1
|
Riccio J, Alcaine A, Rocher S, Martinez-Mateu L, Laranjo S, Saiz J, Laguna P, Martínez JP. Characterization of Atrial Propagation Patterns and Fibrotic Substrate With a Modified Omnipolar Electrogram Strategy in Multi-Electrode Arrays. Front Physiol 2021; 12:674223. [PMID: 34539424 PMCID: PMC8446360 DOI: 10.3389/fphys.2021.674223] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 07/13/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction: The omnipolar electrogram method was recently proposed to try to generate orientation-independent electrograms. It estimates the electric field from the bipolar electrograms of a clique, under the assumption of locally plane and homogeneous propagation. The local electric field evolution over time describes a loop trajectory from which omnipolar signals in the propagation direction, substrate and propagation features, are derived. In this work, we propose substrate and conduction velocity mapping modalities based on a modified version of the omnipolar electrogram method, which aims to reduce orientation-dependent residual components in the standard approach. Methods: A simulated electrical propagation in 2D, with a tissue including a circular patch of diffuse fibrosis, was used for validation. Unipolar electrograms were calculated in a multi-electrode array, also deriving bipolar electrograms along the two main directions of the grid. Simulated bipolar electrograms were also contaminated with real noise, to assess the robustness of the mapping strategies against noise. The performance of the maps in identifying fibrosis and in reproducing unipolar reference voltage maps was evaluated. Bipolar voltage maps were also considered for performance comparison. Results: Results show that the modified omnipolar mapping strategies are more accurate and robust against noise than bipolar and standard omnipolar maps in fibrosis detection (accuracies higher than 85 vs. 80% and 70%, respectively). They present better correlation with unipolar reference voltage maps than bipolar and original omnipolar maps (Pearson's correlations higher than 0.75 vs. 0.60 and 0.70, respectively). Conclusion: The modified omnipolar method improves fibrosis detection, characterization of substrate and propagation, also reducing the residual sensitivity to directionality over the standard approach and improving robustness against noise. Nevertheless, studies with real electrograms will elucidate its impact in catheter ablation interventions.
Collapse
Affiliation(s)
- Jennifer Riccio
- Biomedical Signal Interpretation and Computational Simulation Group, Aragón Institute of Engineering Research, IIS Aragón, Universidad de Zaragoza, Zaragoza, Spain
| | - Alejandro Alcaine
- Biomedical Signal Interpretation and Computational Simulation Group, Aragón Institute of Engineering Research, IIS Aragón, Universidad de Zaragoza, Zaragoza, Spain
- Facultad de Ciencias de la Salud, Universidad San Jorge, Zaragoza, Spain
- Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina, Zaragoza, Spain
| | - Sara Rocher
- Centro de Investigación e Innovación en Ingeniería, Universitat Politècnica de València, Valencia, Spain
| | - Laura Martinez-Mateu
- Departamento de Teoría de la Señal y Comunicaciones y Sistemas Telemáticos y Computación, Universidad Rey Juan Carlos, Madrid, Spain
| | - Sergio Laranjo
- Department of Pediatric Cardiology, Hospital Santa Marta, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Javier Saiz
- Centro de Investigación e Innovación en Ingeniería, Universitat Politècnica de València, Valencia, Spain
| | - Pablo Laguna
- Biomedical Signal Interpretation and Computational Simulation Group, Aragón Institute of Engineering Research, IIS Aragón, Universidad de Zaragoza, Zaragoza, Spain
- Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina, Zaragoza, Spain
| | - Juan Pablo Martínez
- Biomedical Signal Interpretation and Computational Simulation Group, Aragón Institute of Engineering Research, IIS Aragón, Universidad de Zaragoza, Zaragoza, Spain
- Centro de Investigación Biomédica en Red en Bioingeniería, Biomateriales y Nanomedicina, Zaragoza, Spain
| |
Collapse
|
2
|
Sánchez J, Luongo G, Nothstein M, Unger LA, Saiz J, Trenor B, Luik A, Dössel O, Loewe A. Using Machine Learning to Characterize Atrial Fibrotic Substrate From Intracardiac Signals With a Hybrid in silico and in vivo Dataset. Front Physiol 2021; 12:699291. [PMID: 34290623 PMCID: PMC8287829 DOI: 10.3389/fphys.2021.699291] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/08/2021] [Indexed: 11/15/2022] Open
Abstract
In patients with atrial fibrillation, intracardiac electrogram signal amplitude is known to decrease with increased structural tissue remodeling, referred to as fibrosis. In addition to the isolation of the pulmonary veins, fibrotic sites are considered a suitable target for catheter ablation. However, it remains an open challenge to find fibrotic areas and to differentiate their density and transmurality. This study aims to identify the volume fraction and transmurality of fibrosis in the atrial substrate. Simulated cardiac electrograms, combined with a generalized model of clinical noise, reproduce clinically measured signals. Our hybrid dataset approach combines in silico and clinical electrograms to train a decision tree classifier to characterize the fibrotic atrial substrate. This approach captures different in vivo dynamics of the electrical propagation reflected on healthy electrogram morphology and synergistically combines it with synthetic fibrotic electrograms from in silico experiments. The machine learning algorithm was tested on five patients and compared against clinical voltage maps as a proof of concept, distinguishing non-fibrotic from fibrotic tissue and characterizing the patient's fibrotic tissue in terms of density and transmurality. The proposed approach can be used to overcome a single voltage cut-off value to identify fibrotic tissue and guide ablation targeting fibrotic areas.
Collapse
Affiliation(s)
- Jorge Sánchez
- Institute of Biomedical Engineering, Karlsruhe Institute for Technology, Karlsruhe, Germany
- Centro de Investigación e Innovación en Bioingeniería (Ci2B), Universitàt Politècnica de València, Valencia, Spain
| | - Giorgio Luongo
- Institute of Biomedical Engineering, Karlsruhe Institute for Technology, Karlsruhe, Germany
| | - Mark Nothstein
- Institute of Biomedical Engineering, Karlsruhe Institute for Technology, Karlsruhe, Germany
| | - Laura A. Unger
- Institute of Biomedical Engineering, Karlsruhe Institute for Technology, Karlsruhe, Germany
| | - Javier Saiz
- Centro de Investigación e Innovación en Bioingeniería (Ci2B), Universitàt Politècnica de València, Valencia, Spain
| | - Beatriz Trenor
- Centro de Investigación e Innovación en Bioingeniería (Ci2B), Universitàt Politècnica de València, Valencia, Spain
| | - Armin Luik
- Medizinische Klinik IV, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - Olaf Dössel
- Institute of Biomedical Engineering, Karlsruhe Institute for Technology, Karlsruhe, Germany
| | - Axel Loewe
- Institute of Biomedical Engineering, Karlsruhe Institute for Technology, Karlsruhe, Germany
| |
Collapse
|
3
|
Rottner L, Heeger CH, Lemes C, Wohlmuth P, Maurer T, Reissmann B, Fink T, Mathew S, Ouyang F, Kuck KH, Metzner A, Rillig A. Quantification of Left Atrial Fibrosis in Patients After Pulmonary Vein Isolation Using the Second-Generation Cryoballoon. Int Heart J 2021; 62:65-71. [PMID: 33455982 DOI: 10.1536/ihj.20-301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Left atrial (LA) fibrosis is associated with a poor outcome after atrial fibrillation (AF) ablation. This study examined the extent of low-voltage areas in patients with recurrence of atrial tachyarrhythmia (ATA) after CB-based pulmonary vein isolation (PVI).Sixty patients (mean age 67 ± 10 years, n = 32 female; n = 34 paroxysmal AF) who received radiofrequency redo-procedure due to recurrence of ATA within 6 months after CB-based PVI were included. A point-by point 3D-map was performed, and low-voltage sites were delineated based on bipolar voltage < 0.5 mV. The extent of fibrosis was categorized as stage A (0-10% of the LA wall), stage B (10-30%), stage C (30-50%), and stage D (> 50%).The median area of LA low-voltage sites was 28.9 (9; 50.3) cm2, corresponding to 17.4 (6; 30.6) % of the LA wall surface. 17/60 (28.3%) patients were categorized as fibrosis stage A, 21/60 (35%) as stage B, 18/60 (30%) as stage C, and 4/60 (6.7%) as stage D. Patient age and LA diameter were associated with more pronounced LA fibrosis; the extent of LA fibrosis was significantly higher in patients with LA tachycardia (LAT) during redo-procedures (P < 0.01), and ablation of linear lesions was more often performed (P < 0.01).In patients after CB2-based PVI, expanded LA tissue fibrosis was associated with the occurrence of LAT and more extensive LA ablation during redo-procedures.
