1
|
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.
Collapse
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
| |
Collapse
|
2
|
Franco E, Lozano Granero C, Matía R, Hernández-Madrid A, Sánchez Pérez I, Zamorano JL, Moreno J. Stabilization of unstable reentrant atrial tachycardias via fractionated continuous electrical activity ablation (CHAOS study). Cardiol J 2022; 30:799-809. [PMID: 35578756 PMCID: PMC10635713 DOI: 10.5603/cj.a2022.0036] [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: 08/05/2021] [Revised: 11/11/2021] [Accepted: 11/19/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Unstable reentrant atrial tachycardias (ATs) (i.e., those with frequent circuit modification or conversion to atrial fibrillation) are challenging to ablate. We tested a strategy to achieve arrhythmia stabilization into mappable stable ATs based on the detection and ablation of rotors. METHODS All consecutive patients from May 2017 to December 2019 were included. Mapping was performed using conventional high-density mapping catheters (IntellaMap ORION, PentaRay NAV, or Advisor HD Grid). Rotors were subjectively identified as fractionated continuous (or quasi-continuous) electrograms on 1-2 adjacent bipoles, without dedicated software. In patients without detectable rotors, sites with spatiotemporal dispersion (i.e., all the cycle length comprised within the mapping catheter) plus non-continuous fractionation on single bipoles were targeted. Ablation success was defined as conversion to a stable AT or sinus rhythm. RESULTS Ninety-seven patients with reentrant ATs were ablated. Of these, 18 (18.6%) presented unstable circuits. Thirteen (72%) patients had detectable rotors (median 2 [1-3] rotors per patient); focal ablation was successful in 12 (92%). In the other 5 patients, 17 sites with spatiotemporal dispersion were identified and targeted. Globally, and excluding 1 patient with spontaneous AT stabilization, ablation success was achieved in 16/17 patients (94.1%). One-year freedom from atrial arrhythmias was similar between patients with unstable and stable ATs (66.7% vs. 65.8%, p = 0.946). CONCLUSIONS Most unstable reentrant ATs show detectable rotors, identified as sites with single-bipole fractionated quasi-continuous signals, or spatiotemporal dispersion plus non-continuous fractionation. Ablation of these sites is highly effective to stabilize the AT or convert it into sinus rhythm.
Collapse
Affiliation(s)
- Eduardo Franco
- Arrhythmia Unit, Cardiology Department, University Hospital Ramón y Cajal, Madrid, Spain.
| | | | - Roberto Matía
- Arrhythmia Unit, Cardiology Department, University Hospital Ramón y Cajal, Madrid, Spain
| | | | | | - José Luis Zamorano
- Arrhythmia Unit, Cardiology Department, University Hospital Ramón y Cajal, Madrid, Spain
| | - Javier Moreno
- Arrhythmia Unit, Cardiology Department, University Hospital Ramón y Cajal, Madrid, Spain
| |
Collapse
|
3
|
Hartley A, Shalhoub J, Ng FS, Krahn AD, Laksman Z, Andrade JG, Deyell MW, Kanagaratnam P, Sikkel MB. Size matters in atrial fibrillation: the underestimated importance of reduction of contiguous electrical mass underlying the effectiveness of catheter ablation. Europace 2021; 23:1698-1707. [PMID: 33948648 PMCID: PMC8576280 DOI: 10.1093/europace/euab078] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 03/22/2021] [Indexed: 11/13/2022] Open
Abstract
Evidence has accumulated over the last century of the importance of a critical electrical mass in sustaining atrial fibrillation (AF). AF ablation certainly reduces electrically contiguous atrial mass, but this is not widely accepted to be an important part of its mechanism of action. In this article, we review data showing that atrial size is correlated in many settings with AF propensity. Larger mammals are more likely to exhibit AF. This is seen both in the natural world and in animal models, where it is much easier to create a goat model than a mouse model of AF, for example. This also extends to humans-athletes, taller people, and obese individuals all have large atria and are more likely to exhibit AF. Within an individual, risk factors such as hypertension, valvular disease and ischaemia can enlarge the atrium and increase the risk of AF. With respect to AF ablation, we explore how variations in ablation strategy and the relative effectiveness of these strategies may suggest that a reduction in electrical atrial mass is an important mechanism of action. We counter this with examples in which there is no doubt that mass reduction is less important than competing theories such as ganglionated plexus ablation. We conclude that, when considering future strategies for the ablative therapy of AF, it is important not to discount the possibility that contiguous electrical mass reduction is the most important mechanism despite the disappointing consequence being that enhancing success rates in AF ablation may involve greater tissue destruction.
