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Nyuta E, Takemoto M, Antoku Y, Mito T, Sakai T, Takiguchi T, Ikeda S, Koga T, Tsuchihashi T. Role of Sleep-Disordered Breathing and Epicardial Connections in the Recurrence of Atrial Fibrillation. Int Heart J 2024; 65:414-426. [PMID: 38749745 DOI: 10.1536/ihj.23-653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/04/2024]
Abstract
The presence of epicardial connections (ECs) between the pulmonary veins (PVs) and atrium may contribute to atrial fibrillation (AF) recurrence. This study aimed to determine the impact of sleep-disordered breathing (SDB) on the presence of ECs and the interplay between SDB and ECs on AF recurrence.We retrospectively reviewed 400 consecutive non-valvular AF patients. Among them, 235 patients exhibiting a 3% oxygen desaturation index (ODI) of ≥ 10 events/hour underwent polysomnography to evaluate the SDB severity, measured by the apnea-hypopnea index (AHI). To facilitate the ablation of AF and ECs, a high-density mapping catheter (HDMC) was employed. AF recurrence was evaluated over a 12-month period post-AF ablation.The key findings included: 1) 63% of AF patients with ECs had SDB with an AHI ≥ 20 events/hour. 2) Despite achieving complete PV isolations and precise EC ablation using an HDMC, SDB presence was associated with an increased AF recurrence. 3) Continuous positive airway pressure therapy for SDB improved AF recurrence among the AF patients with both ECs and SDB (57% versus 73%; P = 0.016). 4) AHI (odds ratio [OR] = 1.91, ≥ 28.4 events/hour) and left atrial volume (LAV) (OR = 1.42, ≥ 128.3 mL) were independent predictors of the presence of ECs, and AHI (OR = 1.44, ≥ 27.8 events/hour) was an independent predictor of the presence of AF recurrence.It is essential for physicians to recognise the potential complexity of ECs and SDB in AF patients. Thus, screening and treating SDB in AF patients presenting with ECs might play a pivotal role in suppressing AF recurrence.
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Affiliation(s)
- Eiji Nyuta
- Cardiovascular Centre, Steel Memorial Yawata Hospital
| | | | | | | | - Togo Sakai
- Cardiovascular Centre, Steel Memorial Yawata Hospital
| | | | - Shota Ikeda
- Cardiovascular Centre, Steel Memorial Yawata Hospital
| | - Tokushi Koga
- Cardiovascular Centre, Steel Memorial Yawata Hospital
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van Schie MS, de Groot NMS. Clinical Relevance of Sinus Rhythm Mapping to Quantify Electropathology Related to Atrial Fibrillation. Arrhythm Electrophysiol Rev 2022; 11:e11. [PMID: 35846426 PMCID: PMC9277615 DOI: 10.15420/aer.2022.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 05/25/2022] [Indexed: 11/28/2022] Open
Abstract
Progression of AF is accompanied by structural and electrical remodelling, resulting in complex electrical conduction disorders. This is defined as electropathology and it increases with the progression of AF. The severity of electropathology, thus, defines the stage of AF and is a major determinant of effectiveness of AF therapy. As specific features of AF-related electropathology are still unknown, it is essential to first quantify the electrophysiological properties of atrial tissue and then to examine the inter- and intra-individual variation during normal sinus rhythm. Comparison of these parameters between patients with and without a history of AF unravels quantified electrophysiological features that are specific to AF patients. This can help to identify patients at risk for early onset or progression of AF. This review summarises current knowledge on quantified features of atrial electrophysiological properties during sinus rhythm and discusses its relevance in identifying AF-related electropathology.
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Affiliation(s)
- Mathijs S van Schie
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Natasja MS de Groot
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
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van Schie MS, Veen D, Kharbanda RK, Heida A, Starreveld R, van Schaagen FRN, Bogers AJJC, Taverne YJHJ, de Groot NMS. Characterization of pre-existing arrhythmogenic substrate associated with de novo early and late postoperative atrial fibrillation. Int J Cardiol 2022; 363:71-79. [PMID: 35705170 DOI: 10.1016/j.ijcard.2022.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/01/2022] [Accepted: 06/10/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND PoAF is the most common complication after cardiac surgery and may occur in patients with pre-existing arrhythmogenic substrate. Characterization of this substrate could aid in identifying patients at risk for PoAF. We therefore compared intra-atrial conduction parameters and electrogram morphology between patients without and with early- (≤5 days after surgery) and late- (up to 5 years) postoperative atrial fibrillation (PoAF). METHODS AND RESULTS Epicardial mapping of the right and left atrium and Bachmann's Bundle (BB) was performed during sinus rhythm (SR) in 263 patients (207male, 67 ± 11 years). Unipolar potentials were classified as single, short or long double and fractionated potentials. Unipolar voltage, fractionation delay (time difference between the first and last deflection), conduction velocity (CV) and conduction block (CB) prevalence were measured. Comparing patients without (N = 166) and with PoAF (N = 97), PoAF was associated with lower CV and more CB at BB. Unipolar voltages were lower and more low-voltage areas were found at the left and right atrium and BB in PoAF patients. These differences were more pronounced in patients with late-PoAF (6%), which could even occur up to 5 years after surgery. Although several electrophysiological parameters were related to PoAF, age was the only independent predictor. CONCLUSIONS Patients with de novo PoAF have more extensive arrhythmogenic substrate prior to cardiac surgery compared to those who remained in SR, which is even more pronounced in late-PoAF patients. Future studies should evaluate whether intra-operative electrophysiological examination enables identification of patients at risk for developing PoAF and hence (preventive) therapy.
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Affiliation(s)
- Mathijs S van Schie
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Danny Veen
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Rohit K Kharbanda
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands; Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Annejet Heida
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Roeliene Starreveld
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Frank R N van Schaagen
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Yannick J H J Taverne
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
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Vraka A, Bertomeu-González V, Fácila L, Moreno-Arribas J, Alcaraz R, Rieta JJ. The Dissimilar Impact in Atrial Substrate Modificationof Left and Right Pulmonary Veins Isolation after Catheter Ablation of Paroxysmal Atrial Fibrillation. J Pers Med 2022; 12:462. [PMID: 35330463 PMCID: PMC8955667 DOI: 10.3390/jpm12030462] [Citation(s) in RCA: 1] [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: 02/04/2022] [Revised: 03/04/2022] [Accepted: 03/07/2022] [Indexed: 12/13/2022] Open
Abstract
Since the discovery of pulmonary veins (PVs) as foci of atrial fibrillation (AF), the commonest cardiac arrhythmia, investigation revolves around PVs catheter ablation (CA) results. Notwithstanding, CA process itself is rather neglected. We aim to decompose crucial CA steps: coronary sinus (CS) catheterization and the impact of left and right PVs isolation (LPVI, RPVI), separately. We recruited 40 paroxysmal AF patients undergoing first-time CA and obtained five-minute lead II and bipolar CS recordings during sinus rhythm (SR) before CA (B), after LPVI (L) and after RPVI (R). Among others, duration, amplitude and atrial-rate variability (ARV) were calculated for P-waves and CS local activation waves (LAWs). LAWs features were compared among CS channels for reliability analysis. P-waves and LAWs features were compared after each ablation step (B, L, R). CS channels: amplitude and area were different between distal/medial (p≤0.0014) and distal/mid-proximal channels (p≤0.0025). Medial and distal showed the most and least coherent values, respectively. Correlation was higher in proximal (≥93%) than distal (≤91%) areas. P-waves: duration was significantly shortened after LPVI (after L: p=0.0012, −13.30%). LAWs: insignificant variations. ARV modification was more prominent in LAWs (L: >+73.12%, p≤0.0480, R: <−33.94%, p≤0.0642). Medial/mid-proximal channels are recommended during SR. CS LAWs are not significantly affected by CA but they describe more precisely CA-induced ARV modifications. LPVI provokes the highest impact in paroxysmal AF CA, significantly modifying P-wave duration.