Collapse
Affiliation(s)
- Laura Rottner
- Department of Cardiology, Asklepios Klinik St. Georg.,University Heart and Cardiovascular Care Center Hamburg-Eppendorf
| | - Christian-Hendrik Heeger
- Department of Cardiology, Asklepios Klinik St. Georg.,University Heart Center Luebeck, Medical Clinic II (Department of Cardiology, Angiology and Intensive Care Medicine), University Hospital Schleswig-Holstein
| | | | - Peter Wohlmuth
- Department of Cardiology, Asklepios Klinik St. Georg.,Asklepios proresearch
| | - Tilman Maurer
- Department of Cardiology, Asklepios Klinik St. Georg
| | - Bruno Reissmann
- Department of Cardiology, Asklepios Klinik St. Georg.,University Heart and Cardiovascular Care Center Hamburg-Eppendorf
| | - Thomas Fink
- Department of Cardiology, Asklepios Klinik St. Georg.,University Heart Center Luebeck, Medical Clinic II (Department of Cardiology, Angiology and Intensive Care Medicine), University Hospital Schleswig-Holstein
| | - Shibu Mathew
- Department of Cardiology, Asklepios Klinik St. Georg
| | - Feifan Ouyang
- Department of Cardiology, Asklepios Klinik St. Georg
| | | | - Andreas Metzner
- Department of Cardiology, Asklepios Klinik St. Georg.,University Heart and Cardiovascular Care Center Hamburg-Eppendorf
| | - Andreas Rillig
- Department of Cardiology, Asklepios Klinik St. Georg.,Charité, Universitätsmedizin Berlin, Campus Benjamin Franklin.,University Heart and Cardiovascular Care Center Hamburg-Eppendorf
| |
Collapse
|
4
|
Substrate mapping of the left atrium in persistent atrial fibrillation: spatial correlation of localized complex conduction patterns in global charge-density maps to low-voltage areas in 3D contact bipolar voltage maps. J Interv Card Electrophysiol 2021; 62:539-547. [PMID: 33420713 PMCID: PMC8645534 DOI: 10.1007/s10840-020-00926-4] [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: 10/16/2020] [Accepted: 12/27/2020] [Indexed: 12/02/2022]
Abstract
Purpose This study aimed to investigate the spatial relationship between low-voltage areas (LVAs) in bipolar voltage mapping (BVM) and localized complex conduction (LCC)-cores in a global, non-contact, charge-density-based imaging, and mapping system (AcM). Methods Patients with history of index PVI for PsAF and scheduled for a repeat ablation procedure for recurrence of the same arrhythmia were enrolled between August 2018 and February 2020. All patients underwent both substrate mappings of the left atrium (LA) with the CARTO 3D map-ping system and with AcM. Results Ten patients where included in our analysis. All presented with persistency of PVI in all veins at the moment of repeat procedure. There was no linear relationship in BVM maps between SR and CSd (correlation coefficient 0.31 ± 0.15), SR and CSp (0.36 ± 0.12) and CSd and CSp (0.43 ± 0.10). The % overlap of localized irregular activation (LIA), localized rotational activation (LRA) and Focal (F) regions with LVA was lower at 0.2 mV compared to 0.5 mV (4.97 ± 7.39%, 3.27 ± 5.25%, 1.09 ± 1.92% and 12.59 ± 11.81%, 7.8 ± 9.20%, 4.62 ± 5.27%). Sensitivity and specificity are not significantly different when comparing composite maps with different LVA cut-offs. AURC was 0.46, 0.48, and 0.39 for LIA, LRA, and Focal, respectively. Conclusion Due to wave front direction dependency, LVAs mapped with BVM in sinus rhythm and during coronary sinus pacing only partially overlap in patients with PsAF. LCC-cores mapped during PsAF partially co-localize with LVAs.
Collapse
|
5
|
Ho G, Lin AY, Krummen DE. Linking Electrical Drivers With Atrial Cardiomyopathy for the Targeted Treatment of Atrial Fibrillation. Front Physiol 2020; 11:570740. [PMID: 33281614 PMCID: PMC7689158 DOI: 10.3389/fphys.2020.570740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/22/2020] [Indexed: 12/19/2022] Open
Abstract
The relationship between atrial fibrillation (AF) and underlying functional and structural abnormalities has received substantial attention in the research literature over the past decade. Significant progress has been made in identifying these changes using non-invasive imaging, voltage mapping, and electrical recordings. Advances in computed tomography and cardiac magnetic resonance imaging can now provide insight regarding the presence and extent of cardiac fibrosis. Additionally, multiple technologies able to identify electrical targets during AF have emerged. However, an organized strategy to employ these resources in the targeted treatment of AF remains elusive. In this work, we will discuss the basis for mechanistic importance of atrial fibrosis and scar as potential sites promoting AF and emerging technologies to identify and target these structural and functional substrates in the electrophysiology laboratory. We also propose an approach to the use of such technologies to serve as a basis for ongoing work in the field.
