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Huttelmaier MT, Gabel A, Herting J, Vogel M, Störk S, Frantz S, Morbach C, Fischer TH. Non-invasive prediction of atrial cardiomyopathy characterized by multipolar high-density contact mapping. J Interv Card Electrophysiol 2025:10.1007/s10840-025-02001-2. [PMID: 39899140 DOI: 10.1007/s10840-025-02001-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2024] [Accepted: 01/16/2025] [Indexed: 02/04/2025]
Abstract
INTRODUCTION Atrial cardiomyopathy (AC) establishes links between atrial fibrillation (AF), left atrial (LA) mechanical dysfunction, structural remodeling, and thromboembolic events. Early diagnosis of AC may impact AF treatment and stroke risk prevention. Modern endocardial contact-mapping provides high-resolution electro-anatomical (EA) maps of the LA, thus allowing to display the myocardial substrate based on impaired signal amplitude and to characterize AC. Correlation of invasively assessed AC using a novel, multipolar mapping catheter (OCTARAY™, Biosense Webster, limited market release) and LA echocardiographic parameters could form the basis for a set of echo parameters for non-invasive prediction of AC. METHODS We retrospectively identified 50 adult patients who underwent primary pulmonary vein isolation (PVI) for paroxysmal or persistent AF between 08/22 and 05/23 fulfilling the selection criteria: (i) EA mapping with a novel multipolar mapping catheter (Octaray®); (ii) acquisition of voltage maps in sinus rhythm (SR) with ≥ 5000 points/map; and (iii) transthoracic echocardiography acquired in SR ≤ 48 h before PVI. Exclusion criterion was previous LA ablation. We generated EA maps with two sets of upper voltage thresholds (0.2-0.5 mV and 0.2-1.0 mV) and assessed total LA low voltage area (LVA). As LVA thresholds for the classification of AC are not yet established, an unsupervised machine learning cluster analysis was performed using a Gaussian mixture model (GMM), and two groups of patients with mild and severe AC were identified. Based on these two groups, we selected echo parameters for further analysis by applying the Boruta algorithm. The predictive capacity of the selected parameters was evaluated using a support vector machine. RESULTS The mean age of the studied sample (n = 50) was 63 ± 11 years, 62% were men, 64% showed persistent AF, median CHA2DS2-VASc score was 2 (quartiles 1, 3), and NT-proBNP was 190 (71, 391) pg/ml. A median of 5771 (5217, 6988) points/map were acquired. GMM yielded clusters of mild AC (n = 28) and severe AC (n = 22). Median LVA was 0.6 cm2 (< 0.5 mV) resp. 4.1 cm2 (< 1.0 mV) in group mild AC and 6.9 cm2 (< 0.5 mV) resp. 27.2 cm2 (< 1.0 mV) in group severe AC. Several echocardiographic parameters differed between the groups of mild and severe AC: dynamic LA parameters (end diastolic LA reservoir strain: 24.5% (22, 29) vs 15% (12, 19), p < 0.001; LA reservoir strain at atrial contraction: 22% (19, 25) vs 15% (11, 18), p < 0.001, end diastolic LA contraction strain: 13% (8, 15) vs 7.5% (3, 13), p < 0.01) as well as LA end-systolic volume index to a´ ratio (LAVI/a': 297 (231,365) vs 510 (326,781), p < 0.01). Consistent distribution of NT-proBNP (mild AC: 125 (48,189) pg/ml, severe AC: 408 (254,557) pg/ml, p < 0.0001) and CHA2DS2-VASc score (mild AC: 1 (1-2), severe AC: 3 (3-4), p < 0.0001) served as proof of concept. Applying the selected echocardiographic parameters, the machine learning algorithm correctly identified both subgroups with a mean AUC of 0.9 (95% CI 0.83-0.99). At 12 months, AF recurrence rate was 10.7% in mild AC and 40.9% in severe AC (p < 0.05). CONCLUSION Among patients qualifying for PVI, machine learning analysis of high-resolution LA maps allowed to identify subgroups with mild and severe AC avoiding the use of arbitrary LVA thresholds. The subgroups were predicted non-invasively with good accuracy using a machine learning approach that incorporated a set of echocardiographic markers. This data could advance the clinical triage of patients with AF.
