1
|
Franco E, Lozano-Granero C, Matía Francés R, Hernández-Madrid A, Sánchez I, Zamorano JL, Moreno J. Subjective identification and ablation of drivers improves rhythm control in patients with persistent atrial fibrillation. The CHAOS-AF study. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024:S1885-5857(24)00042-2. [PMID: 38336154 DOI: 10.1016/j.rec.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 01/22/2024] [Indexed: 02/12/2024]
Abstract
INTRODUCTION AND OBJECTIVES The optimal approach for persistent atrial fibrillation (AF) ablation remains unknown. In patients with persistent AF, we compared an ablation strategy based on pulmonary vein isolation (PVI) plus ablation of drivers (PVI+D), with a conventional PVI-only approach performed in a 1:1 propensity score-matched cohort. METHODS Drivers were subjectively identified using conventional high-density mapping catheters (IntellaMap ORION, PentaRay NAV or Advisor HD Grid), without dedicated software, as fractionated continuous or quasicontinuous electrograms on 1 to 2 adjacent bipoles, which were ablated first; and as sites with spatiotemporal dispersion (the entire cycle length comprised within the mapping catheter) plus noncontinuous fractionation, which were only targeted in patients without fractionated continuous electrograms, or without AF conversion after ablation of fractionated continuous electrograms. Ablation included PVI plus focal or linear ablation targeting drivers. RESULTS A total of 50 patients were included in each group (61±10 years, 25% women). Fractionated continuous electrograms were found and ablated in 21 patients from the PVI+D group (42%), leading to AF conversion in 7 patients. In the remaining 43 patients, 143 sites with spatiotemporal dispersion plus noncontinuous fractionation were targeted. Globally, AF conversion was achieved in 21 patients (42%). The PVI+D group showed lower atrial arrhythmia recurrences at 1 year of follow-up (30.6% vs 48%; P=.048) and at the last follow-up (46% vs 72%; P=.013), and less progression to permanent AF (10% vs 40%; P=.001). CONCLUSIONS Subjective identification and ablation of drivers, added to PVI, increased 1-year freedom from atrial arrhythmia and decreased long-term recurrences and progression to permanent AF.
Collapse
Affiliation(s)
- Eduardo Franco
- Departamento de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
| | - Cristina Lozano-Granero
- Departamento de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | | | | | - Inmaculada Sánchez
- Departamento de Cardiología Pediátrica, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - José Luis Zamorano
- Departamento de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Javier Moreno
- Departamento de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| |
Collapse
|
2
|
Nanbu T, Yotsukura A, Suzuki G, Takekawa H, Tanaka Y, Yamanashi K, Tsuda M, Yoshida I, Sakurai M, Ashihara T. Organization of atrial fibrillation using a pure sodium channel blocker: Implications of rotor ablation therapy. J Arrhythm 2023. [DOI: 10.1002/joa3.12844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Affiliation(s)
- Tadafumi Nanbu
- Department of Cardiovascular Medicine Hokko Memorial Hospital Sapporo‐shi Japan
| | - Akihiko Yotsukura
- Department of Cardiovascular Medicine Hokko Memorial Hospital Sapporo‐shi Japan
| | - George Suzuki
- Department of Cardiovascular Medicine Hokko Memorial Hospital Sapporo‐shi Japan
| | - Hiroyuki Takekawa
- Department of Cardiovascular Medicine Hokko Memorial Hospital Sapporo‐shi Japan
| | - Yuki Tanaka
- Department of Cardiovascular Medicine Hokko Memorial Hospital Sapporo‐shi Japan
| | - Katsuma Yamanashi
