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3
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Wesselink R, Vroomen M, Overeinder I, Neefs J, van den Berg NW, Meulendijks ER, Piersma FR, Al-Shama RF, de Vries TA, Verstraelen TE, Luermans J, Maesen B, de Asmundis C, Chierchia GB, La Meir M, Pison L, van Boven WJP, Driessen AH, de Groot JR. El fracaso de la ablación por catéter de la fibrilación auricular se asocia con mayor remodelado y menos eficacia de una posterior ablación toracoscópica. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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4
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Nery PB, Wells GA, Verma A, Joza J, Nair GM, Veenhuyzen G, Andrade J, Nault I, Wong JA, Sikkel M, Essebag V, Macle L, Sapp J, Roux JF, Skanes A, Angaran P, Novak P, Redfearn D, Golian M, Redpath CJ, Sturmer M, Birnie D. Characterization of arrhythmia substrate to ablate persistent atrial fibrillation (COAST-AF): Randomized controlled trial design and rationale. Am Heart J 2022; 254:133-140. [PMID: 36030965 DOI: 10.1016/j.ahj.2022.08.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 08/21/2022] [Accepted: 08/22/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Atrial low voltage area (LVA) catheter ablation has emerged as a promising strategy for ablation of persistent atrial fibrillation (AF). It is unclear if catheter ablation of atrial LVA increases treatment success rates in patients with persistent AF. OBJECTIVE The primary aim of this trial is to assess the potential benefit of adjunctive catheter ablation of atrial LVA in addition to pulmonary vein isolation (PVI) in patients with persistent AF, when compared to PVI alone. The secondary aims are to evaluate safety outcomes, the quality of life and the healthcare resource utilization. METHODS/DESIGN A multicenter, prospective, parallel-group, 2-arm, single-blinded randomized controlled trial is under way (NCT03347227). Patients who are candidates for catheter ablation for persistent AF will be randomly assigned (1:1) to either PVI alone or PVI + atrial LVA ablation. The primary outcome is 18-month documented event rate of atrial arrhythmia (AF, atrial tachycardia or atrial flutter) post catheter ablation. Secondary outcomes include procedure-related complications, freedom from atrial arrhythmia at 12 months, AF burden, need for emergency department visits/hospitalization, need for repeat ablation for atrial arrhythmia, quality of life at 12 and 18 months, ablation time, and procedure duration. DISCUSSION Characterization of Arrhythmia Mechanism to Ablate Atrial Fibrillation (COAST-AF) is a multicenter randomized trial evaluating ablation strategies for catheter ablation. We hypothesize that catheter ablation of atrial LVA in addition to PVI will result in higher procedural success rates when compared to PVI alone in patients with persistent AF.
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Affiliation(s)
- Pablo B Nery
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Canada..
| | - George A Wells
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Canada.; Cardiovascular Research Methods Center, University of Ottawa Heart Institute, Ottawa, Canada
| | - Atul Verma
- McGill University Health Center, Montreal, Quebec, Canada
| | | | - Girish M Nair
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Canada
| | - George Veenhuyzen
- Libin Cardiovascular Institute, University of Calgary, Calgary, Canada
| | - Jason Andrade
- Vancouver General Hospital, University of British Columbia,Vancouver, Canada
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (IUCPQ), Quebec City, Quebec, Canada
| | - Jorge A Wong
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Markus Sikkel
- Victoria Cardiac Arrhythmia Trials, Victoria, British Columbia, Canada
| | - Vidal Essebag
- McGill University Health Center, Montreal, Quebec, Canada; Hôpital Sacré-Cœur, Université de Montréal, Montréal, Québec, Canada
| | | | - John Sapp
- Queen Elizabeth II Health Sciences, Halifax, Nova Scotia, Canada
| | | | - Allan Skanes
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Paul Angaran
- St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Paul Novak
- Victoria Cardiac Arrhythmia Trials, Victoria, British Columbia, Canada
| | | | - Mehrdad Golian
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Canada
| | - Calum J Redpath
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Canada
| | - Marcio Sturmer
- Hôpital Sacré-Cœur, Université de Montréal, Montréal, Québec, Canada
| | - David Birnie
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Canada
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5
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Characteristics and outcomes of recurrent atrial fibrillation after prior failed pulmonary vein isolation. J Interv Card Electrophysiol 2022; 64:715-722. [PMID: 35169965 PMCID: PMC9378768 DOI: 10.1007/s10840-022-01160-w] [Citation(s) in RCA: 4] [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: 08/04/2021] [Accepted: 02/11/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND The mechanisms for atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI) catheter ablation are unclear. Non-PV organized atrial arrhythmias (PAC, AT, macro-reentrant AFL) are possible contributors; however the prevalence and effect of their ablation on recurrent AF are unknown. We hypothesize that the identification and ablation of non-PV organized atrial arrhythmias were associated with less AF recurrence. METHODS Patients who underwent repeat ablation for recurrent AF after prior PVI were retrospectively enrolled. The prevalence and characteristics of PV reconnections and non-PV organized atrial arrhythmias were identified. The outcomes of time to clinical AF recurrence, heart failure (HF) hospitalization, and mortality were analyzed in patients using multivariable adjusted Cox regression. RESULTS In 74 patients with recurrent AF (age 66 ± 9 years, left atrial volume index 38 ± 10 ml/m2, 59% persistent AF), PV reconnections were found in 46 patients (61%), macro-reentrant atrial flutter in 27 patients (36%), and focal tachycardia in 12 patients (16%). Mapping and ablation of non-PV organized atrial arrhythmias were associated with a reduced recurrence of late clinical AF (adjusted HR 0.26, CI 0.08-0.85, p = 0.03) and the composite outcome of recurrence of late AF, HF hospitalization, and mortality (adjusted HR 0.38, CI 0.17-0.85, p = 0.02), with median follow-up of 1.6 (IQR 0.7-6.3) years. The presence of PV reconnections or empiric linear ablation was not associated with reduction in clinical AF or composite endpoints. CONCLUSION The ablation of non-PV organized atrial arrhythmias resulted in a reduction of late clinical AF recurrence and composite outcome. In this challenging population, alternate mechanisms beyond PV reconnections need to be considered. Prospective studies are needed.