Collapse
Affiliation(s)
- Gordon Ho
- Division of Cardiology, Department of Medicine, University of California, San Diego, San Diego, CA, United States
- Division of Cardiology, Veterans Affairs San Diego Medical Center, San Diego, CA, United States
| | - Andrew Y. Lin
- Division of Cardiology, Department of Medicine, University of California, San Diego, San Diego, CA, United States
- Division of Cardiology, Veterans Affairs San Diego Medical Center, San Diego, CA, United States
| | - David E. Krummen
- Division of Cardiology, Department of Medicine, University of California, San Diego, San Diego, CA, United States
- Division of Cardiology, Veterans Affairs San Diego Medical Center, San Diego, CA, United States
| |
Collapse
|
6
|
Fujito T, Mochizuki A, Kamiyama N, Koyama M, Nagahara D, Miura T. Is Incomplete Left Atrial Posterior Wall Isolation Associated With Recurrence of Atrial Fibrillation After Radiofrequency Catheter Ablation? Circ Rep 2020; 2:648-656. [PMID: 33693191 PMCID: PMC7937498 DOI: 10.1253/circrep.cr-20-0044] [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] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background: Complete left atrial posterior wall isolation (LAPI) is not always achieved. We examined whether incomplete LAPI has an effect on outcomes after catheter ablation (CA). Methods and Results: This study enrolled 75 consecutive patients (mean [±SD] age 62.6±8.9 years, 74.7% male) who underwent LAPI by radiofrequency CA for persistent atrial fibrillation (AF). The median follow-up period was 541 days (interquartile range 338-840 days). Incomplete LAPI was defined as the presence of a successfully created roof or floor linear lesion. The rate of complete LAPI was 41.3% (31/75). Either a roof or floor linear lesion was created in 38 patients, whereas neither was created in 6. Multivariate Cox proportional hazards regression analysis revealed that female sex (hazard ratio [HR] 5.29; 95% confidence interval [CI] 1.81-16.8; P=0.002) and complete or incomplete LAPI (HR 0.17; 95% CI 0.03-0.79; P=0.027) were independent predictors of AF recurrence. Kaplan-Meier curves indicated that better outcome was associated with at least one rather than no successful linear lesion (86.5% vs. 50.0% at 1 year; P=0.043). There were no significant differences in outcomes between the complete LAPI and incomplete LAPI groups. Conclusions: Complete LAPI is unachievable in a significant percentage of patients with persistent AF. However, incomplete LAPI, as a result of aiming for complete LAPI, may have a benefit comparable to that of complete LAPI.
Collapse
Affiliation(s)
- Takefumi Fujito
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine Sapporo Japan
| | - Atsushi Mochizuki
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine Sapporo Japan
| | - Naoyuki Kamiyama
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine Sapporo Japan
| | - Masayuki Koyama
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine Sapporo Japan
| | - Daigo Nagahara
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine Sapporo Japan
| | - Tetsuji Miura
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine Sapporo Japan
| |
Collapse
|
7
|
Ng FS, Handa BS, Li X, Peters NS. Toward Mechanism-Directed Electrophenotype-Based Treatments for Atrial Fibrillation. Front Physiol 2020; 11:987. [PMID: 33013435 PMCID: PMC7493660 DOI: 10.3389/fphys.2020.00987] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 07/20/2020] [Indexed: 12/19/2022] Open
Abstract
Current treatment approaches for persistent atrial fibrillation (AF) have a ceiling of success of around 50%. This is despite 15 years of developing adjunctive ablation strategies in addition to pulmonary vein isolation to target the underlying arrhythmogenic substrate in AF. A major shortcoming of our current approach to AF treatment is its predominantly empirical nature. This has in part been due to a lack of consensus on the mechanisms that sustain human AF. In this article, we review evidence suggesting that the previous debates on AF being either an organized arrhythmia with a focal driver or a disorganized rhythm sustained by multiple wavelets, may prove to be a false dichotomy. Instead, a range of fibrillation electrophenotypes exists along a continuous spectrum, and the predominant mechanism in an individual case is determined by the nature and extent of remodeling of the underlying substrate. We propose moving beyond the current empirical approach to AF treatment, highlight the need to prescribe AF treatments based on the underlying AF electrophenotype, and review several possible novel mapping algorithms that may be useful in discerning the AF electrophenotype to guide tailored treatments, including Granger Causality mapping.
Collapse
Affiliation(s)
- Fu Siong Ng
- National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | | | | | | |
Collapse
|
8
|
Kim Y, Chen S, Ernst S, Guzman CE, Han S, Kalarus Z, Labadet C, Lin Y, Lo L, Nogami A, Saad EB, Sapp J, Sticherling C, Tilz R, Tung R, Kim YG, Stiles MK. 2019 APHRS expert consensus statement on three-dimensional mapping systems for tachycardia developed in collaboration with HRS, EHRA, and LAHRS. J Arrhythm 2020; 36:215-270. [PMID: 32256872 PMCID: PMC7132207 DOI: 10.1002/joa3.12308] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 01/20/2020] [Indexed: 12/24/2022] Open
Affiliation(s)
- Young‐Hoon Kim
- Department of Internal MedicineArrhythmia CenterKorea University Medicine Anam HospitalSeoulRepublic of Korea
| | - Shih‐Ann Chen
- Division of CardiologyDepartment of MedicineTaipei Veterans General HospitalTaipeiROC
| | - Sabine Ernst
- Department of CardiologyRoyal Brompton and Harefield HospitalImperial College LondonLondonUK
| | | | - Seongwook Han
- Division of CardiologyDepartment of Internal MedicineKeimyung University School of MedicineDaeguRepublic of Korea
| | - Zbigniew Kalarus
- Department of CardiologyMedical University of SilesiaKatowicePoland
| | - Carlos Labadet
- Cardiology DepartmentArrhythmias and Electrophysiology ServiceClinica y Maternidad Suizo ArgentinaBuenos AiresArgentina
| | - Yenn‐Jian Lin
- Division of CardiologyDepartment of MedicineTaipei Veterans General HospitalTaipeiROC
| | - Li‐Wei Lo
- Division of CardiologyDepartment of MedicineTaipei Veterans General HospitalTaipeiROC
| | - Akihiko Nogami
- Department of CardiologyFaculty of MedicineUniversity of TsukubaTsukubaJapan
| | - Eduardo B. Saad
- Center for Atrial FibrillationHospital Pro‐CardiacoRio de JaneiroBrazil
| | - John Sapp
- Division of CardiologyDepartment of MedicineQEII Health Sciences CentreDalhousie UniversityHalifaxNSCanada
| | | | - Roland Tilz
- Medical Clinic II (Department of Cardiology, Angiology and Intensive Care Medicine)University Hospital Schleswig‐Holstein (UKSH) – Campus LuebeckLuebeckGermany
| | - Roderick Tung
- Center for Arrhythmia CarePritzker School of MedicineUniversity of Chicago MedicineChicagoILUSA
| | - Yun Gi Kim
- Department of Internal MedicineArrhythmia CenterKorea University Medicine Anam HospitalSeoulRepublic of Korea
| | | |
Collapse
|
9
|
Abstract
Determining optimal treatment strategies for complex arrhythmogenesis in AF is confounded by the lack of consensus regarding the mechanisms causing AF. Studies report different mechanisms for AF, ranging from hierarchical drivers to anarchical multiple activation wavelets. Differences in the assessment of AF mechanisms are likely due to AF being recorded across diverse models using different investigational tools, spatial scales and clinical populations. The authors review different AF mechanisms, including anatomical and functional re-entry, hierarchical drivers and anarchical multiple wavelets. They then describe different cardiac mapping techniques and analysis tools, including activation mapping, phase mapping and fibrosis identification. They explain and review different data challenges, including differences between recording devices in spatial and temporal resolutions, spatial coverage and recording surface, and report clinical outcomes using different data modalities. They suggest future research directions for investigating the mechanisms underlying human AF.