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Affiliation(s)
- Aikaterini Vraka
- BioMIT.org, Electronic Engineering Department, Universitat Politecnica de Valencia, 46022 Valencia, Spain;
| | - Vicente Bertomeu-González
- Cardiology Department, Saint John’s University Hospital, 03550 Alicante, Spain; (V.B.-G.); (J.M.-A.)
| | - Lorenzo Fácila
- Cardiology Department, General University Hospital Consortium of Valencia, 46014 Valencia, Spain;
| | - José Moreno-Arribas
- Cardiology Department, Saint John’s University Hospital, 03550 Alicante, Spain; (V.B.-G.); (J.M.-A.)
| | - Raúl Alcaraz
- Research Group in Electronic, Biomedical and Telecommunication Engineering, University of Castilla-La Mancha, 16071 Cuenca, Spain;
| | - José J. Rieta
- BioMIT.org, Electronic Engineering Department, Universitat Politecnica de Valencia, 46022 Valencia, Spain;
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Evaluation of interatrial conduction pattern after pulmonary vein isolation using an ultrahigh-resolution electroanatomical mapping system. Heart Vessels 2022; 37:1425-1435. [PMID: 35174414 DOI: 10.1007/s00380-022-02040-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 02/03/2022] [Indexed: 11/04/2022]
Abstract
Interatrial conduction consists of various muscular bundles, including the Bachmann bundle. In this study, we investigated interatrial activation patterns using ultrahigh-resolution left atrial endocardial mapping. This study investigated 58 patients who underwent catheter ablation of atrial arrhythmia via an ultrahigh-resolution mapping system (Rhythmia) at our hospital from May 2020 to January 2021. Left atrial voltage maps and activation maps were acquired after the ablation procedure during right atrial appendage (RAA) pacing. We defined left atrial breakout sites (LABSs) as centrifugal activation patterns shown by the LUMIPOINT Activation Search Tool. The distance between each LABS in the left atrial anterior wall and the superior border of the interatrial septum (DLABS-IAS) was measured on the shell of the electroanatomical map, and anterior LABSs were divided equally into roof- and septal-side groups. Fifty-three (91%) patients underwent cryoballoon pulmonary vein isolation. Ultrahigh-resolution left atrial mapping was successfully performed in all patients (6831 ± 2158 points). A total of 82 LABSs were identified in left atrial anterior wall; 34 patients had single LABS and 24 patients had dual LABSs. The mean DLABS-IAS was 10.3 ± 9.6 mm. Seven patients also exhibited posterior LABS near the interatrial raphe below the right inferior pulmonary vein. Patients with a single roof-side LABS had significantly shorter left atrial activation times than those with a single septal-side LABS (81.6 ± 13.2 ms vs. 93.5 ± 13.7 ms, p < 0.05). Interatrial conduction patterns during RAA pacing varied between patients and affected the left atrial activation time.
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S. Ramos K, Pool L, van Schie MS, Wijdeveld LFJM, van der Does WFB, Baks L, Sultan HMD, van Wijk SW, Bogers AJJC, Verheule S, de Groot NMS, Brundel BJJM. Degree of Fibrosis in Human Atrial Tissue Is Not the Hallmark Driving AF. Cells 2022; 11:cells11030427. [PMID: 35159236 PMCID: PMC8834228 DOI: 10.3390/cells11030427] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/11/2022] [Accepted: 01/20/2022] [Indexed: 02/07/2023] Open
Abstract
Background: The current paradigm is that fibrosis promotes electrophysiological disorders and drives atrial fibrillation (AF). In this current study, we investigated the relation between the degree of fibrosis in human atrial tissue samples of controls and patients in various stages of AF and the degree of electrophysiological abnormalities. Methods: The degree of fibrosis was measured in the atrial tissue and serum of patients in various stages of AF and the controls. Hereto, picrosirius and H&E staining were performed to quantify degree of total, endo-perimysial fibrosis, and cardiomyocyte diameter. Western blot quantified fibrosis markers: neural cell adhesion molecule, tissue inhibitor of metalloproteinase, lysyl oxidase, and α-smooth muscle actin. In serum, the ratio carboxyl-terminal telopeptide of collagen/matrix-metalloproteinase1 was determined. High-resolution epicardial mapping evaluated low-voltage areas and conduction abnormalities. Results: No significant differences were observed in the degree of fibrosis between the groups. Finally, no significant correlation—absolute nor spatial—was observed between all electrophysiological parameters and histological fibrosis markers. Conclusions: No differences in the degree of fibrosis were observed in patients from various stages of AF compared to the controls. Moreover, electrophysiological abnormalities did not correlate with any of the fibrosis markers. The findings indicate that fibrosis is not the hallmark of structural remodeling in AF.
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Affiliation(s)
- Kennedy S. Ramos
- Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, 1081 HV Amsterdam, The Netherlands; (L.P.); (L.F.J.M.W.); (L.B.); (H.M.D.S.); (S.W.v.W.)
- Department Cardiology, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands; (M.S.v.S.); (W.F.B.v.d.D.); (N.M.S.d.G.)
- Correspondence: (K.S.R.); (B.J.J.M.B.)
| | - Lisa Pool
- Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, 1081 HV Amsterdam, The Netherlands; (L.P.); (L.F.J.M.W.); (L.B.); (H.M.D.S.); (S.W.v.W.)