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6
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Lange M, Hirahara AM, Ranjan R, Stoddard GJ, Dosdall DJ. Atrial slow conduction develops and dynamically expands during premature stimulation in an animal model of persistent atrial fibrillation. PLoS One 2021; 16:e0258285. [PMID: 34618871 PMCID: PMC8496790 DOI: 10.1371/journal.pone.0258285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 09/24/2021] [Indexed: 11/18/2022] Open
Abstract
Slow conduction areas and conduction block in the atria are considered pro-arrhythmic conditions. Studies examining the size and distribution of slow conduction regions in the context of persistent atrial fibrillation (AF) may help to develop improved therapeutic strategies for patients with AF. In this work, we studied the differences of size and number in slow conduction areas between control and persistent AF goats and the influence of propagation direction on the development of these pathological conduction areas. Epicardial atrial electrical activations from the left atrial roof were optically mapped with physiological pacing cycle lengths and for the shortest captured cycle lengths. The recordings were converted to local activation times and conduction velocity measures. Regions with slow conduction velocity (less than [Formula: see text]) were identified. The size of the connected regions and the number of non-connected regions were counted for propagation from different orthogonal directions. We found that regions of slow conduction significantly increases in our 15 persistent AF goat recordings in response to premature stimulation (24.4±4.3% increase to 36.6±4.4%, p < 0.001). This increase is driven by an increase of size from (3.70±0.89[mm2] to 6.36±0.91[mm2], p = 0.014) for already existing regions and not by generation of new slow conduction regions (11.6±1.8 vs. 13±1.9, p = 0.242). In 12 control goat recordings, no increase from baseline pacing to premature pacing was found. Similarly, size of the slow conduction areas and the count did not change significantly in control animals.
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Affiliation(s)
- Matthias Lange
- Nora Eccles Harrison Cardiovasular Research and Training Institute, University of Utah, Salt Lake City, Utah, United States of America
| | - Annie M. Hirahara
- Nora Eccles Harrison Cardiovasular Research and Training Institute, University of Utah, Salt Lake City, Utah, United States of America
- Biomedical Engineering, University of Utah, Salt Lake City, Utah, United States of America
| | - Ravi Ranjan
- Nora Eccles Harrison Cardiovasular Research and Training Institute, University of Utah, Salt Lake City, Utah, United States of America
- Biomedical Engineering, University of Utah, Salt Lake City, Utah, United States of America
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
| | - Gregory J. Stoddard
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
| | - Derek J. Dosdall
- Nora Eccles Harrison Cardiovasular Research and Training Institute, University of Utah, Salt Lake City, Utah, United States of America
- Biomedical Engineering, University of Utah, Salt Lake City, Utah, United States of America
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
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Remodeling of Cardiac Gap Junctional Cell-Cell Coupling. Cells 2021; 10:cells10092422. [PMID: 34572071 PMCID: PMC8465208 DOI: 10.3390/cells10092422] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 09/03/2021] [Accepted: 09/08/2021] [Indexed: 12/29/2022] Open
Abstract
The heart works as a functional syncytium, which is realized via cell-cell coupling maintained by gap junction channels. These channels connect two adjacent cells, so that action potentials can be transferred. Each cell contributes a hexameric hemichannel (=connexon), formed by protein subuntis named connexins. These hemichannels dock to each other and form the gap junction channel. This channel works as a low ohmic resistor also allowing the passage of small molecules up to 1000 Dalton. Connexins are a protein family comprising of 21 isoforms in humans. In the heart, the main isoforms are Cx43 (the 43 kDa connexin; ubiquitous), Cx40 (mostly in atrium and specific conduction system), and Cx45 (in early developmental states, in the conduction system, and between fibroblasts and cardiomyocytes). These gap junction channels are mainly located at the polar region of the cardiomyocytes and thus contribute to the anisotropic pattern of cardiac electrical conductivity. While in the beginning the cell–cell coupling was considered to be static, similar to an anatomically defined structure, we have learned in the past decades that gap junctions are also subject to cardiac remodeling processes in cardiac disease such as atrial fibrillation, myocardial infarction, or cardiomyopathy. The underlying remodeling processes include the modulation of connexin expression by e.g., angiotensin, endothelin, or catecholamines, as well as the modulation of the localization of the gap junctions e.g., by the direction and strength of local mechanical forces. A reduction in connexin expression can result in a reduced conduction velocity. The alteration of gap junction localization has been shown to result in altered pathways of conduction and altered anisotropy. In particular, it can produce or contribute to non-uniformity of anisotropy, and thereby can pre-form an arrhythmogenic substrate. Interestingly, these remodeling processes seem to be susceptible to certain pharmacological treatment.