Collapse
Affiliation(s)
- Caroline H Roney
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.,Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Andrew L Wit
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK.,Department of Pharmacology, Columbia University College of Physicians and Surgeons, New York, NY, US
| | - Nicholas S Peters
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| |
Collapse
|
10
|
Qureshi NA, Kim SJ, Cantwell CD, Afonso VX, Bai W, Ali RL, Shun-Shin MJ, Malcolme-Lawes LC, Luther V, Leong KMW, Lim E, Wright I, Nagy S, Hayat S, Ng FS, Wing MK, Linton NWF, Lefroy DC, Whinnett ZI, Davies DW, Kanagaratnam P, Peters NS, Lim PB. Voltage during atrial fibrillation is superior to voltage during sinus rhythm in localizing areas of delayed enhancement on magnetic resonance imaging: An assessment of the posterior left atrium in patients with persistent atrial fibrillation. Heart Rhythm 2019; 16:1357-1367. [PMID: 31170484 PMCID: PMC6722483 DOI: 10.1016/j.hrthm.2019.05.032] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Bipolar electrogram voltage during sinus rhythm (VSR) has been used as a surrogate for atrial fibrosis in guiding catheter ablation of persistent atrial fibrillation (AF), but the fixed rate and wavefront characteristics present during sinus rhythm may not accurately reflect underlying functional vulnerabilities responsible for AF maintenance. OBJECTIVE The purpose of this study was determine whether, given adequate temporal sampling, the spatial distribution of mean AF voltage (VmAF) better correlates with delayed-enhancement magnetic resonance imaging (MRI-DE)-detected atrial fibrosis than VSR. METHODS AF was mapped (8 seconds) during index ablation for persistent AF (20 patients) using a 20-pole catheter (660 ± 28 points/map). After cardioversion, VSR was mapped (557 ± 326 points/map). Electroanatomic and MRI-DE maps were co-registered in 14 patients. RESULTS The time course of VmAF was assessed from 1-40 AF cycles (∼8 seconds) at 1113 locations. VmAF stabilized with sampling >4 seconds (mean voltage error 0.05 mV). Paired point analysis of VmAF from segments acquired 30 seconds apart (3667 sites; 15 patients) showed strong correlation (r = 0.95; P <.001). Delayed enhancement (DE) was assessed across the posterior left atrial (LA) wall, occupying 33% ± 13%. VmAF distributions were (median [IQR]) 0.21 [0.14-0.35] mV in DE vs 0.52 [0.34-0.77] mV in non-DE regions. VSR distributions were 1.34 [0.65-2.48] mV in DE vs 2.37 [1.27-3.97] mV in non-DE. VmAF threshold of 0.35 mV yielded sensitivity of 75% and specificity of 79% in detecting MRI-DE compared with 63% and 67%, respectively, for VSR (1.8-mV threshold). CONCLUSION: The correlation between low-voltage and posterior LA MRI-DE is significantly improved when acquired during AF vs sinus rhythm. With adequate sampling, mean AF voltage is a reproducible marker reflecting the functional response to the underlying persistent AF substrate.
Collapse
Affiliation(s)
- Norman A Qureshi
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | | | | | | | - Wenjia Bai
- Imperial College London, London, United Kingdom
| | | | - Matt J Shun-Shin
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | | | - Vishal Luther
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Kevin M W Leong
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Elaine Lim
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Ian Wright
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Szabi Nagy
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Sajad Hayat
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Fu Siong Ng
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Michael Koa Wing
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Nick W F Linton
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - David C Lefroy
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Zachary I Whinnett
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - D Wyn Davies
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Prapa Kanagaratnam
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Nicholas S Peters
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Phang Boon Lim
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom.
| |
Collapse
|
11
|
Kawai S, Mukai Y, Inoue S, Yakabe D, Nagaoka K, Sakamoto K, Takase S, Chishaki A, Tsutsui H. Non-Pulmonary Vein Triggers of Atrial Fibrillation Are Likely to Arise from Low-Voltage Areas in the Left Atrium. Sci Rep 2019; 9:12271. [PMID: 31439861 PMCID: PMC6706423 DOI: 10.1038/s41598-019-48669-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 08/07/2019] [Indexed: 11/17/2022] Open
Abstract
The pathophysiology of non-pulmonary vein (PV) triggers of atrial fibrillation (AF) is unclear. We hypothesized that left atrial non-PV (LANPV) triggers are associated with atrial tissue degeneration. This study analyzed 431 patients that underwent catheter ablation (mean age 62 yrs, 303 men, 255 paroxysmal AF [pAF] patients). Clinical and electrophysiological characteristics of non-PV trigger were analyzed. Fifty non-PV triggers in 40 patients (9.3%) were documented; LANPV triggers were the most prevalent (n = 19, 38%). LANPV triggers were correlated with non-paroxysmal AF (non-pAF) (OR 3.31, p = 0.04) whereas right atrial non-PV (RANPV) triggers (n = 14) and SVC triggers (n = 17) were not. The voltage at the LANPV sites during SR was 0.3 ± 0.16 mV (p < 0.001 vs. control site). Low-voltage areas (LVAs) in the LA were significantly greater in non-pAF compared to pAF (14.2% vs. 5.8%, p < 0.01). RANPV trigger sites had preserved voltage (0.74 ± 0.48 mV). Long-term outcomes of patients with non-PV triggers treated with tailored targeting strategies were not significantly inferior to those without non-PV triggers. In conclusion, non-PV triggers arise from the LA with degeneration, which may have an important role in AF persistence. A trigger-oriented, patient-tailored ablation strategy considering LA voltage map may be feasible and effective in persistent/recurrent AF.
Collapse
Affiliation(s)
- Shunsuke Kawai
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Yasushi Mukai
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan.
| | - Shujiro Inoue
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Daisuke Yakabe
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Kazuhiro Nagaoka
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Kazuo Sakamoto
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Susumu Takase
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Akiko Chishaki
- Department of Health Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| |
Collapse
|
12
|
Abstract
Ablation of AF through electrical isolation of the pulmonary veins is a well-established technique and a cornerstone in the ablation of AF, although there are a variety of techniques and ablation strategies now available. However, high numbers of patients are returning to hospital after ablation procedures such as pulmonary vein isolation (PVI). Scar tissue (as identified by contact voltage mapping) is found to be present in many of these patients, especially those with persistent AF and even those with paroxysmal AF. This scarring is associated with poor outcomes after PVI. Cardiac mapping is necessary to locate triggers and substrate so that an ablation strategy can be optimised. Multipolar mapping catheters offer more information regarding the status of the tissue than standard ablation catheters. A patient-tailored catheter ablation approach, targeting the patient-specific low voltage/fibrotic substrate can lead to improved outcomes.