- Department of Cardiovascular Medicine Hokko Memorial Hospital Sapporo‐shi Japan
| | - Masaya Tsuda
- Department of Cardiovascular Medicine Hokko Memorial Hospital Sapporo‐shi Japan
| | - Izumi Yoshida
- Department of Cardiovascular Medicine Hokko Memorial Hospital Sapporo‐shi Japan
| | - Masayuki Sakurai
- Department of Cardiovascular Medicine Hokko Memorial Hospital Sapporo‐shi Japan
| | - Takashi Ashihara
- Department of Medical Informatics and Biomedical Engineering Shiga University of Medical Science Seta Tsukinowa‐cho, Otsu Japan
| |
Collapse
|
3
|
Xu CH, Xiong F, Jiang WF, Liu X, Liu T, Qin M. Rotor mechanism and its mapping in atrial fibrillation. Europace 2023; 25:783-792. [PMID: 36734272 PMCID: PMC10062333 DOI: 10.1093/europace/euad002] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 12/28/2022] [Indexed: 02/04/2023] Open
Abstract
Treatment of atrial fibrillation (AF) remains challenging despite significant progress in understanding its underlying mechanisms. The first detailed, quantitative theory of functional re-entry, the 'leading circle' model, was developed more than 40 years ago. Subsequently, in decades of study, an alternative paradigm based on spiral waves has long been postulated to drive AF. The rotor as a 'spiral wave generator' is a curved 'vortex' formed by spin motion in the two-dimensional plane, identified using advanced mapping methods in experimental and clinical AF. However, it is challenging to achieve complementary results between experimental results and clinical studies due to the limitation in research methods and the complexity of the rotor mechanism. Here, we review knowledge garnered over decades on generation, electrophysiological properties, and three-dimensional (3D) structure diversity of the rotor mechanism and make a comparison among recent clinical approaches to identify rotors. Although initial studies of rotor ablation at many independent centres have achieved promising results, some inconclusive outcomes exist in others. We propose that the clinical rotor identification might be substantially influenced by (i) non-identical surface activation patterns, which resulted from a diverse 3D form of scroll wave, and (ii) inadequate resolution of mapping techniques. With rapidly advancing theoretical and technological developments, future work is required to resolve clinically relevant limitations in current basic and clinical research methodology, translate from one to the other, and resolve available mapping techniques.
Collapse
Affiliation(s)
- Chang-Hao Xu
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine,
Shanghai Jiao Tong University, 241 Huaihai West Road, Xuhui
District, Shanghai 200030, China
| | - Feng Xiong
- Montreal Heart Institute, Department of Medicine, University of
Montreal, 5000, Bélanger street, Montréal, Québec H1T
1C8, Canada
| | - Wei-Feng Jiang
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine,
Shanghai Jiao Tong University, 241 Huaihai West Road, Xuhui
District, Shanghai 200030, China
| | - Xu Liu
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine,
Shanghai Jiao Tong University, 241 Huaihai West Road, Xuhui
District, Shanghai 200030, China
| | - Tao Liu
- Corresponding authors. Tao Liu, 238 Jiefang Road, Wuchang
District, Wuhan, Hubei 430060, China. Tel: +86 (027) 8804 1911, Fax:+86-(027)-8804-2292.
E-mail address:; Mu Qin, 241 Huaihai
West Road, Xuhui District, Shanghai, 200030, China. Tel: +8621628219902603, Fax:
+862162821105. E-mail address:
| | - Mu Qin
- Corresponding authors. Tao Liu, 238 Jiefang Road, Wuchang
District, Wuhan, Hubei 430060, China. Tel: +86 (027) 8804 1911, Fax:+86-(027)-8804-2292.