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8
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Novel insights in pathophysiology of postoperative atrial fibrillation. JTCVS OPEN 2021; 6:120-129. [PMID: 36003566 PMCID: PMC9390318 DOI: 10.1016/j.xjon.2021.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 01/08/2021] [Indexed: 11/29/2022]
Abstract
Objectives Atrial extrasystoles are usually benign; however, they can also trigger atrial fibrillation. It is most likely that if atrial extrasystoles provoke a larger amount of conduction disorders and a greater degree of endo-epicardial asynchrony, the risk of postoperative atrial fibrillation increases. To test this hypothesis, we investigated the effect of programmed atrial extrasystoles on endo-epicardial conduction and postoperative atrial fibrillation. Methods Twelve patients (58% male, age 68 ± 7 years) underwent simultaneous endo-epicardial mapping (256 electrodes) of the right atrium during sinus rhythm and programmed atrial extrasystoles provoked from the right atrial free wall. Areas of conduction block were defined as conduction delays of ≥12 milliseconds and endo-epicardial asynchrony as activation time differences of exact opposite electrodes of ≥15 milliseconds. Results Endo-epicardial mapping data of all programmed atrial extrasystoles were analyzed and compared with sinus rhythm (median preceding cycle length = 531 milliseconds [345-787] and median sinus rhythm cycle length = 843 milliseconds [701-992]). All programmed atrial extrasystoles were aberrant (severe, moderate, and mildly aberrant, respectively, n = 6, 3, and 3) and had a mean prematurity index of 50.1 ± 11.9%. The amount of endo-epicardial asynchrony (1% [1-2] vs 6.7 [2.7-16.9], P = .006) and conduction block (1.4% [0.6-2.6] vs 8.5% [4.2-10.4], P = .005) both increased during programmed atrial extrasystoles. Interestingly, conduction block during programmed atrial extrasystoles was more severe in patients (n = 4, 33.3%) who developed postoperative atrial fibrillation (5.1% [2.9-8.8] vs 11.3% [10.1-12.1], P = .004). Conclusions Atrial conduction disorders and endo-epicardial asynchrony, which play an important role in arrhythmogenesis, are enhanced during programmed atrial extrasystoles compared with sinus rhythm. The findings of this pilot study provide a possible explanation for enhanced vulnerability for postoperative atrial extrasystoles to induce postoperative atrial fibrillation in patients after cardiac surgery.
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9
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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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Mikhailov AV, Kalyanasundaram A, Li N, Scott SS, Artiga EJ, Subr MM, Zhao J, Hansen BJ, Hummel JD, Fedorov VV. Comprehensive evaluation of electrophysiological and 3D structural features of human atrial myocardium with insights on atrial fibrillation maintenance mechanisms. J Mol Cell Cardiol 2020; 151:56-71. [PMID: 33130148 DOI: 10.1016/j.yjmcc.2020.10.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/22/2020] [Accepted: 10/23/2020] [Indexed: 12/14/2022]
Abstract
Atrial fibrillation (AF) occurrence and maintenance is associated with progressive remodeling of electrophysiological (repolarization and conduction) and 3D structural (fibrosis, fiber orientations, and wall thickness) features of the human atria. Significant diversity in AF etiology leads to heterogeneous arrhythmogenic electrophysiological and structural substrates within the 3D structure of the human atria. Since current clinical methods have yet to fully resolve the patient-specific arrhythmogenic substrates, mechanism-based AF treatments remain underdeveloped. Here, we review current knowledge from in-vivo, ex-vivo, and in-vitro human heart studies, and discuss how these studies may provide new insights on the synergy of atrial electrophysiological and 3D structural features in AF maintenance. In-vitro studies on surgically acquired human atrial samples provide a great opportunity to study a wide spectrum of AF pathology, including functional changes in single-cell action potentials, ion channels, and gene/protein expression. However, limited size of the samples prevents evaluation of heterogeneous AF substrates and reentrant mechanisms. In contrast, coronary-perfused ex-vivo human hearts can be studied with state-of-the-art functional and structural technologies, such as high-resolution near-infrared optical mapping and contrast-enhanced MRI. These imaging modalities can resolve atrial arrhythmogenic substrates and their role in reentrant mechanisms maintaining AF and validate clinical approaches. Nonetheless, longitudinal studies are not feasible in explanted human hearts. As no approach is perfect, we suggest that combining the strengths of direct human atrial studies with high fidelity approaches available in the laboratory and in realistic patient-specific computer models would elucidate deeper knowledge of AF mechanisms. We propose that a comprehensive translational pipeline from ex-vivo human heart studies to longitudinal clinically relevant AF animal studies and finally to clinical trials is necessary to identify patient-specific arrhythmogenic substrates and develop novel AF treatments.
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Affiliation(s)
- Aleksei V Mikhailov
- Department of Physiology & Cell Biology, Bob and Corrine Frick Center for Heart Failure and Arrhythmia, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Arrhythmology Research Department, Almazov National Medical Research Centre, Saint-Petersburg, Russia
| | - Anuradha Kalyanasundaram
- Department of Physiology & Cell Biology, Bob and Corrine Frick Center for Heart Failure and Arrhythmia, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Ning Li
- Department of Physiology & Cell Biology, Bob and Corrine Frick Center for Heart Failure and Arrhythmia, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Shane S Scott
- Department of Physiology & Cell Biology, Bob and Corrine Frick Center for Heart Failure and Arrhythmia, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Esthela J Artiga
- Department of Physiology & Cell Biology, Bob and Corrine Frick Center for Heart Failure and Arrhythmia, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Megan M Subr
- Department of Physiology & Cell Biology, Bob and Corrine Frick Center for Heart Failure and Arrhythmia, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jichao Zhao
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Brian J Hansen
- Department of Physiology & Cell Biology, Bob and Corrine Frick Center for Heart Failure and Arrhythmia, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - John D Hummel
- Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Vadim V Fedorov
- Department of Physiology & Cell Biology, Bob and Corrine Frick Center for Heart Failure and Arrhythmia, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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11
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Hansen BJ, Zhao J, Helfrich KM, Li N, Iancau A, Zolotarev AM, Zakharkin SO, Kalyanasundaram A, Subr M, Dastagir N, Sharma R, Artiga EJ, Salgia N, Houmsse MM, Kahaly O, Janssen PML, Mohler PJ, Mokadam NA, Whitson BA, Afzal MR, Simonetti OP, Hummel JD, Fedorov VV. Unmasking Arrhythmogenic Hubs of Reentry Driving Persistent Atrial Fibrillation for Patient-Specific Treatment. J Am Heart Assoc 2020; 9:e017789. [PMID: 33006292 PMCID: PMC7792422 DOI: 10.1161/jaha.120.017789] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background Atrial fibrillation (AF) driver mechanisms are obscured to clinical multielectrode mapping approaches that provide partial, surface‐only visualization of unstable 3‐dimensional atrial conduction. We hypothesized that transient modulation of refractoriness by pharmacologic challenge during multielectrode mapping improves visualization of hidden paths of reentrant AF drivers for targeted ablation. Methods and Results Pharmacologic challenge with adenosine was tested in ex vivo human hearts with a history of AF and cardiac diseases by multielectrode and high‐resolution subsurface near‐infrared optical mapping, integrated with 3‐dimensional structural imaging and heart‐specific computational simulations. Adenosine challenge was also studied on acutely terminated AF drivers in 10 patients with persistent AF. Ex vivo, adenosine stabilized reentrant driver paths within arrhythmogenic fibrotic hubs and improved visualization of reentrant paths, previously seen as focal or unstable breakthrough activation pattern, for targeted AF ablation. Computational simulations suggested that shortening of atrial refractoriness by adenosine may (1) improve driver stability by annihilating spatially unstable functional blocks and tightening reentrant circuits around fibrotic substrates, thus unmasking the common reentrant path; and (2) destabilize already stable reentrant drivers along fibrotic substrates by accelerating competing fibrillatory wavelets or secondary drivers. In patients with persistent AF, adenosine challenge unmasked hidden common reentry paths (9/15 AF drivers, 41±26% to 68±25% visualization), but worsened visualization of previously visible reentry paths (6/15, 74±14% to 34±12%). AF driver ablation led to acute termination of AF. Conclusions Our ex vivo to in vivo human translational study suggests that transiently altering atrial refractoriness can stabilize reentrant paths and unmask arrhythmogenic hubs to guide targeted AF driver ablation treatment.