- Department Cardiology, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands; (M.S.v.S.); (W.F.B.v.d.D.); (N.M.S.d.G.)
| | - Mathijs S. van Schie
- Department Cardiology, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands; (M.S.v.S.); (W.F.B.v.d.D.); (N.M.S.d.G.)
| | - Leonoor F. J. M. Wijdeveld
- Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, 1081 HV Amsterdam, The Netherlands; (L.P.); (L.F.J.M.W.); (L.B.); (H.M.D.S.); (S.W.v.W.)
| | - Willemijn F. B. van der Does
- Department Cardiology, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands; (M.S.v.S.); (W.F.B.v.d.D.); (N.M.S.d.G.)
| | - Luciënne Baks
- Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, 1081 HV Amsterdam, The Netherlands; (L.P.); (L.F.J.M.W.); (L.B.); (H.M.D.S.); (S.W.v.W.)
| | - H. M. Danish Sultan
- Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, 1081 HV Amsterdam, The Netherlands; (L.P.); (L.F.J.M.W.); (L.B.); (H.M.D.S.); (S.W.v.W.)
| | - Stan W. van Wijk
- Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, 1081 HV Amsterdam, The Netherlands; (L.P.); (L.F.J.M.W.); (L.B.); (H.M.D.S.); (S.W.v.W.)
| | - Ad J. J. C. Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands;
| | - Sander Verheule
- Department of Physiology, University Maastricht, 6211 LK Maastricht, The Netherlands;
| | - Natasja M. S. de Groot
- Department Cardiology, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands; (M.S.v.S.); (W.F.B.v.d.D.); (N.M.S.d.G.)
| | - Bianca J. J. M. Brundel
- Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, 1081 HV Amsterdam, The Netherlands; (L.P.); (L.F.J.M.W.); (L.B.); (H.M.D.S.); (S.W.v.W.)
- Correspondence: (K.S.R.); (B.J.J.M.B.)
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van Schie MS, Starreveld R, Roos-Serote MC, Taverne YJHJ, van Schaagen FRN, Bogers AJJC, de Groot NMS. Classification of sinus rhythm single potential morphology in patients with mitral valve disease. Europace 2021; 22:1509-1519. [PMID: 33033830 PMCID: PMC7544534 DOI: 10.1093/europace/euaa130] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/24/2020] [Accepted: 04/28/2020] [Indexed: 12/31/2022] Open
Abstract
Aims The morphology of unipolar single potentials (SPs) contains information on intra-atrial conduction disorders and possibly the substrate underlying atrial fibrillation (AF). This study examined the impact of AF episodes on features of SP morphology during sinus rhythm (SR) in patients with mitral valve disease. Methods and results Intraoperative epicardial mapping (interelectrode distance 2 mm) of the right and left atrium (RA, LA), Bachmann’s bundle (BB), and pulmonary vein area (PVA) was performed in 67 patients (27 male, 67 ± 11 years) with or without a history of paroxysmal AF (PAF). Unipolar SPs were classified according to their differences in relative R- and S-wave amplitude ratios. A clear predominance of S-waves was observed at BB and the RA in both the no AF and PAF groups (BB 88.8% vs. 85.9%, RA 92.1% vs. 85.1%, respectively). Potential voltages at the RA, BB, and PVA were significantly lower in the PAF group (P < 0.001 for each) and were mainly determined by the size of the S-waves amplitudes. The largest difference in S-wave amplitudes was found at BB; the S-wave amplitude was lower in the PAF group [4.08 (2.45–6.13) mV vs. 2.94 (1.40–4.75) mV; P < 0.001]. In addition, conduction velocity (CV) at BB was lower as well [0.97 (0.70–1.21) m/s vs. 0.89 (0.62–1.16) m/s, P < 0.001]. Conclusion Though excitation of the atria during SR is heterogeneously disrupted, a history of AF is characterized by decreased SP amplitudes at BB due to loss of S-wave amplitudes and decreased CV. This suggests that SP morphology could provide additional information on wavefront propagation.
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Affiliation(s)
- Mathijs S van Schie
- Department of Cardiology, Unit Translational Electrophysiology, Erasmus Medical Centre, Dr Molewaterplein 40, 3015GD Rotterdam, the Netherlands
| | - Roeliene Starreveld
- Department of Cardiology, Unit Translational Electrophysiology, Erasmus Medical Centre, Dr Molewaterplein 40, 3015GD Rotterdam, the Netherlands
| | - Maarten C Roos-Serote
- Department of Cardiology, Unit Translational Electrophysiology, Erasmus Medical Centre, Dr Molewaterplein 40, 3015GD Rotterdam, the Netherlands
| | - Yannick J H J Taverne
- Department of Cardiothoracic Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Frank R N van Schaagen
- Department of Cardiothoracic Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Natasja M S de Groot
- Department of Cardiology, Unit Translational Electrophysiology, Erasmus Medical Centre, Dr Molewaterplein 40, 3015GD Rotterdam, the Netherlands
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Chaumont C, Suffee N, Gandjbakhch E, Balse E, Anselme F, Hatem SN. Epicardial origin of cardiac arrhythmias: clinical evidences and pathophysiology. Cardiovasc Res 2021; 118:1693-1702. [PMID: 34152392 PMCID: PMC9215195 DOI: 10.1093/cvr/cvab213] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 06/18/2021] [Indexed: 11/16/2022] Open
Abstract
Recent developments in imaging, mapping, and ablation techniques have shown that the epicardial region of the heart is a key player in the occurrence of ventricular arrhythmic events in several cardiac diseases, such as Brugada syndrome, arrhythmogenic cardiomyopathy, or dilated cardiomyopathy. At the atrial level as well, the epicardial region has emerged as an important determinant of the substrate of atrial fibrillation, pointing to common underlying pathophysiological mechanisms. Alteration in the gradient of repolarization between myocardial layers favouring the occurrence of re-entry circuits has largely been described. The fibro-fatty infiltration of the subepicardium is another shared substrate between ventricular and atrial arrhythmias. Recent data have emphasized the role of the epicardial reactivation in the formation of this arrhythmogenic substrate. There are new evidences supporting this structural remodelling process to be regulated by the recruitment of epicardial progenitor cells that can differentiate into adipocytes or fibroblasts under various stimuli. In addition, immune-inflammatory processes can also contribute to fibrosis of the subepicardial layer. A better understanding of such ‘electrical fragility’ of the epicardial area will open perspectives for novel biomarkers and therapeutic strategies. In this review article, a pathophysiological scheme of epicardial-driven arrhythmias will be proposed.
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Affiliation(s)
- Corentin Chaumont
- Cardiology Department, Rouen University Hospital, Rouen, France.,FHU REMOD-VHF, UNIROUEN, INSERM U1096, F76000, France
| | - Nadine Suffee
- INSERM UMRS1166, ICAN-Institute of CardioMetabolism and Nutrition, Sorbonne University, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Estelle Gandjbakhch
- INSERM UMRS1166, ICAN-Institute of CardioMetabolism and Nutrition, Sorbonne University, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Elise Balse
- INSERM UMRS1166, ICAN-Institute of CardioMetabolism and Nutrition, Sorbonne University, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Frédéric Anselme
- Cardiology Department, Rouen University Hospital, Rouen, France.,FHU REMOD-VHF, UNIROUEN, INSERM U1096, F76000, France
| | - Stéphane N Hatem
- INSERM UMRS1166, ICAN-Institute of CardioMetabolism and Nutrition, Sorbonne University, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
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van Schie MS, Kharbanda RK, Houck CA, Lanters EAH, Taverne YJHJ, Bogers AJJC, de Groot NMS. Identification of Low-Voltage Areas: A Unipolar, Bipolar, and Omnipolar Perspective. Circ Arrhythm Electrophysiol 2021; 14:e009912. [PMID: 34143644 PMCID: PMC8294660 DOI: 10.1161/circep.121.009912] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Low-voltage areas (LVAs) are commonly considered surrogate markers for an arrhythmogenic substrate underlying tachyarrhythmias. It remains challenging to define a proper threshold to classify LVA, and it is unknown whether unipolar, bipolar, and the recently introduced omnipolar voltage mapping techniques are complementary or contradictory in classifying LVAs. Therefore, this study examined similarities and dissimilarities in unipolar, bipolar, and omnipolar voltage mapping and explored the relation between various types of voltages and conduction velocity (CV).