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Affiliation(s)
- Moritz T Huttelmaier
- Dept. of Internal Medicine I, University Hospital Würzburg (UKW), University of Wuerzburg-University Clinic, Oberdürrbacherstr. 6, 97080, Würzburg, Germany
| | - Alexander Gabel
- Institute of Medical Virology, Goethe-University Frankfurt, 60596, Frankfurt am Main, Germany
- Infection Control and Antimicrobial Stewardship Unit, UKW, Würzburg, Germany
| | - Jonas Herting
- Dept. of Internal Medicine I, University Hospital Würzburg (UKW), University of Wuerzburg-University Clinic, Oberdürrbacherstr. 6, 97080, Würzburg, Germany
| | - Manuel Vogel
- Dept. of Internal Medicine I, University Hospital Würzburg (UKW), University of Wuerzburg-University Clinic, Oberdürrbacherstr. 6, 97080, Würzburg, Germany
| | - Stefan Störk
- Dept. of Internal Medicine I, University Hospital Würzburg (UKW), University of Wuerzburg-University Clinic, Oberdürrbacherstr. 6, 97080, Würzburg, Germany
- Dept. Clinical Research & Epidemiology, Comprehensive Heart Failure Centre Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - Stefan Frantz
- Dept. of Internal Medicine I, University Hospital Würzburg (UKW), University of Wuerzburg-University Clinic, Oberdürrbacherstr. 6, 97080, Würzburg, Germany
- Dept. Clinical Research & Epidemiology, Comprehensive Heart Failure Centre Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - Caroline Morbach
- Dept. of Internal Medicine I, University Hospital Würzburg (UKW), University of Wuerzburg-University Clinic, Oberdürrbacherstr. 6, 97080, Würzburg, Germany
- Dept. Clinical Research & Epidemiology, Comprehensive Heart Failure Centre Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - Thomas H Fischer
- Dept. of Internal Medicine I, University Hospital Würzburg (UKW), University of Wuerzburg-University Clinic, Oberdürrbacherstr. 6, 97080, Würzburg, Germany.
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Sim I, Lemus JAS, O'Shea C, Razeghi O, Whitaker J, Mukherjee R, O'Hare D, Fitzpatrick N, Harrison J, Gharaviri A, O'Neill L, Kotadia I, Roney CH, Grubb N, Newby DE, Dweck MR, Masci P, Wright M, Chiribiri A, Niederer S, O'Neill M, Williams SE. Quantification of atrial cardiomyopathy disease severity by electroanatomic voltage mapping and cardiac magnetic resonance imaging. J Cardiovasc Electrophysiol 2025; 36:467-479. [PMID: 39739521 PMCID: PMC11837893 DOI: 10.1111/jce.16462] [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: 07/06/2023] [Revised: 09/04/2024] [Accepted: 10/03/2024] [Indexed: 01/02/2025]
Abstract
INTRODUCTION Atrial late gadolinium enhancement (Atrial-LGE) and electroanatomic voltage mapping (Atrial-EAVM) quantify the anatomical and functional extent of atrial cardiomyopathy. We aimed to explore the relationships between, and outcomes from, these modalities in patients with atrial fibrillation undergoing ablation. METHODS Patients undergoing first-time ablation had disease severities quantified using both Atrial-LGE and Atrial-EAVM. Correlations between modalities and their relationships with clinical features and arrhythmia recurrence were assessed. RESULTS In 123 atrial fibrillation patients (60 ± 10 years), Atrial-EAVM was moderately correlated with Atrial-LGE (r = .34, p < .001), with a mean fibrosis burden of 47.2% ± 14.91%. Agreement was strongest in the highest tertile of fibrosis burden (mean of differences 16.8% (95% CI = -24.4% to 57.9%, p = .433). Fibrosis burden was greater for Atrial-LGE than Atrial-EAVM (50.7% ± 10.7% vs. 13.7% ± 7.13%, p < .005) for patients in the lowest tertile who were younger, had smaller atria and a greater frequency of paroxysmal atrial fibrillation. Both Atrial EAVM and Atrial LGE were associated with recurrence of arrhythmia following ablation (Atrial-LGE HR = 1.02 (95% CI = 1.01-1.04), p = .047; Atrial-EAVM HR = 1.02 (95% CI = 1.005-1.03), p = .007). A low fibrosis burden (<15%) by Atrial-EAVM identified patients with very low arrhythmia recurrence. In contrast, a much higher fibrosis burden (>66%) by Atrial-LGE identified patients failing to respond to ablation. CONCLUSIONS We demonstrate for the first time that the level of agreement between Atrial-EAVM and Atrial-LGE is dependent on the level of atrial cardiomyopathy disease severity. The functional consequences of atrial cardiomyopathy are most evident in patients with the highest anatomical extent of disease.