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Affiliation(s)
- Brian J Hansen
- Department of Physiology & Cell Biology and Frick Center for Heart Failure and Arrhythmia The Ohio State University Wexner Medical Center Columbus OH.,Davis Heart & Lung Research InstituteThe Ohio State University Wexner Medical Center Columbus OH
| | | | - Katelynn M Helfrich
- Department of Physiology & Cell Biology and Frick Center for Heart Failure and Arrhythmia The Ohio State University Wexner Medical Center Columbus OH.,Davis Heart & Lung Research InstituteThe Ohio State University Wexner Medical Center Columbus OH
| | - Ning Li
- Department of Physiology & Cell Biology and Frick Center for Heart Failure and Arrhythmia The Ohio State University Wexner Medical Center Columbus OH.,Davis Heart & Lung Research InstituteThe Ohio State University Wexner Medical Center Columbus OH
| | - Alexander Iancau
- Department of Physiology & Cell Biology and Frick Center for Heart Failure and Arrhythmia The Ohio State University Wexner Medical Center Columbus OH
| | - Alexander M Zolotarev
- Department of Physiology & Cell Biology and Frick Center for Heart Failure and Arrhythmia The Ohio State University Wexner Medical Center Columbus OH.,Skolkovo Institute of Science and Technology Moscow Russia
| | - Stanislav O Zakharkin
- Department of Physiology & Cell Biology and Frick Center for Heart Failure and Arrhythmia The Ohio State University Wexner Medical Center Columbus OH
| | - Anuradha Kalyanasundaram
- Department of Physiology & Cell Biology and Frick Center for Heart Failure and Arrhythmia The Ohio State University Wexner Medical Center Columbus OH.,Davis Heart & Lung Research InstituteThe Ohio State University Wexner Medical Center Columbus OH
| | - Megan Subr
- Department of Physiology & Cell Biology and Frick Center for Heart Failure and Arrhythmia The Ohio State University Wexner Medical Center Columbus OH
| | | | | | - Esthela J Artiga
- Department of Physiology & Cell Biology and Frick Center for Heart Failure and Arrhythmia The Ohio State University Wexner Medical Center Columbus OH.,Davis Heart & Lung Research InstituteThe Ohio State University Wexner Medical Center Columbus OH
| | - Nicholas Salgia
- Department of Physiology & Cell Biology and Frick Center for Heart Failure and Arrhythmia The Ohio State University Wexner Medical Center Columbus OH
| | - Mustafa M Houmsse
- Department of Physiology & Cell Biology and Frick Center for Heart Failure and Arrhythmia The Ohio State University Wexner Medical Center Columbus OH
| | - Omar Kahaly
- Davis Heart & Lung Research InstituteThe Ohio State University Wexner Medical Center Columbus OH.,Department of Internal Medicine The Ohio State University Wexner Medical Center Columbus OH
| | - Paul M L Janssen
- Department of Physiology & Cell Biology and Frick Center for Heart Failure and Arrhythmia The Ohio State University Wexner Medical Center Columbus OH.,Davis Heart & Lung Research InstituteThe Ohio State University Wexner Medical Center Columbus OH
| | - Peter J Mohler
- Department of Physiology & Cell Biology and Frick Center for Heart Failure and Arrhythmia The Ohio State University Wexner Medical Center Columbus OH.,Davis Heart & Lung Research InstituteThe Ohio State University Wexner Medical Center Columbus OH
| | - Nahush A Mokadam
- Davis Heart & Lung Research InstituteThe Ohio State University Wexner Medical Center Columbus OH.,Division of Cardiac Surgery The Ohio State University Wexner Medical Center Columbus OH
| | - Bryan A Whitson
- Davis Heart & Lung Research InstituteThe Ohio State University Wexner Medical Center Columbus OH.,Division of Cardiac Surgery The Ohio State University Wexner Medical Center Columbus OH
| | - Muhammad R Afzal
- Davis Heart & Lung Research InstituteThe Ohio State University Wexner Medical Center Columbus OH.,Department of Internal Medicine The Ohio State University Wexner Medical Center Columbus OH
| | - Orlando P Simonetti
- Davis Heart & Lung Research InstituteThe Ohio State University Wexner Medical Center Columbus OH.,Department of Biomedical Engineering The Ohio State University Wexner Medical Center Columbus OH
| | - John D Hummel
- Davis Heart & Lung Research InstituteThe Ohio State University Wexner Medical Center Columbus OH.,Department of Internal Medicine The Ohio State University Wexner Medical Center Columbus OH
| | - Vadim V Fedorov
- Department of Physiology & Cell Biology and Frick Center for Heart Failure and Arrhythmia The Ohio State University Wexner Medical Center Columbus OH.,Davis Heart & Lung Research InstituteThe Ohio State University Wexner Medical Center Columbus OH
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12
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Nery PB, Alqarawi W, Nair GM, Sadek MM, Redpath CJ, Golian M, Al Dawood W, Chen L, Hansom SP, Klein A, Wells GA, Birnie DH. Catheter Ablation of Low-Voltage Areas for Persistent Atrial Fibrillation: Procedural Outcomes Using High-Density Voltage Mapping. Can J Cardiol 2020; 36:1956-1964. [PMID: 32738208 DOI: 10.1016/j.cjca.2020.03.040] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 03/25/2020] [Accepted: 03/25/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Several approaches have been proposed to address the challenge of catheter ablation of persistent atrial fibrillation (AF). However, the optimal ablation strategy is unknown. We sought to evaluate the efficacy of pulmonary vein isolation (PVI) plus low-voltage area (LVA) ablation using contemporary high-density mapping to identify LVA in patients with persistent AF. METHODS Consecutive patients accepted