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Affiliation(s)
- Mathijs S van Schie
- Department of Cardiology (M.S.v.S., R.K.K., C.A.H., E.A.H.L., N.M.S.d.G.), Erasmus Medical Center, Rotterdam, the Netherlands
| | - Rohit K Kharbanda
- Department of Cardiology (M.S.v.S., R.K.K., C.A.H., E.A.H.L., N.M.S.d.G.), Erasmus Medical Center, Rotterdam, the Netherlands.,Department of Cardiothoracic Surgery (R.K.K., C.A.H., Y.J.H.J.T., A.J.J.C.B.), Erasmus Medical Center, Rotterdam, the Netherlands
| | - Charlotte A Houck
- Department of Cardiothoracic Surgery (R.K.K., C.A.H., Y.J.H.J.T., A.J.J.C.B.), Erasmus Medical Center, Rotterdam, the Netherlands
| | - Eva A H Lanters
- Department of Cardiology (M.S.v.S., R.K.K., C.A.H., E.A.H.L., N.M.S.d.G.), Erasmus Medical Center, Rotterdam, the Netherlands
| | - Yannick J H J Taverne
- Department of Cardiothoracic Surgery (R.K.K., C.A.H., Y.J.H.J.T., A.J.J.C.B.), Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery (R.K.K., C.A.H., Y.J.H.J.T., A.J.J.C.B.), Erasmus Medical Center, Rotterdam, the Netherlands
| | - Natasja M S de Groot
- Department of Cardiology (M.S.v.S., R.K.K., C.A.H., E.A.H.L., N.M.S.d.G.), Erasmus Medical Center, Rotterdam, the Netherlands
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Kharbanda RK, Wesselius FJ, van Schie MS, Taverne YJHJ, Bogers AJJC, de Groot NMS. Endo-Epicardial Mapping of In Vivo Human Sinoatrial Node Activity. JACC Clin Electrophysiol 2021; 7:693-702. [PMID: 33640354 DOI: 10.1016/j.jacep.2020.11.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 10/08/2020] [Accepted: 11/18/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The aim of the current study was to examine electrophysiological characteristics of sinoatrial node (SAN) activity from an endo-epicardial perspective. BACKGROUND Electrophysiological properties of the in vivo human SAN and its exit pathways remain poorly understood. METHODS Twenty patients (75% male; median age 66 years [59 to 73 years]) with structural heart disease underwent simultaneous endo-epicardial mapping (256 unipolar electrodes, interelectrode distance 2 mm). Conduction times, endo-epicardial delays (EEDs), and R/S ratio were examined in the surrounding 10 mm of SAN activation. Areas of conduction block were defined as conduction delays ≥12 ms and endo-epicardial asynchrony as EED ≥15 m. RESULTS Three distinct activation patterns were observed in a total of 28 SAN-focal activation patterns (SAN-FAPs) (4 patients exhibited >1 different exit site), including SAN activation patterns with: 1) solely an endocardial exit site (n = 10 [36%]); 2) solely an epicardial exit site (n = 13 [46%]); and 3) simultaneously activated endo-epicardial exit sites (n = 5 [18%]). Median (interquartile range) EED at the origin of the SAN-FAP was 10 ms (6 to 14 ms) and the prevalence of endo-epicardial asynchrony in the surroundings of the SAN-FAP was 5% (2% to 18%). Electrograms at the origin of the SAN-FAPs exhibited significantly larger R-peaks in the mid right atrium (RA) compared with the superior RA (mid R/S ratio 0.15 [0.067 to 0.34] vs. superior R/S ratio 0.045 [0.026 to 0.062]; p = 0.004). Conduction velocity within a distance of 10 mm from the SAN-FAP was 125 cm/s (80 to 250 cm/s). All 6 SAN-FAPs at the mid RA were observed in patients with a history of atrial fibrillation. CONCLUSIONS Variations in activation patterns of the SAN observed in this study highlight the complex 3-dimensional SAN geometry and indicate the presence of interindividual differences in SAN exit pathways. Solely in patients with a history of atrial fibrillation, SAN activity occurred more caudally, which indicates changes in preferential SAN exit pathways.
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Affiliation(s)
- Rohit K Kharbanda
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands; Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Fons J Wesselius
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Mathijs S van Schie
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Yannick J H J Taverne
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
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11
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Khan MS, Lange M, Ranjan R, Sharma V, Glotzbach JP, Selzman C, Dosdall DJ. Premature atrial stimulation accentuates conduction abnormalities in cardiac surgery patients that develop postoperative atrial fibrillation. J Electrocardiol 2021; 69:36-43. [PMID: 34555557 PMCID: PMC9265137 DOI: 10.1016/j.jelectrocard.2021.09.003] [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] [Received: 07/13/2021] [Revised: 09/03/2021] [Accepted: 09/06/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND postoperative atrial fibrillation (POAF) is a common cardiac surgery complication that is associated with increased complications and negative outcomes, but the association between presurgical atrial conduction abnormalities and POAF has not been investigated clinically during premature atrial S1S2 stimulation. This clinical study sought to examine whether intraoperative premature atrial stimulation reveals increased areas of slowed and/or blocked conduction in patients that develop POAF. METHODS High-density intraoperative epicardial left atrial mapping was conducted in 20 cardiac surgery patients with no prior history of atrial fibrillation (AF). In 20 patients, 6 (30%) developed POAF. A flexible-array of 240-electrodes was placed on the posterior left atrial wall in between the pulmonary veins. Activation maps were generated for sinus and premature atrial S1S2 stimulated beats. The area of conduction block (CB), conduction delay (CD) and the combination of both (CDCB) for conduction velocity < 0.1, 0.1 ≤ x < 0.2 and < 0.2 m/s, respectively were quantified. RESULTS For a premature atrial S2 beat with shortest cycle length captured, conduction velocity maps revealed a significantly higher area for CD (13.19 ± 6.59 versus 6.06 ± 4.22 mm2, p = 0.028) and CDCB (17.36 ± 8.75 versus 7.41 ± 6.39 mm2, p = 0.034), and a trend toward a larger area for CB (4.17 ± 3.66 versus 1.34 ± 2.86 mm2, p = 0.063) in patients who developed POAF in comparison to those that remained in the sinus. Sinus and S1 paced beats did not show substantial differences in abnormal conduction areas between patients with and without POAF. CONCLUSION In comparison to sinus and S1 beats, premature atrial S2 beats accentuate conduction abnormalities in the posterior left atrial wall of cardiac surgery patients that developed POAF.