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Affiliation(s)
- Iain Sim
- Division of Imaging Sciences and Biomedical EngineeringKing's College LondonLondonUK
| | | | - Christopher O'Shea
- Department of Cardiovascular ScienesUniversity of BirminghamBirminghamUK
| | - Orod Razeghi
- Division of Imaging Sciences and Biomedical EngineeringKing's College LondonLondonUK
| | - John Whitaker
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Rahul Mukherjee
- Division of Imaging Sciences and Biomedical EngineeringKing's College LondonLondonUK
| | - Daniel O'Hare
- Division of Imaging Sciences and Biomedical EngineeringKing's College LondonLondonUK
| | - Noel Fitzpatrick
- Division of Imaging Sciences and Biomedical EngineeringKing's College LondonLondonUK
| | - James Harrison
- Division of Imaging Sciences and Biomedical EngineeringKing's College LondonLondonUK
| | - Ali Gharaviri
- Centre for Cardiovascular ScienceThe University of EdinburghEdinburghUK
| | - Louisa O'Neill
- Division of Imaging Sciences and Biomedical EngineeringKing's College LondonLondonUK
| | - Irum Kotadia
- Division of Imaging Sciences and Biomedical EngineeringKing's College LondonLondonUK
| | - Caroline H. Roney
- Division of Imaging Sciences and Biomedical EngineeringKing's College LondonLondonUK
| | - Neil Grubb
- Centre for Cardiovascular ScienceThe University of EdinburghEdinburghUK
| | - David E. Newby
- Centre for Cardiovascular ScienceThe University of EdinburghEdinburghUK
| | - Marc R. Dweck
- Centre for Cardiovascular ScienceThe University of EdinburghEdinburghUK
| | - Pier‐Giorgio Masci
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Matthew Wright
- Department of CardiologyGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Amedeo Chiribiri
- Division of Imaging Sciences and Biomedical EngineeringKing's College LondonLondonUK
| | - Steven Niederer
- Division of Imaging Sciences and Biomedical EngineeringKing's College LondonLondonUK
| | - Mark O'Neill
- Division of Imaging Sciences and Biomedical EngineeringKing's College LondonLondonUK
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Lacaita PG, Beyer C, Plank F, Stühlinger M, Feuchtner GM. Late Enhancement Computed Tomography for Left Atrial Fibrosis Imaging: A Pilot "Proof-of-Concept" Study. Diagnostics (Basel) 2024; 14:2753. [PMID: 39682660 DOI: 10.3390/diagnostics14232753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2024] [Revised: 12/02/2024] [Accepted: 12/04/2024] [Indexed: 12/18/2024] Open
Abstract
Background/Objective: Left atrial (LA) fibrosis imaging improves the guidance of LA catheter ablation. Cardiac computed tomography (CT) may be a reasonable alternative to CMR. The aim was to evaluate late enhancement (LE) fibrosis mapping by CT, and to correlate the results with low-voltage areas on electroanatomical mapping (EAM). Methods: In patients with atrial fibrillation who underwent 128-slice dual-source CT angiography (CTA) prior to LA catheter ablation, an additional LE-CT scan was performed 7 min after CTA. (1) Left atrial wall thickness (LAWT) was measured at three sites along the LA ridge. (2) Late enhancement (LE) was quantified co-axially aligned to LAWT and compared with low-voltage areas (LVA) on EAM. Results: Of 137 patients (age: 59.8 years; 27.7% females), 108 were included. The prevalence of LE was higher in patients with LAWT > 2 mm compared with 1.5 mm, with 78 (91.7%) vs. 77 (80.2%) (p = 0.022). Of 78 patients with LE, 60 (77.1%) had focal, 13 (16.5%) had diffuse, and 5 (6.3%) had mixed LE patterns. The CT density of focal LE was not different from that of diffuse patterns (104.2 +/- 21 HU vs. 98.9 +/- 18 HU; p = 0.360). Increasing LAWT and LE-HU were weakly correlated (r = 0.229; p = 0.041). LA wall artifacts had higher CT density compared with LE (154.1 HU vs. 114.2 HU; p = 0.002). The effective radiation dose was 0.95 mSv (range, 0.52-1.2 mSv) for LE-CT. The agreement of LE-CT was 80% for LVA < 0.5 mV and 86.6% for LVA < 0.7 mV in a subset of 30 patients. Conclusions: Left atrial fibrosis mapping by LE-CT is feasible. Late enhancement was found more frequently in LAWTs of more than 2 mm, and LE was correlated with increasing LA remodeling and low-voltage areas.