Collapse
Affiliation(s)
- Adam Hartley
- National Heart and Lung Institute,Imperial College London, London, UK
| | - Joseph Shalhoub
- National Heart and Lung Institute,Imperial College London, London, UK
| | - Fu Siong Ng
- National Heart and Lung Institute,Imperial College London, London, UK
| | - Andrew D Krahn
- Division of Cardiology, University of British Columbia, 740 Hillside Ave, Vancouver, BC V8T 1Z4, Canada
| | - Zachary Laksman
- Division of Cardiology, University of British Columbia, 740 Hillside Ave, Vancouver, BC V8T 1Z4, Canada
| | - Jason G Andrade
- Division of Cardiology, University of British Columbia, 740 Hillside Ave, Vancouver, BC V8T 1Z4, Canada
| | - Marc W Deyell
- Division of Cardiology, University of British Columbia, 740 Hillside Ave, Vancouver, BC V8T 1Z4, Canada
| | | | - Markus B Sikkel
- Division of Cardiology, University of British Columbia, 740 Hillside Ave, Vancouver, BC V8T 1Z4, Canada
- Division of Medical Sciences, University of Victoria, Victoria, Canada
| |
Collapse
|
4
|
Cámara-Vázquez MÁ, Hernández-Romero I, Morgado-Reyes E, Guillem MS, Climent AM, Barquero-Pérez O. Non-invasive Estimation of Atrial Fibrillation Driver Position With Convolutional Neural Networks and Body Surface Potentials. Front Physiol 2021; 12:733449. [PMID: 34721065 PMCID: PMC8552066 DOI: 10.3389/fphys.2021.733449] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 09/03/2021] [Indexed: 11/18/2022] Open
Abstract
Atrial fibrillation (AF) is characterized by complex and irregular propagation patterns, and AF onset locations and drivers responsible for its perpetuation are the main targets for ablation procedures. ECG imaging (ECGI) has been demonstrated as a promising tool to identify AF drivers and guide ablation procedures, being able to reconstruct the electrophysiological activity on the heart surface by using a non-invasive recording of body surface potentials (BSP). However, the inverse problem of ECGI is ill-posed, and it requires accurate mathematical modeling of both atria and torso, mainly from CT or MR images. Several deep learning-based methods have been proposed to detect AF, but most of the AF-based studies do not include the estimation of ablation targets. In this study, we propose to model the location of AF drivers from BSP as a supervised classification problem using convolutional neural networks (CNN). Accuracy in the test set ranged between 0.75 (SNR = 5 dB) and 0.93 (SNR = 20 dB upward) when assuming time independence, but it worsened to 0.52 or lower when dividing AF models into blocks. Therefore, CNN could be a robust method that could help to non-invasively identify target regions for ablation in AF by using body surface potential mapping, avoiding the use of ECGI.