for AF catheter ablation were studied. High-density bipolar voltage mapping data were acquired in sinus rhythm using multipolar catheters to detect LVA (defined as bipolar voltage < 0.5 mV). Semiautomated impedance-based software was used to ensure catheter contact during data collection. Patients underwent PVI + LVA ablation (if LVA present). RESULTS A total of 145 patients were studied; 95 patients undergoing PVI + LVA ablation were compared with 50 controls treated with PVI only. Average age was 61 ± 10 years, and 80% were male. Baseline characteristics were comparable. Freedom from atrial tachycardia/AF at 18 months was 72% after PVI + LVA ablation vs 58% in controls (P = 0.022). Median procedure duration (273 [240, 342] vs 305 [262, 360] minutes; P = 0.019) and radiofrequency delivery (50 [43, 63] vs 55 [35, 68] minutes; P = 0.39) were longer in the PVI + LVA ablation group. Multivariable analysis showed that the ablation strategy (PVI + LVA) was the only independent predictor of freedom from atrial tachycardia/AF (hazard ratio, 0.53; 95% confidence interval, 0.29-0.96; P = 0.036). There were no adverse safety outcomes associated with LVA ablation. CONCLUSIONS An individualized strategy of high-density mapping to assess the atrial substrate followed by PVI combined with LVA ablation is associated with improved outcomes. Adequately powered randomized clinical trials are needed to determine the role of PVI + LVA ablation for persistent AF.
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Affiliation(s)
- Pablo B Nery
- Arrhythmia Service, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
| | - Wael Alqarawi
- Arrhythmia Service, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Girish M Nair
- Arrhythmia Service, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Mouhannad M Sadek
- Arrhythmia Service, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Calum J Redpath
- Arrhythmia Service, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Mehrdad Golian
- Arrhythmia Service, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Wafa Al Dawood
- Arrhythmia Service, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Li Chen
- Cardiovascular Research Methods Center, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Simon P Hansom
- Arrhythmia Service, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Andres Klein
- Arrhythmia Service, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - George A Wells
- Cardiovascular Research Methods Center, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - David H Birnie
- Arrhythmia Service, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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13
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van der Does LJ, Kharbanda RK, Teuwen CP, Knops P, Kik C, Bogers AJ, de Groot NM. Atrial Ectopy Increases Asynchronous Activation of the Endo- and Epicardium at the Right Atrium. J Clin Med 2020; 9:jcm9020558. [PMID: 32085601 PMCID: PMC7074567 DOI: 10.3390/jcm9020558] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 02/05/2020] [Accepted: 02/14/2020] [Indexed: 11/16/2022] Open
Abstract
The predisposition of atrial extrasystoles (AES) to trigger cardiac tachyarrhythmia may arise from intramural conduction disorders causing endo-epicardial asynchrony (EEA). This study aimed to determine whether spontaneous AES disturb endo-epicardial conduction. Simultaneous endo-epicardial mapping of the right atrium was performed in patients during cardiac surgery with two 128-electrode arrays. Sixty spontaneous AES were observed in 23 patients and were analyzed for incidence of conduction delay, conduction block and amount of EEA compared to the previous sinus rhythm beat. Both conduction delay and block occurred more often in AES compared to sinus rhythm. The difference in lines of conduction block between the epicardium and endocardium increased in AES causing a greater imbalance of conduction disorders between the layers. The incidence of EEA with differences ≥10 ms increased significantly in AES. AES caused delays between the epicardium and endocardium up to 130 ms and EEA to increase for up to half (47%) of the mapping area. Conduction disturbances between the epicardial and endocardial layer giving rise to EEA increase during AES. Asynchronous activation of the atrial layers increases during AES which may be a mechanism for triggering cardiac tachyarrhythmia under the right conditions but EEA cannot be recognized by current mapping tools.
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Affiliation(s)
- Lisette J.M.E. van der Does
- Department of Cardiology, Erasmus Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands (R.K.K.); (C.P.T.); (P.K.)
| | - Rohit K. Kharbanda
- Department of Cardiology, Erasmus Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands (R.K.K.); (C.P.T.); (P.K.)
- Department of Cardiothoracic Surgery, Erasmus Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands; (C.K.)
| | - Christophe P. Teuwen
- Department of Cardiology, Erasmus Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands (R.K.K.); (C.P.T.); (P.K.)
| | - Paul Knops
- Department of Cardiology, Erasmus Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands (R.K.K.); (C.P.T.); (P.K.)
| | - Charles Kik
- Department of Cardiothoracic Surgery, Erasmus Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands; (C.K.)
| | - Ad J.J.C. Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands; (C.K.)
| | - Natasja M.S. de Groot
- Department of Cardiology, Erasmus Medical Center Rotterdam, 3015 GD Rotterdam, The Netherlands (R.K.K.); (C.P.T.); (P.K.)