Collapse
|
13
|
Tzeis S, Asvestas D, Vardas P. Atrial Fibrosis: Translational Considerations for the Management of AF Patients. Arrhythm Electrophysiol Rev 2019; 8:37-41. [PMID: 30918665 PMCID: PMC6434500 DOI: 10.15420/aer.2018.79.3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Fibrosis plays a fundamental role in the initiation and maintenance of AF, mainly due to enhanced automaticity and anisotropy-related re-entry. The identification and quantification of atrial fibrosis is achieved either preprocedurally by late gadolinium enhancement MRI or intraprocedurally using electroanatomic voltage mapping. The presence and extent of left atrial fibrosis among AF patients may influence relevant decision making regarding the need for anticoagulation, the adoption of rate versus rhythm control and mainly the type of ablation strategy that will be followed during interventional treatment. Several types of individualised substrate modifications targeting atrial fibrotic areas have been proposed, although their impact on patient outcome needs to be further investigated in adequately powered prospective randomised controlled clinical trials.
Collapse
Affiliation(s)
- Stylianos Tzeis
- Cardiology Department, Mitera General Hospital, Hygeia Group Athens, Greece
| | - Dimitrios Asvestas
- Cardiology Department, Mitera General Hospital, Hygeia Group Athens, Greece
| | - Panos Vardas
- Heart Sector, Hygeia Group Hospitals Athens, Greece
| |
Collapse
|
14
|
Higuchi S, Ejima K, Shoda M, Yamamoto E, Iwanami Y, Yagishita D, Hagiwara N. Impact of a prolonged interatrial conduction time for predicting the recurrence of atrial fibrillation after circumferential pulmonary vein isolation of persistent atrial fibrillation. Heart Vessels 2018; 34:616-624. [PMID: 30291411 DOI: 10.1007/s00380-018-1272-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 09/28/2018] [Indexed: 11/26/2022]
Abstract
There are some cases that are difficult to cure with only circumferential pulmonary vein isolation (CPVI) of persistent atrial fibrillation (PerAF). Recently, prolonged interatrial conduction times (IACTs), which seem to be associated with progressive remodeled atria, have been reported as a predictor of new-onset AF. This study aimed to investigate the prognostic value of a prolonged IACT for predicting AF recurrences after CPVI of PerAF. One hundred thirteen patients who underwent CPVI without an empirical substrate modification of PerAF were retrospectively analyzed. The IACT was defined as the interval from the earliest P-wave onset on the ECG to the latest activation in the coronary sinus and was measured after achieving the CPVI and conversion to sinus rhythm. During a mean 22.7-month follow-up after the initial procedure, 56 patients (50%) had AF recurrences. Patients with AF recurrence had a longer IACT than those without AF recurrence (p < 0.001). The best discriminative cut-off value for the IACT was 123 ms (sensitivity 53%, specificity 85%). In a Cox multivariate analysis, a prolonged IACT of ≥ 123 ms was the only independent predictor (hazard ratio: 2.38; 95% confidence interval: 1.36-4.16, p = 0.002) of being associated with the incidence of an AF recurrence. Even after multiple CPVI procedures, patients with an IACT ≥ 123 ms had a higher AF recurrence rate than those with an IACT < 123 ms (p = 0.002). In conclusion, a prolonged IACT of ≥ 123 ms may be a useful marker for predicting AF recurrences after both initial and multiple CPVI procedures for PerAF.
Collapse
Affiliation(s)
- Satoshi Higuchi
- Department of Cardiology, Tokyo Women'S Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Koichiro Ejima
- Department of Cardiology, Tokyo Women'S Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
| | - Morio Shoda
- Department of Cardiology, Tokyo Women'S Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Eri Yamamoto
- Department of Cardiology, Tokyo Women'S Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Yuji Iwanami
- Department of Cardiology, Tokyo Women'S Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Daigo Yagishita
- Department of Cardiology, Tokyo Women'S Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Nobuhisa Hagiwara
- Department of Cardiology, Tokyo Women'S Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| |
Collapse
|
15
|
Kumagai K, Minami K, Sugai Y, Oshima S. Evaluation of the atrial substrate based on low-voltage areas and dominant frequencies after pulmonary vein isolation in nonparoxysmal atrial fibrillation. J Arrhythm 2018; 34:230-238. [PMID: 29951137 PMCID: PMC6009773 DOI: 10.1002/joa3.12049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Accepted: 03/01/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND This study aimed to evaluate the atrial substrate in the left atrium (LA) by low-voltage areas (LVAs) and high-dominant frequencies (DFs) after circumferential pulmonary vein isolation (PVI) in nonparoxysmal atrial fibrillation (AF). METHODS In 70 patients with nonparoxysmal AF patients (41 persistent AF), LA voltage maps were created during sinus rhythm by external cardioversion after PVI and DF mapping. The patients were divided into AF-free and AF-recurrent groups. RESULTS The AF freedom rate without antiarrhythmic drugs was 69.0% after PVI after 1 procedure during a 12-month follow-up. There was a significant difference in the LVA (<0.5 mV)/LA surface area after PVI between the AF-free and AF-recurrent groups (15% vs 23%, P = .033). AF freedom was significantly greater in those with LVAs of ≤24% than in those with LVAs of >24% during 12 months of follow-up (78.6% vs 53.8%, Log-rank test P = .020). Fifty-six (72%) of the 78 high-DF sites (≥8 Hz) overlapped with LVAs. Thirty-one (55%) of 56 high-DF sites overlapped with LVAs that existed at LVA border zones. There were no significant differences in number of high-DF sites that overlapped with LVAs in the LA between the two groups. However, in persistent AF patients, the max-DF value in the LA exhibited a significant difference between the two groups (P = .008). CONCLUSIONS LVAs were associated with AF recurrences after PVI in nonparoxysmal AF patients and overlapped with many high-DF sites. PVI alone may be enough to treat patients with mild-to-moderate extent (≤24%) of LVAs.
