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Honarbakhsh S, Roney C, Wharmby A, Vidal Horrach C, Hunter RJ. Spatial and temporal relationship between focal and rotational activations and their relationship to structural remodeling in patients with persistent atrial fibrillation. Heart Rhythm 2024; 21:752-761. [PMID: 38286244 DOI: 10.1016/j.hrthm.2024.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 01/17/2024] [Accepted: 01/19/2024] [Indexed: 01/31/2024]
Abstract
BACKGROUND Focal and rotational activations have been demonstrated in atrial fibrillation (AF), but their relationship to each other and to structural remodeling remains unclear. OBJECTIVE The purpose of this study was to assess the relationship of focal and rotational activations to underlying low-voltage zones (LVZs) (<0.5 mV) and to determine whether there was a temporal (≤500 ms) and spatial (≤12 mm) relationship between these activations. METHODS Patients undergoing catheter ablation for persistent AF were included. All patients underwent pulmonary vein isolation. Unipolar signals were collected to identify focal and rotational activations using a wavefront propagation algorithm. RESULTS In 40 patients, 105 activations were identified (57 [54.3%] focal; 48 [45.7%] rotational). Rotational activations were co-localized to LVZs (35/48 [72.9%]) whereas focal activations were not (11/57 in LVZ [19.3%]; P <.001). The proportion of the left atrium occupied by LVZs predicted rotational activations occurrence (area under the curve 0.96; 95% confidence interval 0.90-1.00; P <.001). In patients with a relatively healthy atrium, in which the atrium consisted of ≤15% LVZs, only focal activations were identified. Thirty-two of the 35 rotational activations (91.4%) located in LVZs also showed a temporal and spatial relationship to a focal activation. The presence of a LVZ within 12 mm of the focal activation was a strong predictor for whether a paired rotational activation would also occur in that vicinity. CONCLUSION Rotational activations are largely confined to areas of structural remodeling and have a clear spatial and temporal relationship with focal activations suggesting they are dependent on them. These novel mechanistic observations outline a plausible model for patient-specific mechanisms maintaining AF.
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Affiliation(s)
- Shohreh Honarbakhsh
- Electrophysiology Department, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Queen Mary University of London, London, United Kingdom.
| | | | - Amy Wharmby
- Electrophysiology Department, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | | | - Ross J Hunter
- Electrophysiology Department, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
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Rossi P, Magnocavallo M, Cauti FM, Polselli M, Niscola M, Della Rocca DG, Del Greco A, Iaia L, Quaglione R, Gianfranco P, Bianchi S. Functional substrate analysis in patients with persistent atrial fibrillation. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01819-6. [PMID: 38811500 DOI: 10.1007/s10840-024-01819-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 04/29/2024] [Indexed: 05/31/2024]
Abstract
OBJECTIVES The aim of this study was to describe the correlation between atrial electrogram duration map (AEDUM), spatiotemporal electrogram dispersion (STED) and low voltage areas (LVA) in patients with persistent atrial fibrillation (PsAF). BACKGROUND The degree of left atrial (LA) tissue remodelling and augmented anisotropic conduction is one of the major issues related to PsAF ablation outcome. METHODS This study enrolled consecutive patients with PsAF undergoing pulmonary vein isolation. In all patients, voltage, AEDUM and STED maps were created, and the correlation was reported between these three mapping methods. RESULTS A total of 40 patients with PsAF were enrolled. The mean age was 62.2 ± 7.4 years, and males were 72.5% (n = 29). The overall bipolar voltage of the LA was 3.06 ± 1.87 mV. All patients had at least one AEDUM area (overall AEDUM area: 21.8 ± 8.2 cm2); the mean longest electrogram (EGMs) duration was 90 ± 19 ms. STED areas with < 120 ms was 46.3 ± 20.2 cm2 which covered 45 ± 22% of the LA surface. AEDUM and STED areas were most frequently reported on the roof, the anterior wall and the septum. The extension of the AEDUM areas was significantly smaller than STED areas with CL < 120 ms (21.8 ± 8.2 vs 46.3 ± 20.2; p-value < 0.0001). In 24 patients (60%), AEDUM areas was entirely included in the STED areas with CL < 120 ms. In the three (7.5%) patients with LVA, no correspondence with STED and AEDUM was noted. CONCLUSION AEDUM and STED maps allow to identify areas of conductive dysfunction as a possible atrial substrate even if a normal voltage is detected.
