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Okuyama Y, Ozawa T, Nishikawa T, Fujii Y, Kato K, Sugimoto Y, Nakagawa Y, Ashihara T. Association with the nonparoxysmal atrial fibrillation duration and outcome of ExTRa Mapping-guided rotor ablation. J Arrhythm 2023; 39:531-538. [PMID: 37560288 PMCID: PMC10407168 DOI: 10.1002/joa3.12897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 06/21/2023] [Accepted: 06/25/2023] [Indexed: 08/11/2023] Open
Abstract
Background Additional ablation strategies after pulmonary vein isolation (PVI) for patients with nonparoxysmal atrial fibrillation (non-PAF) lasting ≥2 years have not been fully effective. This is presumably because of insufficient identification of non-PAF maintenance mechanisms. In this study, we employed a novel online and real-time phase mapping system, ExTRa Mapping, to identify and modulate rotors as one of the non-PAF maintenance mechanisms in patients with non-PAF sustained after PVI. We investigated the relationship between outcomes of ExTRa Mapping-guided rotor ablation (ExTRa-ABL) and non-PAF duration prior to this procedure. Methods This study consisted of 73 non-PAF patients (63 ± 8 years, non-PAF duration 31 ± 37 months) who underwent the first ExTRa-ABL in patients with non-PAF sustained after completion of PVI. Results Freedom from non-PAF/atrial tachycardia (AT) recurrence at 12 months after ExTRa-ABL was achieved in 50 (69%) of patients. The non-PAF duration prior to ExTRa-ABL was significantly longer in patients with non-PAF/AT recurrence after ExTRa-ABL compared with those without (56 ± 50 vs. 19 ± 22 months, p = .001). In patients with non-PAF duration of ≤60 months prior to ExTRa-ABL, compared with >60 months, non-PAF/AT-free rate was significantly higher (68.9% vs. 23.1%, p < .001), during the follow-up of 36 ± 18 months. Conclusions A non-PAF duration of ≤60 months prior to ExTRa-ABL was associated with a better outcome. The effect of ExTRa-ABL was considered to be limited in patients with >60 months of non-PAF duration.
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Affiliation(s)
- Yusuke Okuyama
- Department of Cardiovascular MedicineShiga University of Medical ScienceOtsuJapan
| | - Tomoya Ozawa
- Department of Cardiovascular MedicineShiga University of Medical ScienceOtsuJapan
| | - Takuma Nishikawa
- Department of Cardiovascular MedicineShiga University of Medical ScienceOtsuJapan
| | - Yusuke Fujii
- Department of Cardiovascular MedicineShiga University of Medical ScienceOtsuJapan
| | - Koichi Kato
- Department of Cardiovascular MedicineShiga University of Medical ScienceOtsuJapan
| | - Yoshihisa Sugimoto
- Department of Cardiovascular MedicineShiga University of Medical ScienceOtsuJapan
- Department of Medical Informatics and Biomedical EngineeringShiga University of Medical ScienceOtsuJapan
| | - Yoshihisa Nakagawa
- Department of Cardiovascular MedicineShiga University of Medical ScienceOtsuJapan
| | - Takashi Ashihara
- Department of Cardiovascular MedicineShiga University of Medical ScienceOtsuJapan
- Department of Medical Informatics and Biomedical EngineeringShiga University of Medical ScienceOtsuJapan
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Nanbu T, Yotsukura A, Suzuki G, Takekawa H, Tanaka Y, Yamanashi K, Tsuda M, Yoshida I, Sakurai M, Ashihara T. Organization of atrial fibrillation using a pure sodium channel blocker: Implications of rotor ablation therapy. J Arrhythm 2023; 39:327-340. [PMID: 37324754 PMCID: PMC10264751 DOI: 10.1002/joa3.12844] [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: 10/28/2022] [Revised: 01/29/2023] [Accepted: 03/12/2023] [Indexed: 04/03/2023] Open
Abstract
Background Rotors are the source of atrial fibrillation (AF). However, the ablation of rotors for persistent AF is challenging. The purpose of this study was to identify the dominant rotor by accelerating the organization of AF using a sodium channel blocker and detecting the rotor's preferential area that governs AF. Methods Overall, 30 consecutive patients with persistent AF who underwent pulmonary vein isolation and still sustained AF were enrolled. Pilsicainide 50 mg was administered. An online real-time phase mapping system (ExTRa Mapping™) was used to identify the meandering rotors and multiple wavelets in 11 left atrial segments. The time ratio of non-passive activation (%NP) was evaluated as the frequency of rotor activity in each segment. Results Conduction velocity became slower-from 0.46 ± 0.14 to 0.35 ± 0.14 mm/ms (p = .004)-and the rotational period of the rotor was significantly prolonged-156 ± 21 to 193 ± 28 ms/cycle (p < .001). AF cycle length was prolonged from 169 ± 19 to 223 ± 29 ms (p < .001). A decrease in %NP was observed in seven segments. Additionally, 14 patients had at least one complete passive activation area. Of them, the use of high %NP area ablation resulted in atrial tachycardia and sinus rhythm in two patients each. Conclusions A sodium channel blocker organized persistent AF. In selective patients with a wide organized area, high %NP area ablation could convert AF into atrial tachycardia or terminate AF.
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Affiliation(s)
- Tadafumi Nanbu
- Department of Cardiovascular MedicineHokko Memorial HospitalSapporo‐shiJapan
| | - Akihiko Yotsukura
- Department of Cardiovascular MedicineHokko Memorial HospitalSapporo‐shiJapan
| | - George Suzuki
- Department of Cardiovascular MedicineHokko Memorial HospitalSapporo‐shiJapan
| | - Hiroyuki Takekawa
- Department of Cardiovascular MedicineHokko Memorial HospitalSapporo‐shiJapan
| | - Yuki Tanaka
- Department of Cardiovascular MedicineHokko Memorial HospitalSapporo‐shiJapan
| | - Katsuma Yamanashi
- Department of Cardiovascular MedicineHokko Memorial HospitalSapporo‐shiJapan
| | - Masaya Tsuda
- Department of Cardiovascular MedicineHokko Memorial HospitalSapporo‐shiJapan
| | - Izumi Yoshida
- Department of Cardiovascular MedicineHokko Memorial HospitalSapporo‐shiJapan
| | - Masayuki Sakurai
- Department of Cardiovascular MedicineHokko Memorial HospitalSapporo‐shiJapan
| | - Takashi Ashihara
- Department of Medical Informatics and Biomedical EngineeringShiga University of Medical ScienceSeta Tsukinowa‐cho, OtsuJapan
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Xu CH, Xiong F, Jiang WF, Liu X, Liu T, Qin M. Rotor mechanism and its mapping in atrial fibrillation. Europace 2023; 25:783-792. [PMID: 36734272 PMCID: PMC10062333 DOI: 10.1093/europace/euad002] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 12/28/2022] [Indexed: 02/04/2023] Open
Abstract
Treatment of atrial fibrillation (AF) remains challenging despite significant progress in understanding its underlying mechanisms. The first detailed, quantitative theory of functional re-entry, the 'leading circle' model, was developed more than 40 years ago. Subsequently, in decades of study, an alternative paradigm based on spiral waves has long been postulated to drive AF. The rotor as a 'spiral wave generator' is a curved 'vortex' formed by spin motion in the two-dimensional plane, identified using advanced mapping methods in experimental and clinical AF. However, it is challenging to achieve complementary results between experimental results and clinical studies due to the limitation in research methods and the complexity of the rotor mechanism. Here, we review knowledge garnered over decades on generation, electrophysiological properties, and three-dimensional (3D) structure diversity of the rotor mechanism and make a comparison among recent clinical approaches to identify rotors. Although initial studies of rotor ablation at many independent centres have achieved promising results, some inconclusive outcomes exist in others. We propose that the clinical rotor identification might be substantially influenced by (i) non-identical surface activation patterns, which resulted from a diverse 3D form of scroll wave, and (ii) inadequate resolution of mapping techniques. With rapidly advancing theoretical and technological developments, future work is required to resolve clinically relevant limitations in current basic and clinical research methodology, translate from one to the other, and resolve available mapping techniques.
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Affiliation(s)
- Chang-Hao Xu
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine,
Shanghai Jiao Tong University, 241 Huaihai West Road, Xuhui
District, Shanghai 200030, China
| | - Feng Xiong
- Montreal Heart Institute, Department of Medicine, University of
Montreal, 5000, Bélanger street, Montréal, Québec H1T
1C8, Canada
| | - Wei-Feng Jiang
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine,
Shanghai Jiao Tong University, 241 Huaihai West Road, Xuhui
District, Shanghai 200030, China
| | - Xu Liu
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine,
Shanghai Jiao Tong University, 241 Huaihai West Road, Xuhui
District, Shanghai 200030, China
| | - Tao Liu
- Corresponding authors. Tao Liu, 238 Jiefang Road, Wuchang
District, Wuhan, Hubei 430060, China. Tel: +86 (027) 8804 1911, Fax:+86-(027)-8804-2292.
E-mail address:; Mu Qin, 241 Huaihai
West Road, Xuhui District, Shanghai, 200030, China. Tel: +8621628219902603, Fax:
+862162821105. E-mail address:
| | - Mu Qin
- Corresponding authors. Tao Liu, 238 Jiefang Road, Wuchang
District, Wuhan, Hubei 430060, China. Tel: +86 (027) 8804 1911, Fax:+86-(027)-8804-2292.
E-mail address:; Mu Qin, 241 Huaihai
West Road, Xuhui District, Shanghai, 200030, China. Tel: +8621628219902603, Fax:
+862162821105. E-mail address:
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Shi WR, Wu SH, Zou GC, Xu K, Jiang WF, Zhang Y, Qin M, Liu X. A novel approach for quantitative electrogram analysis for driver identification: Implications for ablation in persistent atrial fibrillation. Front Cardiovasc Med 2022; 9:1049854. [DOI: 10.3389/fcvm.2022.1049854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 11/14/2022] [Indexed: 12/04/2022] Open
Abstract
ObjectiveThis study sought to study the feasibility, efficacy, and safety of using multiscale entropy (MSE) analysis to guide catheter ablation for persistent atrial fibrillation (PsAF) and predict ablation outcomes.MethodsWe prospectively enrolled 108 patients undergoing initial ablation for PsAF. MSE was calculated based on bipolar intracardiac electrograms (iEGMs) to measure the dynamical complexity of biological signals. The iEGMs data were exported after pulmonary vein isolation (PVI), then calculated in a customed platform, and finally re-annotated into the CARTO system. After PVI, regions of the highest mean MSE (mMSE) values were ablated in descending order until AF termination, or three areas had been ablated.ResultsBaseline characteristics were evenly distributed between the AF termination (n = 38, 35.19%) and the non-termination group. The RA-to-LA mean MSE (mMSE) gradient demonstrated a positive gradient in the non-termination group and a negative gradient in the termination group (0.105 ± 0.180 vs. −0.235 ± 0.256, P < 0.001). During a 12-month follow-up, 29 patients (26.9%) had arrhythmia recurrence after single ablation, and 18 of them had AF (62.1%). The termination group had lower rates of arrhythmia recurrence (15.79 vs. 32.86%, Log-Rank P = 0.053) and AF recurrence (10.53 vs. 20%, Log-Rank P = 0.173) after single ablation and a lower rate of arrhythmia recurrence (7.89 vs. 27.14%, Log-Rank P = 0.018) after repeated ablation. Correspondingly, subjects with negative RA-to-LA mMSE gradient had lower incidences of arrhythmia (16.67 vs. 35%, Log-Rank P = 0.028) and AF (16.67 vs. 35%, Log-Rank P = 0.032) recurrence after single ablation and arrhythmia recurrence after repeated ablation (12.5 vs. 26.67%, Log-Rank P = 0.062). Marginal peri-procedural safety outcomes were observed.ConclusionMSE analysis-guided driver ablation in addition to PVI for PsAF could be feasible, efficient, and safe. An RA < LA mMSE gradient before ablation could predict freedom from arrhythmia. The RA-LA MSE gradient could be useful for guiding ablation strategy selection.
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An Evaluation of Phase Analysis to Interpret Atrial Activation Patterns during Persistent Atrial Fibrillation for Targeted Ablation. J Clin Med 2022; 11:jcm11195807. [PMID: 36233675 PMCID: PMC9572396 DOI: 10.3390/jcm11195807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/21/2022] [Accepted: 09/29/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Phase analysis has been used to identify and localize atrial fibrillation (AF) sources for targeted ablation. We previously demonstrated that repetitive wannabe reentry (incomplete reentry) often generated an apparent stable rotor using phase analysis. The misinterpretation caused by phase analysis using atrial electrograms (AEGs) may result from detecting inaccurate time points at phase inversion (π to -π) in the instantaneous phase waveform converted from AEG. The purpose of this study was to evaluate the accuracy of phase analysis to detect atrial activations recorded from the high-density mapping of AF in patients with persistent and long-standing persistent (LSP) AF. METHODS AND RESULTS During open heart surgery, we recorded activation from both atria simultaneously using 512 electrodes in 7 patients with persistent and LSP AF. The phase analysis was compared to manual measurements during 4 s of data. For the accuracy of activation sequence maps, a successful recording site was defined as having ≤4 mismatched activation times during the 4 s. In all AF episodes, the accuracy of the phase analysis was only 82% of the total number of activation times due to either activation time differences (14.7%), under-sensing (2.7%), or over-sensing (0.6%). Only 67.9% of the total recording sites met the requirement of a successful recording site by phase analysis. In unsuccessful recording sites, AEG characteristics were relatively irregular cycle length (CL), complex AEG, and double potential AEG. CONCLUSION The phase analysis was less accurate in recording sites with a relatively irregular CL, complex AEG, or double potential AEG. As a result, phase analysis may lead to the misinterpretation of atrial activation patterns during AF. A visual review of the original AEG is needed to confirm the detected AF sources of phase analysis before performing targeted ablation.