Collapse
Affiliation(s)
- Koji Kumagai
- Division of CardiologyGunma Prefectural Cardiovascular CenterGunmaJapan
| | - Kentaro Minami
- Division of CardiologyGunma Prefectural Cardiovascular CenterGunmaJapan
| | - Yoshinao Sugai
- Division of CardiologyGunma Prefectural Cardiovascular CenterGunmaJapan
| | - Shigeru Oshima
- Division of CardiologyGunma Prefectural Cardiovascular CenterGunmaJapan
| |
Collapse
|
16
|
Zghaib T, Keramati A, Chrispin J, Huang D, Balouch MA, Ciuffo L, Berger RD, Marine JE, Ashikaga H, Calkins H, Nazarian S, Spragg DD. Multimodal Examination of Atrial Fibrillation Substrate: Correlation of Left Atrial Bipolar Voltage Using Multi-Electrode Fast Automated Mapping, Point-by-Point Mapping, and Magnetic Resonance Image Intensity Ratio. JACC Clin Electrophysiol 2018; 4:59-68. [PMID: 29520376 PMCID: PMC5836739 DOI: 10.1016/j.jacep.2017.10.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background Bipolar voltage mapping, as part of atrial fibrillation (AF) ablation, is traditionally performed in a point-by-point (PBP) approach using single-tip ablation catheters. Alternative techniques for fibrosis-delineation include fast-anatomical mapping (FAM) with multi-electrode circular catheters, and late gadolinium-enhanced magnetic-resonance imaging (LGE-MRI). The correlation between PBP, FAM, and LGE-MRI fibrosis assessment is unknown. Objective In this study, we examined AF substrate using different modalities (PBP, FAM, and LGE-MRI mapping) in patients presenting for an AF ablation. Methods LGE-MRI was performed pre-ablation in 26 patients (73% males, age 63±8years). Local image-intensity ratio (IIR) was used to normalize myocardial intensities. PBP- and FAM-voltage maps were acquired, in sinus rhythm, prior to ablation and co-registered to LGE-MRI. Results Mean bipolar voltage for all 19,087 FAM voltage points was 0.88±1.27mV and average IIR was 1.08±0.18. In an adjusted mixed-effects model, each unit increase in local IIR was associated with 57% decrease in bipolar voltage (p<0.0001). IIR of >0.74 corresponded to bipolar voltage <0.5 mV. A total of 1554 PBP-mapping points were matched to the nearest FAM-point. In an adjusted mixed-effects model, log-FAM bipolar voltage was significantly associated with log-PBP bipolar voltage (ß=0.36, p<0.0001). At low-voltages, FAM-mapping distribution was shifted to the left compared to PBP-mapping; at intermediate voltages, FAM and PBP voltages were overlapping; and at high voltages, FAM exceeded PBP-voltages. Conclusion LGE-MRI, FAM and PBP-mapping show good correlation in delineating electro-anatomical AF substrate. Each approach has fundamental technical characteristics, the awareness of which allows proper assessment of atrial fibrosis.
Collapse
Affiliation(s)
- Tarek Zghaib
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ali Keramati
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jonathan Chrispin
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dong Huang
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Muhammad A. Balouch
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Luisa Ciuffo
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ronald D. Berger
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
- Biomedical Engineering, The Johns Hopkins University, Philadelphia, PA
| | - Joseph E. Marine
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hiroshi Ashikaga
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
- Biomedical Engineering, The Johns Hopkins University, Philadelphia, PA
| | - Hugh Calkins
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Saman Nazarian
- Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - David D. Spragg
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
17
|
Zaman JAB, Sauer WH, Alhusseini MI, Baykaner T, Borne RT, Kowalewski CAB, Busch S, Zei PC, Park S, Viswanathan MN, Wang PJ, Brachmann J, Krummen DE, Miller JM, Rappel WJ, Narayan SM, Peters NS. Identification and Characterization of Sites Where Persistent Atrial Fibrillation Is Terminated by Localized Ablation. Circ Arrhythm Electrophysiol 2018; 11:e005258. [PMID: 29330332 PMCID: PMC5769709 DOI: 10.1161/circep.117.005258] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 12/04/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND The mechanisms by which persistent atrial fibrillation (AF) terminates via localized ablation are not well understood. To address the hypothesis that sites where localized ablation terminates persistent AF have characteristics identifiable with activation mapping during AF, we systematically examined activation patterns acquired only in cases of unequivocal termination by ablation. METHODS AND RESULTS We recruited 57 patients with persistent AF undergoing ablation, in whom localized ablation terminated AF to sinus rhythm or organized tachycardia. For each site, we performed an offline analysis of unprocessed unipolar electrograms collected during AF from multipolar basket catheters using the maximum -dV/dt assignment to construct isochronal activation maps for multiple cycles. Additional computational modeling and phase analysis were used to study mechanisms of map variability. At all sites of AF termination, localized repetitive activation patterns were observed. Partial rotational circuits were observed in 26 of 57 (46%) cases, focal patterns in 19 of 57 (33%), and complete rotational activity in 12 of 57 (21%) cases. In computer simulations, incomplete segments of partial rotations coincided with areas of slow conduction characterized by complex, multicomponent electrograms, and variations in assigning activation times at such sites substantially altered mapped mechanisms. CONCLUSIONS Local activation mapping at sites of termination of persistent AF showed repetitive patterns of rotational or focal activity. In computer simulations, complete rotational activation sequence was observed but was sensitive to assignment of activation timing particularly in segments of slow conduction. The observed phenomena of repetitive localized activation and the mechanism by which local ablation terminates putative AF drivers require further investigation.
Collapse
Affiliation(s)
- Junaid A B Zaman
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| | - William H Sauer
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| | - Mahmood I Alhusseini
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| | - Tina Baykaner
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| | - Ryan T Borne
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| | - Christopher A B Kowalewski
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| | - Sonia Busch
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| | - Paul C Zei
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| | - Shirley Park
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| | - Mohan N Viswanathan
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| | - Paul J Wang
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| | - Johannes Brachmann
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| | - David E Krummen
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| | - John M Miller
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| | - Wouter Jan Rappel
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| | - Sanjiv M Narayan
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.).
| | - Nicholas S Peters
- From the Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA (J.A.B.Z., M.I.A., T.B., C.A.B.K., P.C.Z., S.P., M.N.V., P.J.W., S.M.N.); Imperial Centre for Cardiac Engineering, Imperial College London, United Kingdom (J.A.B.Z., N.S.P.); Cardiac Electrophysiology, Cedars Sinai Heart Institute, Los Angeles, CA (J.A.B.Z.); Department of Cardiology, University of Colorado, Aurora (W.H.S., R.T.B.); Departments of Medicine (T.B., D.E.K.) and Physics (W.J.R.), University of California San Diego; Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.); Department of Cardiology, Klinikum Coburg, Germany (S.B., J.B.); and Department of Medicine, Indiana University, Bloomington (J.M.M.)
| |
Collapse
|
18
|
Williams SE, Linton N, O'Neill L, Harrison J, Whitaker J, Mukherjee R, Rinaldi CA, Gill J, Niederer S, Wright M, O'Neill M. The effect of activation rate on left atrial bipolar voltage in patients with paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol 2017; 28:1028-1036. [PMID: 28639747 PMCID: PMC5639376 DOI: 10.1111/jce.13282] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 06/05/2017] [Accepted: 06/12/2017] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Bipolar voltage is used during electroanatomic mapping to define abnormal myocardium, but the effect of activation rate on bipolar voltage is not known. We hypothesized that bipolar voltage may change in response to activation rate. By examining corresponding unipolar signals we sought to determine the mechanisms of such changes. METHODS AND RESULTS LA extrastimulus mapping was performed during CS pacing in 10 patients undergoing first time paroxysmal atrial fibrillation ablation. Bipolar and unipolar electrograms were recorded using a PentaRay catheter (4-4-4 spacing) and indifferent IVC electrode, respectively. An S1S2 pacing protocol was delivered with extrastimulus coupling interval reducing from 350 to 200 milliseconds. At each recording site (119 ± 37 per LA), bipolar peak-to-peak voltage, unipolar peak to peak voltage and activation delay between unipole pairs was measured. Four patterns of bipolar voltage/extrastimulus coupling interval curves were seen: voltage attenuation with plateau voltage >1 mV (48 ± 15%) or <1 mV (22 ± 15%), and voltage unaffected by coupling interval with plateau voltage >1 mV (17 ± 10%) or <1 mV (13 ± 8%). Electrograms showing bipolar voltage attenuation were associated with significantly greater unipolar voltage attenuation at low (25 ± 28 mV/s vs. 9 ± 11 mV/s) and high (23 ± 29 mV/s vs. 6 ± 12 mV/s) plateau voltage sites (P < 0.001). There was a small but significant increase in conduction delay between unipole pairs at sites showing bipolar voltage attenuation (P = 0.026). CONCLUSIONS Bipolar electrogram voltage is dependent on activation rate at a significant proportion of sites. Changes in unipolar voltage and timing underlie these effects. These observations have important implications for use of voltage mapping to delineate abnormal atrial substrate.