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Affiliation(s)
- Muhammad S. Khan
- Nora Eccles Harrison Cardiovascular Research and Training Institute, The University of Utah – Health, Salt Lake City, UT 84112, USA
| | - Matthias Lange
- Nora Eccles Harrison Cardiovascular Research and Training Institute, The University of Utah – Health, Salt Lake City, UT 84112, USA
| | - Ravi Ranjan
- Nora Eccles Harrison Cardiovascular Research and Training Institute, The University of Utah – Health, Salt Lake City, UT 84112, USA.,Division of Cardiovascular Medicine, Department of Internal Medicine, The University of Utah – Health, Salt Lake City, UT 84112, USA.,Department of Bioengineering, The University of Utah – Health, Salt Lake City, UT 84112, USA
| | - Vikas Sharma
- Division of Cardiothoracic Surgery, Department of Surgery, The University of Utah – Health, Salt Lake City, UT 84112, USA
| | - Jason P. Glotzbach
- Division of Cardiothoracic Surgery, Department of Surgery, The University of Utah – Health, Salt Lake City, UT 84112, USA
| | - Craig Selzman
- Nora Eccles Harrison Cardiovascular Research and Training Institute, The University of Utah – Health, Salt Lake City, UT 84112, USA.,Division of Cardiothoracic Surgery, Department of Surgery, The University of Utah – Health, Salt Lake City, UT 84112, USA
| | - Derek J. Dosdall
- Nora Eccles Harrison Cardiovascular Research and Training Institute, The University of Utah – Health, Salt Lake City, UT 84112, USA.,Division of Cardiovascular Medicine, Department of Internal Medicine, The University of Utah – Health, Salt Lake City, UT 84112, USA.,Department of Bioengineering, The University of Utah – Health, Salt Lake City, UT 84112, USA.,Division of Cardiothoracic Surgery, Department of Surgery, The University of Utah – Health, Salt Lake City, UT 84112, USA.,Address For Correspondence: Dr. Derek J. Dosdall, PhD, FHRS, FAHA, Associate Professor of Surgery, Division of Cardiothoracic Surgery, The University of Utah – Health, Salt Lake City, UT 84112 USA, / Ph: (+1) 801-587-2036
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12
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Starreveld R, Knops P, Roos-Serote M, Kik C, Bogers AJJC, Brundel BJJM, de Groot NMS. The Impact of Filter Settings on Morphology of Unipolar Fibrillation Potentials. J Cardiovasc Transl Res 2020; 13:953-964. [PMID: 32410210 PMCID: PMC7708344 DOI: 10.1007/s12265-020-10011-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 04/17/2020] [Indexed: 12/16/2022]
Abstract
Using unipolar atrial electrogram morphology as guidance for ablative therapy is regaining interest. Although standardly used in clinical practice during ablative therapy, the impact of filter settings on morphology of unipolar AF potentials is unknown. Thirty different filters were applied to 2,557,045 high-resolution epicardial AF potentials recorded from ten patients. Deflections with slope ≤ - 0.05 mV/ms and amplitude ≥ 0.3 mV were marked. High-pass filtering decreased the number of detected potentials, deflection amplitude, and percentage of fractionated potentials (≥ 2 deflections) as well as fractionation delay time (FDT) and increased percentage of single potentials. Low-pass filtering decreased the number of potentials, percentage of fractionated potentials, whereas deflection amplitude, percentage of single potentials, and FDT increased. Notch filtering (50 Hz) decreased the number of potentials and deflection amplitude, whereas the percentage of complex fractionated potentials (≥ 3 deflections) increased. Filtering significantly impacted morphology of unipolar fibrillation potentials, becoming a potential source of error in identification of ablative targets. Graphical Abstract Impact of filtering on morphology of unipolar AF potentials. High-pass, low-pass and notch filters were applied to 2,557,045 high-resolution epicardial AF potentials recorded from ten patients. Filtering significantly impacted AF potential morphology, i.e., number of detected potentials, peak-to-peak amplitude, number of deflections, and fractionation delay time. CFP, complex fractionated potential (≥ 3 deflections); DP, double potential (two deflections); FDT, fractionation delay time; SP, single potential (one deflection).
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Affiliation(s)
- Roeliene Starreveld
- Department of Cardiology, Erasmus Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Paul Knops
- Department of Cardiology, Erasmus Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Maarten Roos-Serote
- Department of Cardiology, Erasmus Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Charles Kik
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Bianca J J M Brundel
- Department of Physiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Natasja M S de Groot
- Department of Cardiology, Erasmus Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
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13
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Carmona Puerta R. Bloqueos interauriculares: diagnóstico y significado clínico. Med Clin (Barc) 2020; 155:207-214. [DOI: 10.1016/j.medcli.2020.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 03/05/2020] [Accepted: 03/09/2020] [Indexed: 01/10/2023]
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14
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Kharbanda RK, Knops P, van der Does LJME, Kik C, Taverne YJHJ, Roos‐Serote MC, Heida A, Oei FBS, Bogers AJJC, de Groot NMS. Simultaneous Endo-Epicardial Mapping of the Human Right Atrium: Unraveling Atrial Excitation. J Am Heart Assoc 2020; 9:e017069. [PMID: 32808551 PMCID: PMC7660792 DOI: 10.1161/jaha.120.017069] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/25/2020] [Indexed: 11/23/2022]
Abstract
Background The significance of endo-epicardial asynchrony (EEA) and atrial conduction block (CB), which play an important role in the pathophysiology of atrial fibrillation (AF) during sinus rhythm is poorly understood. The aim of our study was therefore to examine 3-dimensional activation of the human right atrium (RA). Methods and Results Eighty patients (79% men, 39% history of AF) underwent simultaneous endo-epicardial sinus rhythm mapping of the inferior, middle and superior RA. Areas of CB were defined as conduction delays of ≥12 ms, EEA as activation time differences of opposite electrodes of ≥15 ms and transmural CB as CB at similar endo-epicardial sites. CB was more pronounced at the endocardium (all locations P<0.025). Amount, extensiveness and severity of CB was higher at the superior RA. Transmural CB at the inferior RA was associated with a higher incidence of post-operative AF (P=0.03). EEA occurred up to 84 ms and was more pronounced at the superior RA (superior: 27 ms [interquartile range, 18.3-39.3], versus mid-RA: 20.3 ms [interquartile range, 0-29.9], and inferior RA: 0 ms [interquartile range, 0-21], P<0.001). Hypertension (P=0.009), diabetes mellitus (P=0.018), and hypercholesterolemia (P=0.015) were associated with a higher degree of EEA. CB (P=0.007) and EEA (P=0.037) were more pronounced in patients with a history of persistent AF compared with patients without AF history. Conclusions This study provides important insights into complex atrial endo-epicardial excitation. Significant differences in conduction disorders between the endo- and epicardium and a significant degree of EEA are already present during sinus rhythm and are more pronounced in patients with cardiovascular risk factors or a history of persistent AF.