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Tilz RR, Yalin K, Lyan E, Heeger CH, Schlüter M, Fink T, Sciacca V, Liosis S, Kuck KH, Popescu SȘ, Mortensen K, Meyer-Saraei R, Eitel C, Vogler J. Stand-alone Focal Impulse and Rotor Modulation (FIRM) ablation versus second-generation cryoballoon pulmonary vein isolation for paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol 2022; 33:1678-1686. [PMID: 35615939 DOI: 10.1111/jce.15564] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 05/08/2022] [Accepted: 05/22/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Focal Impulse and Rotor Modulation (FIRM) guided catheter ablation aiming at stable rotors has been investigated as a treatment option in patients with atrial fibrillation (AF). The objective of this study was to compare the safety and efficacy of FIRM-guided ablation with second-generation cryoballoon pulmonary vein isolation (CB2-PVI) in paroxysmal AF. METHODS Consecutive patients (n=22, mean age 60 ± 11 years, 59.1% of males) who were treated with a stand-alone FIRM-guided ablation were included in this retrospective single-center study. Procedural data and arrhythmia-free survival at 12 months were compared with n=86 consecutive patients (mean age 62 ± 13 years, 62.4% of males) who received de-novo CB2-PVI. RESULTS Median procedure duration was significantly longer in the FIRM group than in the CB2-PVI group (152 [IQR 120;176] minutes versus 122 [110;145] minutes; p=0.031). One patient (1.2%) in the CB2-PVI group and 5 patients (22.7%) in the FIRM group had vascular access complications. Atrial tachyarrhythmias recurred in 15 patients in the FIRM group and 11 in the CB2-PVI group. Kaplan-Meier estimation of single-procedure arrhythmia-free survival at 12 months was 25% (95% CI 6-44%) in the FIRM group and 87% (95% CI 78-96%) in the CB2-PVI group (p<0.001). Repeat ablations were performed in 14/20 (70.0%) patients in the FIRM group and in 12/85 (14.1%) in the CB2-PVI group (p<0.001). CONCLUSION De novo ablation of AF using FIRM-guided AF ablation results in shorter arrhythmia-free survival after 12 months compared to CB2-PVI and a need for repeat ablation in the majority of patients to achieve stable sinus rhythm. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Roland R Tilz
- University Heart Center Lübeck, Medical Clinic II (Department of Cardiology, Angiology, and Intensive Care Medicine), University Hospital Schleswig-Holstein, Lübeck, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Kivanc Yalin
- University Heart Center Lübeck, Medical Clinic II (Department of Cardiology, Angiology, and Intensive Care Medicine), University Hospital Schleswig-Holstein, Lübeck, Germany.,Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Department of Cardiology, Istanbul, Turkey
| | - Evgeny Lyan
- University Heart Center Lübeck, Medical Clinic II (Department of Cardiology, Angiology, and Intensive Care Medicine), University Hospital Schleswig-Holstein, Lübeck, Germany.,Heart and Vessel Center Bad Bevensen, Clinic for Cardiology, Bad Bevensen, Germany
| | - Christian-Hendrik Heeger
- University Heart Center Lübeck, Medical Clinic II (Department of Cardiology, Angiology, and Intensive Care Medicine), University Hospital Schleswig-Holstein, Lübeck, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | | | - Thomas Fink
- University Heart Center Lübeck, Medical Clinic II (Department of Cardiology, Angiology, and Intensive Care Medicine), University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Vanessa Sciacca
- University Heart Center Lübeck, Medical Clinic II (Department of Cardiology, Angiology, and Intensive Care Medicine), University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Spyridon Liosis
- University Heart Center Lübeck, Medical Clinic II (Department of Cardiology, Angiology, and Intensive Care Medicine), University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Karl-Heinz Kuck
- University Heart Center Lübeck, Medical Clinic II (Department of Cardiology, Angiology, and Intensive Care Medicine), University Hospital Schleswig-Holstein, Lübeck, Germany.,LANS Cardio, Hamburg, Germany
| | - Sorin Ștefan Popescu
- University Heart Center Lübeck, Medical Clinic II (Department of Cardiology, Angiology, and Intensive Care Medicine), University Hospital Schleswig-Holstein, Lübeck, Germany.,"Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Kai Mortensen
- University Heart Center Lübeck, Medical Clinic II (Department of Cardiology, Angiology, and Intensive Care Medicine), University Hospital Schleswig-Holstein, Lübeck, Germany.,Cardiology Kiel, Kiel, Germany
| | - Roza Meyer-Saraei
- University Heart Center Lübeck, Medical Clinic II (Department of Cardiology, Angiology, and Intensive Care Medicine), University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Charlotte Eitel
- University Heart Center Lübeck, Medical Clinic II (Department of Cardiology, Angiology, and Intensive Care Medicine), University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Julia Vogler
- University Heart Center Lübeck, Medical Clinic II (Department of Cardiology, Angiology, and Intensive Care Medicine), University Hospital Schleswig-Holstein, Lübeck, Germany
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Chu GS, Li X, Stafford PJ, Vanheusden FJ, Salinet JL, Almeida TP, Dastagir N, Sandilands AJ, Kirchhof P, Schlindwein FS, Ng GA. Simultaneous Whole-Chamber Non-contact Mapping of Highest Dominant Frequency Sites During Persistent Atrial Fibrillation: A Prospective Ablation Study. Front Physiol 2022; 13:826449. [PMID: 35370796 PMCID: PMC8966840 DOI: 10.3389/fphys.2022.826449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/21/2022] [Indexed: 12/02/2022] Open
Abstract
Purpose Sites of highest dominant frequency (HDF) are implicated by many proposed mechanisms underlying persistent atrial fibrillation (persAF). We hypothesized that prospectively identifying and ablating dynamic left atrial HDF sites would favorably impact the electrophysiological substrate of persAF. We aim to assess the feasibility of prospectively identifying HDF sites by global simultaneous left atrial mapping. Methods PersAF patients with no prior ablation history underwent global simultaneous left atrial non-contact mapping. 30 s of electrograms recorded during AF were exported into a bespoke MATLAB interface to identify HDF regions, which were then targeted for ablation, prior to pulmonary vein isolation. Following ablation of each region, change in AF cycle length (AFCL) was documented (≥ 10 ms considered significant). Baseline isopotential maps of ablated regions were retrospectively analyzed looking for rotors and focal activation or extinction events. Results A total of 51 HDF regions were identified and ablated in 10 patients (median DF 5.8Hz, range 4.4-7.1Hz). An increase in AFCL of was seen in 20 of the 51 regions (39%), including AF termination in 4 patients. 5 out of 10 patients (including the 4 patients where AF termination occurred with HDF-guided ablation) were free from AF recurrence at 1 year. The proportion of HDF occurrences in an ablated region was not associated with change in AFCL (τ = 0.11, p = 0.24). Regions where AFCL decreased by 10 ms or more (i.e., AF disorganization) after ablation also showed lowest baseline spectral organization (p < 0.033 for any comparison). Considering all ablated regions, the average proportion of HDF events which were also HRI events was 8.0 ± 13%. Focal activations predominated (537/1253 events) in the ablated regions on isopotential maps, were modestly associated with the proportion of HDF occurrences represented by the ablated region (Kendall's τ = 0.40, p < 0.0001), and very strongly associated with focal extinction events (τ = 0.79, p < 0.0001). Rotors were rare (4/1253 events). Conclusion Targeting dynamic HDF sites is feasible and can be efficacious, but lacks specificity in identifying relevant human persAF substrate. Spectral organization may have an adjunctive role in preventing unnecessary substrate ablation. Dynamic HDF sites are not associated with observable rotational activity on isopotential mapping, but epi-endocardial breakthroughs could be contributory.
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Affiliation(s)
- Gavin S. Chu
- Department of Cardiovascular Science, University of Leicester, Leicester, United Kingdom
- Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, United Kingdom
| | - Xin Li
- Department of Cardiovascular Science, University of Leicester, Leicester, United Kingdom
- School of Engineering, University of Leicester, Leicester, United Kingdom
| | - Peter J. Stafford
- National Institute for Health Research Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | | | - João L. Salinet
- Center for Engineering, Modeling and Applied Social Sciences, University Federal of ABC, Santo André, Brazil
| | - Tiago P. Almeida
- Department of Cardiovascular Science, University of Leicester, Leicester, United Kingdom
- School of Engineering, University of Leicester, Leicester, United Kingdom
| | - Nawshin Dastagir
- Department of International Foundation, Massey University, Auckland, New Zealand
| | - Alastair J. Sandilands
- National Institute for Health Research Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - Paulus Kirchhof
- University Heart and Vascular Centre, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fernando S. Schlindwein
- School of Engineering, University of Leicester, Leicester, United Kingdom
- National Institute for Health Research Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - G. André Ng
- Department of Cardiovascular Science, University of Leicester, Leicester, United Kingdom
- National Institute for Health Research Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
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Park JW, Lim B, Hwang I, Kwon OS, Yu HT, Kim TH, Uhm JS, Joung B, Lee MH, Pak HN. Restitution Slope Affects the Outcome of Dominant Frequency Ablation in Persistent Atrial Fibrillation: CUVIA-AF2 Post-Hoc Analysis Based on Computational Modeling Study. Front Cardiovasc Med 2022; 9:838646. [PMID: 35310982 PMCID: PMC8927985 DOI: 10.3389/fcvm.2022.838646] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 01/28/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionAlthough the dominant frequency (DF) localizes the reentrant drivers and the maximal slope of the action potential duration (APD) restitution curve (Smax) reflects the tendency of the wave-break, their interaction has never been studied. We hypothesized that DF ablation has different effects on atrial fibrillation (AF) depending on Smax.MethodsWe studied the DF and Smax in 25 realistic human persistent AF model samples (68% male, 60 ± 10 years old). Virtual AF was induced by ramp pacing measuring Smax, followed by spatiotemporal DF evaluation for 34 s. We assessed the DF ablation effect depending on Smax in both computational modeling and a previous clinical trial, CUVIA-AF (170 patients with persistent AF, 70.6% male, 60 ± 11 years old).ResultsMean DF had an inverse relationship with Smax regardless of AF acquisition timing (p < 0.001). Virtual DF ablations increased the defragmentation rate compared to pulmonary vein isolation (PVI) alone (p = 0.015), especially at Smax <1 (61.5 vs. 7.7%, p = 0.011). In post-DF ablation defragmentation episodes, DF was significantly higher (p = 0.002), and Smax was lower (p = 0.003) than in episodes without defragmentation. In the post-hoc analysis of CUVIA-AF2, we replicated the inverse relationship between Smax and DF (r = −0.47, p < 0.001), and we observed better rhythm outcomes of clinical DF ablations in addition to a PVI than of empirical PVI at Smax <1 [hazard ratio 0.45, 95% CI (0.22–0.89), p = 0.022; log-rank p = 0.021] but not at ≥ 1 (log-rank p = 0.177).ConclusionWe found an inverse relationship between DF and Smax and the outcome of DF ablation after PVI was superior at the condition with Smax <1 in both in-silico and clinical trials.
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Vila M, Rocher S, Rivolta MW, Saiz J, Sassi R. Directed Network Mapping Approach to Rotor Localization in Atrial Fibrillation Simulation. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2021; 2021:730-733. [PMID: 34891395 DOI: 10.1109/embc46164.2021.9629911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Catheter ablation for atrial fibrillation (AF) is one of the most commonly performed electrophysiology procedures. Despite significant advances in our understanding of AF mechanisms in the last years, ablation outcomes remain suboptimal for many patients, particularly those with persistent or long-standing AF. A possible reason is that ablation techniques mainly focus on anatomic, rather than patient-specific functional targets for ablation. The identification of such ablation targets remains challenging. The purpose of this study is to investigate a novel approach based on directed networks, which allow the automatic detection of important arrhythmia mechanisms, that can be convenient for guiding the ablation strategy. The networks are generated by processing unipolar electrograms (EGMs) collected by the catheters positioned at the different regions of the atria. Network vertices represent the locations of the recordings and edges are determined using cross-covariance time-delay estimation method. The algorithm identifies rotational activity, spreading from vertex to vertex creating a cycle. This work is a simulation study and it uses a highly detailed computational 3D model of human atria in which sustained rotor activation of the atria was achieved. Virtual electrodes were placed on the endocardial surface, and EGMs were calculated at each of these electrodes. The propagation of the electric wave fronts in the atrial myocardium during AF is very complex, so in order to properly capture wave propagation patterns, we split EGMs into multiple short time frames. Then, a specific network for each of these time frames was generated, and the cycles repeating in consecutive networks point us to the stable rotor's location. The respective atrial voltage map served as reference. By detecting a cycle between the same 3 nodes in 19 out of 58 networks, where 10 of these networks were in consecutive time frames, a stable rotor was successfully located.
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10
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Schotten U, Lee S, Zeemering S, Waldo AL. Paradigm shifts in electrophysiological mechanisms of atrial fibrillation. Europace 2021; 23:ii9-ii13. [PMID: 33837750 DOI: 10.1093/europace/euaa384] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/03/2020] [Indexed: 11/12/2022] Open
Abstract
Determining the sequence of activation is a major source of information for understanding the electrophysiological mechanism(s) of atrial fibrillation (AF). However, the complex morphology of the electrograms hampers their analysis, and has stimulated generations of electrophysiologists to develop a large variety of technologies for recording, pre-processing, and analysis of fibrillation electrograms. This variability of approaches is mirrored by a large variability in the interpretation of fibrillation electrograms and, thereby, opinions regarding the basic electrophysiological mechanism(s) of AF vary widely. Multiple wavelets, different types of re-entry including rotors, double layers, multiple focal activation patterns all have been advocated, and a comprehensive and commonly accepted paradigm for the fundamental mechanisms of AF is still lacking. Here, we summarize the Maastricht perspective and Cleveland perspective regarding AF mechanism(s). We also describe some of the key observations in mapping of AF reported over the past decades, and how they changed over the years, often as results of new techniques introduced in the experimental field of AF research.
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Affiliation(s)
- Ulrich Schotten
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Universiteitssingel 50 6229 ER, Maastricht, The Netherlands
| | - Seungyup Lee
- Department of Medicine, Cardiovascular Research Institute, Case Western Reserve University/University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Stef Zeemering
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Universiteitssingel 50 6229 ER, Maastricht, The Netherlands
| | - Albert L Waldo
- Department of Medicine, Cardiovascular Research Institute, Case Western Reserve University/University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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11
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Schopp M, Dharmaprani D, Kuklik P, Quah J, Lahiri A, Tiver K, Meyer C, Willems S, McGavigan AD, Ganesan AN. Spatial concentration and distribution of phase singularities in human atrial fibrillation: Insights for the AF mechanism. J Arrhythm 2021; 37:922-930. [PMID: 34386118 PMCID: PMC8339121 DOI: 10.1002/joa3.12547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 04/10/2021] [Accepted: 04/14/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is characterized by the repetitive regeneration of unstable rotational events, the pivot of which are known as phase singularities (PSs). The spatial concentration and distribution of PSs have not been systematically investigated using quantitative statistical approaches. OBJECTIVES We utilized a geospatial statistical approach to determine the presence of local spatial concentration and global clustering of PSs in biatrial human AF recordings. METHODS 64-electrode conventional basket (~5 min, n = 18 patients, persistent AF) recordings were studied. Phase maps were produced using a Hilbert-transform based approach. PSs were characterized spatially using the following approaches: (i) local "hotspots" of high phase singularity (PS) concentration using Getis-Ord Gi* (Z ≥ 1.96, P ≤ .05) and (ii) global spatial clustering using Moran's I (inverse distance matrix). RESULTS Episodes of AF were analyzed from basket catheter recordings (H: 41 epochs, 120 000 s, n = 18 patients). The Getis-Ord Gi* statistic showed local PS hotspots in 12/41 basket recordings. As a metric of spatial clustering, Moran's I showed an overall mean of 0.033 (95% CI: 0.0003-0.065), consistent with the notion of complete spatial randomness. CONCLUSION Using a systematic, quantitative geospatial statistical approach, evidence for the existence of spatial concentrations ("hotspots") of PSs were detectable in human AF, along with evidence of spatial clustering. Geospatial statistical approaches offer a new approach to map and ablate PS clusters using substrate-based approaches.