Collapse
Affiliation(s)
- Steven E Williams
- Division of Imaging Sciences and Biomedical ImagingKing's College London
| | - Nick Linton
- Division of Imaging Sciences and Biomedical ImagingKing's College London
| | - Louisa O'Neill
- Division of Imaging Sciences and Biomedical ImagingKing's College London
| | - James Harrison
- Division of Imaging Sciences and Biomedical ImagingKing's College London
| | - John Whitaker
- Division of Imaging Sciences and Biomedical ImagingKing's College London
| | - Rahul Mukherjee
- Division of Imaging Sciences and Biomedical ImagingKing's College London
| | - Christopher A. Rinaldi
- Division of Imaging Sciences and Biomedical ImagingKing's College London
- Cardiovascular DivisionGuy's and St. Thomas’ NHS Foundation Trust
| | - Jaswinder Gill
- Cardiovascular DivisionGuy's and St. Thomas’ NHS Foundation Trust
| | - Steven Niederer
- Division of Imaging Sciences and Biomedical ImagingKing's College London
| | - Matthew Wright
- Division of Imaging Sciences and Biomedical ImagingKing's College London
- Cardiovascular DivisionGuy's and St. Thomas’ NHS Foundation Trust
| | - Mark O'Neill
- Division of Imaging Sciences and Biomedical ImagingKing's College London
- Cardiovascular DivisionGuy's and St. Thomas’ NHS Foundation Trust
| |
Collapse
|
19
|
Iso K, Watanabe I, Kogawa R, Okumura Y, Nagashima K, Takahashi K, Watanabe R, Arai M, Ohkubo K, Nakai T, Hirayama A, Nikaido M. Wavefront direction and cycle length affect left atrial electrogram amplitude. J Arrhythm 2017; 33:269-274. [PMID: 28765756 PMCID: PMC5529329 DOI: 10.1016/j.joa.2017.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 12/27/2016] [Accepted: 01/13/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The relationship between atrial electrogram (EGM) characteristics in atrial fibrillation (AF) and those in sinus rhythm (SR) are generally unknown. The activation rate and direction may affect EGM characteristics. We examined characteristics of left atrial (LA) EGMs obtained during pacing from different sites. METHODS The study included 10 patients undergoing pulmonary vein isolation for AF. Atrial EGMs were recorded from a 64-pole basket catheter placed in the LA, and bipolar EGM amplitudes from the distal electrode pair (1-2) and proximal electrode pair (6-7) from 8 splines were averaged. The high right atrium (HRA), proximal coronary sinus (CSp), and distal coronary sinus (CSd) were paced at 600 ms and 300 ms. RESULTS When the LA voltage at SR was ≥1.5 mV, bipolar voltages of the HRA were greater than those of the CSp, which were greater than those of the CSd, regardless of the pacing cycle length. The shorter pacing cycle length resulted in a reduction of the LA EGM voltage at sites of SR voltage ≥1.5 mV, but no significant difference was seen at sites where the SR EGM amplitude was between >0.5 and <1.5 mV. No significant differences were seen in intra-basket conduction times between pacing cycle lengths of 600 ms and 300 ms at any pacing site. CONCLUSION The rate and direction-dependent reduction of the amplitude of atrial EGMs may explain, in part, the voltage discordance during SR and AF.
Collapse
Affiliation(s)
- Kazuki Iso
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Oyaguchi-kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
| | - Ichiro Watanabe
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Oyaguchi-kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
| | - Rikitake Kogawa
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Oyaguchi-kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Oyaguchi-kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
| | - Koichi Nagashima
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Oyaguchi-kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
| | - Keiko Takahashi
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Oyaguchi-kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
| | - Ryuta Watanabe
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Oyaguchi-kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
| | - Masaru Arai
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Oyaguchi-kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
| | - Kimie Ohkubo
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Oyaguchi-kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
| | - Toshiko Nakai
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Oyaguchi-kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
| | - Atsushi Hirayama
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Oyaguchi-kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
| | | |
Collapse
|
20
|
Sasaki N, Watanabe I, Okumura Y, Nagashima K, Kogawa R, Sonoda K, Iso K, Takahashi K, Arai M, Watanabe R, Kurokawa S, Ohkubo K, Nakai T, Hirayama A, Nikaido M. Complex fractionated atrial electrograms, high dominant frequency regions, and left atrial voltages during sinus rhythm and atrial fibrillation. J Arrhythm 2017; 33:185-191. [PMID: 28607613 PMCID: PMC5459411 DOI: 10.1016/j.joa.2016.10.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 09/26/2016] [Accepted: 10/06/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Ablation targeting complex fractionated atrial electrograms (CFAEs) or high dominant frequency (DF) sites is generally effective for persistent atrial fibrillation (AF). CFAEs and/or high DF sites may exist in low-voltage regions, which theoretically represent abnormal substrates. However, whether CFAEs or high DF sites reflect low voltage substrates during sinus rhythm (SR) is unknown. METHODS Sixteen patients with AF (8 with paroxysmal AF; 8, persistent AF) underwent high-density mapping of the left atrium (LA) with a 3-dimensional electroanatomic mapping system before ablation. The LA was divided into 7 segments and the mean bipolar voltage recorded during AF and SR, CFAEs (cycle lengths of 50-120 ms), and DF sites were assessed in each segment with either a duo-decapolar ring catheter (n=10) or a 64-pole basket catheter (n=6). Low-voltage areas were defined as those of <0.5 mV during AF and <1.0 mV during SR. RESULTS Regional mean voltage recorded from the basket catheter showed good correlation between AF and SR (r=0.60, p<0.01); however, the % low-voltage area in the LA recorded from the ring catheter showed weak correlation (r=0.34, p=0.05). Mean voltage was lower during AF than during SR (1.0 mV [IQR, 0.5-1.4] vs. 2.6 mV [IQR, 1.8-3.6], p<0.01). The regional and overall % low-voltage area of the LA was greater during AF than during SR (20% vs. 11%, p=0.05). CFAEs and high DF sites (>8 Hz) did not correlate with % low-voltage sites during SR; however, CFAEs sites were located in high-voltage regions during AF and high DF sites were located in low voltage regions during AF. CONCLUSIONS CFAEs and high DF areas during AF do not reflect damaged atrial myocardium as shown by the SR voltage. However, CFAEs and high DF sites may demonstrate different electrophysiologic properties because of different voltage amplitude during AF.