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Affiliation(s)
- Rohit K. Kharbanda
- Department of CardiologyErasmus Medical CenterRotterdamThe Netherlands
- Department of Cardiothoracic SurgeryErasmus Medical CenterRotterdamThe Netherlands
| | - Paul Knops
- Department of CardiologyErasmus Medical CenterRotterdamThe Netherlands
| | | | - Charles Kik
- Department of Cardiothoracic SurgeryErasmus Medical CenterRotterdamThe Netherlands
| | | | | | - Annejet Heida
- Department of CardiologyErasmus Medical CenterRotterdamThe Netherlands
| | - Frans B. S. Oei
- Department of Cardiothoracic SurgeryErasmus Medical CenterRotterdamThe Netherlands
| | - Ad J. J. C. Bogers
- Department of Cardiothoracic SurgeryErasmus Medical CenterRotterdamThe Netherlands
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15
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Kharbanda RK, Kik C, Knops P, Bogers AJJC, de Groot NMS. First Evidence of Endo-Epicardial Asynchrony of the Left Atrial Wall in Humans. JACC Case Rep 2020; 2:745-749. [PMID: 34317340 PMCID: PMC8302028 DOI: 10.1016/j.jaccas.2020.02.027] [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] [Received: 09/17/2019] [Revised: 02/03/2020] [Accepted: 02/26/2020] [Indexed: 10/26/2022]
Abstract
Asynchronous activation of the endo-epicardium plays an important role in persistence of atrial fibrillation. So far, endo-epicardial asynchrony has only been demonstrated in the human right atrium. Our data provides the first evidence for existence of a considerable degree of endo-epicardial asynchrony in the human left atrium. (Level of Difficulty: Advanced.).
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Affiliation(s)
- Rohit K Kharbanda
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands.,Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Charles Kik
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Paul Knops
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
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16
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Groot NMS, Allessie MA. Pathophysiology of atrial fibrillation: Focal patterns of activation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:1312-1319. [DOI: 10.1111/pace.13777] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 06/30/2019] [Accepted: 07/26/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Natasja M. S. Groot
- Department of Cardiology, Unit Translational ElectrophysiologyErasmus Medical Center Rotterdam the Netherlands
| | - Maurits A. Allessie
- Department of Cardiology, Unit Translational ElectrophysiologyErasmus Medical Center Rotterdam the Netherlands
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17
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Knol WG, Teuwen CP, Kleinrensink GJ, Bogers AJ, de Groot NM, Taverne YJ. The Bachmann bundle and interatrial conduction: comparing atrial morphology to electrical activity. Heart Rhythm 2019; 16:606-614. [DOI: 10.1016/j.hrthm.2018.10.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Indexed: 11/29/2022]
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18
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Mouws EMJP, Kik C, van der Does LJME, Lanters EAH, Teuwen CP, Knops P, Bogers AJJC, de Groot NMS. Novel Insights in the Activation Patterns at the Pulmonary Vein Area. Circ Arrhythm Electrophysiol 2018; 11:e006720. [PMID: 30520348 DOI: 10.1161/circep.118.006720] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Extensiveness of conduction delay and block at the pulmonary vein area (PVA) was quantified in a previous study. We hypothesized that the combination of lines of conduction block with multiple concomitantly entering sinus rhythm wavefronts at the PVA may result in increased arrhythmogenicity and susceptibility to atrial fibrillation (AF). METHODS Intraoperative high-density epicardial mapping of PVA (N≈450 sites, interelectrode distances: 2 mm) was performed during sinus rhythm in 327 patients (241 male [74%], 67±10 [21-84] years) with and without preoperative AF. For each patient, activation patterns at the PVA were quantified, including the location of entry sites of wavefronts, direction of propagation, and their relative activation times. The association between activation patterns and the presence of AF was examined. RESULTS Excitation of the PVA occurred via multiple consecutive wavefronts in the vast majority of patient (N=216, 81%). In total, 561 wavefronts were observed, which mostly propagated through the septal or paraseptal regions towards the PVA (N=461, 82%). A substantial dissociation of consecutive wavefronts was observed with Δactivation times of 10.6±8.8 (0-46) ms. No difference was observed in Δactivation times of consecutive wavefronts during sinus rhythm between patients without and with AF. An excitation-based risk factor model, including conduction delay ≥6 mm, conduction block ≥6 mm, and conduction delay and block ≥16 mm, wavefronts via the posteroinferior to posterosuperior regions and multiple opposing wavefronts, demonstrated a 5-fold risk of AF when multiple risk factors were present. CONCLUSIONS In contrast to previous findings, quantification of activation patterns at the PVA on high-resolution scale demonstrated complex patterns with often multiple entry sites and high interindividual variability. Altered patterns of activation, consisting of multiple opposing wavefronts combined with long lines of conduction slowing, were associated with the presence of AF.
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Affiliation(s)
- Elisabeth M J P Mouws
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands (E.M.J.P.M., L.J.M.E.v.d.D., E.A.H.L., C.P.T., P.K., N.M.S.d.G.).,Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands (E.M.J.P.M., C.K., A.J.J.C.B.)
| | - Charles Kik
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands (E.M.J.P.M., C.K., A.J.J.C.B.)
| | - Lisette J M E van der Does
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands (E.M.J.P.M., L.J.M.E.v.d.D., E.A.H.L., C.P.T., P.K., N.M.S.d.G.)
| | - Eva A H Lanters
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands (E.M.J.P.M., L.J.M.E.v.d.D., E.A.H.L., C.P.T., P.K., N.M.S.d.G.)
| | - Christophe P Teuwen
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands (E.M.J.P.M., L.J.M.E.v.d.D., E.A.H.L., C.P.T., P.K., N.M.S.d.G.)
| | - Paul Knops
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands (E.M.J.P.M., L.J.M.E.v.d.D., E.A.H.L., C.P.T., P.K., N.M.S.d.G.)
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands (E.M.J.P.M., C.K., A.J.J.C.B.)
| | - Natasja M S de Groot
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands (E.M.J.P.M., L.J.M.E.v.d.D., E.A.H.L., C.P.T., P.K., N.M.S.d.G.)
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19
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Kharbanda RK, Garcia-Izquierdo E, Bogers AJJC, De Groot NMS. Focal activation patterns: breaking new grounds in the pathophysiology of atrial fibrillation. Expert Rev Cardiovasc Ther 2018; 16:479-488. [PMID: 29874118 DOI: 10.1080/14779072.2018.1485488] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
INTRODUCTION High-resolution atrial mapping studies have provided novel insights in the pathophysiology of atrial fibrillation (AF) in the last few years. Increasing attention is being drawn to the so-called focal activation patterns (FAPs); however, there is no consensus on criteria to identify and characterize these patterns. Areas covered: In this expert review, an overview of definitions and criteria used to examine FAPs obtained from atrial mapping studies is provided and studies reporting on the underlying mechanisms are discussed. Expert commentary: High-resolution cardiac mapping has revealed the importance of FAPs in the pathophysiology of AF. There is increasing evidence supporting the concept of endo-epicardial (E-E) asynchrony enabling transmural conduction of electrical waves resulting in FAPs. Uniform reports of FAPs in future studies are needed to provide more knowledge on its clinical importance.