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Affiliation(s)
- Madeline Schopp
- College of Science and EngineeringFlinders University of South AustraliaAdelaideSAAustralia
| | - Dhani Dharmaprani
- College of Science and EngineeringFlinders University of South AustraliaAdelaideSAAustralia
- College of Medicine and Public HealthFlinders University of South AustraliaAdelaideSAAustralia
| | - Pawel Kuklik
- Department of CardiologyUniversity Medical CentreHamburgGermany
| | - Jing Quah
- College of Medicine and Public HealthFlinders University of South AustraliaAdelaideSAAustralia
- Department of Cardiovascular MedicineFlinders Medical CentreAdelaideSAAustralia
| | - Anandaroop Lahiri
- Department of Cardiovascular MedicineFlinders Medical CentreAdelaideSAAustralia
| | - Kathryn Tiver
- College of Medicine and Public HealthFlinders University of South AustraliaAdelaideSAAustralia
- Department of Cardiovascular MedicineFlinders Medical CentreAdelaideSAAustralia
| | - Christian Meyer
- Department of CardiologyUniversity Medical CentreHamburgGermany
| | - Stephan Willems
- Department of CardiologyUniversity Medical CentreHamburgGermany
| | - Andrew D. McGavigan
- Department of Cardiovascular MedicineFlinders Medical CentreAdelaideSAAustralia
| | - Anand N. Ganesan
- College of Medicine and Public HealthFlinders University of South AustraliaAdelaideSAAustralia
- Department of Cardiovascular MedicineFlinders Medical CentreAdelaideSAAustralia
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12
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Mandapati R, Contractor T, Bhardwaj R. Role of Scar and Rotors in Persistent Atrial Fibrillation: Miles to Go Before We Sleep. JACC Clin Electrophysiol 2021; 7:920-922. [PMID: 34294390 DOI: 10.1016/j.jacep.2021.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 06/09/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Ravi Mandapati
- Department of Cardiology, Loma Linda University Medical Center, Loma Linda, California, USA.
| | - Tahmeed Contractor
- Department of Cardiology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Rahul Bhardwaj
- Department of Cardiology, Loma Linda University Medical Center, Loma Linda, California, USA
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13
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Kulikov AA, Sapelnikov OV, Uskach TM, Cherkashin DI, Grishin IR, Akchurin RS. Rotor Drivers in Induction and Maintenance of Atrial Fibrillation. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2021. [DOI: 10.20996/1819-6446-2021-04-16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Atrial fibrillation is the most common arrhythmia in clinical practice. It is associated with an increased risk of stroke, chronic heart failure, and sudden cardiac death. Our options of restoring and maintaining sinus rhythm have a very limited effect, both in the case of antiarrhythmic and catheter treatment. Catheter ablation has proven to be a more effective approach than antiarrhythmic therapy. The success rate of the procedure reaches 70%. However, radiofrequency ablation is associated with a risk of complications, with 4.5% of patients likely to develop major complications, including tamponade (1.31%), femoral pseudoaneurysm (0.71%), and death (0.15%). Given the generally recognized dominant role of the pulmonary veins in the induction of atrial fibrillation, their electrical isolation has become the recommended tactic of the catheter approach. In the case of patients with paroxysmal form of atrial fibrillation, the success rate of the procedure reaches 87%. Unfortunately, in the case of persistent forms of atrial fibrillation, the effectiveness of the primary procedure decreases to 28% and reaches 51% with repeated interventions. In addition to the anatomically oriented isolation of the pulmonary veins, a number of strategies have been proposed to reach the secondary zones of atrial fibrillation induction. The results of recent studies on the effectiveness of strategies for ablation of rotor regions and their role in the induction and maintenance of AF may lead to the further development of catheter ablation techniques and an individual radiofrequency ablation approach in a particular patient.
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14
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Lee S, Khrestian CM, Sahadevan J, Markowitz A, Waldo AL. New Insights Into Understanding Rotor Versus Focal Activation in Patients With Persistent Atrial Fibrillation. JACC Clin Electrophysiol 2021; 7:909-919. [PMID: 33640352 DOI: 10.1016/j.jacep.2020.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/09/2020] [Accepted: 12/01/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study was to test the hypotheses that: 1) when using phase analysis, repetitive Wannabe re-entry produces a phase singularity point (i.e., a rotor); and 2) the location of the stable rotor is close to the focal source. BACKGROUND Recent contact mapping studies in patients with persistent atrial fibrillation (AF) demonstrated that phase analysis produced a different mechanistic result than classical activation sequence analysis. Our studies in patients with persistent AF showed that focal sources sometimes produced repetitive Wannabe re-entry, that is, incomplete re-entry. METHODS During open heart surgery, we recorded activation from both atria simultaneously using 510 to 512 electrodes in 12 patients with persistent AF. We performed activation sequence mapping and phase analyses on 4 s of mapped data. For each detected stable rotor (>2 full rotations [720°] recurring at the same site), the corresponding activation patterns were examined from the activation sequence maps. RESULTS During AF, phase singularity points (rotors) were identified in both atria in all patients. However, stable phase singularity points were only present in 6 of 12 patients. The range of stable phase singularity points per patient was 0 to 6 (total 14). Stable phase singularity points were produced due to repetitive Wannabe re-entry generated from a focal source or by passive activation. A conduction block sometimes created a stable phase singularity point (n = 2). The average distance between a focal source and a stable rotor was 0.9 ± 0.3 cm. CONCLUSIONS Repetitive Wannabe re-entry generated stable rotors adjacent to a focal source. No true re-entry occurred.
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Affiliation(s)
- Seungyup Lee
- Departments of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Celeen M Khrestian
- Departments of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Jayakumar Sahadevan
- Departments of Medicine, Case Western Reserve University, Cleveland, Ohio, USA; Division of Cardiovascular Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Alan Markowitz
- Valve Center, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Albert L Waldo
- Departments of Medicine, Case Western Reserve University, Cleveland, Ohio, USA; Division of Cardiovascular Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA.
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15
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Nakamura T, Kiuchi K, Fukuzawa K, Takami M, Watanabe Y, Izawa Y, Suehiro H, Akita T, Takemoto M, Sakai J, Yatomi A, Sonoda Y, Takahara H, Nakasone K, Yamamoto K, Negi N, Kono A, Ashihara T, Hirata KI. Late-gadolinium enhancement properties associated with atrial fibrillation rotors in patients with persistent atrial fibrillation. J Cardiovasc Electrophysiol 2021; 32:1005-1013. [PMID: 33556994 DOI: 10.1111/jce.14933] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/12/2021] [Accepted: 01/21/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND A computational model demonstrated that atrial fibrillation (AF) rotors could be distributed in patchy late-gadolinium enhancement (LGE) areas and play an important role in AF drivers. However, this was not validated in humans. OBJECTIVE The purpose of this study was to evaluate the LGE properties of AF rotors in patients with persistent AF. METHODS A total of 287 segments in 15 patients with persistent AF (long-standing persistent AF in 9 patients) that underwent AF ablation were assessed. Non-passively activated areas (NPAs), where rotational activation (AF rotor) was frequently observed, were detected by the novel real-time phase mapping (ExTRa Mapping). The properties of the LGE areas were assessed using the LGE heterogeneity and the density which was evaluated by the entropy (LGE-entropy) and the volume ratio of the enhancement voxel (LGE-volume ratio), respectively. RESULTS NPAs were found in 61 (21%) of 287 segments and were mostly found around the pulmonary vein antrum. A receiver operating characteristic curve analysis yielded an optimal cutoff value of 5.7% and 10% for the LGE-entropy and LGE-volume ratio, respectively. The incidence of NPAs was significantly higher at segments with an LGE-entropy of >5.7 and LGE-volume ratio of >10% than at the other segments (38 [30%] of 126 vs. 23 [14%] of 161 segments; p = .001). No NPAs were found at segments with an LGE-volume ratio of >50% regardless of the LGE-entropy. Of five patients with AF recurrence, NPAs outside the PV antrum were not ablated in three patients and the remaining NPAs were ablated, but their LGE-entropy and LGE-volume ratio were low. CONCLUSION AF rotors are mostly distributed in relatively weak and much more heterogenous LGE areas.
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Affiliation(s)
- Toshihiro Nakamura
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kunihiko Kiuchi
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Koji Fukuzawa
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Mitsuru Takami
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoshiaki Watanabe
- Division of Radiology, Center for Radiology and Radiation Oncology, Kobe University Hospital, Kobe, Japan
| | - Yu Izawa
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hideya Suehiro
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tomomi Akita
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Makoto Takemoto
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Jun Sakai
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Atsusuke Yatomi
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yusuke Sonoda
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroyuki Takahara
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kazutaka Nakasone
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kyoko Yamamoto
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Noriyuki Negi
- Division of Radiology, Center for Radiology and Radiation Oncology, Kobe University Hospital, Kobe, Japan
| | - Atsushi Kono
- Department of Radiology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takashi Ashihara
- Department of Medical Informatics and Biomedical Engineering, Shiga University of Medical Science, Otsu, Japan
| | - Ken-Ichi Hirata
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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16
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Honarbakhsh S, Schilling RJ, Providencia R, Dhillon G, Bajomo O, Keating E, Finlay M, Hunter RJ. Ablation guided by STAR-mapping in addition to pulmonary vein isolation is superior to pulmonary vein isolation alone or in combination with CFAE/linear ablation for persistent AF. J Cardiovasc Electrophysiol 2021; 32:200-209. [PMID: 33368766 PMCID: PMC8607469 DOI: 10.1111/jce.14856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/19/2020] [Accepted: 11/27/2020] [Indexed: 11/18/2022]
Abstract
Introduction The optimal ablation approach for persistent atrial fibrillation (AF) remains unclear. Methods and Results Objective was to compare the long‐term rates of freedom from AF/AT in patients that underwent STAR mapping guided ablation against outcomes of patients undergoing conventional ablation procedures. Patients undergoing ablation for persistent AF as part of the Stochastic Trajectory Analysis of Ranked signals (STAR) mapping study were included. Outcomes following 'pulmonary vein isolation (PVI) plus STAR mapping guided ablation (STAR mapping cohort) were compared to patients undergoing PVI alone ablation during the same time period and also a propensity‐matched cohort undergoing PVI plus the addition of complex fractionated electrogram (CFAE) and/or linear ablation (“conventional ablation”). Rates of procedural AF termination and freedom from AF/AT during follow‐up were compared. Sixty‐five patients were included in both the STAR cohort and propensity matched conventional ablation cohort. AF termination rates were significantly higher in the STAR cohort (51/65, 78.5%) than conventional ablation cohort (10/65, 15.4%) and PVI alone ablation cohort (13/50, 26.0%; STAR cohort vs. other 2 cohorts both p < .001). There was no significant difference in procedure time between the three cohorts. During ≥20 months follow‐up a lower proportion of patients had AF/AT recurrence in the STAR cohort (20.0%) compared with the conventional ablation cohort (50.8%) or the PVI alone ablation cohort (50.0%; both p < .05 compared to STAR cohort). Conclusions Outcomes of PVI plus STAR mapping guided ablation was superior to PVI alone or in combination with linear/CFAE ablation. A multicenter randomized controlled trial is planned to confirm these findings.
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Affiliation(s)
| | | | | | | | | | - Emily Keating
- Barts Heart Centre, Barts Health NHS Trust, London, UK
| | | | - Ross J Hunter
- Barts Heart Centre, Barts Health NHS Trust, London, UK.,Queen Mary University of London
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17
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Lee S, Sahadevan J. Conduction Slowing: Association or Causation in Atrial Fibrillation. JACC Clin Electrophysiol 2020; 6:1855-1857. [PMID: 33357583 PMCID: PMC8045138 DOI: 10.1016/j.jacep.2020.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 10/25/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Seungyup Lee
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Jayakumar Sahadevan
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA; Division of Cardiovascular Medicine, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA.
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18
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Nayyar S, Ha ACT, Timmerman N, Suszko A, Ragot D, Chauhan VS. Focal and pseudo/rotational activations in human atrial fibrillation defined with automated periodicity mapping. J Cardiovasc Electrophysiol 2020; 32:212-223. [PMID: 33179399 DOI: 10.1111/jce.14812] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/19/2020] [Accepted: 11/01/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Defining atrial fibrillation (AF) wave propagation is challenging unless local signal features are discrete or periodic. Periodic focal or rotational activity may identify AF drivers. Our objective was to characterize AF propagation at sites with periodic activation to evaluate the prevalence and relationship between focal and rotational activation. METHODS We included 80 patients (61 ± 10 years, persistent AF 49%) from the FaST randomized trial that compared the efficacy of adjunctive focal site ablation versus pulmonary vein isolation. Patients underwent left atrial (LA) activation mapping with a 20-pole circular catheter during spontaneous or induced AF. Five-second bipolar and unipolar electrograms in AF were analyzed. Periodic sites were identified by spectral analysis of the bipolar electrogram. Activation maps of periodic sites were constructed using an automated, validated tracking algorithm, and classified into three patterns: focal sites (FS), rotation (RO), or pseudo-rotation (pRO). RESULTS The most common propagation pattern at periodic sites was FS for 5-s in all patients (4.9 ± 1.9 per patient). RO and pRO were observed in two and seven patients, respectively, but were all transient (3-5 cycles). Activation from a FS evolved into transient RO/pRO in five patients. No patient had autonomous RO/pRO activations. Patients with RO/pRO had greater LA surface area with periodicity (78 ± 7 vs. 63 ± 16%, p = .0002) and shorter LA periodicity CL (166 ± 10 vs. 190±28 ms, p = .0001) than the rest. CONCLUSION Using automated, regional AF periodicity mapping, FS is more prevalent and temporally stable than RO/pRO. Most RO/pRO evolve from neighboring FS. These findings and their implications for AF maintenance require verification with global, panoramic mapping.