Collapse
Affiliation(s)
- Miguel Ángel Cámara-Vázquez
- Department of Signal Theory and Communications, Telematic Systems and Computation, Rey Juan Carlos University, Madrid, Spain
| | - Ismael Hernández-Romero
- Department of Signal Theory and Communications, Telematic Systems and Computation, Rey Juan Carlos University, Madrid, Spain
| | - Eduardo Morgado-Reyes
- Department of Signal Theory and Communications, Telematic Systems and Computation, Rey Juan Carlos University, Madrid, Spain
| | - Maria S Guillem
- ITACA Institute, Universitat Politècnica de València, Valencia, Spain
| | - Andreu M Climent
- ITACA Institute, Universitat Politècnica de València, Valencia, Spain
| | - Oscar Barquero-Pérez
- Department of Signal Theory and Communications, Telematic Systems and Computation, Rey Juan Carlos University, Madrid, Spain.,ITACA Institute, Universitat Politècnica de València, Valencia, Spain
| |
Collapse
|
5
|
Roney CH, Child N, Porter B, Sim I, Whitaker J, Clayton RH, Laughner JI, Shuros A, Neuzil P, Williams SE, Razavi RS, O'Neill M, Rinaldi CA, Taggart P, Wright M, Gill JS, Niederer SA. Time-Averaged Wavefront Analysis Demonstrates Preferential Pathways of Atrial Fibrillation, Predicting Pulmonary Vein Isolation Acute Response. Front Physiol 2021; 12:707189. [PMID: 34646149 PMCID: PMC8503618 DOI: 10.3389/fphys.2021.707189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 08/24/2021] [Indexed: 11/13/2022] Open
Abstract
Electrical activation during atrial fibrillation (AF) appears chaotic and disorganised, which impedes characterisation of the underlying substrate and treatment planning. While globally chaotic, there may be local preferential activation pathways that represent potential ablation targets. This study aimed to identify preferential activation pathways during AF and predict the acute ablation response when these are targeted by pulmonary vein isolation (PVI). In patients with persistent AF (n = 14), simultaneous biatrial contact mapping with basket catheters was performed pre-ablation and following each ablation strategy (PVI, roof, and mitral lines). Unipolar wavefront activation directions were averaged over 10 s to identify preferential activation pathways. Clinical cases were classified as responders or non-responders to PVI during the procedure. Clinical data were augmented with a virtual cohort of 100 models. In AF pre-ablation, pathways originated from the pulmonary vein (PV) antra in PVI responders (7/7) but not in PVI non-responders (6/6). We proposed a novel index that measured activation waves from the PV antra into the atrial body. This index was significantly higher in PVI responders than non-responders (clinical: 16.3 vs. 3.7%, p = 0.04; simulated: 21.1 vs. 14.1%, p = 0.02). Overall, this novel technique and proof of concept study demonstrated that preferential activation pathways exist during AF. Targeting patient-specific activation pathways that flowed from the PV antra to the left atrial body using PVI resulted in AF termination during the procedure. These PV activation flow pathways may correspond to the presence of drivers in the PV regions.
Collapse
Affiliation(s)
- Caroline H. Roney
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Nicholas Child
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Bradley Porter
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Iain Sim
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - John Whitaker
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Richard H. Clayton
- INSIGNEO Institute for In Silico Medicine and Department of Computer Science, University of Sheffield, Sheffield, United Kingdom
| | | | - Allan Shuros
- Boston Scientific Corp, St. Paul, MN, United States
| | - Petr Neuzil
- Department of Cardiology, Na Holmolce Hospital, Prague, Czechia
| | - Steven E. Williams
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Reza S. Razavi
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Mark O'Neill
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | | | - Peter Taggart
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Matt Wright
- Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom
| | - Jaswinder S. Gill
- Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom
| | - Steven A. Niederer
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Kowalewski C. Mapping atrial fibrillation : An overview of potential mechanisms underlying atrial fibrillation. Herz 2021; 46:305-311. [PMID: 34104977 DOI: 10.1007/s00059-021-05045-y] [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] [Accepted: 04/29/2021] [Indexed: 11/24/2022]
Abstract
Mechanisms sustaining atrial fibrillation are yet to be clarified. This article focuses on milestones in the theory of atrial fibrillation and addresses the different leading hypotheses concerning atrial fibrillation mechanisms. We start off with electric potential originating from the pulmonary vein, which triggers atrial fibrillation, discuss classic activation mapping and phase mapping as well as computer models, which have contributed to the our understanding of atrial fibrillation, and end with new mapping methods and studies highlighting the advantages and disadvantages of current mechanistic hypotheses. The technical evolution of mapping atrial fibrillation has led to new insights into the potential mechanisms underlying atrial fibrillation. A comparison between methods is essential for understanding the advantages and disadvantages of each method when mapping atrial fibrillation. Ultimately, the combination of several methods might shed light on the underlying mechanisms of atrial fibrillation and lead to a better understanding of atrial fibrillation and subsequently improve treatment of this condition.