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Affiliation(s)
- Rohit K Kharbanda
- a Department of Cardiology , Erasmus Medical Center , Rotterdam , The Netherlands.,b Department of Cardiothoracic Surgery , Erasmus Medical Center , Rotterdam , The Netherlands
| | | | - Ad J J C Bogers
- b Department of Cardiothoracic Surgery , Erasmus Medical Center , Rotterdam , The Netherlands
| | - Natasja M S De Groot
- a Department of Cardiology , Erasmus Medical Center , Rotterdam , The Netherlands
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20
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Lanters EAH, Teuwen CP, Yaksh A, Kik C, van der Does LJME, Mouws EMJP, Knops P, van Groningen NJ, Hokken T, Bogers AJJC, de Groot NMS. Intraoperative Inducibility of Atrial Fibrillation Does Not Predict Early Postoperative Atrial Fibrillation. J Am Heart Assoc 2018. [PMID: 29525787 PMCID: PMC5907553 DOI: 10.1161/jaha.117.007879] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Early postoperative atrial fibrillation (EPoAF) is associated with thromboembolic events, prolonged hospitalization, and development of late PoAF (LPoAF). It is, however, unknown if EPoAF can be predicted by intraoperative AF inducibility. The aims of this study are therefore to explore (1) the value of intraoperative inducibility of AF for development of both EPoAF and LPoAF and (2) the predictive value of de novo EPoAF for recurrence of LPoAF. Methods and Results Patients (N=496, 75% male) undergoing cardiothoracic surgery for coronary and/or valvular heart disease were included. AF induction was attempted by atrial pacing, before extracorporeal circulation. All patients were on continuous rhythm monitoring until discharge to detect EPoAF. During a follow‐up period of 2 years, LPoAF was detected by ECGs and Holter recordings. Sustained AF was inducible in 56% of patients. There was no difference in patients with or without AF before surgery (P=0.159), or between different types of surgery (P=0.687). In patients without a history of AF, incidence of EPoAF and LPoAF was 37% and 2%, respectively. EPoAF recurred in 58% patients with preoperative AF, 53% developed LPoAF. There were no correlations between intraoperative inducibility and EPoAF or LPoAF (P>0.05). EPoAF was not correlated with LPoAF in patients without a history of AF (P=0.116), in contrast to patients with AF before surgery (P<0.001). Conclusions Intraoperative AF inducibility does not predict development of either EPoAF or LPoAF. In patients with AF before surgery, EPoAF is correlated with LPoAF recurrences. This correlation is absent in patients without AF before surgery.
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Affiliation(s)
- Eva A H Lanters
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Christophe P Teuwen
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ameeta Yaksh
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Charles Kik
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Elisabeth M J P Mouws
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands.,Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Paul Knops
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Thijmen Hokken
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
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21
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Mouws EMJP, Lanters EAH, Teuwen CP, van der Does LJME, Kik C, Knops P, Yaksh A, Bekkers JA, Bogers AJJC, de Groot NMS. Impact of Ischemic and Valvular Heart Disease on Atrial Excitation:A High-Resolution Epicardial Mapping Study. J Am Heart Assoc 2018. [PMID: 29519812 PMCID: PMC5907575 DOI: 10.1161/jaha.117.008331] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background The influence of underlying heart disease or presence of atrial fibrillation (AF) on atrial excitation during sinus rhythm (SR) is unknown. We investigated atrial activation patterns and total activation times of the entire atrial epicardial surface during SR in patients with ischemic and/or valvular heart disease with or without AF. Methods and Results Intraoperative epicardial mapping (N=128/192 electrodes, interelectrode distances: 2 mm) of the right atrium, Bachmann's bundle (BB), left atrioventricular groove, and pulmonary vein area was performed during SR in 253 patients (186 male [74%], age 66±11 years) with ischemic heart disease (N=132, 52%) or ischemic valvular heart disease (N=121, 48%). As expected, SR origin was located at the superior intercaval region of the right atrium in 232 patients (92%). BB activation occurred via 1 wavefront from right‐to‐left (N=163, 64%), from the central part (N=18, 7%), or via multiple wavefronts (N=72, 28%). Left atrioventricular groove activation occurred via (1) BB: N=108, 43%; (2) pulmonary vein area: N=9, 3%; or (3) BB and pulmonary vein area: N=136, 54%; depending on which route had the shortest interatrial conduction time (P<0.001). Ischemic valvular heart disease patients more often had central BB activation and left atrioventricular groove activation via pulmonary vein area compared with ischemic heart disease patients (N=16 [13%] versus N=2 [2%]; P=0.009 and N=86 [71%] versus N=59 [45%]; P<0.001, respectively). Total activation times were longer in patients with AF (AF: 136±20 [92–186] ms; no AF: 114±17 [74–156] ms; P<0.001), because of prolongation of right atrium (P=0.018) and BB conduction times (P<0.001). Conclusions Atrial excitation during SR is affected by underlying heart disease and AF, resulting in alternative routes for BB and left atrioventricular groove activation and prolongation of total activation times. Knowledge of atrial excitation patterns during SR and its electropathological variations, as demonstrated in this study, is essential to further unravel the pathogenesis of AF.
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Affiliation(s)
- Elisabeth M J P Mouws
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands.,Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Eva A H Lanters
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Christophe P Teuwen
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Charles Kik
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Paul Knops
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ameeta Yaksh
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Jos A Bekkers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
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Abstract
BACKGROUND Endo-epicardial asynchrony (EEA) and the interplay between the endocardial and epicardial layers could be important in the pathophysiology of atrial arrhythmias. The morphologic differences between epicardial and endocardial atrial electrograms have not yet been described, and electrogram morphology may hold information about the presence of EEA. OBJECTIVE The purpose of this study was to directly compare epicardial to endocardial unipolar electrogram morphology during sinus rhythm (SR) and to evaluate whether EEA contributes to electrogram fractionation by correlating fractionation to spatial activation patterns. METHODS In 26 patients undergoing cardiac surgery, unipolar electrograms were simultaneously recorded from the epicardium and endocardium at the inferior, middle, and superior right atrial (RA) free wall during SR. Potentials were analyzed for epi-endocardial differences in local activation time, voltage, RS ratio, and fractionation. The surrounding and opposite electrograms of fractionated deflections were evaluated for corresponding local activation times in order to determine whether fractionation originated from EEA. RESULTS The superior RA was predisposed to delayed activation, EEA, and fractionation. Both epicardial and endocardial electrograms demonstrated an S-predominance. Fractionation was mostly similar between the 2 sides; however, incidentally deflections up to 4 mV on 1 side could be absent on the other side. Remote activation was responsible for most fractionated deflections (95%) in SR, of which 4% could be attributed to EEA. CONCLUSION Local epi-endocardial differences in electrogram fractionation occur occasionally during SR but will likely increase during arrhythmias due to increasing EEA and (functional) conduction disorders. Electrogram fractionation can originate from EEA, and this study demonstrated that unipolar electrogram fractionation can potentially identify EEA.