E-mail address:; Mu Qin, 241 Huaihai
West Road, Xuhui District, Shanghai, 200030, China. Tel: +8621628219902603, Fax:
+862162821105. E-mail address:
| |
Collapse
|
4
|
Nagase T, Kato R, Asano S, Fukunaga H, Yoshida Y, Hayashi Y, Sekiguchi Y, Nanasato M, Nitta J, Isobe M. Spatial relationship of localized sources of persistent atrial fibrillation identified by a unipolar-based automated algorithm to complex fractionated atrial electrocardiograms and atrial low voltage areas. J Cardiovasc Electrophysiol 2023; 34:337-344. [PMID: 36423234 DOI: 10.1111/jce.15755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/10/2022] [Accepted: 10/31/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Spatial characteristics of localized sources of persistent atrial fibrillation (AF) identified by unipolar-based panoramic mapping software (CARTOFINDER) remain unclear. We evaluated spatial characteristics of bi-atrial AF localized sources in relation to complex fractionated atrial electrocardiograms (CFAEs) and atrial low voltage area (LVAs) (≤0.35 mV during AF). METHODS AND RESULTS Twenty consecutive patients with persistent AF underwent bi-atrial voltage, CFAE, and CARTOFINDER mapping before the beginning of ablation (18 [90%] patients, initial procedure; 2 [10%] patients, repeat procedure). CFAEs were recorded using the interval confidence level (ICL) mode and defined as sites with a confidence level of ≥80% of maximal ICL number. We elucidated the following: (1) differences in the rate of AF localized sources and CFAEs inside or outside the atrial LVAs; (2) distribution of AF localized sources and CFAEs; and (3) distance between the closest points of AF localized sources and CFAEs. A total of 270 AF localized sources and 486 CFAEs were identified in 20 patients. AF localized sources were confirmed more often outside atrial LVAs than CFAEs (71% vs. 46% outside LVA, p < .001). AF localized sources and CFAEs were diffusely distributed without any tendency in bi-atria. Mean distance between closest AF localized sources and CFAEs was 22 ± 8 mm. CONCLUSION AF localized sources identified by CARTOFINDER are different therapeutic targets as compared to CFAEs and could be confirmed both inside and outside atrial LVAs.
Collapse
Affiliation(s)
- Takahiko Nagase
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Ryuichi Kato
- Department of Cardiology, Higashiyamato Hospital, Tokyo, Japan
| | - So Asano
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Hiroshi Fukunaga
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | | | - Yosuke Hayashi
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Yukio Sekiguchi
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Mamoru Nanasato
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Junichi Nitta
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | | |
Collapse
|
5
|
Convolutional Neural Networks for Mechanistic Driver Detection in Atrial Fibrillation. Int J Mol Sci 2022; 23:ijms23084216. [PMID: 35457044 PMCID: PMC9032062 DOI: 10.3390/ijms23084216] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 04/04/2022] [Accepted: 04/04/2022] [Indexed: 02/04/2023] Open
Abstract
The maintaining and initiating mechanisms of atrial fibrillation (AF) remain controversial. Deep learning is emerging as a powerful tool to better understand AF and improve its treatment, which remains suboptimal. This paper aims to provide a solution to automatically identify rotational activity drivers in endocardial electrograms (EGMs) with convolutional recurrent neural networks (CRNNs). The CRNN model was compared with two other state-of-the-art methods (SimpleCNN and attention-based time-incremental convolutional neural network (ATI-CNN)) for different input signals (unipolar EGMs, bipolar EGMs, and unipolar local activation times), sampling frequencies, and signal lengths. The proposed CRNN obtained a detection score based on the Matthews correlation coefficient of 0.680, an ATI-CNN score of 0.401, and a SimpleCNN score of 0.118, with bipolar EGMs as input signals exhibiting better overall performance. In terms of signal length and sampling frequency, no significant differences were found. The proposed architecture opens the way for new ablation strategies and driver detection methods to better understand the AF problem and its treatment.