Collapse
|
8
|
Salinet J, Molero R, Schlindwein FS, Karel J, Rodrigo M, Rojo-Álvarez JL, Berenfeld O, Climent AM, Zenger B, Vanheusden F, Paredes JGS, MacLeod R, Atienza F, Guillem MS, Cluitmans M, Bonizzi P. Electrocardiographic Imaging for Atrial Fibrillation: A Perspective From Computer Models and Animal Experiments to Clinical Value. Front Physiol 2021; 12:653013. [PMID: 33995122 PMCID: PMC8120164 DOI: 10.3389/fphys.2021.653013] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/22/2021] [Indexed: 01/16/2023] Open
Abstract
Electrocardiographic imaging (ECGI) is a technique to reconstruct non-invasively the electrical activity on the heart surface from body-surface potential recordings and geometric information of the torso and the heart. ECGI has shown scientific and clinical value when used to characterize and treat both atrial and ventricular arrhythmias. Regarding atrial fibrillation (AF), the characterization of the electrical propagation and the underlying substrate favoring AF is inherently more challenging than for ventricular arrhythmias, due to the progressive and heterogeneous nature of the disease and its manifestation, the small volume and wall thickness of the atria, and the relatively large role of microstructural abnormalities in AF. At the same time, ECGI has the advantage over other mapping technologies of allowing a global characterization of atrial electrical activity at every atrial beat and non-invasively. However, since ECGI is time-consuming and costly and the use of electrical mapping to guide AF ablation is still not fully established, the clinical value of ECGI for AF is still under assessment. Nonetheless, AF is known to be the manifestation of a complex interaction between electrical and structural abnormalities and therefore, true electro-anatomical-structural imaging may elucidate important key factors of AF development, progression, and treatment. Therefore, it is paramount to identify which clinical questions could be successfully addressed by ECGI when it comes to AF characterization and treatment, and which questions may be beyond its technical limitations. In this manuscript we review the questions that researchers have tried to address on the use of ECGI for AF characterization and treatment guidance (for example, localization of AF triggers and sustaining mechanisms), and we discuss the technological requirements and validation. We address experimental and clinical results, limitations, and future challenges for fruitful application of ECGI for AF understanding and management. We pay attention to existing techniques and clinical application, to computer models and (animal or human) experiments, to challenges of methodological and clinical validation. The overall objective of the study is to provide a consensus on valuable directions that ECGI research may take to provide future improvements in AF characterization and treatment guidance.
Collapse
Affiliation(s)
- João Salinet
- Biomedical Engineering, Centre for Engineering, Modelling and Applied Social Sciences (CECS), Federal University of ABC, São Bernardo do Campo, Brazil
| | - Rubén Molero
- ITACA Institute, Universitat Politècnica de València, València, Spain
| | - Fernando S. Schlindwein
- School of Engineering, University of Leicester, United Kingdom and National Institute for Health Research, Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - Joël Karel
- Department of Data Science and Knowledge Engineering, Maastricht University, Maastricht, Netherlands
| | - Miguel Rodrigo
- Electronic Engineering Department, Universitat de València, València, Spain
| | - José Luis Rojo-Álvarez
- Department of Signal Theory and Communications and Telematic Systems and Computation, University Rey Juan Carlos, Madrid, Spain
| | - Omer Berenfeld
- Center for Arrhythmia Research, University of Michigan, Ann Arbor, MI, United States
| | - Andreu M. Climent
- ITACA Institute, Universitat Politècnica de València, València, Spain
| | - Brian Zenger
- Biomedical Engineering Department, Scientific Computing and Imaging Institute (SCI), and Cardiovascular Research and Training Institute (CVRTI), The University of Utah, Salt Lake City, UT, United States
| | - Frederique Vanheusden
- Department of Engineering, School of Science and Technology, Nottingham Trent University, Nottingham, United Kingdom
| | - Jimena Gabriela Siles Paredes
- Biomedical Engineering, Centre for Engineering, Modelling and Applied Social Sciences (CECS), Federal University of ABC, São Bernardo do Campo, Brazil
| | - Rob MacLeod
- Biomedical Engineering Department, Scientific Computing and Imaging Institute (SCI), and Cardiovascular Research and Training Institute (CVRTI), The University of Utah, Salt Lake City, UT, United States
| | - Felipe Atienza
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, and Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - María S. Guillem
- ITACA Institute, Universitat Politècnica de València, València, Spain
| | - Matthijs Cluitmans
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Pietro Bonizzi
- Department of Data Science and Knowledge Engineering, Maastricht University, Maastricht, Netherlands
| |
Collapse
|
9
|
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.