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Affiliation(s)
- Sachin Nayyar
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Andrew C T Ha
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Nicholas Timmerman
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Adrian Suszko
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Don Ragot
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Vijay S Chauhan
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Canada
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19
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Zolotarev AM, Hansen BJ, Ivanova EA, Helfrich KM, Li N, Janssen PML, Mohler PJ, Mokadam NA, Whitson BA, Fedorov MV, Hummel JD, Dylov DV, Fedorov VV. Optical Mapping-Validated Machine Learning Improves Atrial Fibrillation Driver Detection by Multi-Electrode Mapping. Circ Arrhythm Electrophysiol 2020; 13:e008249. [PMID: 32921129 DOI: 10.1161/circep.119.008249] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) can be maintained by localized intramural reentrant drivers. However, AF driver detection by clinical surface-only multielectrode mapping (MEM) has relied on subjective interpretation of activation maps. We hypothesized that application of machine learning to electrogram frequency spectra may accurately automate driver detection by MEM and add some objectivity to the interpretation of MEM findings. METHODS Temporally and spatially stable single AF drivers were mapped simultaneously in explanted human atria (n=11) by subsurface near-infrared optical mapping (NIOM; 0.3 mm2 resolution) and 64-electrode MEM (higher density or lower density with 3 and 9 mm2 resolution, respectively). Unipolar MEM and NIOM recordings were processed by Fourier transform analysis into 28 407 total Fourier spectra. Thirty-five features for machine learning were extracted from each Fourier spectrum. RESULTS Targeted driver ablation and NIOM activation maps efficiently defined the center and periphery of AF driver preferential tracks and provided validated annotations for driver versus nondriver electrodes in MEM arrays. Compared with analysis of single electrogram frequency features, averaging the features from each of the 8 neighboring electrodes, significantly improved classification of AF driver electrograms. The classification metrics increased when less strict annotation, including driver periphery electrodes, were added to driver center annotation. Notably, f1-score for the binary classification of higher-density catheter data set was significantly higher than that of lower-density catheter (0.81±0.02 versus 0.66±0.04, P<0.05). The trained algorithm correctly highlighted 86% of driver regions with higher density but only 80% with lower-density MEM arrays (81% for lower-density+higher-density arrays together). CONCLUSIONS The machine learning model pretrained on Fourier spectrum features allows efficient classification of electrograms recordings as AF driver or nondriver compared with the NIOM gold-standard. Future application of NIOM-validated machine learning approach may improve the accuracy of AF driver detection for targeted ablation treatment in patients.
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Affiliation(s)
- Alexander M Zolotarev
- Department of Physiology and Cell Biology and Bob and Corrine Frick Center for Heart Failure and Arrhythmia (A.M.Z., B.J.H., K.M.H., N.L., P.M.L.J., P.J.M., V.V.F.), The Ohio State University Wexner Medical Center, Columbus, OH.,Center of Computational and Data-Intensive Science and Engineering, Skolkovo Institute of Science and Technology, Moscow, Russia (A.M.Z., E.A.I., M.V.F., D.V.D.)
| | - Brian J Hansen
- Department of Physiology and Cell Biology and Bob and Corrine Frick Center for Heart Failure and Arrhythmia (A.M.Z., B.J.H., K.M.H., N.L., P.M.L.J., P.J.M., V.V.F.), The Ohio State University Wexner Medical Center, Columbus, OH
| | - Ekaterina A Ivanova
- Center of Computational and Data-Intensive Science and Engineering, Skolkovo Institute of Science and Technology, Moscow, Russia (A.M.Z., E.A.I., M.V.F., D.V.D.)
| | - Katelynn M Helfrich
- Department of Physiology and Cell Biology and Bob and Corrine Frick Center for Heart Failure and Arrhythmia (A.M.Z., B.J.H., K.M.H., N.L., P.M.L.J., P.J.M., V.V.F.), The Ohio State University Wexner Medical Center, Columbus, OH
| | - Ning Li
- Department of Physiology and Cell Biology and Bob and Corrine Frick Center for Heart Failure and Arrhythmia (A.M.Z., B.J.H., K.M.H., N.L., P.M.L.J., P.J.M., V.V.F.), The Ohio State University Wexner Medical Center, Columbus, OH.,Davis Heart and Lung Research Institute (N.L., P.M.L.J., P.J.M., N.A.M., B.A.W., J.D.H., V.V.F.), The Ohio State University Wexner Medical Center, Columbus, OH
| | - Paul M L Janssen
- Department of Physiology and Cell Biology and Bob and Corrine Frick Center for Heart Failure and Arrhythmia (A.M.Z., B.J.H., K.M.H., N.L., P.M.L.J., P.J.M., V.V.F.), The Ohio State University Wexner Medical Center, Columbus, OH.,Davis Heart and Lung Research Institute (N.L., P.M.L.J., P.J.M., N.A.M., B.A.W., J.D.H., V.V.F.), The Ohio State University Wexner Medical Center, Columbus, OH
| | - Peter J Mohler
- Department of Physiology and Cell Biology and Bob and Corrine Frick Center for Heart Failure and Arrhythmia (A.M.Z., B.J.H., K.M.H., N.L., P.M.L.J., P.J.M., V.V.F.), The Ohio State University Wexner Medical Center, Columbus, OH.,Davis Heart and Lung Research Institute (N.L., P.M.L.J., P.J.M., N.A.M., B.A.W., J.D.H., V.V.F.), The Ohio State University Wexner Medical Center, Columbus, OH
| | - Nahush A Mokadam
- Davis Heart and Lung Research Institute (N.L., P.M.L.J., P.J.M., N.A.M., B.A.W., J.D.H., V.V.F.), The Ohio State University Wexner Medical Center, Columbus, OH.,Division of Cardiac Surgery (N.A.M., B.A.W., J.D.H.), The Ohio State University Wexner Medical Center, Columbus, OH
| | - Bryan A Whitson
- Davis Heart and Lung Research Institute (N.L., P.M.L.J., P.J.M., N.A.M., B.A.W., J.D.H., V.V.F.), The Ohio State University Wexner Medical Center, Columbus, OH.,Division of Cardiac Surgery (N.A.M., B.A.W., J.D.H.), The Ohio State University Wexner Medical Center, Columbus, OH
| | - Maxim V Fedorov
- Center of Computational and Data-Intensive Science and Engineering, Skolkovo Institute of Science and Technology, Moscow, Russia (A.M.Z., E.A.I., M.V.F., D.V.D.)
| | - John D Hummel
- Davis Heart and Lung Research Institute (N.L., P.M.L.J., P.J.M., N.A.M., B.A.W., J.D.H., V.V.F.), The Ohio State University Wexner Medical Center, Columbus, OH.,Division of Cardiac Surgery (N.A.M., B.A.W., J.D.H.), The Ohio State University Wexner Medical Center, Columbus, OH.,Department of Internal Medicine (J.D.H), The Ohio State University Wexner Medical Center, Columbus, OH
| | - Dmitry V Dylov
- Center of Computational and Data-Intensive Science and Engineering, Skolkovo Institute of Science and Technology, Moscow, Russia (A.M.Z., E.A.I., M.V.F., D.V.D.)
| | - Vadim V Fedorov
- Department of Physiology and Cell Biology and Bob and Corrine Frick Center for Heart Failure and Arrhythmia (A.M.Z., B.J.H., K.M.H., N.L., P.M.L.J., P.J.M., V.V.F.), The Ohio State University Wexner Medical Center, Columbus, OH.,Davis Heart and Lung Research Institute (N.L., P.M.L.J., P.J.M., N.A.M., B.A.W., J.D.H., V.V.F.), The Ohio State University Wexner Medical Center, Columbus, OH
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20
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Li X, Almeida TP, Dastagir N, Guillem MS, Salinet J, Chu GS, Stafford PJ, Schlindwein FS, Ng GA. Standardizing Single-Frame Phase Singularity Identification Algorithms and Parameters in Phase Mapping During Human Atrial Fibrillation. Front Physiol 2020; 11:869. [PMID: 32792983 PMCID: PMC7386053 DOI: 10.3389/fphys.2020.00869] [Citation(s) in RCA: 13] [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: 03/05/2020] [Accepted: 06/29/2020] [Indexed: 12/03/2022] Open
Abstract
PURPOSE Recent investigations failed to reproduce the positive rotor-guided ablation outcomes shown by initial studies for treating persistent atrial fibrillation (persAF). Phase singularity (PS) is an important feature for AF driver detection, but algorithms for automated PS identification differ. We aim to investigate the performance of four different techniques for automated PS detection. METHODS 2048-channel virtual electrogram (VEGM) and electrocardiogram signals were collected for 30 s from 10 patients undergoing persAF ablation. QRST-subtraction was performed and VEGMs were processed using sinusoidal wavelet reconstruction. The phase was obtained using Hilbert transform. PSs were detected using four algorithms: (1) 2D image processing based and neighbor-indexing algorithm; (2) 3D neighbor-indexing algorithm; (3) 2D kernel convolutional algorithm estimating topological charge; (4) topological charge estimation on 3D mesh. PS annotations were compared using the structural similarity index (SSIM) and Pearson's correlation coefficient (CORR). Optimized parameters to improve detection accuracy were found for all four algorithms using F β score and 10-fold cross-validation compared with manual annotation. Local clustering with density-based spatial clustering of applications with noise (DBSCAN) was proposed to improve algorithms 3 and 4. RESULTS The PS density maps created by each algorithm with default parameters were poorly correlated. Phase gradient threshold and search radius (or kernels) were shown to affect PS detections. The processing times for the algorithms were significantly different (p < 0.0001). The F β scores for algorithms 1, 2, 3, 3 + DBSCAN, 4 and 4 + DBSCAN were 0.547, 0.645, 0.742, 0.828, 0.656, and 0.831. Algorithm 4 + DBSCAN achieved the best classification performance with acceptable processing time (2.0 ± 0.3 s). CONCLUSION AF driver identification is dependent on the PS detection algorithms and their parameters, which could explain some of the inconsistencies in rotor-guided ablation outcomes in different studies. For 3D triangulated meshes, algorithm 4 + DBSCAN with optimal parameters was the best solution for real-time, automated PS detection due to accuracy and speed. Similarly, algorithm 3 + DBSCAN with optimal parameters is preferred for uniform 2D meshes. Such algorithms - and parameters - should be preferred in future clinical studies for identifying AF drivers and minimizing methodological heterogeneities. This would facilitate comparisons in rotor-guided ablation outcomes in future works.
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Affiliation(s)
- Xin Li
- Department of Cardiovascular Science, University of Leicester, Leicester, United Kingdom
- School of Engineering, University of Leicester, Leicester, United Kingdom
| | - Tiago P. Almeida
- Department of Cardiovascular Science, University of Leicester, Leicester, United Kingdom
- School of Engineering, University of Leicester, Leicester, United Kingdom
- Aeronautics Institute of Technology, ITA, São José dos Campos, Brazil
| | - Nawshin Dastagir
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | | | - João Salinet
- Centre for Engineering, Modelling and Applied Social Sciences, Federal University of ABC, Santo André, Brazil
| | - Gavin S. Chu
- Department of Cardiovascular Science, University of Leicester, Leicester, United Kingdom
| | - Peter J. Stafford
- National Institute for Health Research Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - Fernando S. Schlindwein
- School of Engineering, University of Leicester, Leicester, United Kingdom
- National Institute for Health Research Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - G. André Ng
- Department of Cardiovascular Science, University of Leicester, Leicester, United Kingdom
- National Institute for Health Research Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
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21
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Aryana A, Chierchia GB, de Asmundis C. Recurrent Atrial Fibrillation After Cryoballoon Ablation: What to Expect! Card Electrophysiol Clin 2020; 12:199-208. [PMID: 32451104 DOI: 10.1016/j.ccep.2020.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Atrial fibrillation (AF) recurrence following cryoballoon ablation may occur as a consequence of pulmonary vein (PV) reconnection, which can be treated effectively by performing repeat PV isolation. Alternatively, AF recurrence can manifest in presence of bilateral antral PV isolation. In such circumstances, one may pursue catheter ablation of AF triggers, if present, or proceed with empiric posterior left atrial wall ablation. Although traditionally, focal radiofrequency ablation has been used for this, cryoballoon ablation, itself, may also be used for ablation/isolation of certain structures such as the superior vena cava, the left atrial appendage and even the posterior left atrial wall.
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Affiliation(s)
- Arash Aryana
- Mercy General Hospital and Dignity Health Heart and Vascular Institute, Suite #350, 3941 J Street, Sacramento, CA 95819, USA.
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22
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Liu PR, Friedman DJ, Barnett AS, Jackson KP, Daubert JP, Piccini JP. Focal impulse and rotor modulation of atrial rotors during atrial fibrillation leads to organization of left atrial activation as reflected by waveform morphology recurrence quantification analysis and organizational index. J Arrhythm 2020; 36:311-318. [PMID: 32256880 PMCID: PMC7132180 DOI: 10.1002/joa3.12311] [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: 10/14/2019] [Revised: 12/19/2019] [Accepted: 12/26/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Focal impulse and rotor modulation (FIRM) can cause slowing, organization, and occasionally termination of atrial fibrillation (AF), although results have been mixed. To further characterize changes in AF during rotor ablation, we quantified morphologic and temporal activation changes following FIRM. METHODS In patients undergoing FIRM ablation for AF, we retrospectively analyzed coronary sinus bipolar EGMs before and after rotor ablation, including EGM activation frequency and regularity, dominant frequency (DF), and organizational index (OI). Changes in EGM waveform morphology were determined with recurrence quantification analysis (RQA) consisting of recurrence rate (RR), determinism (DET), laminarity (LAM), average diagonal line length (L), and trapping time (TT) using Wilcoxon signed-rank testing. RESULTS Overall, 36 rotors from 21 patients undergoing FIRM ablation were analyzed. All morphology RQA parameters demonstrated significant organization of atrial activation after rotor ablation (RR P = .03, DET P = .005, LAM P = .03, L P = .005, TT P = .009). The organizational index also showed a significant increase after rotor ablation (P = .01), and the change in OI correlated with changes in all morphology parameters. Of the rotors, 14/36 (39%) rotors showed organizational changes in all morphology parameters and OI, and an additional 5 rotors (19/36, 53%) showed organizational changes in 4 of 5 morphology parameters and OI. CONCLUSIONS Coronary sinus EGM waveform morphologies and activation patterns are significantly altered after FIRM ablation even when there is no fibrillatory slowing. RQA morphology analysis and organizational index may impart important information regarding underlying AF organization and may be useful in quantifying the acute response to ablation.