Collapse
|
6
|
Chang TY, Lin CY, Lin YJ, Wu CI, Chang SL, Lo LW, Hu YF, Chung FP, Tuan TC, Chao TF, Liao JN, Kuo L, Liu CM, Chen SA. Long-term Outcome of Patients with Long-standing Persistent Atrial Fibrillation undergoing Ablation Guided by a Novel High-Density Panoramic Mapping System - A Propensity Score Matching Study. Heart Rhythm O2 2022; 3:269-278. [PMID: 35734294 PMCID: PMC9207729 DOI: 10.1016/j.hroo.2022.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background Catheter ablation is a current therapeutic approach for atrial fibrillation (AF). However, its efficacy for long-standing persistent AF remains suboptimal. Objective The purpose of this study was to test the hypothesis that a panoramic mapping system (CARTOFINDER, Biosense Webster) can guide pulmonary vein (PV) isolation and additional potential AF drivers. Methods A total of 76 patients with nonparoxysmal AF referred for ablation guided by a novel high-density panoramic mapping system with CARTOFINDER were prospectively enrolled. Of this cohort, 40 patients (52.6%) had long-standing persistent AF (CARTOFINDER group). We then retrospectively screened the patients with long-standing persistent AF undergoing conventional PV isolation and elimination of non-PV triggers during the contemporary period (conventional group). They were matched at a 1:2 ratio (40 patients in group 1 received ablation guided by CARTOFINDER; 80 patients in group 2 receiving conventional PV isolation and elimination of non-PV triggers). Results During follow-up, patients in group 1 had a lower recurrence AF rate than those in group 2 (P = .040). There was no difference in recurrence of atrial flutter (P = .996) and atrial tachycardia (P = .525). In Cox proportional hazards regression analysis, AF duration and PV isolation along with AF driver ablation using a panoramic mapping system with CARTOFINDER both were independent predictors of recurrent AF after catheter ablation of long-standing persistent AF. Conclusion Identification of the potential drivers in long-standing AF is crucial. Compared with conventional PV isolation and elimination of non-PV triggers, ablation guided by a high-density panoramic mapping system (CARTOFINDER) might have a better outcome in patients with long-standing persistent AF.
Collapse
Affiliation(s)
- Ting-Yung Chang
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
- National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Chin-Yu Lin
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Address reprint requests and correspondence: Dr Yenn-Jiang Lin, Division of Cardiology, Internal Medicine Department, Taipei Veterans General Hospital, No. 201, Section 2, Shipai Road, Beitou District, Taipei, Taiwan 112.
| | - Cheng-I Wu
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Lin Chang
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Li-Wei Lo
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yu-Feng Hu
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Fa-Po Chung
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ta-Chuan Tuan
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tze-Fan Chao
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jo-Nan Liao
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ling Kuo
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chih-Min Liu
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Ann Chen
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| |
Collapse
|
7
|
Zaman JAB, Grace AA, Narayan SM. Future Directions for Mapping Atrial Fibrillation. Arrhythm Electrophysiol Rev 2022; 11:e08. [PMID: 35734143 PMCID: PMC9194915 DOI: 10.15420/aer.2021.52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 11/08/2021] [Indexed: 01/14/2023] Open
Abstract
Mapping for AF focuses on the identification of regions of interest that may guide management and - in particular - ablation therapy. Mapping may point to specific mechanisms associated with localised scar or fibrosis, or electrical features, such as localised repetitive, rotational or focal activation. In patients in whom AF is caused by disorganised waves with no spatial predilection, as proposed in the multiwavelet theory for AF, mapping would be of less benefit. The role of AF mapping is controversial at the current time in view of the debate over the underlying mechanisms. However, recent clinical expansions of mapping technologies confirm the importance of understanding the state of the art, including limitations of current approaches and potential areas of future development.
Collapse
Affiliation(s)
- Junaid AB Zaman
- Keck School of Medicine, University of Southern California, Los Angeles, CA, US
| | - Andrew A Grace
- Department of Biochemistry, University of Cambridge, Cambridge, UK
| | - Sanjiv M Narayan
- Cardiovascular Institute and Department of Medicine, Stanford University, CA, US
| |
Collapse
|
8
|
Tailoring the Ablative Strategy for Atrial Fibrillation: A State-of-the-Art Review. Cardiol Res Pract 2022; 2022:9295326. [PMID: 35449606 PMCID: PMC9017557 DOI: 10.1155/2022/9295326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 12/15/2021] [Accepted: 01/29/2022] [Indexed: 12/15/2022] Open
Abstract
In spite of technological progress and the improving skills of operators, atrial fibrillation (AF) ablation results appear to date to be at a plateau. In any case, the superiority of ablation over pharmacological therapy in terms of effectiveness, reduction of hospitalizations, and improvement has been well demonstrated in recent randomized trials. Triggers, substrate, and modulating factors (elements of Coumel’s triangle) play different roles in paroxysmal and persistent AF, so induction and perpetuation mechanisms of arrhythmia may be different in each patient. Although effective ablative strategies are available for the treatment of paroxysmal AF triggers and persistent AF substrates, an adequate clinical evaluation of the patient is crucial in order to increase the chances of success. Recognizing triggers allows not only performing an effective ablation but also to avoid unnecessary lesions and at the same time reducing the risk of complications. AF beginning and triggers could be recorded by 12-lead ECG, continuous Holter monitoring, or implantable devices. In case of an unsuccessful noninvasive evaluation, nonpulmonary vein triggers should be investigated with an electrophysiological study. Persistent AF needs more effort to perform an accurate substrate characterization. Among the many methods proposed, recently the use of high-density mapping and multipolar catheters seems of particular benefit in order to clarify the arrhythmia mechanisms. Surgical and hybrid techniques allow to treat regions such as the posterior wall or Bachmann’s bundle, which is fundamental for an ablative strategy that goes beyond just pulmonary vein isolation. Too often, patients are referred to electrophysiology laboratories without adequate preprocedural screening and planning in order to submit them to a standard “ready-made” procedure. The accurate search for triggers in paroxysmal AF and the correct recognition of the link between a possible underlying heart disease and the substrate in persistent AF could allow us to tailor the interventional approach in order to overcome the current plateau, increasing ablative procedure success and minimizing complications.