Collapse
Affiliation(s)
- Naoko Sasaki
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Oyaguchi-Kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
| | - Ichiro Watanabe
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Oyaguchi-Kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Oyaguchi-Kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
| | - Koichi Nagashima
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Oyaguchi-Kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
| | - Rikitake Kogawa
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Oyaguchi-Kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
| | - Kazumasa Sonoda
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Oyaguchi-Kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
| | - Kazuki Iso
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Oyaguchi-Kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
| | - Keiko Takahashi
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Oyaguchi-Kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
| | - Masaru Arai
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Oyaguchi-Kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
| | - Ryuta Watanabe
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Oyaguchi-Kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
| | - Sayaka Kurokawa
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Oyaguchi-Kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
| | - Kimie Ohkubo
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Oyaguchi-Kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
| | - Toshiko Nakai
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Oyaguchi-Kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
| | - Atsushi Hirayama
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Oyaguchi-Kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
| | - Mizuki Nikaido
- Nihon Kohden Corporation, 1-11-15 Higashigotanda, Shinagawa-ku, Tokyo 141-0022, Japan
| |
Collapse
|
21
|
Chen M. Scar homogenization in AF ablation: Evolution and practice. J Atr Fibrillation 2017; 10:1618. [PMID: 29250226 PMCID: PMC5673332 DOI: 10.4022/jafib.1618] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 06/19/2017] [Accepted: 06/25/2017] [Indexed: 11/10/2022]
Abstract
Laboratory studies, histology studies, image studies and the clinical studies all prove the positive correlation between atrial fibrillation and atrial fibrosis from different perspectives. Atrial fibrosis, by separating myocardial cell coupling, diminishing conduction velocity and promoting anisotropic conduction, produce the substrate to sustain atrial fibrillation (AF). These fibrotic areas can be translated into signal abnormalities (low voltage and complex electrgram), and be depicted by electroanatomic high density map. Ablation targeting these areas after circumferential pulmonary vein produces isolation as the additional substrate modification strategy has proved its beneficial results. However, the unified methodology regarding the scar definition, the mapping rhythm (AF or sinus rhythm) and the modification endpoint is yet to be negotiated. Large-scale clinical trials, long-term follow-up results are needed to prove its contribution to the overall success rate of AF ablation.
Collapse
Affiliation(s)
- Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| |
Collapse
|
22
|
BLANDINO ALESSANDRO, BIANCHI FRANCESCA, GROSSI STEFANO, BIONDI-ZOCCAI GIUSEPPE, CONTE MARIAROSA, GAIDO LUCA, GAITA FIORENZO, SCAGLIONE MARCO, RAMETTA FRANCESCO. Left Atrial Substrate Modification Targeting Low-Voltage Areas for Catheter Ablation of Atrial Fibrillation: A Systematic Review and Meta-Analysis. Pacing Clin Electrophysiol 2017; 40:199-212. [PMID: 28054377 DOI: 10.1111/pace.13015] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 12/07/2016] [Accepted: 12/18/2016] [Indexed: 02/05/2023]
Affiliation(s)
- ALESSANDRO BLANDINO
- Division of Cardiology, Department of Internal Medicine; S. Andrea Hospital; Vercelli Italy
| | | | - STEFANO GROSSI
- Division of Cardiology; Mauriziano Umberto I Hospital; Turin Italy
| | - GIUSEPPE BIONDI-ZOCCAI
- Department of Medico-Surgical Sciences and Biotechnologies; Sapienza University of Rome; Latina Italy
- Department of AngioCardioNeurology; IRCCS Neuromed; Pozzilli Italy
| | - MARIA ROSA CONTE
- Division of Cardiology; Mauriziano Umberto I Hospital; Turin Italy
| | - LUCA GAIDO
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza; University of Turin; Turin Italy
| | - FIORENZO GAITA
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza; University of Turin; Turin Italy
| | - MARCO SCAGLIONE
- Division of Cardiology, Department of Internal Medicine; Cardinal Gugliemo Massaia Hospital; Asti Italy
| | - FRANCESCO RAMETTA
- Division of Cardiology, Department of Internal Medicine; S. Andrea Hospital; Vercelli Italy
| |
Collapse
|
23
|
ROTTNER LAURA, METZNER ANDREAS, OUYANG FEIFAN, HEEGER CHRISTIAN, HAYASHI KENTARO, FINK THOMAS, LEMES CHRISTINE, MATHEW SHIBU, MAURER TILMAN, REIßMANN BRUNO, REXHA ENIDA, RIEDL JOHANNES, SAGUNER ARDANM, SANTORO FRANCESCO, KUCK KARLHEINZ, SOHNS CHRISTIAN. Direct Comparison of Point-by-Point and Rapid Ultra-High-Resolution Electroanatomical Mapping in Patients Scheduled for Ablation of Atrial Fibrillation. J Cardiovasc Electrophysiol 2017; 28:289-297. [DOI: 10.1111/jce.13160] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 12/15/2016] [Accepted: 12/27/2016] [Indexed: 11/29/2022]
Affiliation(s)
- LAURA ROTTNER
- Department of Cardiology; Asklepios Klinik St. Georg; Hamburg Germany
| | - ANDREAS METZNER
- Department of Cardiology; Asklepios Klinik St. Georg; Hamburg Germany
| | - FEIFAN OUYANG
- Department of Cardiology; Asklepios Klinik St. Georg; Hamburg Germany
| | - CHRISTIAN HEEGER
- Department of Cardiology; Asklepios Klinik St. Georg; Hamburg Germany
| | - KENTARO HAYASHI
- Department of Cardiology; Asklepios Klinik St. Georg; Hamburg Germany
| | - THOMAS FINK
- Department of Cardiology; Asklepios Klinik St. Georg; Hamburg Germany
| | - CHRISTINE LEMES
- Department of Cardiology; Asklepios Klinik St. Georg; Hamburg Germany
| | - SHIBU MATHEW
- Department of Cardiology; Asklepios Klinik St. Georg; Hamburg Germany
| | - TILMAN MAURER
- Department of Cardiology; Asklepios Klinik St. Georg; Hamburg Germany
| | - BRUNO REIßMANN
- Department of Cardiology; Asklepios Klinik St. Georg; Hamburg Germany
| | - ENIDA REXHA
- Department of Cardiology; Asklepios Klinik St. Georg; Hamburg Germany
| | - JOHANNES RIEDL
- Department of Cardiology; Asklepios Klinik St. Georg; Hamburg Germany
| | - ARDAN M. SAGUNER
- Department of Cardiology; Asklepios Klinik St. Georg; Hamburg Germany
| | - FRANCESCO SANTORO
- Department of Cardiology; Asklepios Klinik St. Georg; Hamburg Germany
| | - KARL-HEINZ KUCK
- Department of Cardiology; Asklepios Klinik St. Georg; Hamburg Germany
| | - CHRISTIAN SOHNS
- Department of Cardiology; Asklepios Klinik St. Georg; Hamburg Germany
| |
Collapse
|