Collapse
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)
| |
Collapse
|
10
|
Cámara-Vázquez MÁ, Hernández-Romero I, Rodrigo M, Alonso-Atienza F, Figuera C, Morgado-Reyes E, Atienza F, Guillem MS, Climent AM, Barquero-Pérez Ó. Electrocardiographic imaging including intracardiac information to achieve accurate global mapping during atrial fibrillation. Biomed Signal Process Control 2021. [DOI: 10.1016/j.bspc.2020.102354] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
|
11
|
Abstract
Determining optimal treatment strategies for complex arrhythmogenesis in AF is confounded by the lack of consensus regarding the mechanisms causing AF. Studies report different mechanisms for AF, ranging from hierarchical drivers to anarchical multiple activation wavelets. Differences in the assessment of AF mechanisms are likely due to AF being recorded across diverse models using different investigational tools, spatial scales and clinical populations. The authors review different AF mechanisms, including anatomical and functional re-entry, hierarchical drivers and anarchical multiple wavelets. They then describe different cardiac mapping techniques and analysis tools, including activation mapping, phase mapping and fibrosis identification. They explain and review different data challenges, including differences between recording devices in spatial and temporal resolutions, spatial coverage and recording surface, and report clinical outcomes using different data modalities. They suggest future research directions for investigating the mechanisms underlying human AF.
Collapse
Affiliation(s)
- Caroline H Roney
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.,Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Andrew L Wit
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK.,Department of Pharmacology, Columbia University College of Physicians and Surgeons, New York, NY, US
| | - Nicholas S Peters
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| |
Collapse
|
12
|
Leef G, Shenasa F, Bhatia NK, Rogers AJ, Sauer W, Miller JM, Swerdlow M, Tamboli M, Alhusseini MI, Armenia E, Baykaner T, Brachmann J, Turakhia MP, Atienza F, Rappel WJ, Wang PJ, Narayan SM. Wavefront Field Mapping Reveals a Physiologic Network Between Drivers Where Ablation Terminates Atrial Fibrillation. Circ Arrhythm Electrophysiol 2019; 12:e006835. [PMID: 31352796 DOI: 10.1161/circep.118.006835] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Localized drivers are proposed mechanisms for persistent atrial fibrillation (AF) from optical mapping of human atria and clinical studies of AF, yet are controversial because drivers fluctuate and ablating them may not terminate AF. We used wavefront field mapping to test the hypothesis that AF drivers, if concurrent, may interact to produce fluctuating areas of control to explain their appearance/disappearance and acute impact of ablation. METHODS We recruited 54 patients from an international registry in whom persistent AF terminated by targeted ablation. Unipolar AF electrograms were analyzed from 64-pole baskets to reconstruct activation times, map propagation vectors each 20 ms, and create nonproprietary phase maps. RESULTS Each patient (63.6±8.5 years, 29.6% women) showed 4.0±2.1 spatially anchored rotational or focal sites in AF in 3 patterns. First, a single (type I; n=7) or, second, paired chiral-antichiral (type II; n=5) rotational drivers controlled most of the atrial area. Ablation of 1 to 2 large drivers terminated all cases of types I or II AF. Third, interaction of 3 to 5 drivers (type III; n=42) with changing areas of control. Targeted ablation at driver centers terminated AF and required more ablation in types III versus I (P=0.02 in left atrium). CONCLUSIONS Wavefront field mapping of persistent AF reveals a pathophysiologic network of a small number of spatially anchored rotational and focal sites, which interact, fluctuate, and control varying areas. Future work should define whether AF drivers that control larger atrial areas are attractive targets for ablation.