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Affiliation(s)
- Pietro G Lacaita
- Department of Radiology, Innsbruck Medical University, 6020 Innsbruck, Austria
| | - Christoph Beyer
- Department of Cardiology, Tyrol Clinicum Hall, 6060 Hall, Austria
| | - Fabian Plank
- Department of Cardiology, Tyrol Clinicum Hall, 6060 Hall, Austria
| | - Markus Stühlinger
- Department of Cardiology, Innsbruck Medical University, 6020 Innsbruck, Austria
| | - Gudrun M Feuchtner
- Department of Radiology, Innsbruck Medical University, 6020 Innsbruck, Austria
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Ali SY, Mohsen Y, Mao Y, Sakata K, Kholmovski EG, Prakosa A, Yamamoto C, Loeffler S, Elia M, Zandieh G, Stöckigt F, Horlitz M, Sinha SK, Marine J, Calkins H, Sommer P, Sciacca V, Fink T, Sohns C, Spragg D, Trayanova N. Unipolar voltage electroanatomic mapping detects structural atrial remodeling identified by LGE-MRI. Heart Rhythm 2024:S1547-5271(24)03430-1. [PMID: 39396602 DOI: 10.1016/j.hrthm.2024.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 10/05/2024] [Accepted: 10/08/2024] [Indexed: 10/15/2024]
Abstract
BACKGROUND In atrial fibrillation (AF) management, understanding left atrial (LA) substrate is crucial. While both electroanatomic mapping (EAM) and late gadolinium enhancement magnetic resonance imaging (LGE-MRI) are accepted methods for assessing the atrial substrate and are associated with ablation outcome, recent findings have highlighted discrepancies between low-voltage areas (LVAs) in EAM and LGE areas. OBJECTIVE The purpose of this study was to explore the relationship between LGE regions and unipolar and bipolar LVAs using multipolar high-density mapping. METHODS Twenty patients scheduled for AF ablation underwent preablation LGE-MRI. LA segmentation was conducted using a deep learning approach, which subsequently generated a 3-dimensional mesh integrating the LGE data. High-density EAM was performed in sinus rhythm for each patient. The electroanatomic map and LGE-MRI mesh were coregistered. LVAs were defined using cutoffs of 0.5 mV for bipolar voltage and 2.5 mV for unipolar voltage. The correspondence between LGE areas and LVAs in the LA was analyzed using confusion matrices and performance metrics. RESULTS A considerable 87.3% of LGE regions overlapped with unipolar LVAs, compared with only 16.2% overlap observed with bipolar LVAs. Across all performance metrics, unipolar LVAs outperformed bipolar LVAs in identifying LGE areas (precision: 78.6% vs 61.1%; sensitivity: 87.3% vs 16.2%; F1 score: 81.3% vs 26.0%; accuracy: 74.0% vs 35.3%). CONCLUSION Our findings demonstrate that unipolar LVAs strongly correlate with LGE regions. These findings support the integration of unipolar mapping alongside bipolar mapping into clinical practice. This would offer a nuanced approach to diagnose and manage AF by revealing critical insights into the complex architecture of the atrial substrate.
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Affiliation(s)
- Syed Yusuf Ali
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Yazan Mohsen
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland; Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland; Department of Cardiology, Faculty of Health, School of Medicine, University Witten/Herdecke, Witten, Germany
| | - Yuncong Mao
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Kensuke Sakata
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland
| | - Eugene G Kholmovski
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland
| | - Adityo Prakosa
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland
| | - Carolyna Yamamoto
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland; Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland
| | - Shane Loeffler
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland
| | - Marianna Elia
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Ghazal Zandieh
- Department of Radiology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Florian Stöckigt
- Department of Cardiology, University Hospital Bonn, Bonn, Germany
| | - Marc Horlitz
- Department of Cardiology, Faculty of Health, School of Medicine, University Witten/Herdecke, Witten, Germany
| | - Sunil Kumar Sinha
- Department of Cardiology, Heart and Vascular Institute, Johns Hopkins Hospital, Baltimore, Maryland
| | - Joseph Marine
- Department of Cardiology, Heart and Vascular Institute, Johns Hopkins Hospital, Baltimore, Maryland
| | - Hugh Calkins
- Department of Cardiology, Heart and Vascular Institute, Johns Hopkins Hospital, Baltimore, Maryland
| | - Philipp Sommer
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr- Universität Bochum, Bad Oeynhausen, Germany
| | - Vanessa Sciacca
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr- Universität Bochum, Bad Oeynhausen, Germany
| | - Thomas Fink
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr- Universität Bochum, Bad Oeynhausen, Germany
| | - Christian Sohns
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr- Universität Bochum, Bad Oeynhausen, Germany
| | - David Spragg
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr- Universität Bochum, Bad Oeynhausen, Germany
| | - Natalia Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland; Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland.