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Affiliation(s)
- Peter R. Liu
- Department of MedicineJohns Hopkins HospitalBaltimoreMDUSA
| | - Daniel J. Friedman
- Duke Center for Atrial FibrillationDuke Clinical Research InstituteDuke University Medical CenterDurhamNCUSA
| | - Adam S. Barnett
- Duke Center for Atrial FibrillationDuke Clinical Research InstituteDuke University Medical CenterDurhamNCUSA
| | - Kevin P. Jackson
- Duke Center for Atrial FibrillationDuke Clinical Research InstituteDuke University Medical CenterDurhamNCUSA
| | - James P. Daubert
- Duke Center for Atrial FibrillationDuke Clinical Research InstituteDuke University Medical CenterDurhamNCUSA
| | - Jonathan P. Piccini
- Duke Center for Atrial FibrillationDuke Clinical Research InstituteDuke University Medical CenterDurhamNCUSA
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23
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Borlich M, Sommer P. Cardiac Mapping Systems: Rhythmia, Topera, EnSite Precision, and CARTO. Card Electrophysiol Clin 2020; 11:449-458. [PMID: 31400869 DOI: 10.1016/j.ccep.2019.05.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Novel cardiac mapping systems allow a safe and highly accurate 3-D reconstruction of cardiac structures as well as fast and accurate visualization of cardiac arrhythmias. In addition, they are increasingly reducing the need for fluoroscopy in these procedures. The current state of the art, as well as the presentation of possible uses of individual systems and their limitations, is presented in this article. Cardiac mapping systems can significantly contribute to an optimal therapeutic decision making in invasive electrophysiology. This article introduces new developments of Rhythmia, Topera, EnSite Precision, and CARTO systems and provides a look ahead to the future.
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Affiliation(s)
- Martin Borlich
- Heart Center, Segeberger Kliniken (Academic Teaching Hospital of the Universities of Kiel, Lübeck and Hamburg), Am Kurpark 1, Bad Segeberg, Schleswig-Holstein 23795, Germany.
| | - Philipp Sommer
- Clinic of Electrophysiology, Heart and Diabetes Center NRW, University Hospital of Ruhr-University Bochum, Georgstr. 11, Bad Oeynhausen, Nordrhein-Westfalen 32545, Germany
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24
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Zaman J, Baykaner T, Narayan SM. Mapping and Ablation of Rotational and Focal Drivers in Atrial Fibrillation. Card Electrophysiol Clin 2020; 11:583-595. [PMID: 31706467 DOI: 10.1016/j.ccep.2019.08.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Drivers are increasingly studied ablation targets for atrial fibrillation (AF). However, results from ablation remain controversial. First, outcomes vary between centers and patients. Second, it is unclear how best to perform driver ablation. Third, there is a lack of practical guidance on how to identify critical from secondary sites using different AF mapping methods. This article addresses each of these issues.
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Affiliation(s)
- Junaid Zaman
- Stanford University, 780 Welch Road, Suite CJ250F, Stanford, CA 94305, USA; Imperial College London, London, UK
| | - Tina Baykaner
- Department of Medicine/Cardiovascular Medicine, Stanford University, 780 Welch Road, Suite CJ250F, Stanford, CA 94305, USA
| | - Sanjiv M Narayan
- Department of Medicine/Cardiovascular Medicine and Cardiovascular Institute, Stanford University, 780 Welch Road, Suite CJ250F, MC 5773, Stanford, CA 94305, USA.
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25
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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.
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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
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26
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Qin M, Jiang WF, Wu SH, Xu K, Liu X. Electrogram dispersion-guided driver ablation adjunctive to high-quality pulmonary vein isolation in atrial fibrillation of varying durations. J Cardiovasc Electrophysiol 2019; 31:48-60. [PMID: 31701626 DOI: 10.1111/jce.14268] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 10/29/2019] [Accepted: 11/05/2019] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To investigate the role of driver mechanism and the effect of electrogram dispersion-guided driver mapping and ablation in atrial fibrillation (AF) at different stages of progression. METHODS A total of 256 consecutive patients with AF who had undergone pulmonary vein isolation (PVI) plus driver ablation or conventional ablation were divided into three groups: paroxysmal atrial fibrillation (PAF; group A, n = 51); persistent atrial fibrillation (PsAF; group B, n = 38); and long standing-persistent atrial fibrillation (LS-PsAF; group C, n = 39). PVI was performed with the guidance of the ablation index. The electrogram dispersion was analyzed for driver mapping. RESULTS The most prominent driver regions were at roof (28.0%), posterior wall (17.6%), and bottom (21.3%). From patients with PAF to those with PsAF and LS-PsAF: the complexity of extra-pulmonary vein (PV) drivers including distribution, mean number, and area of dispersion region increased (P < .001). Patients who underwent driver ablation vs conventional ablation had higher procedural AF termination rate (76.6% vs 28.1%; P < .001). With AF progression, the termination rate gradually decreased from group A to group C, and the role of PVI in AF termination was also gradually weakened from group A to group C (39.6%, 7.4%, and 4.3%; P < .001) in patients with driver ablation. At the end of the follow-up, the rate of sinus rhythm maintenance was higher in patients with driver ablation than those with conventional ablation (89.1% vs 70.3%; P < .001). CONCLUSION The formation of extra-PV drivers provides an important mechanism for AF maintenance with their complexity increasing with AF progression. Electrogram dispersion-guided driver ablation appears to be an efficient adjunctive approach to PVI for AF treatment.
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Affiliation(s)
- Mu Qin
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Wei-Feng Jiang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Shao-Hui Wu
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Kai Xu
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Xu Liu
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
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27
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Wolf M, Tavernier R, Zeidan Z, El Haddad M, Vandekerckhove Y, Pooter JD, Phlips T, Strisciuglio T, Almorad A, Kyriakopoulou M, Lycke M, Duytschaever M, Knecht S. Identification of repetitive atrial activation patterns in persistent atrial fibrillation by direct contact high-density electrogram mapping. J Cardiovasc Electrophysiol 2019; 30:2704-2712. [PMID: 31588635 DOI: 10.1111/jce.14214] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 08/08/2019] [Accepted: 08/31/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Recent studies have characterized drivers in persistent atrial fibrillation using automated algorithm detection with panoramic endocardial mapping by means of basket catheters. We aimed to identify repetitive atrial activation patterns (RAAPs) during ongoing atrial fibrillation (AF) based upon automated annotation of unipolar electrograms (EGMs) recorded with a high-density regional endocardial contact mapping catheter. METHODS In 14 persistent AF patients, high-resolution EGMs were recorded for 30 seconds at sequential PentaRay (Biosense Inc) positions covering the entire biatrial surface. All recordings were reviewed off-line with dedicated software allowing automated annotation of the local activation time of the unipolar fibrillatory EGMs (CARTOFINDER; Biosense Inc). RAAPs were defined as a consistent activation pattern (for ≥3 consecutive beats) of either focal activity with centrifugal spread (RAAPfocal ) or rotational activity across the PentaRay splines spanning the AF cycle length (RAAProtational ). RESULTS A total of 498 PentaRay recordings were analyzed (35.6 ± 7.6 per patient). The number of PentaRay recordings displaying RAAP was 9.8 ± 3.1 per patient (range = 3-15), of which 2.4 ± 2.4 RAAProtational (range = 0-7), and 7.4 ± 4.4 RAAPfocal (range = 1-13). 77% of RAAPs portrayed focal firing. The median number of repetitions per 30 second recording was 11 (range = 3-225) per recording. RAAPs were observed both in the right atrium (RA) (35%) and left atrium (LA) (65%), with the majority being near the left PVs/appendage (35% of all RAAPs) and the superior vena cava/right appendage (23% of all RAAPs). CONCLUSION High-resolution, sequential endocardial EGM-based mapping allows identification of RAAPs in persistent AF. In our series, focal firing was the most frequently observed pattern.
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Affiliation(s)
- Michael Wolf
- Department of Cardiology, Sint-Jan Hospital Bruges, Bruges, Belgium.,Department of Cardiology, Hartcentrum ZNA Middelheim, Antwerp, Belgium.,Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - René Tavernier
- Department of Cardiology, Sint-Jan Hospital Bruges, Bruges, Belgium
| | - Ziad Zeidan
- Clinical Development - Research and Development, Biosense Webster, Inc, South Diamond Bar, California
| | - Milad El Haddad
- Department of Cardiology, Sint-Jan Hospital Bruges, Bruges, Belgium
| | | | - Jan De Pooter
- Department of Cardiology, Sint-Jan Hospital Bruges, Bruges, Belgium
| | - Thomas Phlips
- Department of Cardiology, Sint-Jan Hospital Bruges, Bruges, Belgium
| | | | | | | | - Michelle Lycke
- Department of Cardiology, Sint-Jan Hospital Bruges, Bruges, Belgium
| | | | - Sébastien Knecht
- Department of Cardiology, Sint-Jan Hospital Bruges, Bruges, Belgium
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28
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Honarbakhsh S, Schilling RJ, Dhillon G, Ullah W, Keating E, Providencia R, Chow A, Earley MJ, Hunter RJ. A Novel Mapping System for Panoramic Mapping of the Left Atrium: Application to Detect and Characterize Localized Sources Maintaining Atrial Fibrillation. JACC Clin Electrophysiol 2019; 4:124-134. [PMID: 29387810 PMCID: PMC5777816 DOI: 10.1016/j.jacep.2017.09.177] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Objectives This study sought to use a novel panoramic mapping system (CARTOFINDER) to detect and characterize drivers in persistent atrial fibrillation (AF). Background Mechanisms sustaining persistent AF remain uncertain. Methods Patients undergoing catheter ablation for persistent AF were included. A 64-pole basket catheter was used to acquire unipolar signals, which were processed by the mapping system to generate wavefront propagation maps. The system was used to identify and characterize potential drivers in AF pre- and post-pulmonary vein (PV) isolation. The effect of ablation on drivers identified post-PV isolation was assessed. Results Twenty patients were included in the study with 112 CARTOFINDER maps created. Potential drivers were mapped in 19 of 20 patients with AF (damage to the basket and noise on electrograms was present in 1 patient). Thirty potential drivers were identified all of which were transient but repetitive; 19 were rotational and 11 focal. Twenty-six drivers were ablated with a predefined response in 22 of 26 drivers: AF terminated with 12 and cycle length slowed (≥30 ms) with 10. Drivers with rotational activation were predominantly mapped to sites of low-voltage zones (81.8%). PV isolation had no remarkable impact on the cycle length at the driver sites (138.4 ± 14.3 ms pre-PV isolation vs. 137.2 ± 15.2 ms post-PV isolation) and drivers that had also been identified on pre-PV isolation maps were more commonly associated with AF termination. Conclusions Drivers were identified in almost all patients in the form of intermittent but repetitive focal or rotational activation patterns. The mechanistic importance of these phenomena was confirmed by the response to ablation.
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Affiliation(s)
- Shohreh Honarbakhsh
- Barts Heart Centre, St. Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Richard J Schilling
- Barts Heart Centre, St. Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Gurpreet Dhillon
- Barts Heart Centre, St. Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Waqas Ullah
- Barts Heart Centre, St. Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Emily Keating
- Barts Heart Centre, St. Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Rui Providencia
- Barts Heart Centre, St. Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Anthony Chow
- Barts Heart Centre, St. Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Mark J Earley
- Barts Heart Centre, St. Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Ross J Hunter
- Barts Heart Centre, St. Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom.
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29
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Child N, Clayton RH, Roney CH, Laughner JI, Shuros A, Neuzil P, Petru J, Jackson T, Porter B, Bostock J, Niederer SA, Razavi RS, Rinaldi CA, Taggart P, Wright MJ, Gill J. Unraveling the Underlying Arrhythmia Mechanism in Persistent Atrial Fibrillation: Results From the STARLIGHT Study. Circ Arrhythm Electrophysiol 2019; 11:e005897. [PMID: 29858382 DOI: 10.1161/circep.117.005897] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 03/20/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND The mechanisms that initiate and sustain persistent atrial fibrillation are not well characterized. Ablation results remain significantly worse than in paroxysmal atrial fibrillation in which the mechanism is better understood and subsequent targeted therapy has been developed. The aim of this study was to characterize and quantify patterns of activation during atrial fibrillation using contact mapping. METHODS Patients with persistent atrial fibrillation (n=14; mean age, 61±8 years; ejection fraction, 59±10%) underwent simultaneous biatrial contact mapping with 64 electrode catheters. The atrial electrograms were transformed into phase, and subsequent spatiotemporal mapping was performed to identify phase singularities (PSs). RESULTS PSs were located in both atria, but we observed more PSs in the left atrium compared with the right atrium (779±302, 552±235; P=0.015). Although some PSs of duration sufficient to complete >1 rotation were detected, the maximum PS duration was only 1150 ms, and the vast majority (97%) of PSs persisted for too short a period to complete a full rotation. Although in selected patients there was evidence of PS local clustering, overall, PSs were distributed globally throughout both chambers with no clear anatomic predisposition. In a subset of patients (n=7), analysis was repeated using an alternative established atrial PS mapping technique, which confirmed our initial findings. CONCLUSIONS No sustained rotors or localized drivers were detected, and instead, the mechanism of arrhythmia maintenance was consistent with the multiple wavelet hypothesis, with passive activation of short-lived rotational activity. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT01765075.