Collapse
Affiliation(s)
- George Leef
- Department of Medicine, Stanford University, California (G.L., F.S., N.K.B., A.J.R., M.S., M.T., M.I.A., T.B., P.J.W., S.M.N.)
| | - Fatemah Shenasa
- Department of Medicine, Stanford University, California (G.L., F.S., N.K.B., A.J.R., M.S., M.T., M.I.A., T.B., P.J.W., S.M.N.)
| | - Neal K Bhatia
- Department of Medicine, Stanford University, California (G.L., F.S., N.K.B., A.J.R., M.S., M.T., M.I.A., T.B., P.J.W., S.M.N.)
| | - Albert J Rogers
- Department of Medicine, Stanford University, California (G.L., F.S., N.K.B., A.J.R., M.S., M.T., M.I.A., T.B., P.J.W., S.M.N.)
| | - William Sauer
- Department of Medicine, University of Colorado, Denver (W.S., E.A.)
| | - John M Miller
- Department of Medicine, University of Indiana, Indianapolis (J.M.M.)
| | - Mark Swerdlow
- Department of Medicine, Stanford University, California (G.L., F.S., N.K.B., A.J.R., M.S., M.T., M.I.A., T.B., P.J.W., S.M.N.)
| | - Mallika Tamboli
- Department of Medicine, Stanford University, California (G.L., F.S., N.K.B., A.J.R., M.S., M.T., M.I.A., T.B., P.J.W., S.M.N.)
| | - Mahmood I Alhusseini
- Department of Medicine, Stanford University, California (G.L., F.S., N.K.B., A.J.R., M.S., M.T., M.I.A., T.B., P.J.W., S.M.N.)
| | - Erin Armenia
- Department of Medicine, University of Colorado, Denver (W.S., E.A.)
| | - Tina Baykaner
- Department of Medicine, Stanford University, California (G.L., F.S., N.K.B., A.J.R., M.S., M.T., M.I.A., T.B., P.J.W., S.M.N.)
| | | | - Mintu P Turakhia
- Department of Medicine, Veterans Affairs Palo Alto Health Care System, CA (M.P.T.)
| | - Felipe Atienza
- Departamento de Cardiologia, Hospital General Universitario Gregorio Maranon, Madrid, Spain (F.A.)
| | | | - Paul J Wang
- Department of Medicine, Stanford University, California (G.L., F.S., N.K.B., A.J.R., M.S., M.T., M.I.A., T.B., P.J.W., S.M.N.)
| | - Sanjiv M Narayan
- Department of Medicine, Stanford University, California (G.L., F.S., N.K.B., A.J.R., M.S., M.T., M.I.A., T.B., P.J.W., S.M.N.)
| |
Collapse
|
13
|
Mesquita J, Maniar N, Baykaner T, Rogers AJ, Swerdlow M, Alhusseini MI, Shenasa F, Brizido C, Matos D, Freitas P, Santos AR, Rodrigues G, Silva C, Rodrigo M, Dong Y, Clopton P, Ferreira AM, Narayan SM. Online webinar training to analyse complex atrial fibrillation maps: A randomized trial. PLoS One 2019; 14:e0217988. [PMID: 31269029 PMCID: PMC6609132 DOI: 10.1371/journal.pone.0217988] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 05/22/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Specific tools have been recently developed to map atrial fibrillation (AF) and help guide ablation. However, when used in clinical practice, panoramic AF maps generated from multipolar intracardiac electrograms have yielded conflicting results between centers, likely due to their complexity and steep learning curve, thus limiting the proper assessment of its clinical impact. OBJECTIVES The main purpose of this trial was to assess the impact of online training on the identification of AF driver sites where ablation terminated persistent AF, through a standardized training program. Extending this concept to mobile health was defined as a secondary objective. METHODS An online database of panoramic AF movies was generated from a multicenter registry of patients in whom targeted ablation terminated non-paroxysmal AF, using a freely available method (Kuklik et al-method A) and a commercial one (RhythmView-method B). Cardiology Fellows naive to AF mapping were enrolled and randomized to training vs no training (control). All participants evaluated an initial set of movies to identify sites of AF termination. Participants randomized to training evaluated a second set of movies in which they received feedback on their answers. Both groups re-evaluated the initial set to assess the impact of training. This concept was then migrated to a smartphone application (App). RESULTS 12 individuals (median age of 30 years (IQR 28-32), 6 females) read 480 AF maps. Baseline identification of AF termination sites by ablation was poor (40%±12% vs 42%±11%, P = 0.78), but similar for both mapping methods (P = 0.68). Training improved accuracy for both methods A (P = 0.001) and B (p = 0.012); whereas controls showed no change in accuracy (P = NS). The Smartphone App accessed AF maps from multiple systems on the cloud to recreate this training environment. CONCLUSION Digital online training improved interpretation of panoramic AF maps in previously inexperienced clinicians. Combining online clinical data, smartphone apps and other digital resources provides a powerful, scalable approach for training in novel techniques in electrophysiology.