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Bijvoet GP, Hermans BJM, Linz D, Luermans JGLM, Maesen B, Nijveldt R, Mihl C, Vernooy K, Wildberger JE, Holtackers RJ, Schotten U, Chaldoupi SM. Optimal Threshold and Interpatient Variability in Left Atrial Ablation Scar Assessment by Dark-Blood LGE CMR. JACC Clin Electrophysiol 2024; 10:2186-2197. [PMID: 39001763 DOI: 10.1016/j.jacep.2024.05.017] [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: 11/29/2023] [Revised: 05/06/2024] [Accepted: 05/08/2024] [Indexed: 07/15/2024]
Abstract
BACKGROUND Dark-blood late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) has better correlation with bipolar voltage (BiV) to define ablation scar in the left atrium (LA) compared to conventional bright-blood LGE CMR. OBJECTIVES This study sought to determine the optimal signal intensity threshold of dark-blood LGE CMR to identify LA ablation scar. METHODS In 54 patients scheduled for atrial fibrillation ablation, image intensity ratios (IIRs) were derived from preprocedural dark-blood LGE CMR. In 26 patients without previous ablation, the upper limit of normal was derived from the 95th and 98th percentiles of pooled IIR values. In 28 patients with previous atrial fibrillation ablation, BiV was compared with the corresponding IIR. Receiver-operating characteristics analyses were employed to determine the optimal IIR threshold (ie, the point with the smallest distance to the upper left corner of the receiver-operating characteristics) for LA ablation scar (BiV ≤0.15 mV). RESULTS Upper limit of normal corresponded to IIR values 1.16 and 1.21, yielding low sensitivities of 0.32 and 0.09 to detect LA ablation scar. Receiver-operating characteristics analysis of IIR and BiV comparison achieved a median area under the curve of 0.77. Median optimal IIR threshold for LA ablation scar was 1.09, with an average sensitivity of 0.73, specificity of 0.75, and accuracy of 0.71. Median IIR thresholds of 1.00 and 1.10 corresponded to 80% sensitivity and 80% specificity, respectively. There was considerable interpatient variability: optimal IIR thresholds per patient ranged from 1.01 to 1.22. CONCLUSIONS The optimal IIR threshold to identify LA ablation scar by dark-blood LGE CMR is 1.09. Because of interpatient variability, the investigators recommend using a lower (1.00) and upper (1.10) threshold to prevent over- or underestimation of ablation scar.
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Affiliation(s)
- Geertruida Petronella Bijvoet
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands.
| | - Ben J M Hermans
- Department of Physiology, CARIM, Maastricht University, Maastricht, the Netherlands
| | - Dominik Linz
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands; Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Justin G L M Luermans
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Bart Maesen
- Department of Cardiothoracic Surgery, CARIM, MUMC+, Maastricht, the Netherlands
| | - Robin Nijveldt
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Casper Mihl
- Department of Radiology and Nuclear Medicine, CARIM, MUMC+, Maastricht, the Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Joachim E Wildberger
- Department of Radiology and Nuclear Medicine, CARIM, MUMC+, Maastricht, the Netherlands
| | - Rob J Holtackers
- Department of Radiology and Nuclear Medicine, CARIM, MUMC+, Maastricht, the Netherlands
| | - Ulrich Schotten
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands; Department of Physiology, CARIM, Maastricht University, Maastricht, the Netherlands
| | - Sevasti-Maria Chaldoupi
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands.
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La Rosa G, Morillo CA, Quintanilla JG, Doltra A, Mont L, Rodríguez-Mañero M, Sarkozy A, Merino JL, Vivas D, Datino T, Calvo D, Pérez-Castellano N, Pérez-Villacastín J, Fauchier L, Lip G, Hatem SN, Jalife J, Sanchis L, Marín F, Filgueiras-Rama D. Practical approach for atrial cardiomyopathy characterization in patients with atrial fibrillation. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:656-666. [PMID: 38428580 DOI: 10.1016/j.rec.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/16/2024] [Indexed: 03/03/2024]
Abstract
Atrial fibrillation (AF) causes progressive structural and electrical changes in the atria that can be summarized within the general concept of atrial remodeling. In parallel, other clinical characteristics and comorbidities may also affect atrial tissue properties and make the atria susceptible to AF initiation and its long-term persistence. Overall, pathological atrial changes lead to atrial cardiomyopathy with important implications for rhythm control. Although there is general agreement on the role of the atrial substrate for successful rhythm control in AF, the current classification oversimplifies clinical management. The classification uses temporal criteria and does not establish a well-defined strategy to characterize the individual-specific degree of atrial cardiomyopathy. Better characterization of atrial cardiomyopathy may improve the decision-making process on the most appropriate therapeutic option. We review current scientific evidence and propose a practical characterization of the atrial substrate based on 3 evaluation steps starting with a clinical evaluation (step 1), then assess outpatient complementary data (step 2), and finally include information from advanced diagnostic tools (step 3). The information from each of the steps or a combination thereof can be used to classify AF patients in 4 stages of atrial cardiomyopathy, which we also use to estimate the success on effective rhythm control.