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Affiliation(s)
- Nicholas Child
- Department of Imaging Sciences and Biomedical Engineering, King's College London, United Kingdom (N.C., C.R.R., T.J., B.P., S.A.N., R.S.R.).
| | - Richard H Clayton
- INSIGNEO Institute for In Silico Medicine, University of Sheffield, United Kingdom (R.H.C.)
| | - Caroline H Roney
- Department of Imaging Sciences and Biomedical Engineering, King's College London, United Kingdom (N.C., C.R.R., T.J., B.P., S.A.N., R.S.R.)
| | | | - Allan Shuros
- Boston Scientific Corp, St. Paul, MN (J.I.L., A.S.)
| | - Petr Neuzil
- Department of Cardiology, Na Holmolce Hospital, Prague, Czech Republic (P.N., J.P.)
| | - Jan Petru
- Department of Cardiology, Na Holmolce Hospital, Prague, Czech Republic (P.N., J.P.)
| | - Tom Jackson
- Department of Imaging Sciences and Biomedical Engineering, King's College London, United Kingdom (N.C., C.R.R., T.J., B.P., S.A.N., R.S.R.)
| | - Bradley Porter
- Department of Imaging Sciences and Biomedical Engineering, King's College London, United Kingdom (N.C., C.R.R., T.J., B.P., S.A.N., R.S.R.)
| | - Julian Bostock
- Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (J.B., C.A.R., M.J.W., J.G.)
| | - Steven A Niederer
- Department of Imaging Sciences and Biomedical Engineering, King's College London, United Kingdom (N.C., C.R.R., T.J., B.P., S.A.N., R.S.R.)
| | - Reza S Razavi
- Department of Imaging Sciences and Biomedical Engineering, King's College London, United Kingdom (N.C., C.R.R., T.J., B.P., S.A.N., R.S.R.)
| | - Christopher A Rinaldi
- Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (J.B., C.A.R., M.J.W., J.G.)
| | | | - Matthew J Wright
- Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (J.B., C.A.R., M.J.W., J.G.)
| | - Jaswinder Gill
- Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (J.B., C.A.R., M.J.W., J.G.)
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30
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Friedman DJ, Liu P, Barnett AS, Campbell KB, Jackson KP, Bahnson TD, Daubert JP, Piccini JP. Obstructive sleep apnea is associated with increased rotor burden in patients undergoing focal impulse and rotor modification guided atrial fibrillation ablation. Europace 2019; 20:f337-f342. [PMID: 29016785 DOI: 10.1093/europace/eux248] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 07/03/2017] [Indexed: 01/21/2023] Open
Abstract
Aims To assess whether obstructive sleep apnea (OSA) was associated with increased rotor burden among atrial fibrillation (AF) patients. Methods and results We studied 33 consecutive patients who were scheduled for focal impulse and rotor modulation (FIRM) ablation at our institution to describe the mapping, ablation, and outcomes, among patients with and without OSA. Patients underwent biatrial FIRM mapping in AF with ablation of stable rotors in addition to conventional ablation lesion sets. Differences between groups were tested with student's t-tests and Fisher's exact tests, as appropriate. Survival analyses were performed using the Kaplan-Meier method. Twelve of the 33 (36%) patients had OSA and 8 (66%) used continuous positive airway pressure ventilation (CPAP). Obstructive sleep apnea patients had a higher body mass index (BMI) (33.6 vs. 28.8 kg/m2, P = 0.01) and were more commonly on beta blockers (67% vs. 29%, P = 0.03) but were otherwise similar regarding baseline characteristics, medication use, and prior AF treatments, including antiarrhythmic drugs and prior ablation. Focal impulse and rotor modulation mapping demonstrated increased rotor burden in the OSA patients (2.6 ± 0.9 vs. 2.0 ± 1.0, P =0.03). The increased rotor burden was more evident in the right atrium (RA) (1.0 ± 0.7 vs. 0.5 ± 0.7, P =0.04 compared with left atrium (1.7 ± 0.8 vs. 1.4 ± 0.7, P = 0.15). There was no correlation between BMI and total number of rotors (r = 0.0961, P = 0.59). Among the population of patients with OSA, CPAP therapy was associated with a lower number of RA rotors (0.8 ± 0.7 vs. 1.5 ± 0.6, P = 0.05) but no significant difference in overall rotors (P = 0.33). Conclusion Obstructive sleep apnea patients demonstrate increased rotor prevalence, driven predominantly by an increase in RA rotors. CPAP therapy was associated with fewer RA rotors.
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Affiliation(s)
- Daniel J Friedman
- Duke Center for Atrial Fibrillation, Duke University Hospital, Durham, NC, USA.,Electrophysiology Section, Duke Clinical Research Institute, Pratt Street, Durham, NC, USA
| | - Peter Liu
- Duke Center for Atrial Fibrillation, Duke University Hospital, Durham, NC, USA.,Electrophysiology Section, Duke Clinical Research Institute, Pratt Street, Durham, NC, USA
| | - Adam S Barnett
- Duke Center for Atrial Fibrillation, Duke University Hospital, Durham, NC, USA
| | | | - Kevin P Jackson
- Duke Center for Atrial Fibrillation, Duke University Hospital, Durham, NC, USA
| | - Tristram D Bahnson
- Duke Center for Atrial Fibrillation, Duke University Hospital, Durham, NC, USA
| | - James P Daubert
- Duke Center for Atrial Fibrillation, Duke University Hospital, Durham, NC, USA
| | - Jonathan P Piccini
- Duke Center for Atrial Fibrillation, Duke University Hospital, Durham, NC, USA.,Electrophysiology Section, Duke Clinical Research Institute, Pratt Street, Durham, NC, USA
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31
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Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, Akar JG, Badhwar V, Brugada J, Camm J, Chen PS, Chen SA, Chung MK, Nielsen JC, Curtis AB, Wyn Davies D, Day JD, d'Avila A, de Groot NMSN, Di Biase L, Duytschaever M, Edgerton JR, Ellenbogen KA, Ellinor PT, Ernst S, Fenelon G, Gerstenfeld EP, Haines DE, Haissaguerre M, Helm RH, Hylek E, Jackman WM, Jalife J, Kalman JM, Kautzner J, Kottkamp H, Kuck KH, Kumagai K, Lee R, Lewalter T, Lindsay BD, Macle L, Mansour M, Marchlinski FE, Michaud GF, Nakagawa H, Natale A, Nattel S, Okumura K, Packer D, Pokushalov E, Reynolds MR, Sanders P, Scanavacca M, Schilling R, Tondo C, Tsao HM, Verma A, Wilber DJ, Yamane T. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation: executive summary. J Interv Card Electrophysiol 2019; 50:1-55. [PMID: 28914401 PMCID: PMC5633646 DOI: 10.1007/s10840-017-0277-z] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Hugh Calkins
- Johns Hopkins Medical Institutions, Baltimore, MD, USA.
| | | | - Riccardo Cappato
- Humanitas Research Hospital, Arrhythmias and Electrophysiology Research Center, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS, Humanitas Clinical and Research Center, Milan, Italy
| | | | - Eduardo B Saad
- Hospital Pro-Cardiaco and Hospital Samaritano, Botafogo, Rio de Janeiro, Brazil
| | | | - Joseph G Akar
- Yale University School of Medicine, New Haven, CT, USA
| | - Vinay Badhwar
- West Virginia University School of Medicine, Morgantown, WV, USA
| | - Josep Brugada
- Cardiovascular Institute, Hospital Clínic, University of Barcelona, Catalonia, Spain
| | - John Camm
- St. George's University of London, London, UK
| | - Peng-Sheng Chen
- Indiana University School of Medicine, Indianapolis, IN, USA
| | | | | | | | | | - D Wyn Davies
- Imperial College Healthcare NHS Trust, London, UK
| | - John D Day
- Intermountain Medical Center Heart Institute, Salt Lake City, UT, USA
| | | | | | - Luigi Di Biase
- Albert Einstein College of Medicine, Montefiore-Einstein Center for Heart & Vascular Care, Bronx, NY, USA
| | | | | | | | | | - Sabine Ernst
- Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, UK
| | - Guilherme Fenelon
- Albert Einstein Jewish Hospital, Federal University of São Paulo, São Paulo, Brazil
| | | | | | | | | | - Elaine Hylek
- Boston University School of Medicine, Boston, MA, USA
| | - Warren M Jackman
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Jose Jalife
- University of Michigan, Ann Arbor, MI, USA
- The National Center for Cardiovascular Research Carlos III (CNIC), Madrid, Spain
- CIBERCV, Madrid, Spain
| | - Jonathan M Kalman
- Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia
| | - Josef Kautzner
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Hans Kottkamp
- Hirslanden Hospital, Department of Electrophysiology, Zurich, Switzerland
| | | | | | - Richard Lee
- Saint Louis University Medical School, St. Louis, MO, USA
| | - Thorsten Lewalter
- Department of Cardiology and Intensive Care, Hospital Munich-Thalkirchen, Munich, Germany
| | | | - Laurent Macle
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montréal, Canada
| | | | - Francis E Marchlinski
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | | | - Hiroshi Nakagawa
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Andrea Natale
- St. David's Medical Center, Texas Cardiac Arrhythmia Institute, Austin, TX, USA
| | - Stanley Nattel
- Montreal Heart Institute, Montreal, QC, Canada
- Université de Montréal, Montreal, QC, Canada
- McGill University, Montreal, QC, Canada
- University Duisburg-Essen, Essen, Germany
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | | | - Evgeny Pokushalov
- State Research Institute of Circulation Pathology, Novosibirsk, Russia
| | | | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide, Adelaide, Australia
- Royal Adelaide Hospital, Adelaide, Australia
| | | | | | - Claudio Tondo
- Cardiac Arrhythmia Research Center, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Cardiovascular Sciences, University of Milan, Milan, Italy
| | | | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Toronto, ON, Canada
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32
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Gianni C, Mohanty S, Trivedi C, Di Biase L, Natale A. Novel concepts and approaches in ablation of atrial fibrillation: the role of non-pulmonary vein triggers. Europace 2019; 20:1566-1576. [PMID: 29697759 DOI: 10.1093/europace/euy034] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 02/26/2018] [Indexed: 12/25/2022] Open
Abstract
Ablation of non-pulmonary vein (PV) triggers is an important step to improve outcomes in atrial fibrillation ablation. Non-pulmonary vein triggers typically originates from predictable sites (such as the left atrial posterior wall, superior vena cava, coronary sinus, interatrial septum, and crest terminalis), and these areas can be ablated either empirically or after observing significant ectopy (with or without drug challenge). In this review, we will focus on ablation of non-PV triggers, summarizing the existing evidence and our current approach for their mapping and ablation.
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Affiliation(s)
- Carola Gianni
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA.,U.O.C. Cardiologia, IRCCS Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Sanghamitra Mohanty
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA.,Dell Medical School, University of Texas, Austin, TX, USA
| | - Chintan Trivedi
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | - Luigi Di Biase
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA.,Department of Biomedical Engineering, University of Texas, Austin, TX, USA.,Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA.,Dell Medical School, University of Texas, Austin, TX, USA.,Department of Biomedical Engineering, University of Texas, Austin, TX, USA.,MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Division of Cardiology, Stanford University, Stanford, CA, USA.,Electrophysiology and Arrhythmia Services, California Pacific Medical Center, San Francisco, CA, USA
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33
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Honarbakhsh S, Hunter RJ, Ullah W, Keating E, Finlay M, Schilling RJ. Ablation in Persistent Atrial Fibrillation Using Stochastic Trajectory Analysis of Ranked Signals (STAR) Mapping Method. JACC Clin Electrophysiol 2019; 5:817-829. [PMID: 31320010 DOI: 10.1016/j.jacep.2019.04.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 04/23/2019] [Accepted: 04/24/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The aim of this study was to demonstrate that a stochastic vector-based mapping approach could guide ablation of atrial fibrillation (AF) drivers as evidenced by ablation response and long-term follow-up outcomes. BACKGROUND The optimal method for mapping and ablation of AF drivers is yet to be defined. METHODS Patients undergoing persistent AF ablation were recruited. Patients underwent pulmonary vein isolation (PVI) with further ablation guided by the stochastic trajectory analysis of ranked signals (STAR) mapping method. The proportion of the time an electrode's activation was seen to precede its neighboring electrodes activation was used to determine early sites of activation (ESA). A positive ablation response at ESA was defined as AF termination or cycle length slowing of ≥30 ms. Clinical outcome was defined as recurrence of AF/atrial tachycardia (AT) during a follow-up of 12 months. RESULTS Thirty-five patients were included (AF duration of 14.4 ± 5.3 months). After PVI, an average of 2.6 ± 0.8 ESA were ablated per patient with study-defined ablation response achieved in all patients. Of the 86 STAR maps created post-PVI, the same ESA was identified on 73.8 ± 26.1% of maps. ESA that resulted in AF termination were more likely to be identified on both pre- and post-PVI maps than those associated with cycle length slowing (23 of 24 vs. 16 of 49; p < 0.001). During a follow-up of 18.5 ± 3.7 months, 28 (80%) patients were free from AF/AT. CONCLUSIONS The ablation response at ESA suggests they may be drivers of AF. Ablation guided by STAR mapping produced a favorable clinical outcome and warrants testing through a randomized controlled trial. (Identification, Electro-mechanical Characterisation and Ablation of Driver Regions in Persistent Atrial Fibrillation [STAR MAPPING]; NCT02950844).
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Affiliation(s)
- Shohreh Honarbakhsh
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom
| | - Ross J Hunter
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom
| | - Waqas Ullah
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom
| | - Emily Keating
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom
| | - Malcolm Finlay
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom
| | - Richard J Schilling
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom.
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34
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Aronis KN, Berger RD, Ashikaga H. Rotors: How Do We Know When They Are Real? Circ Arrhythm Electrophysiol 2019; 10:CIRCEP.117.005634. [PMID: 28887363 DOI: 10.1161/circep.117.005634] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 08/12/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Konstantinos N Aronis
- From the Cardiac Arrhythmia Service (K.N.A., R.D.B., H.A.) and Department of Biomedical Engineering (R.D.B., H.A.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ronald D Berger
- From the Cardiac Arrhythmia Service (K.N.A., R.D.B., H.A.) and Department of Biomedical Engineering (R.D.B., H.A.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hiroshi Ashikaga
- From the Cardiac Arrhythmia Service (K.N.A., R.D.B., H.A.) and Department of Biomedical Engineering (R.D.B., H.A.), Johns Hopkins University School of Medicine, Baltimore, MD.
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35
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Martinez-Mateu L, Romero L, Saiz J, Berenfeld O. Far-field contributions in multi-electrodes atrial recordings blur distinction between anatomical and functional reentries and may cause imaginary phase singularities - A computational study. Comput Biol Med 2019; 108:276-287. [PMID: 31015048 DOI: 10.1016/j.compbiomed.2019.02.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 02/14/2019] [Accepted: 02/21/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common cardiac arrhythmia and the most important cause of embolic stroke, requiring new technologies for its better understanding and therapies. Recent approaches to map the electrical activity during AF with multi-electrode systems aim at localizing patient-specific ablation targets of reentrant patterns. However, there is a critical need to determine the accuracy of those mapping systems. We performed computer simulations as a numerical approach of systematically evaluating the influence of far-field sources on the electrical recordings and detection of rotors. METHODS We constructed 2 computer models of atrial tissue: (i) a 2D sheet model with varying non-active cells area in its center, and (ii) a whole realistic 3D atrial model. Phase maps were built based on the Hilbert transform of the unipolar electrograms recorded by virtual 2D and 3D multi-electrode systems and rotors were tracked through phase singularities detections. RESULTS Analysis of electrograms recorded away from the 2D atrial model shows that the larger the distance between an electrode and the tissue model, the stronger the far-field sources contribution to the electrogram is. Importantly, even if an electrode is positioned in contact with the tissue, the electrogram contains significant contributions from distal sources that blur the distinction between anatomical and functional reentries. Moreover, when mapping the 3D atrial model, remote activity generated false phase singularities at locations without local reentrant excitation patterns. CONCLUSIONS Far-field contributions to electrograms during AF reduce the accuracy of detecting and interpreting reentrant activity.