Collapse
Affiliation(s)
- João Mesquita
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Gaia, Portugal
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, United States of America
- * E-mail:
| | - Natasha Maniar
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, United States of America
| | - Tina Baykaner
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, United States of America
- Department of Cardiovascular Medicine, Stanford University, Stanford, California, United States of America
| | - Albert J. Rogers
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, United States of America
- Department of Cardiovascular Medicine, Stanford University, Stanford, California, United States of America
| | - Mark Swerdlow
- 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
| | - Fatemah Shenasa
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, United States of America
| | - Catarina Brizido
- Department of Cardiology, Centro Hospitalar de Lisboa Ocidental–Hospital de Santa Cruz, Carnaxide, Portugal
| | - Daniel Matos
- Department of Cardiology, Centro Hospitalar de Lisboa Ocidental–Hospital de Santa Cruz, Carnaxide, Portugal
| | - Pedro Freitas
- Department of Cardiology, Centro Hospitalar de Lisboa Ocidental–Hospital de Santa Cruz, Carnaxide, Portugal
| | - Ana Rita Santos
- Department of Internal Medicine, Centro Hospitalar de Lisboa Ocidental–Hospital de São Francisco Xavier, Lisboa, Portugal
| | - Gustavo Rodrigues
- Department of Cardiology, Centro Hospitalar de Lisboa Ocidental–Hospital de Santa Cruz, Carnaxide, Portugal
| | - Claudia Silva
- Department of Cardiology, Centro Hospitalar de Lisboa Ocidental–Hospital de Santa Cruz, Carnaxide, Portugal
| | - Miguel Rodrigo
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, United States of America
- Universitat Politècnica de València, Valencia, Spain
| | - Yan Dong
- Department of Cardiovascular Medicine, Stanford University, Stanford, California, United States of America
| | - Paul Clopton
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, United States of America
| | - António M. Ferreira
- Department of Cardiology, Centro Hospitalar de Lisboa Ocidental–Hospital de Santa Cruz, Carnaxide, Portugal
| | - Sanjiv M. Narayan
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, United States of America
- Department of Cardiovascular Medicine, Stanford University, Stanford, California, United States of America
| |
Collapse
|
14
|
Roney CH, Bayer JD, Cochet H, Meo M, Dubois R, Jaïs P, Vigmond EJ. Variability in pulmonary vein electrophysiology and fibrosis determines arrhythmia susceptibility and dynamics. PLoS Comput Biol 2018; 14:e1006166. [PMID: 29795549 PMCID: PMC5997352 DOI: 10.1371/journal.pcbi.1006166] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 06/12/2018] [Accepted: 04/30/2018] [Indexed: 11/28/2022] Open
Abstract
Success rates for catheter ablation of persistent atrial fibrillation patients are currently low; however, there is a subset of patients for whom electrical isolation of the pulmonary veins alone is a successful treatment strategy. It is difficult to identify these patients because there are a multitude of factors affecting arrhythmia susceptibility and maintenance, and the individual contributions of these factors are difficult to determine clinically. We hypothesised that the combination of pulmonary vein (PV) electrophysiology and atrial body fibrosis determine driver location and effectiveness of pulmonary vein isolation (PVI). We used bilayer biatrial computer models based on patient geometries to investigate the effects of PV properties and atrial fibrosis on arrhythmia inducibility, maintenance mechanisms, and the outcome of PVI. Short PV action potential duration (APD) increased arrhythmia susceptibility, while longer PV APD was found to be protective. Arrhythmia inducibility increased with slower conduction velocity (CV) at the LA/PV junction, but not for cases with homogeneous CV changes or slower CV at the distal PV. Phase singularity (PS) density