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Affiliation(s)
- Giulio La Rosa
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Centro Neurolesi Bonino Pulejo, Messina, Italy
| | - Carlos A Morillo
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Programa Nuevos Mecanismos Arritmogénicos, Madrid, Spain; Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jorge G Quintanilla
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Programa Nuevos Mecanismos Arritmogénicos, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Adelina Doltra
- Institut Clínic Cardiovascular, Hospital Clínic, Barcelona, Spain
| | - Lluis Mont
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Institut Clínic Cardiovascular, Hospital Clínic, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Universitat de Barcelona, Barcelona, Spain
| | - Moisés Rodríguez-Mañero
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Departamento de Cardiología y Unidad Coronaria, Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Complexo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Andrea Sarkozy
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| | - José Luis Merino
- Departamento de Cardiología, Hospital Universitario La Paz, IDIPaz, Universidad Autónoma, Madrid, Spain
| | - David Vivas
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Instituto Cardiovascular, Madrid, Spain
| | - Tomás Datino
- Departamento de Cardiología, Hospitales Universitarios Quirónsalud Pozuelo y Ruber Juan Bravo, Universidad Europea de Madrid, Madrid, Spain
| | - David Calvo
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Instituto Cardiovascular, Madrid, Spain
| | - Nicasio Pérez-Castellano
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Instituto Cardiovascular, Madrid, Spain; Fundación Interhospitalaria para la Investigación Cardiovascular (FIC), Madrid, Spain
| | - Julián Pérez-Villacastín
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Instituto Cardiovascular, Madrid, Spain; Fundación Interhospitalaria para la Investigación Cardiovascular (FIC), Madrid, Spain
| | - Laurent Fauchier
- Centre Hospitalier Régional Universitaire de Tours, Tours, France
| | - Gregory Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Stéphane N Hatem
- Sorbonne Université, Foundation for Innovation in Cardiometabolism and Nutrition - ICAN, INSERM UMRS 1166, Institute of Cardiology, AP-HP Pitié-Salpêtrière Paris, France
| | - José Jalife
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Programa Nuevos Mecanismos Arritmogénicos, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States
| | - Laura Sanchis
- Institut Clínic Cardiovascular, Hospital Clínic, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Universitat de Barcelona, Barcelona, Spain.
| | - Francisco Marín
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Departamento de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Pascual Parrilla), El Palmar, Murcia, Spain.
| | - David Filgueiras-Rama
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Programa Nuevos Mecanismos Arritmogénicos, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Instituto Cardiovascular, Madrid, Spain.
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Bates AP, Paisey J, Yue A, Banks P, Roberts PR, Ullah W. Comparison of voltages between atria: differences in sinus rhythm and atrial fibrillation. J Interv Card Electrophysiol 2024; 67:649-656. [PMID: 37875609 PMCID: PMC11016007 DOI: 10.1007/s10840-023-01671-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 10/12/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND Ultra high-density mapping systems allow for comparison of atrial electroanatomical maps in unprecedented detail. Atrial scar determined by voltages and surface area between atria, rhythm and atrial fibrillation (AF) types was assessed. METHODS Left (LA) and right atrial (RA) maps were created using Rhythmia HDx in patients listed for ablation for paroxysmal (PAF, sinus rhythm (SR) maps only) or persistent AF (PeAF, AF and SR maps). Electrograms on corresponding SR/AF maps were paired for direct comparison. Percentage surface area of scar was assigned low- (LVM, ≤ 0.05 mV), intermediate- (IVM, 0.05-0.5 mV) or normal voltage myocardium, (NVM, > 0.5 mV). RESULTS Thirty-eight patients were recruited generating 96 maps using 913,480 electrograms. Paired SR-AF bipolar electrograms showed fair correlation in LA (Spearman's ρ = 0.32) and weak correlation in RA (ρ = 0.19) and were significantly higher in SR in both (LA: 0.61 mV (0.20-1.67) vs 0.31 mV (0.10-0.74), RA: 0.68 mV (0.19-1.88) vs 0.47 mV (0.14-1.07), p < 0.0005 both). Voltages were significantly higher in patients with PAF over PeAF, (LA: 1.13 mV (0.39-2.93) vs 0.52 mV (0.16-1.49); RA: 0.93 mV (0.24-2.46) vs 0.57 mV (0.17-1.69)). Minimal differences were seen in electrogram voltages between atria. Significantly more IVM/LVM surface areas were seen in AF over SR (LA only, p < 0005), and PeAF over PAF (LA: p = 0.01, RA: p = 0.04). There was minimal difference between atria within patients. CONCLUSIONS Ultra high-density mapping shows paired electrograms correlate poorly between SR and AF. SR electrograms are typically (but not always) larger than those in AF. Patients with PeAF have a lower global electrogram voltage than those with PAF. Electrogram voltages are similar between atria within individual patients.
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Affiliation(s)
- Alexander P Bates
- Department of Cardiology, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK.