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23
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Teuwen CP, Kik C, van der Does LJME, Lanters EAH, Knops P, Mouws EMJP, Bogers AJJC, de Groot NMS. Quantification of the Arrhythmogenic Effects of Spontaneous Atrial Extrasystole Using High-Resolution Epicardial Mapping. Circ Arrhythm Electrophysiol 2017; 11:CIRCEP.117.005745. [PMID: 29269560 DOI: 10.1161/circep.117.005745] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 11/15/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Atrial extrasystoles (AES) can initiate atrial fibrillation. However, the impact of spontaneous AES on intra-atrial conduction is unknown. The aims of this study were to examine conduction disorders provoked by AES and to correlate these conduction differences with patient characteristics, mapping locations, and type of AES. METHODS AND RESULTS High-resolution epicardial mapping (electrodes N=128 or N=192; interelectrode distance, 2 mm) of the entire atrial surface was performed in patients (N=164; 69.5% male; age 67.2±10.5 years) undergoing open-chest cardiac surgery. AES were classified as premature, aberrant, or prematurely aberrant. Conduction delay and conduction block were quantified during sinus rhythm and AES and subsequently compared. Median incidence of conduction delay and conduction block during sinus rhythm was 1.2% (interquartile, 0%-2.3%) and 0.4% (interquartile, 0%-2.1%). In comparison, the median incidence of conduction delay and conduction block during 339 AES was respectively 2.8% (interquartile, 1.3%-4.6%) and 2.2% (interquartile, 0.3%-5.1%) and differed between the types of AES (prematurely aberrant>aberrant>premature). The degree of prematurity was not associated with a higher incidence of conduction disorders (P>0.05). In contrast, a higher degree of aberrancy was associated with a higher incidence of conduction disorders; AES emerging as epicardial breakthrough provoked most conduction disorders (P≥0.002). AES caused most conduction disorders in patients with diabetes mellitus and left atrial dilatation (P<0.05). CONCLUSIONS Intraoperative high-resolution epicardial mapping showed that conduction disorders are mainly provoked by prematurely aberrant AES, particularly in patients with left atrial dilation and diabetes mellitus or emerging as epicardial breakthrough.
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Affiliation(s)
- Christophe P Teuwen
- From the Department of Cardiology (C.P.T., L.J.M.E.v.d.D., E.A.H.L., P.K., N.M.S.d.G.) and Department of Cardio-Thoracic Surgery (C.K., E.M.J.P.M., A.J.J.C.B.), Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Charles Kik
- From the Department of Cardiology (C.P.T., L.J.M.E.v.d.D., E.A.H.L., P.K., N.M.S.d.G.) and Department of Cardio-Thoracic Surgery (C.K., E.M.J.P.M., A.J.J.C.B.), Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Lisette J M E van der Does
- From the Department of Cardiology (C.P.T., L.J.M.E.v.d.D., E.A.H.L., P.K., N.M.S.d.G.) and Department of Cardio-Thoracic Surgery (C.K., E.M.J.P.M., A.J.J.C.B.), Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Eva A H Lanters
- From the Department of Cardiology (C.P.T., L.J.M.E.v.d.D., E.A.H.L., P.K., N.M.S.d.G.) and Department of Cardio-Thoracic Surgery (C.K., E.M.J.P.M., A.J.J.C.B.), Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Paul Knops
- From the Department of Cardiology (C.P.T., L.J.M.E.v.d.D., E.A.H.L., P.K., N.M.S.d.G.) and Department of Cardio-Thoracic Surgery (C.K., E.M.J.P.M., A.J.J.C.B.), Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Elisabeth M J P Mouws
- From the Department of Cardiology (C.P.T., L.J.M.E.v.d.D., E.A.H.L., P.K., N.M.S.d.G.) and Department of Cardio-Thoracic Surgery (C.K., E.M.J.P.M., A.J.J.C.B.), Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ad J J C Bogers
- From the Department of Cardiology (C.P.T., L.J.M.E.v.d.D., E.A.H.L., P.K., N.M.S.d.G.) and Department of Cardio-Thoracic Surgery (C.K., E.M.J.P.M., A.J.J.C.B.), Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Natasja M S de Groot
- From the Department of Cardiology (C.P.T., L.J.M.E.v.d.D., E.A.H.L., P.K., N.M.S.d.G.) and Department of Cardio-Thoracic Surgery (C.K., E.M.J.P.M., A.J.J.C.B.), Erasmus University Medical Center, Rotterdam, The Netherlands.
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Calvo D, Filgueiras-Rama D, Jalife J. Propagation of Sinus Waves in the Atrial Architecture: When Laminar Electrical Fluxes Turn Turbulent. Circ Arrhythm Electrophysiol 2017; 10:CIRCEP.117.005699. [PMID: 28912207 DOI: 10.1161/circep.117.005699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 08/21/2017] [Indexed: 11/16/2022]
Affiliation(s)
- David Calvo
- From the Arrhythmia Unit, Instituto de Investigación Sanitaria del Principado de Asturias, Hospital Universitario Central de Asturias, Oviedo, Spain (D.C.); Fundación Centro Nacional de Investigaciones Cardiovasculares (CNIC) Carlos III, Madrid, Spain (D.F., J.J.); Hospital Clínico Universitario San Carlos, Madrid, Spain (D.F.-R.); Center for Arrhythmia Research, University of Michigan, Ann Arbor (D.F., J.J.); and CIBERCV, Madrid, Spain (D.F., J.J.)
| | - David Filgueiras-Rama
- From the Arrhythmia Unit, Instituto de Investigación Sanitaria del Principado de Asturias, Hospital Universitario Central de Asturias, Oviedo, Spain (D.C.); Fundación Centro Nacional de Investigaciones Cardiovasculares (CNIC) Carlos III, Madrid, Spain (D.F., J.J.); Hospital Clínico Universitario San Carlos, Madrid, Spain (D.F.-R.); Center for Arrhythmia Research, University of Michigan, Ann Arbor (D.F., J.J.); and CIBERCV, Madrid, Spain (D.F., J.J.)
| | - José Jalife
- From the Arrhythmia Unit, Instituto de Investigación Sanitaria del Principado de Asturias, Hospital Universitario Central de Asturias, Oviedo, Spain (D.C.); Fundación Centro Nacional de Investigaciones Cardiovasculares (CNIC) Carlos III, Madrid, Spain (D.F., J.J.); Hospital Clínico Universitario San Carlos, Madrid, Spain (D.F.-R.); Center for Arrhythmia Research, University of Michigan, Ann Arbor (D.F., J.J.); and CIBERCV, Madrid, Spain (D.F., J.J.).
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