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Affiliation(s)
- Laura Martinez-Mateu
- Centro de Investigación e Innovación en Bioingeniería, Universitat Politècnica de València, Valencia, Spain.
| | - Lucia Romero
- Centro de Investigación e Innovación en Bioingeniería, Universitat Politècnica de València, Valencia, Spain
| | - Javier Saiz
- Centro de Investigación e Innovación en Bioingeniería, Universitat Politècnica de València, Valencia, Spain
| | - Omer Berenfeld
- Center for Arrhythmia Research, University of Michigan, Ann Arbor, MI, USA
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36
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Donal E, Galli E, Lederlin M, Martins R, Schnell F. Multimodality Imaging for Best Dealing With Patients in Atrial Arrhythmias. JACC Cardiovasc Imaging 2019; 12:2245-2261. [PMID: 30878420 DOI: 10.1016/j.jcmg.2018.06.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 05/21/2018] [Accepted: 06/22/2018] [Indexed: 12/28/2022]
Abstract
The management of atrial fibrillation (AF) is not only a clinical challenge but also an imaging challenge. The role of different imaging modalities to estimate the thromboembolic risk in AF is a key clinical question. The present review summarizes the advances of myocardial imaging in the stratification of thromboembolic risk, diagnosis, and management of left atrial thrombosis in patients with AF. These imaging techniques are also important for understanding arrhythmias and their consequences. It is becoming fundamental for guiding therapy. Still, large studies are required, but be sure that left atrial imaging will become more and more clinically fundamental.
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Affiliation(s)
- Erwan Donal
- Service de Cardiologie, CIC-IT INSERM 1414, CHU Pontchaillou, Rennes, France; Laboratoire Traitement du Signal et de l'Image, Université de Rennes 1, INSERM, UMR 1099, Rennes, France.
| | - Elena Galli
- Service de Cardiologie, CIC-IT INSERM 1414, CHU Pontchaillou, Rennes, France; Laboratoire Traitement du Signal et de l'Image, Université de Rennes 1, INSERM, UMR 1099, Rennes, France
| | - Matthieu Lederlin
- Laboratoire Traitement du Signal et de l'Image, Université de Rennes 1, INSERM, UMR 1099, Rennes, France; Service de Radiologie, CHU Pontchaillou, Rennes, France
| | - Raphael Martins
- Service de Cardiologie, CIC-IT INSERM 1414, CHU Pontchaillou, Rennes, France; Laboratoire Traitement du Signal et de l'Image, Université de Rennes 1, INSERM, UMR 1099, Rennes, France
| | - Frederic Schnell
- Service de Cardiologie, CIC-IT INSERM 1414, CHU Pontchaillou, Rennes, France; Service de médecine du sport et laboratoire de physiologie, Université Rennes 1, CHU Pontchaillou, Rennes, France
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37
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Entropy Mapping Approach for Functional Reentry Detection in Atrial Fibrillation: An In-Silico Study. ENTROPY 2019; 21:e21020194. [PMID: 33266909 PMCID: PMC7514676 DOI: 10.3390/e21020194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 02/06/2019] [Accepted: 02/15/2019] [Indexed: 12/19/2022]
Abstract
Catheter ablation of critical electrical propagation sites is a promising tool for reducing the recurrence of atrial fibrillation (AF). The spatial identification of the arrhythmogenic mechanisms sustaining AF requires the evaluation of electrograms (EGMs) recorded over the atrial surface. This work aims to characterize functional reentries using measures of entropy to track and detect a reentry core. To this end, different AF episodes are simulated using a 2D model of atrial tissue. Modified Courtemanche human action potential and Fenton–Karma models are implemented. Action potential propagation is modeled by a fractional diffusion equation, and virtual unipolar EGM are calculated. Episodes with stable and meandering rotors, figure-of-eight reentry, and disorganized propagation with multiple reentries are generated. Shannon entropy (ShEn), approximate entropy (ApEn), and sample entropy (SampEn) are computed from the virtual EGM, and entropy maps are built. Phase singularity maps are implemented as references. The results show that ApEn and SampEn maps are able to detect and track the reentry core of rotors and figure-of-eight reentry, while the ShEn results are not satisfactory. Moreover, ApEn and SampEn consistently highlight a reentry core by high entropy values for all of the studied cases, while the ability of ShEn to characterize the reentry core depends on the propagation dynamics. Such features make the ApEn and SampEn maps attractive tools for the study of AF reentries that persist for a period of time that is similar to the length of the observation window, and reentries could be interpreted as AF-sustaining mechanisms. Further research is needed to determine and fully understand the relation of these entropy measures with fibrillation mechanisms other than reentries.
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38
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Analysis of the preferable site and stability of rotational reentry: its role for the maintenance of atrial fibrillation. Heart Vessels 2019; 34:1014-1023. [DOI: 10.1007/s00380-018-01331-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 12/21/2018] [Indexed: 10/27/2022]
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39
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Yu HT, Jeong DS, Pak HN, Park HS, Kim JY, Kim J, Lee JM, Kim KH, Yoon NS, Roh SY, Oh YS, Cho YJ, Shim J. 2018 Korean Guidelines for Catheter Ablation of Atrial Fibrillation: Part II. INTERNATIONAL JOURNAL OF ARRHYTHMIA 2018. [DOI: 10.18501/arrhythmia.2018.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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40
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Miller JM, Shirazi JT. Multimodal Mapping in Human Atrial Fibrillation: Getting Closer to FIRM Conclusions? JACC Clin Electrophysiol 2018; 4:1516-1518. [PMID: 30573113 DOI: 10.1016/j.jacep.2018.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 10/18/2018] [Indexed: 11/16/2022]
Affiliation(s)
- John M Miller
- Krannert Institute of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.
| | - Jonathan T Shirazi
- Krannert Institute of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
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41
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Williams SE, Harrison JL, Chubb H, Whitaker J, Kiedrowicz R, Rinaldi CA, Cooklin M, Wright M, Niederer S, O'Neill MD. Local activation time sampling density for atrial tachycardia contact mapping: how much is enough? Europace 2018; 20:e11-e20. [PMID: 28379525 PMCID: PMC5834039 DOI: 10.1093/europace/eux037] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 02/12/2017] [Indexed: 11/25/2022] Open
Abstract
Aims Local activation time (LAT) mapping forms the cornerstone of atrial tachycardia diagnosis. Although anatomic and positional accuracy of electroanatomic mapping (EAM) systems have been validated, the effect of electrode sampling density on LAT map reconstruction is not known. Here, we study the effect of chamber geometry and activation complexity on optimal LAT sampling density using a combined in silico and in vivo approach. Methods and results In vivo 21 atrial tachycardia maps were studied in three groups: (1) focal activation, (2) macro-re-entry, and (3) localized re-entry. In silico activation was simulated on a 4×4cm atrial monolayer, sampled randomly at 0.25–10 points/cm2 and used to re-interpolate LAT maps. Activation patterns were studied in the geometrically simple porcine right atrium (RA) and complex human left atrium (LA). Activation complexity was introduced into the porcine RA by incomplete inter-caval linear ablation. In all cases, optimal sampling density was defined as the highest density resulting in minimal further error reduction in the re-interpolated maps. Optimal sampling densities for LA tachycardias were 0.67 ± 0.17 points/cm2 (focal activation), 1.05 ± 0.32 points/cm2 (macro-re-entry) and 1.23 ± 0.26 points/cm2 (localized re-entry), P = 0.0031. Increasing activation complexity was associated with increased optimal sampling density both in silico (focal activation 1.09 ± 0.14 points/cm2; re-entry 1.44 ± 0.49 points/cm2; spiral-wave 1.50 ± 0.34 points/cm2, P < 0.0001) and in vivo (porcine RA pre-ablation 0.45 ± 0.13 vs. post-ablation 0.78 ± 0.17 points/cm2, P = 0.0008). Increasing chamber geometry was also associated with increased optimal sampling density (0.61 ± 0.22 points/cm2 vs. 1.0 ± 0.34 points/cm2, P = 0.0015). Conclusion Optimal sampling densities can be identified to maximize diagnostic yield of LAT maps. Greater sampling density is required to correctly reveal complex activation and represent activation across complex geometries. Overall, the optimal sampling density for LAT map interpolation defined in this study was ∼1.0–1.5 points/cm2.
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Affiliation(s)
- Steven E Williams
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor North Wing, St Thomas' Hospital, 249 Westminster Bridge Road, SE1 7EH London
| | - James L Harrison
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor North Wing, St Thomas' Hospital, 249 Westminster Bridge Road, SE1 7EH London
| | - Henry Chubb
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor North Wing, St Thomas' Hospital, 249 Westminster Bridge Road, SE1 7EH London
| | - John Whitaker
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor North Wing, St Thomas' Hospital, 249 Westminster Bridge Road, SE1 7EH London
| | - Radek Kiedrowicz
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, 249 Westminster Bridge Road, SE1 7EH London, UK
| | - Christopher A Rinaldi
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, 249 Westminster Bridge Road, SE1 7EH London, UK
| | - Michael Cooklin
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, 249 Westminster Bridge Road, SE1 7EH London, UK
| | - Matthew Wright
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor North Wing, St Thomas' Hospital, 249 Westminster Bridge Road, SE1 7EH London
| | - Steven Niederer
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor North Wing, St Thomas' Hospital, 249 Westminster Bridge Road, SE1 7EH London
| | - Mark D O'Neill
- Division of Imaging Sciences and Biomedical Engineering, King's College London, 4th Floor North Wing, St Thomas' Hospital, 249 Westminster Bridge Road, SE1 7EH London
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42
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Sohn D, Aronis K, Ashikaga H. Scale-invariant structures of spiral waves. Comput Biol Med 2018; 104:291-298. [PMID: 30458961 DOI: 10.1016/j.compbiomed.2018.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 11/06/2018] [Accepted: 11/07/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND Spiral waves are considered to be one of the potential mechanisms that maintain complex arrhythmias such as atrial and ventricular fibrillation. The aim of the present study was to quantify the complex dynamics of spiral waves as the organizing manifolds of information flow at multiple scales. METHOD We simulated spiral waves using a numerical model of cardiac excitation in a two-dimensional (2-D) lattice. We created a renormalization group by coarse graining and re-scaling the original time series in multiple spatiotemporal scales, and quantified the Lagrangian coherent structures (LCS) of the information flow underlying the spiral waves. To quantify the scale-invariant structures, we compared the value of the finite-time Lyapunov exponent between the corresponding components of the 2-D lattice in each spatiotemporal scale of the renormalization group with that of the original scale. RESULTS Both the repelling and the attracting LCS changed across the different spatial and temporal scales of the renormalization group. However, despite the change across the scales, some LCS were scale-invariant. The patterns of those scale-invariant structures were not obvious from the trajectory of the spiral waves based on voltage mapping of the lattice. CONCLUSIONS Some Lagrangian coherent structures of information flow underlying spiral waves are preserved across multiple spatiotemporal scales.
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Affiliation(s)
- Daniel Sohn
- Cardiac Arrhythmia Service, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Carnegie 568, Baltimore, MD, USA
| | - Konstantinos Aronis
- Cardiac Arrhythmia Service, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Carnegie 568, Baltimore, MD, USA
| | - Hiroshi Ashikaga
- Cardiac Arrhythmia Service, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Carnegie 568, Baltimore, MD, USA; IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, F-33600, Pessac-Bordeaux, France.
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43
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Qin M, Lin RJ, Wu SH, Liu X. Extra pulmonary vein driver mapping and ablation in paroxysmal atrial fibrillation by electrogram dispersion analysis. J Cardiovasc Electrophysiol 2018; 30:164-170. [PMID: 30375072 DOI: 10.1111/jce.13784] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 10/13/2018] [Accepted: 10/23/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND The adjunctive approach is still unknown for atrial fibrillation (AF), which cannot be terminated after pulmonary vein isolation (PVI). We hypothesized that the driver ablation plus PVI was superior to PVI alone. METHODS AND RESULTS A total of 98 patients with paroxysmal AF were enrolled in this study and were divided into two groups, with one group undergoing PVI (n = 49) and the other group undergoing PVI + driver ablation (n = 49). The driver regions were defined as clusters of bipolar electrograms that displayed spatial dispersion spread over mean AF cycle length at a minimum of three adjacent bipolars of a PentaRay catheter. During the procedure, the most prominent driver regions before PVI were the roof (n = 27; 55.1%), PV antrum (n = 23; 46.9%), and the inferoposterior wall (n = 11; 22.4%). PVI can eliminate all drivers at PV antrum, but only terminate 30.4% of AF in the driver group. The AF termination rate in the driver ablation group was significantly higher than that in conventional ablation (93.9% vs 40.6%; P < 0.001). The rate of freedom from atrial tachyarrhythmia episodes by a single procedure at 6 months was significantly higher in the driver group than in the conventional group (91.6% vs 72.4%; P = 0.02). CONCLUSION The present method is effective for AF driver identification. It guided ablation adjunctive to PVI increasing the rate of AF termination and improving the outcomes in patients with paroxysmal AF.