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Affiliation(s)
- Pietro Rossi
- Arrhythmology Unit, Isola Tiberina - Gemelli Isola, Rome, Italy.
| | | | - Filippo Maria Cauti
- Arrhythmology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Polselli
- Arrhythmology Unit, Isola Tiberina - Gemelli Isola, Rome, Italy
| | - Marta Niscola
- Abbott Medical, Via Paracelso 20, 20864, Agrate Brianza, Italy
| | - Domenico Giovanni Della Rocca
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard - Heart, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| | - Ambra Del Greco
- Abbott Medical, Via Paracelso 20, 20864, Agrate Brianza, Italy
| | - Luigi Iaia
- Arrhythmology Unit, Isola Tiberina - Gemelli Isola, Rome, Italy
| | - Raffaele Quaglione
- Department of Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Umberto I, Sapienza University of Rome, 00185, Rome, Italy
| | - Piccirillo Gianfranco
- Department of Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Umberto I, Sapienza University of Rome, 00185, Rome, Italy
| | - Stefano Bianchi
- Arrhythmology Unit, Isola Tiberina - Gemelli Isola, Rome, Italy
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Rossi P, Cauti FM, Polselli M, Magnocavallo M, Niscola M, Fanti V, Limite LR, Evangelista A, Bellisario A, De Paolis R, Facchetti S, Quaglione R, Piccirillo G, Bianchi S. Ablation of persistent atrial fibrillation based on atrial electrogram duration map: methodology and clinical outcomes from the AEDUM pilot study. J Interv Card Electrophysiol 2024:10.1007/s10840-023-01721-7. [PMID: 38206451 DOI: 10.1007/s10840-023-01721-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/06/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Catheter ablation of persistent atrial fibrillation (PsAF) represents a challenge for the electrophysiologist and there are still divergences regarding the best ablative approach to adopt. Create a new map of the duration of atrial bipolar electrograms (Atrial Electrogram DUration Map, AEDUM) to recognize a functional substrate during sinus rhythm and guide a patient-tailored ablative strategy for PsAF. METHODS Forty PsAF subjects were assigned in a 1:1 ratio to either for PVI alone (Group B1) or PVI+AEDUM areas ablation (Group B2). A cohort of 15 patients without AF history undergoing left-sided accessory pathway ablation was used as a control group (Group A). In all patients, voltage and AEDUM maps were created during sinus rhythm. The minimum follow-up was 12 months, with rhythm monitoring via 48-h ECG Holter or by implantable cardiac device. RESULTS Electrogram (EGM) duration was higher in Group B than in Group A (49±16.2ms vs 34.2±3.8ms; p-value<0.001). In Group B the mean cumulative AEDUM area was 21.8±8.2cm2; no difference between the two subgroups was observed (22.3±9.1cm2 vs 21.2±7.2cm2; p-value=0.45). The overall bipolar voltage recorded inside the AEDUM areas was lower than in the remaining atrial areas [median: 1.30mV (IQR: 0.71-2.38mV) vs 1.54mV (IQR: 0.79-2.97mV); p-value: <0.001)]. Low voltage areas (<0.5mV) were recorded in three (7.5%) patients in Group B. During the follow-up [median 511 days (376-845days)] patients who underwent PVI-only experienced more AF recurrence than those receiving a tailored approach (65% vs 35%; p-value= 0.04). CONCLUSIONS All PsAF patients exhibited AEDUM areas. An ablation approach targeting these areas resulted in a more effective strategy compared with PVI only.
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Affiliation(s)
- Pietro Rossi
- Arrhythmology Unit, Ospedale Fatebenefratelli Isola Tiberina-Gemelli Isola, Via Ponte Quattro Capi, 39, 00186, Rome, Italy.
| | - Filippo Maria Cauti
- Arrhythmology Unit, Ospedale Fatebenefratelli Isola Tiberina-Gemelli Isola, Via Ponte Quattro Capi, 39, 00186, Rome, Italy
| | - Marco Polselli
- Arrhythmology Unit, Ospedale Fatebenefratelli Isola Tiberina-Gemelli Isola, Via Ponte Quattro Capi, 39, 00186, Rome, Italy
| | - Michele Magnocavallo
- Arrhythmology Unit, Ospedale Fatebenefratelli Isola Tiberina-Gemelli Isola, Via Ponte Quattro Capi, 39, 00186, Rome, Italy
| | - Marta Niscola
- Abbott Medical, Via Paracelso 20, 20864, Agrate Brianza, Italy
| | - Veronica Fanti
- Abbott Medical, Via Paracelso 20, 20864, Agrate Brianza, Italy
| | | | - Antonietta Evangelista
- Arrhythmology Unit, Ospedale Fatebenefratelli Isola Tiberina-Gemelli Isola, Via Ponte Quattro Capi, 39, 00186, Rome, Italy
| | | | | | | | - Raffaele Quaglione
- Department of Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Umberto I, Sapienza University of Rome, 00185, Rome, Italy
| | - Gianfranco Piccirillo
- Department of Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Umberto I, Sapienza University of Rome, 00185, Rome, Italy
| | - Stefano Bianchi
- Arrhythmology Unit, Ospedale Fatebenefratelli Isola Tiberina-Gemelli Isola, Via Ponte Quattro Capi, 39, 00186, Rome, Italy