- Correspondence: ; Tel.: +31-10-7034479; Fax: +31-10-7035258
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14
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Hendon CP, Lye TH, Yao X, Gan Y, Marboe CC. Optical coherence tomography imaging of cardiac substrates. Quant Imaging Med Surg 2019; 9:882-904. [PMID: 31281782 PMCID: PMC6571187 DOI: 10.21037/qims.2019.05.09] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 05/06/2019] [Indexed: 01/02/2023]
Abstract
Cardiovascular disease is the leading cause of morbidity and mortality in the United States. Knowledge of a patient's heart structure will help to plan procedures, potentially identifying arrhythmia substrates, critical structures to avoid, detect transplant rejection, and reduce ambiguity when interpreting electrograms and functional measurements. Similarly, basic research of numerous cardiac diseases would greatly benefit from structural imaging at cellular scale. For both applications imaging on the scale of a myocyte is needed, which is approximately 100 µm × 10 µm. The use of optical coherence tomography (OCT) as a tool for characterizing cardiac tissue structure and function has been growing in the past two decades. We briefly review OCT principles and highlight important considerations when imaging cardiac muscle. In particular, image penetration, tissue birefringence, and light absorption by blood during in vivo imaging are important factors when imaging the heart with OCT. Within the article, we highlight applications of cardiac OCT imaging including imaging heart tissue structure in small animal models, quantification of myofiber organization, monitoring of radiofrequency ablation (RFA) lesion formation, structure-function analysis enabled by functional extensions of OCT and multimodal analysis and characterizing important substrates within the human heart. The review concludes with a summary and future outlook of OCT imaging the heart, which is promising with progress in optical catheter development, functional extensions of OCT, and real time image processing to enable dynamic imaging and real time tracking during therapeutic procedures.
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Affiliation(s)
| | | | | | - Yu Gan
- Columbia University, New York, NY, USA
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15
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Roney CH, Whitaker J, Sim I, O'Neill L, Mukherjee RK, Razeghi O, Vigmond EJ, Wright M, O'Neill MD, Williams SE, Niederer SA. A technique for measuring anisotropy in atrial conduction to estimate conduction velocity and atrial fibre direction. Comput Biol Med 2019; 104:278-290. [PMID: 30415767 PMCID: PMC6506689 DOI: 10.1016/j.compbiomed.2018.10.019] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 10/17/2018] [Accepted: 10/17/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Cardiac conduction properties exhibit large variability, and affect patient-specific arrhythmia mechanisms. However, it is challenging to clinically measure conduction velocity (CV), anisotropy and fibre direction. Our aim is to develop a technique to estimate conduction anisotropy and fibre direction from clinically available electrical recordings. METHODS We developed and validated automated algorithms for estimating cardiac CV anisotropy, from any distribution of recording locations on the atrial surface. The first algorithm is for elliptical wavefront fitting to a single activation map (method 1), which works well close to the pacing location, but decreases in accuracy further from the pacing location (due to spatial heterogeneity in the conductivity and fibre fields). As such, we developed a second methodology for measuring local conduction anisotropy, using data from two or three activation maps (method 2: ellipse fitting to wavefront propagation velocity vectors from multiple activation maps). RESULTS Ellipse fitting to CV vectors from two activation maps (method 2) leads to an improved estimation of longitudinal and transverse CV compared to method 1, but fibre direction estimation is still relatively poor. Using three activation maps with method 2 provides accurate estimation, with approximately 70% of atrial fibres estimated within 20∘. We applied the technique to clinical activation maps to demonstrate the presence of heterogeneous conduction anisotropy, and then tested the effects of this conduction anisotropy on predicted arrhythmia dynamics using computational simulation. CONCLUSIONS We have developed novel algorithms for calculating CV and measuring the direction dependency of atrial activation to estimate atrial fibre direction, without the need for specialised pacing protocols, using clinically available electrical recordings.
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Affiliation(s)
- Caroline H Roney
- School of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom.
| | - John Whitaker
- School of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | - Iain Sim
- School of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | - Louisa O'Neill
- School of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | - Rahul K Mukherjee
- School of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | - Orod Razeghi
- School of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | - Edward J Vigmond
- LIRYC Electrophysiology and Heart Modeling Institute, Campus Xavier Arnozan, Avenue du Haut Lévêque, 33600, Pessac, France; Univ. Bordeaux, IMB, UMR 5251, F-33400, Talence, France
| | - Matthew Wright
- School of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | - Mark D O'Neill
- School of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | - Steven E Williams
- School of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | - Steven A Niederer
- School of Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
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16
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Fibrosis and Atrial Fibrillation: Computerized and Optical Mapping; A View into the Human Atria at Submillimeter Resolution. JACC Clin Electrophysiol 2017; 3:531-546. [PMID: 29159313 DOI: 10.1016/j.jacep.2017.05.002] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Recent studies strongly suggest that the majority of atrial fibrillation (AF) patients with diagnosed or subclinical cardiac diseases have established or even pre-existing fibrotic structural remodeling, which may lead to conduction abnormalities and reentrant activity that sustain AF. As conventional treatments fail to treat AF in far too many cases, an urgent need exists to identify specific structural arrhythmogenic fibrosis patterns, which may maintain AF, in order to identify effective ablation targets for AF treatment. However, the existing challenge is to define what exact structural remodeling within the complex 3D human atrial wall is arrhythmogenic, as well as linking arrhythmogenic fibrosis to an underlying mechanism of AF maintenance in the clinical setting. This review is focused on the role of 3D fibrosis architecture in the mechanisms of AF maintenance revealed by submillimeter, high-resolution ex-vivo imaging modalities directly of human atria, as well as from in-silico 3D computational techniques that can be able to overcome in-vivo clinical limitations. The systematic integration of functional and structural imaging ex-vivo may inform the necessary integration of electrode and structural mapping in-vivo. A holistic view of AF driver mechanisms may begin to identify the defining characteristics or "fingerprints" of reentrant AF drivers, such as 3D fibrotic architecture, in order to design optimal patient-specific ablation strategies.