- Faculty of Medicine, School of Human Development and Health, University of Southampton, Southampton, UK.
| | - John Paisey
- Department of Cardiology, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK
| | - Arthur Yue
- Department of Cardiology, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK
| | - Phil Banks
- Department of Cardiology, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK
| | - Paul R Roberts
- Department of Cardiology, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK
- Faculty of Medicine, School of Human Development and Health, University of Southampton, Southampton, UK
| | - Waqas Ullah
- Department of Cardiology, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK
- Faculty of Medicine, School of Human Development and Health, University of Southampton, Southampton, UK
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Mitran RE, Popa-Fotea NM, Iorgulescu C, Nastasa A, Pupaza A, Gondos V, Petre IG, Paja SC, Vatasescu RG. Left Atrial Low-Voltage Areas Predict the Risk of Atrial Fibrillation Recurrence after Radiofrequency Ablation. Biomedicines 2023; 11:3261. [PMID: 38137482 PMCID: PMC10740849 DOI: 10.3390/biomedicines11123261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 11/26/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023] Open
Abstract
Atrial fibrillation (AF), the most frequently encountered arrhythmia worldwide, is associated with increased cardiovascular morbidity and mortality. Left atrial (LA) and antral region of the pulmonary veins (PVs) remodeling are risk factors for AF perpetuation. Among the methods of LA fibrosis quantification, bipolar voltage mapping during three-dimensional electro-anatomical mapping is less studied. The main aim of this study was to analyze the relationship between the degree of LA fibrosis quantified in low-voltage areas and the efficacy of AF radiofrequency catheter ablation. All consecutive patients with AF ablation were included, and the degree of LA fibrosis was measured based on the low-voltage areas in the LA and the antral region of PVs (<0.5 mV for patients in sinus rhythm and <0.25 mV for patients in AF at the time of the ablation procedure). The efficacy of AF ablation was determined by the rate of recurrence after a blanking period of three months. A total of 106 patients were included; from these, 38 (35.8%) had AF recurrence after RF ablation, while 68 (64.2%) were free of events. The area and percentage of LA fibrosis were significantly higher in the patients with AF recurrence (p = 0.018 and p = 0.019, respectively). However, no significant differences were found between the patients with and without AF recurrence in terms of the area and percentage of PVs fibrosis (p = 0.896 and p = 0.888, respectively). Moreover, LA fibrosis parameters proved to be excellent predictors for AF recurrence (areas under the curve of 0.834 and 0.832, respectively, p < 0.001) even after adjustment for LA indexed volume and CHA2DS2-VASc score. In conclusion, LA fibrosis measured on bipolar voltage maps increases the risk of AF recurrence after the RF catheter ablation procedure.
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Affiliation(s)
- Raluca-Elena Mitran
- Department of Cardiology, Clinic Emergency Hospital of Bucharest, Calea Floreasca 8, 014461 Bucharest, Romania; (R.-E.M.); (N.-M.P.-F.); (C.I.); (A.P.); (I.-G.P.); (S.-C.P.)
| | - Nicoleta-Monica Popa-Fotea
- Department of Cardiology, Clinic Emergency Hospital of Bucharest, Calea Floreasca 8, 014461 Bucharest, Romania; (R.-E.M.); (N.-M.P.-F.); (C.I.); (A.P.); (I.-G.P.); (S.-C.P.)
- Department IV—Cardio-Thoracic Pathology, Carol Davila University of Medicine and Pharmacy, Eroii Sanitari Bvd. 8, 050474 Bucharest, Romania
| | - Corneliu Iorgulescu
- Department of Cardiology, Clinic Emergency Hospital of Bucharest, Calea Floreasca 8, 014461 Bucharest, Romania; (R.-E.M.); (N.-M.P.-F.); (C.I.); (A.P.); (I.-G.P.); (S.-C.P.)
| | - Alexandrina Nastasa
- Department of Cardiology, “Elias” University Emergency Hospital, 011461 Bucharest, Romania;
| | - Adelina Pupaza
- Department of Cardiology, Clinic Emergency Hospital of Bucharest, Calea Floreasca 8, 014461 Bucharest, Romania; (R.-E.M.); (N.-M.P.-F.); (C.I.); (A.P.); (I.-G.P.); (S.-C.P.)
| | - Viviana Gondos
- Department of Medical Electronics and Informatics, Polytechnic University of Bucharest, 060042 Bucharest, Romania;
| | - Ioana-Gabriela Petre
- Department of Cardiology, Clinic Emergency Hospital of Bucharest, Calea Floreasca 8, 014461 Bucharest, Romania; (R.-E.M.); (N.-M.P.-F.); (C.I.); (A.P.); (I.-G.P.); (S.-C.P.)