in the PV region for cases with PV fibrosis was increased. Arrhythmia dynamics depend on both PV properties and fibrosis distribution, varying from meandering rotors to PV reentry (in cases with baseline or long APD), to stable rotors at regions of high fibrosis density. Measurement of fibrosis and PV properties may indicate patient specific susceptibility to AF initiation and maintenance. PV PS density before PVI was higher for cases in which AF terminated or converted to a macroreentry; thus, high PV PS density may indicate likelihood of PVI success. Atrial fibrillation is the most commonly encountered cardiac arrhythmia, affecting a significant portion of the population. Currently, ablation is the most effective treatment but success rates are less than optimal, being 70% one-year post-treatment. There is a large effort to find better ablation strategies to permanently cure the condition. Pulmonary vein isolation by ablation is more or less the standard of care, but many questions remain since pulmonary vein ectopy by itself does not explain all of the clinical successes or failures. We used computer simulations to investigate how electrophysiological properties of the pulmonary veins can affect rotor formation and maintenance in patients suffering from atrial fibrillation. We used complex, biophysical representations of cellular electrophysiology in highly detailed geometries constructed from patient scans. We heterogeneously varied electrophysiological and structural properties to see their effects on rotor initiation and maintenance. Our study suggests a metric for indicating the likelihood of success of pulmonary vein isolation. Thus either measuring this clinically, or running patient-specific simulations to estimate this metric may suggest whether ablation in addition to pulmonary vein isolation should be performed. Our study provides motivation for a retrospective clinical study or experimental study into this metric.
Collapse
Affiliation(s)
- Caroline H. Roney
- IHU Liryc, Electrophysiology and Heart Modeling Institute, foundation Bordeaux Université, F-33600 Pessac- Bordeaux, France
- Division of Imaging Sciences and Biomedical Engineering, King’s College London, London, United Kingdom
| | - Jason D. Bayer
- IHU Liryc, Electrophysiology and Heart Modeling Institute, foundation Bordeaux Université, F-33600 Pessac- Bordeaux, France
- Univ. Bordeaux, IMB UMR 5251, CNRS, F-33400 Talence, France
| | - Hubert Cochet
- IHU Liryc, Electrophysiology and Heart Modeling Institute, foundation Bordeaux Université, F-33600 Pessac- Bordeaux, France
- Hôpital Cardiologique du Haut-L’évêque, Université de Bordeaux, LIRYC Institute: IHU LIRYC ANR-10-IAHU-04 and Equipex MUSIC ANR-11-EQPX-0030, Bordeaux, France
| | - Marianna Meo
- IHU Liryc, Electrophysiology and Heart Modeling Institute, foundation Bordeaux Université, F-33600 Pessac- Bordeaux, France
| | - Rémi Dubois
- IHU Liryc, Electrophysiology and Heart Modeling Institute, foundation Bordeaux Université, F-33600 Pessac- Bordeaux, France
| | - Pierre Jaïs
- IHU Liryc, Electrophysiology and Heart Modeling Institute, foundation Bordeaux Université, F-33600 Pessac- Bordeaux, France
- Hôpital Cardiologique du Haut-L’évêque, Université de Bordeaux, LIRYC Institute: IHU LIRYC ANR-10-IAHU-04 and Equipex MUSIC ANR-11-EQPX-0030, Bordeaux, France
| | - Edward J. Vigmond
- IHU Liryc, Electrophysiology and Heart Modeling Institute, foundation Bordeaux Université, F-33600 Pessac- Bordeaux, France
- Univ. Bordeaux, IMB UMR 5251, CNRS, F-33400 Talence, France
- * E-mail:
| |
Collapse
|
15
|
Sauer WH. Mapping repetitive activation in atrial fibrillation: Active drivers or passengers along for the ride? J Cardiovasc Electrophysiol 2018; 29:696-698. [PMID: 29512225 DOI: 10.1111/jce.13473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 02/26/2018] [Indexed: 11/29/2022]
Affiliation(s)
- William H Sauer
- University of Colorado, Section of Cardiac Electrophysiology, Division of Cardiology, Aurora, CO, USA
| |
Collapse
|