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17
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Siland JE, Geelhoed B, van Gelder IC, van der Harst P, Rienstra M. Telomere length and incident atrial fibrillation - data of the PREVEND cohort. PLoS One 2017; 12:e0171545. [PMID: 28158257 PMCID: PMC5291433 DOI: 10.1371/journal.pone.0171545] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 01/23/2017] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND The incidence of atrial fibrillation (AF) increases with age. Telomere length is considered a marker of biological ageing. We investigated the association between leukocyte telomere length and incident AF in the Dutch Prevention of Renal and Vascular End-stage Disease (PREVEND) study. METHODS We included 7775 individuals without prevalent AF, and with leukocyte telomere length measured. Mean telomere length was determined by a monochrome multiplex quantitative polymerase chain reaction-based assay. RESULTS Mean age of our cohort was 49±13 years, and 50% were men. During a mean follow-up of 11.4±2.9 years incident AF was detected in 367 (4.7%) individuals. Telomere length was shorter in individuals developing incident AF compared to those without AF (p = 0.013). Incident AF was inversely related to the telomere length. In the quartile with the longest telomere length 68 (3.5%) individuals developed AF, in the shortest telomere length quartile 100 (5.1%) individuals (p = 0.032). Telomere length was associated with incident AF in the second shortest telomere length quartile using the longest telomere length quartile as reference (hazard ratio 1.64; 95% CI 1.02-2.66; p = 0.043). After including age or AF risk factors, the relation between telomere length and incident AF was no longer significant. We found a significant interaction of age, male sex, systolic blood pressure, BMI, heart failure, and myocardial infarction with telomere length for the association with incident AF. CONCLUSIONS We found that shorter leukocyte telomere length is not independently associated with incident AF in a community-based cohort.
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Affiliation(s)
- Joylene E. Siland
- Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands
| | - Bastiaan Geelhoed
- Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands
| | - Isabelle C. van Gelder
- Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands
| | - Pim van der Harst
- Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands
- * E-mail:
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19
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Reentry and Ectopic Pacemakers Emerge in a Three-Dimensional Model for a Slab of Cardiac Tissue with Diffuse Microfibrosis near the Percolation Threshold. PLoS One 2016; 11:e0166972. [PMID: 27875591 PMCID: PMC5119821 DOI: 10.1371/journal.pone.0166972] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 11/07/2016] [Indexed: 02/07/2023] Open
Abstract
Arrhythmias in cardiac tissue are generally associated with irregular electrical wave propagation in the heart. Cardiac tissue is formed by a discrete cell network, which is often heterogeneous. Recently, it was shown in simulations of two-dimensional (2D) discrete models of cardiac tissue that a wave crossing a fibrotic, heterogeneous region may produce reentry and transient or persistent ectopic activity provided the fraction of conducting connections is just above the percolation threshold. Here, we investigate the occurrence of these phenomena in three-dimensions by simulations of a discrete model representing a thin slab of cardiac tissue. This is motivated (i) by the necessity to study the relevance and properties of the percolation-related mechanism for the emergence of microreentries in three dimensions and (ii) by the fact that atrial tissue is quite thin in comparison with ventricular tissue. Here, we simplify the model by neglecting details of tissue anatomy, e. g. geometries of atria or ventricles and the anisotropy in the conductivity. Hence, our modeling study is confined to the investigation of the effect of the tissue thickness as well as to the comparison of the dynamics of electrical excitation in a 2D layer with the one in a 3D slab. Our results indicate a strong and non-trivial effect of the thickness even for thin tissue slabs on the probability of microreentries and ectopic beat generation. The strong correlation of the occurrence of microreentry with the percolation threshold reported earlier in 2D layers persists in 3D slabs. Finally, a qualitative agreement of 3D simulated electrograms in the fibrotic region with the experimentally observed complex fractional atrial electrograms (CFAE) as well as strong difference between simulated electrograms in 2D and 3D were found for the cases where reentry and ectopic activity were triggered by the micro-fibrotic region.
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20
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Morgan R, Colman MA, Chubb H, Seemann G, Aslanidi OV. Slow Conduction in the Border Zones of Patchy Fibrosis Stabilizes the Drivers for Atrial Fibrillation: Insights from Multi-Scale Human Atrial Modeling. Front Physiol 2016; 7:474. [PMID: 27826248 PMCID: PMC5079097 DOI: 10.3389/fphys.2016.00474] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 10/03/2016] [Indexed: 01/12/2023] Open
Abstract
Introduction: The genesis of atrial fibrillation (AF) and success of AF ablation therapy have been strongly linked with atrial fibrosis. Increasing evidence suggests that patient-specific distributions of fibrosis may determine the locations of electrical drivers (rotors) sustaining AF, but the underlying mechanisms are incompletely understood. This study aims to elucidate a missing mechanistic link between patient-specific fibrosis distributions and AF drivers. Methods: 3D atrial models integrated human atrial geometry, rule-based fiber orientation, region-specific electrophysiology, and AF-induced ionic remodeling. A novel detailed model for an atrial fibroblast was developed, and effects of myocyte-fibroblast (M-F) coupling were explored at single-cell, 1D tissue and 3D atria levels. Left atrial LGE MRI datasets from 3 chronic AF patients were segmented to provide the patient-specific distributions of fibrosis. The data was non-linearly registered and mapped to the 3D atria model. Six distinctive fibrosis levels (0-healthy tissue, 5-dense fibrosis) were identified based on LGE MRI intensity and modeled as progressively increasing M-F coupling and decreasing atrial tissue coupling. Uniform 3D atrial model with diffuse (level 2) fibrosis was considered for comparison. Results: In single cells and tissue, the largest effect of atrial M-F coupling was on the myocyte resting membrane potential, leading to partial inactivation of sodium current and reduction of conduction velocity (CV). In the 3D atria, further to the M-F coupling, effects of fibrosis on tissue coupling greatly reduce atrial CV. AF was initiated by fast pacing in each 3D model with either uniform or patient-specific fibrosis. High variation in fibrosis distributions between the models resulted in varying complexity of AF, with several drivers emerging. In the diffuse fibrosis models, waves randomly meandered through the atria, whereas in each the patient-specific models, rotors stabilized in fibrotic regions. The rotors propagated slowly around the border zones of patchy fibrosis (levels 3-4), failing to spread into inner areas of dense fibrosis. Conclusion: Rotors stabilize in the border zones of patchy fibrosis in 3D atria, where slow conduction enable the development of circuits within relatively small regions. Our results can provide a mechanistic explanation for the clinical efficacy of ablation around fibrotic regions.