- Department IV—Cardio-Thoracic Pathology, Carol Davila University of Medicine and Pharmacy, Eroii Sanitari Bvd. 8, 050474 Bucharest, Romania
| | - Steliana-Cosmina Paja
- Department of Cardiology, Clinic Emergency Hospital of Bucharest, Calea Floreasca 8, 014461 Bucharest, Romania; (R.-E.M.); (N.-M.P.-F.); (C.I.); (A.P.); (I.-G.P.); (S.-C.P.)
| | - Radu-Gabriel Vatasescu
- Department of Cardiology, Clinic Emergency Hospital of Bucharest, Calea Floreasca 8, 014461 Bucharest, Romania; (R.-E.M.); (N.-M.P.-F.); (C.I.); (A.P.); (I.-G.P.); (S.-C.P.)
- Department IV—Cardio-Thoracic Pathology, Carol Davila University of Medicine and Pharmacy, Eroii Sanitari Bvd. 8, 050474 Bucharest, Romania
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Rodero C, Baptiste TMG, Barrows RK, Lewalle A, Niederer SA, Strocchi M. Advancing clinical translation of cardiac biomechanics models: a comprehensive review, applications and future pathways. FRONTIERS IN PHYSICS 2023; 11:1306210. [PMID: 38500690 PMCID: PMC7615748 DOI: 10.3389/fphy.2023.1306210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
Cardiac mechanics models are developed to represent a high level of detail, including refined anatomies, accurate cell mechanics models, and platforms to link microscale physiology to whole-organ function. However, cardiac biomechanics models still have limited clinical translation. In this review, we provide a picture of cardiac mechanics models, focusing on their clinical translation. We review the main experimental and clinical data used in cardiac models, as well as the steps followed in the literature to generate anatomical meshes ready for simulations. We describe the main models in active and passive mechanics and the different lumped parameter models to represent the circulatory system. Lastly, we provide a summary of the state-of-the-art in terms of ventricular, atrial, and four-chamber cardiac biomechanics models. We discuss the steps that may facilitate clinical translation of the biomechanics models we describe. A well-established software to simulate cardiac biomechanics is lacking, with all available platforms involving different levels of documentation, learning curves, accessibility, and cost. Furthermore, there is no regulatory framework that clearly outlines the verification and validation requirements a model has to satisfy in order to be reliably used in applications. Finally, better integration with increasingly rich clinical and/or experimental datasets as well as machine learning techniques to reduce computational costs might increase model reliability at feasible resources. Cardiac biomechanics models provide excellent opportunities to be integrated into clinical workflows, but more refinement and careful validation against clinical data are needed to improve their credibility. In addition, in each context of use, model complexity must be balanced with the associated high computational cost of running these models.
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Affiliation(s)
- Cristobal Rodero
- Cardiac Electro-Mechanics Research Group (CEMRG), National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Tiffany M. G. Baptiste
- Cardiac Electro-Mechanics Research Group (CEMRG), National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
- Department of Biomedical Engineering, School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Rosie K. Barrows
- Cardiac Electro-Mechanics Research Group (CEMRG), National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
- Department of Biomedical Engineering, School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Alexandre Lewalle
- Cardiac Electro-Mechanics Research Group (CEMRG), National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Steven A. Niederer
- Cardiac Electro-Mechanics Research Group (CEMRG), National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
- Turing Research and Innovation Cluster in Digital Twins (TRIC: DT), The Alan Turing Institute, London, United Kingdom
| | - Marina Strocchi
- Cardiac Electro-Mechanics Research Group (CEMRG), National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
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Gu Y, Shao Y, Li S, Liu T. Research Progress of Low-Voltage Areas Associated with Atrial Fibrillation. Rev Cardiovasc Med 2023; 24:320. [PMID: 39076424 PMCID: PMC11262451 DOI: 10.31083/j.rcm2411320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/05/2023] [Accepted: 05/24/2023] [Indexed: 07/31/2024] Open
Abstract
Atrial fibrosis is an independent predictor of the recurrence of atrial fibrillation (AF) after catheter ablation. Low-voltage areas (LVA) measured during catheter ablation for AF are a commonly used surrogate for the presence of atrial fibrosis. LVA are associated with clinical outcomes and comorbidities and have links to triggering sites for AF. Several trials have shown promising data of targeting ablation in LVA, however the results have been mixed. This article will review the role of LVA in the prediction of adverse events in AF patients, including stroke, how to predict the presence of LVA, and the impact of LVA ablation on the recurrence of AF.
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Affiliation(s)
- Yunfei Gu
- Department of Cardiology, Luoyang Central Hospital Affiliated to Zhengzhou
University, 471000 Luoyang, Henan, China
- Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital
of Tianjin Medical University, 300091 Tianjin, China
| | - Yang Shao
- The Department of Cardiology, Sahlgrenska University Hospital, 41345
Gothenburg, Sweden
| | - Songsen Li
- Department of Cardiology, Luoyang Central Hospital Affiliated to Zhengzhou
University, 471000 Luoyang, Henan, China
| | - Tong Liu
- Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital
of Tianjin Medical University, 300091 Tianjin, China
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