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Affiliation(s)
- Mu Qin
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Rong-Jie Lin
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Shao-Hui Wu
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Xu Liu
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
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Dharmaprani D, McGavigan AD, Chapman D, Kutlieh R, Thanigaimani S, Dykes L, Kalman J, Sanders P, Pope K, Kuklik P, Ganesan AN. Temporal stability and specificity of high bipolar electrogram entropy regions in sustained atrial fibrillation: Implications for mapping. J Electrocardiol 2018; 53:18-27. [PMID: 30580097 DOI: 10.1016/j.jelectrocard.2018.11.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 11/02/2018] [Accepted: 11/17/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND The potential utility of entropy (En) for atrial fibrillation (AF) mapping has been demonstrated in previous studies by multiple groups, where an association between high bipolar electrogram (EGM) entropy and the pivot of rotors has been shown. Though En is potentially attractive new approach to ablation, no studies have examined its temporal stability and specificity, which are critical to the application of entropy to clinical ablation. In the current study, we sought to objectively measure the temporal stability and specificity of bipolar EGM entropy in medium to long term recordings using three studies: i) a human basket catheter AF study, ii) a tachypaced sheep AF study and iii) a computer simulation study. OBJECTIVE To characterize the temporal dynamics and specificity of Approximate, Sample and Shannon entropy (ApEn/SampEn/ShEn) in human (H), sheep (S), and computer simulated AF. METHODS 64-electrode basket bi-atria sustained AF recordings (H:15 min; S:40 min) were separated into 5 s segments. ShEn/ApEn/SampEn were computed, and co-registered with NavX 3D maps. Temporal stability was determined in terms of: (i) global pattern stability of En and (ii) the relative stability the top 10% of En regions. To provide mechanistic insights into underlying mechanisms, stability characteristics were compared to models depicting various propagation patterns. To verify these results, cross-validation was performed across multiple En algorithms, across species, and compared with dominant frequency (DF) temporal characteristics. The specificity of En was also determined by looking at the association of En to rotors and areas of wave cross propagation. RESULTS Episodes of AF were analysed (H:26 epochs, 6040 s; S:15 epochs, 14,160 s). The global pattern of En was temporally unstable (CV- H:13.42% ± 4.58%; S:14.13% ± 8.13%; Friedman- H: p > 0.001; S: p > 0.001). However, within this dynamic flux, the top 10% of ApEn/SampEn/ShEn regions were relatively temporally stable (Kappa >0.6) whilst the top 10% of DF regions were unstable (Kappa <0.06). In simulated AF scenarios, the experimental data were optimally reproduced in the context of an AF pattern with stable rotating waves surrounded by wavelet breakup (Kappa: 0.610; p < 0.0001). CONCLUSION En shows global temporal instability, however within this dynamic flux, the top 10% regions exhibited relative temporal stability. This suggests that high En regions may be an appealing ablation target. Despite this, high En was associated with not just the pivot of rotors but also with areas of cross propagation, which suggests the need for future work before clinical application is possible.
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Affiliation(s)
- Dhani Dharmaprani
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, SA, Australia
| | - Andrew D McGavigan
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, SA, Australia; Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia
| | | | | | - Shivshankar Thanigaimani
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, SA, Australia
| | - Lukah Dykes
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, SA, Australia
| | | | - Prashanthan Sanders
- University of Adelaide, Adelaide, SA, Australia; South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Kenneth Pope
- College of Science and Engineering, Flinders University of South Australia, Adelaide, SA, Australia
| | - Pawel Kuklik
- Department of Cardiology, University Medical Centre, Hamburg, Germany
| | - Anand N Ganesan
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, SA, Australia; Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia.
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45
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Mohanty S, Gianni C, Trivedi C, Metz T, Bai R, Al-Ahmad A, Bailey S, Burkhardt JD, Gallinghouse GJ, Horton R, Hranitzky PM, Sanchez JE, Di Biase L, Natale A. Impact of rotor ablation in non-paroxysmal AF patients: Findings from the per-protocol population of the OASIS trial at long-term follow-up. Am Heart J 2018; 205:145-148. [PMID: 30144981 DOI: 10.1016/j.ahj.2018.05.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 05/15/2018] [Indexed: 11/25/2022]
Abstract
The objective of this study was to evaluate the long-term efficacy of FIRM ablation with PVAI vs PVAI plus posterior wall isolation (PWI) and non-PV trigger ablation in persistent (PeAF) and long-standing persistent AF (LSPAF) patients. The procedure time was recorded to be 180.6 ± 35.9 and 124.03 ± 45.4 minutes in the FIRM+PVI and PVI + PWI + non-PV trigger ablation group respectively. At 24-month follow-up, 24% (95% CI 8.7%-37.8%) in the FIRM-ablation group and 48% (95% CI 27.6-63.3%) in the non-PV trigger ablation group remained arrhythmia-free off-antiarrhythmic drugs after a single procedure. Clinical Trial Registration:ClinicalTrials.gov (Identifier: NCT02533843).
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46
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Hansen BJ, Zhao J, Li N, Zolotarev A, Zakharkin S, Wang Y, Atwal J, Kalyanasundaram A, Abudulwahed SH, Helfrich KM, Bratasz A, Powell KA, Whitson B, Mohler PJ, Janssen PML, Simonetti OP, Hummel JD, Fedorov VV. Human Atrial Fibrillation Drivers Resolved With Integrated Functional and Structural Imaging to Benefit Clinical Mapping. JACC Clin Electrophysiol 2018; 4:1501-1515. [PMID: 30573112 DOI: 10.1016/j.jacep.2018.08.024] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 07/19/2018] [Accepted: 08/23/2018] [Indexed: 12/23/2022]
Abstract
OBJECTIVES This study sought to improve atrial fibrillation (AF) driver identification by integrating clinical multielectrode mapping with driver fingerprints defined by high-resolution ex vivo 3-dimensional (3D) functional and structural imaging. BACKGROUND Clinical multielectrode mapping of AF drivers suffers from variable contact, signal processing, and structural complexity within the 3D human atrial wall, raising questions on the validity of such drivers. METHODS Sustained AF was mapped in coronary-perfused explanted human hearts (n = 11) with transmural near-infrared optical mapping (∼0.3 mm2 resolution). Simultaneously, custom FIRMap catheters (∼9 × 9 mm2 resolution) mapped endocardial and epicardial surfaces, which were analyzed by Focal Impulse and Rotor Mapping activation and Rotational Activity Profile (Abbott Labs, Chicago, Illinois). Functional maps were integrated with contrast-enhanced cardiac magnetic resonance imaging (∼0.1 mm3 resolution) analysis of 3D fibrosis architecture. RESULTS During sustained AF, near-infrared optical mapping identified 1 to 2 intramural, spatially stable re-entrant AF drivers per heart. Driver targeted ablation affecting 2.2 ± 1.1% of the atrial surface terminated and prevented AF. Driver regions had significantly higher phase singularity density and dominant frequency than neighboring nondriver regions. Focal Impulse and Rotor Mapping had 80% sensitivity to near-infrared optical mapping-defined driver locations (16 of 20), and matched 14 of 20 driver visualizations: 10 of 14 re-entries seen with Rotational Activity Profile; and 4 of 6 breakthrough/focal patterns. Focal Impulse and Rotor Mapping detected 1.1 ± 0.9 false-positive rotational activity profiles per recording, but these regions had lower intramural contrast-enhanced cardiac magnetic resonance imaging fibrosis than did driver regions (14.9 ± 7.9% vs. 23.2 ± 10.5%; p < 0.005). CONCLUSIONS The study revealed that both re-entrant and breakthrough/focal AF driver patterns visualized by surface-only clinical multielectrodes can represent projections of 3D intramural microanatomic re-entries. Integration of multielectrode mapping and 3D fibrosis analysis may enhance AF driver detection, thereby improving the efficacy of driver-targeted ablation.
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Affiliation(s)
- Brian J Hansen
- Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio; Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jichao Zhao
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Ning Li
- Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio; Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Alexander Zolotarev
- Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio; Phystech School of Biological and Medical Physics, Moscow Institute of Physic and Technology, Dolgoprudny, Russian Federation
| | - Stanislav Zakharkin
- Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Yufeng Wang
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Josh Atwal
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Anuradha Kalyanasundaram
- Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio; Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Suhaib H Abudulwahed
- Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Katelynn M Helfrich
- Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Anna Bratasz
- Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Kimerly A Powell
- Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Bryan Whitson
- Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Peter J Mohler
- Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Paul M L Janssen
- Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio; Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Orlando P Simonetti
- Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Biomedical Engineering, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - John D Hummel
- Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Vadim V Fedorov
- Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio; Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio.
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47
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Wann D, Waks JW, Kramer DB. Clinical and regulatory considerations for novel electrophysiology mapping systems: Lessons from FIRM. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:1669-1680. [DOI: 10.1111/pace.13509] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/23/2018] [Accepted: 09/12/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Daniel Wann
- Division of Cardiology, Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
| | - Jonathan W. Waks
- Division of Cardiology, Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
| | - Daniel B. Kramer
- Division of Cardiology, Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
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48
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Cheniti G, Vlachos K, Pambrun T, Hooks D, Frontera A, Takigawa M, Bourier F, Kitamura T, Lam A, Martin C, Dumas-Pommier C, Puyo S, Pillois X, Duchateau J, Klotz N, Denis A, Derval N, Jais P, Cochet H, Hocini M, Haissaguerre M, Sacher F. Atrial Fibrillation Mechanisms and Implications for Catheter Ablation. Front Physiol 2018; 9:1458. [PMID: 30459630 PMCID: PMC6232922 DOI: 10.3389/fphys.2018.01458] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 09/26/2018] [Indexed: 01/14/2023] Open
Abstract
AF is a heterogeneous rhythm disorder that is related to a wide spectrum of etiologies and has broad clinical presentations. Mechanisms underlying AF are complex and remain incompletely understood despite extensive research. They associate interactions between triggers, substrate and modulators including ionic and anatomic remodeling, genetic predisposition and neuro-humoral contributors. The pulmonary veins play a key role in the pathogenesis of AF and their isolation is associated to high rates of AF freedom in patients with paroxysmal AF. However, ablation of persistent AF remains less effective, mainly limited by the difficulty to identify the sources sustaining AF. Many theories were advanced to explain the perpetuation of this form of AF, ranging from a single localized focal and reentrant source to diffuse bi-atrial multiple wavelets. Translating these mechanisms to the clinical practice remains challenging and limited by the spatio-temporal resolution of the mapping techniques. AF is driven by focal or reentrant activities that are initially clustered in a relatively limited atrial surface then disseminate everywhere in both atria. Evidence for structural remodeling, mainly represented by atrial fibrosis suggests that reentrant activities using anatomical substrate are the key mechanism sustaining AF. These reentries can be endocardial, epicardial, and intramural which makes them less accessible for mapping and for ablation. Subsequently, early interventions before irreversible remodeling are of major importance. Circumferential pulmonary vein isolation remains the cornerstone of the treatment of AF, regardless of the AF form and of the AF duration. No ablation strategy consistently demonstrated superiority to pulmonary vein isolation in preventing long term recurrences of atrial arrhythmias. Further research that allows accurate identification of the mechanisms underlying AF and efficient ablation should improve the results of PsAF ablation.
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Affiliation(s)
- Ghassen Cheniti
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France.,Cardiology Department, Hopital Sahloul, Universite de Sousse, Sousse, Tunisia
| | - Konstantinos Vlachos
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Thomas Pambrun
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Darren Hooks
- Cardiology Department, Wellington Hospital, Wellington, New Zealand
| | - Antonio Frontera
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Masateru Takigawa
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Felix Bourier
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Takeshi Kitamura
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Anna Lam
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Claire Martin
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | | | - Stephane Puyo
- Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Xavier Pillois
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France
| | - Josselin Duchateau
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Nicolas Klotz
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Arnaud Denis
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Nicolas Derval
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Pierre Jais
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Hubert Cochet
- Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France.,Department of Cardiovascular Imaging, Hopital Haut Leveque, Bordeaux, France
| | - Meleze Hocini
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Michel Haissaguerre
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Frederic Sacher
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
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49
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Verma A, Sarkozy A, Skanes A, Duytschaever M, Bulava A, Urman R, Amos YA, Potter TD. Characterization and significance of localized sources identified by a novel automated algorithm during mapping of human persistent atrial fibrillation. J Cardiovasc Electrophysiol 2018; 29:1480-1488. [DOI: 10.1111/jce.13742] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 07/11/2018] [Accepted: 07/31/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Atul Verma
- Department of Cardiology, Southlake Regional Health Center, University of Toronto Canada
| | | | - Allan Skanes
- Department of Cardiology, London Health Sciences CenterLondon Canada
| | | | - Alan Bulava
- Department of Cardiology, University of South BohemiaCeske Budejovice Czech Republic
| | - Roy Urman
- Haifa Technology Center, Biosense WebsterHaifa Israel
| | - Yariv A. Amos
- Haifa Technology Center, Biosense WebsterHaifa Israel
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50
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Stiles MK, Sanders P, Lau DH. Targeting the Substrate in Ablation of Persistent Atrial Fibrillation: Recent Lessons and Future Directions. Front Physiol 2018; 9:1158. [PMID: 30279660 PMCID: PMC6154526 DOI: 10.3389/fphys.2018.01158] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 08/02/2018] [Indexed: 12/16/2022] Open
Abstract
While isolation of the pulmonary veins is firmly established as effective treatment for the majority of paroxysmal atrial fibrillation (AF) patients, there is recognition that patients with persistent AF have substrate for perpetuation of arrhythmia existing outside of the pulmonary veins. Various computational approaches have been used to identify targets for effective ablation of persistent AF. This paper aims to discuss the clinical aspects of computational approaches that aim to identify critical sites for treatment. Various analyses of electrogram characteristics have been performed with this aim. Leading techniques for electrogram analysis are Complex Fractionated Atrial Electrograms (CFAE) and Dominant Frequency (DF). These techniques have been the subject of clinical trials of which the results are discussed. Evaluation of the activation patterns of atria in AF has been another avenue of research. Focal Impulse and Rotor Modulation (FIRM) mapping and forms of Body Surface Mapping aim to characterize multiple atrial wavelets, macro-reentry and focal sources which have been proposed as basic mechanisms perpetuating AF. Both invasive and non-invasive activation mapping techniques are reviewed. The presence of atrial fibrosis causes non-uniform anisotropic impulse propagation. Therefore, identification of fibrosis by imaging techniques is an avenue of potential research. The leading contender for imaging-based techniques is Cardiac Magnetic Resonance (CMR). As this technology advances, improvements in resolution and scar identification have positioned CMR as the mode of choice for analysis of atrial structure. AF has been demonstrated to be associated with obesity, inactivity and diseases of modern life. An opportunity exists for detailed computational analysis of the impact of risk factor modification on atrial substrate. This ranges from microstructural investigation through to examination at a population level via registries and public health interventions. Computational analysis of atrial substrate has moved from basic science toward clinical application. Future directions and potential limitations of such analyses are examined in this review.
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Affiliation(s)
- Martin K Stiles
- Waikato Clinical School, University of Auckland, Hamilton, New Zealand.,Department of Cardiology, Waikato District Health Board, Hamilton, New Zealand
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders (CHRD), South Australian Health and Medical Research Institute (SAHMRI), The University of Adelaide and Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders (CHRD), South Australian Health and Medical Research Institute (SAHMRI), The University of Adelaide and Royal Adelaide Hospital, Adelaide, SA, Australia
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