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Affiliation(s)
- Ross Morgan
- Division of Imaging Sciences and Biomedical Engineering, Department of Biomedical Engineering, King's College LondonLondon, UK
| | | | - Henry Chubb
- Division of Imaging Sciences and Biomedical Engineering, Department of Biomedical Engineering, King's College LondonLondon, UK
| | - Gunnar Seemann
- Institute for Experimental Cardiovascular Medicine, University Heart Center - Bad Krozingen, Medical Center - University of FreiburgFreiburg, Germany
| | - Oleg V. Aslanidi
- Division of Imaging Sciences and Biomedical Engineering, Department of Biomedical Engineering, King's College LondonLondon, UK
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Manani KA, Christensen K, Peters NS. Myocardial architecture and patient variability in clinical patterns of atrial fibrillation. Phys Rev E 2016; 94:042401. [PMID: 27766317 PMCID: PMC5068559 DOI: 10.1103/physreve.94.042401] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Indexed: 11/07/2022]
Abstract
Atrial fibrillation (AF) increases the risk of stroke by a factor of 4-5 and is the most common abnormal heart rhythm. The progression of AF with age, from short self-terminating episodes to persistence, varies between individuals and is poorly understood. An inability to understand and predict variation in AF progression has resulted in less patient-specific therapy. Likewise, it has been a challenge to relate the microstructural features of heart muscle tissue (myocardial architecture) with the emergent temporal clinical patterns of AF. We use a simple model of activation wave-front propagation on an anisotropic structure, mimicking heart muscle tissue, to show how variation in AF behavior arises naturally from microstructural differences between individuals. We show that the stochastic nature of progressive transversal uncoupling of muscle strands (e.g., due to fibrosis or gap junctional remodeling), as occurs with age, results in variability in AF episode onset time, frequency, duration, burden, and progression between individuals. This is consistent with clinical observations. The uncoupling of muscle strands can cause critical architectural patterns in the myocardium. These critical patterns anchor microreentrant wave fronts and thereby trigger AF. It is the number of local critical patterns of uncoupling as opposed to global uncoupling that determines AF progression. This insight may eventually lead to patient-specific therapy when it becomes possible to observe the cellular structure of a patient's heart.
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Affiliation(s)
- Kishan A Manani
- The Blackett Laboratory, Imperial College London, London SW7 2BW, United Kingdom; National Heart and Lung Institute, Imperial College London, London W12 0NN, United Kingdom; Centre for Complexity Science, Imperial College London, London SW7 2AZ, United Kingdom
| | - Kim Christensen
- The Blackett Laboratory, Imperial College London, London SW7 2BW, United Kingdom; Centre for Complexity Science, Imperial College London, London SW7 2AZ, United Kingdom
| | - Nicholas S Peters
- National Heart and Lung Institute, Imperial College London, London W12 0NN, United Kingdom
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Begg GA, Holden AV, Lip GY, Plein S, Tayebjee MH. Assessment of atrial fibrosis for the rhythm control of atrial fibrillation. Int J Cardiol 2016; 220:155-61. [DOI: 10.1016/j.ijcard.2016.06.144] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 06/11/2016] [Accepted: 06/24/2016] [Indexed: 01/26/2023]
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Effects of Heterogeneous Diffuse Fibrosis on Arrhythmia Dynamics and Mechanism. Sci Rep 2016; 6:20835. [PMID: 26861111 PMCID: PMC4748409 DOI: 10.1038/srep20835] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 12/30/2015] [Indexed: 12/19/2022] Open
Abstract
Myocardial fibrosis is an important risk factor for cardiac arrhythmias. Previous experimental and numerical studies have shown that the texture and spatial distribution of fibrosis may play an important role in arrhythmia onset. Here, we investigate how spatial heterogeneity of fibrosis affects arrhythmia onset using numerical methods. We generate various tissue textures that differ by the mean amount of fibrosis, the degree of heterogeneity and the characteristic size of heterogeneity. We study the onset of arrhythmias using a burst pacing protocol. We confirm that spatial heterogeneity of fibrosis increases the probability of arrhythmia induction. This effect is more pronounced with the increase of both the spatial size and the degree of heterogeneity. The induced arrhythmias have a regular structure with the period being mostly determined by the maximal local fibrosis level. We perform ablations of the induced fibrillatory patterns to classify their type. We show that in fibrotic tissue fibrillation is usually of the mother rotor type but becomes of the multiple wavelet type with increase in tissue size. Overall, we conclude that the most important factor determining the formation and dynamics of arrhythmia in heterogeneous fibrotic tissue is the value of maximal local fibrosis.
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Zaman JAB, Narayan SM. When Is Structure, Function? Revisiting an Old Concept in Atrial Fibrillation. J Cardiovasc Electrophysiol 2015; 26:1361-3. [PMID: 26359793 DOI: 10.1111/jce.12836] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Junaid A B Zaman
- Department of Medicine, Stanford University, Palo Alto, California, USA.,National Heart & Lung Institute, Imperial College London, UK
| | - Sanjiv M Narayan
- Department of Medicine, Stanford University, Palo Alto, California, USA
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