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Frontera A, Pagani S, Limite LR, Peirone A, Fioravanti F, Enache B, Cuellar Silva J, Vlachos K, Meyer C, Montesano G, Manzoni A, Dedé L, Quarteroni A, Lațcu DG, Rossi P, Della Bella P. Slow Conduction Corridors and Pivot Sites Characterize the Electrical Remodeling in Atrial Fibrillation. JACC Clin Electrophysiol 2022; 8:561-577. [PMID: 35589168 DOI: 10.1016/j.jacep.2022.01.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 12/14/2021] [Accepted: 01/12/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This study aimed to evaluate the progression of electrophysiological phenomena in a cohort of patients with paroxysmal atrial fibrillation (PAF) and persistent atrial fibrillation (PsAF). BACKGROUND Electrical remodeling has been conjectured to determine atrial fibrillation (AF) progression. METHODS High-density electroanatomic maps during sinus rhythm of 20 patients with AF (10 PAF, 10 PsAF) were compared with 5 healthy control subjects (subjects undergoing ablation of a left-sided accessory pathway). A computational postprocessing of electroanatomic maps was performed to identify specific electrophysiological phenomena: slow conductions corridors, defined as discrete areas of conduction velocity <50 cm/s, and pivot points, defined as sites showing high wave-front curvature documented by a curl module >2.5 1/s. RESULTS A progressive decrease of mean conduction velocity was recorded across the groups (111.6 ± 55.5 cm/s control subjects, 97.1 ± 56.3 cm/s PAF, and 84.7 ± 55.7 cm/s PsAF). The number and density of slow conduction corridors increase in parallel with the progression of AF (8.6 ± 2.2 control subjects, 13.3 ± 3.2 PAF, and 20.5 ± 4.5 PsAF). In PsAF the atrial substrate is characterized by a higher curvature of wave-front propagation (0.86 ± 0.71 1/s PsAF vs 0.74 ± 0.63 1/s PAF; P = 0.003) and higher number of pivot points (25.1 ± 13.8 PsAF vs 9.5 ± 6.7 PAF; P < 0.0001). Slow conductions: corridors were mostly associated with pivot sites tending to cluster around pulmonary veins antra. CONCLUSIONS The electrical remodeling hinges mainly on corridors of slow conduction and higher curvature of wave-front propagation. Pivot points associated to SC corridors may be the major determinants for functional localized re-entrant circuits creating the substrate for maintenance of AF.
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Affiliation(s)
- Antonio Frontera
- Department of Arrhythmology, San Raffaele Hospital, Milan, Italy.
| | - Stefano Pagani
- MOX-Department of Mathematics, Politecnico di Milano, Milan, Italy
| | | | - Andrea Peirone
- Department of Arrhythmology, San Raffaele Hospital, Milan, Italy
| | | | | | - Jose Cuellar Silva
- University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
| | | | - Christian Meyer
- Division of Cardiology, Angiology, and Intensive Care, EVK Düsseldorf, University of Düsseldorf, Düsseldorf, Germany
| | - Giovanni Montesano
- Optometry and Vision Science - City, University of London, London, United Kingdom
| | - Andrea Manzoni
- MOX-Department of Mathematics, Politecnico di Milano, Milan, Italy
| | - Luca Dedé
- MOX-Department of Mathematics, Politecnico di Milano, Milan, Italy
| | - Alfio Quarteroni
- MOX-Department of Mathematics, Politecnico di Milano, Milan, Italy; Institute of Mathematics, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | | | - Pietro Rossi
- San Giovanni Calibita Hospital, Fatebenefratelli, Rome, Italy
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Zaman JAB, Grace AA, Narayan SM. Future Directions for Mapping Atrial Fibrillation. Arrhythm Electrophysiol Rev 2022; 11:e08. [PMID: 35734143 PMCID: PMC9194915 DOI: 10.15420/aer.2021.52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 11/08/2021] [Indexed: 01/14/2023] Open
Abstract
Mapping for AF focuses on the identification of regions of interest that may guide management and - in particular - ablation therapy. Mapping may point to specific mechanisms associated with localised scar or fibrosis, or electrical features, such as localised repetitive, rotational or focal activation. In patients in whom AF is caused by disorganised waves with no spatial predilection, as proposed in the multiwavelet theory for AF, mapping would be of less benefit. The role of AF mapping is controversial at the current time in view of the debate over the underlying mechanisms. However, recent clinical expansions of mapping technologies confirm the importance of understanding the state of the art, including limitations of current approaches and potential areas of future development.
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Affiliation(s)
- Junaid AB Zaman
- Keck School of Medicine, University of Southern California, Los Angeles, CA, US
| | - Andrew A Grace
- Department of Biochemistry, University of Cambridge, Cambridge, UK
| | - Sanjiv M Narayan
- Cardiovascular Institute and Department of Medicine, Stanford University, CA, US
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