Collapse
|
9
|
Honarbakhsh S, Dhillon G, Abbas H, Waddingham PH, Dennis A, Ahluwalia N, Welch S, Daw H, Sporton S, Chow A A, Earley MJ, Lambiase PD, Hunter RJ. Non-invasive Electrocardiographic Imaging guided targeting of drivers of persistent atrial fibrillation: the TARGET-AF1 trial. Heart Rhythm 2022; 19:875-884. [DOI: 10.1016/j.hrthm.2022.01.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/25/2022] [Accepted: 01/30/2022] [Indexed: 12/12/2022]
|
10
|
Sakamoto Y, Osanai H, Hiramatsu S, Kondo S, Kanbara T, Nakashima Y, Asano H, Ajioka M. Evaluation of arrhythmogenic foci using a novel automated detection algorithm and isoproterenol in persistent atrial fibrillation. J Interv Card Electrophysiol 2022; 65:63-71. [PMID: 35032279 DOI: 10.1007/s10840-022-01124-0] [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: 06/09/2021] [Accepted: 01/10/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE The CARTOFINDER mapping system analyzes activation patterns using unipolar potentials during atrial fibrillation (AF), where isoproterenol (ISP) is conventionally used to induce non-pulmonary vein (PV) foci and confirm PV arrhythmogenicity. In 20 patients with persistent AF who underwent ablation at our hospital, arrhythmogenic foci were evaluated using both these methods. METHODS Before pulmonary vein isolation (PVI), PV and left atrium (LA) were analyzed during AF using CARTOFINDER, and the isolation line was determined based on the results. After PVI, ISP was loaded after return of sinus rhythm and confirmation of the presence of arrhythmogenic foci. The activation site in LA was ablated at the discretion of the surgeon. RESULTS Focal activation sites detected by CARTOFINDER correlated with the arrhythmogenic foci induced by ISP in the PVs. The results also showed that a greater number of focal activation sites in the PVs correlated to an increased response to ISP administration. In one patient, it was observed that the focal activation site identified in the PV also coincided with the site of the origin of automaticity induced by ISP after PVI. CONCLUSION CARTOFINDER and ISP both reliably determined the presence of arrhythmogenic foci in PV, in patients with persistent AF. Knowledge of the nature of arrhythmogenic foci in non-PV is considered to be a topic for future studies, and further data collection is required.
Collapse
Affiliation(s)
- Yusuke Sakamoto
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan.
| | - Hiroyuki Osanai
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Shotaro Hiramatsu
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Shun Kondo
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Takahiro Kanbara
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Yoshihito Nakashima
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Hiroshi Asano
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Masayoshi Ajioka
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| |
Collapse
|
11
|
Atrial fibrillation driver identification through regional mutual information networks: a modeling perspective. J Interv Card Electrophysiol 2022; 64:649-660. [PMID: 34981289 PMCID: PMC9470649 DOI: 10.1007/s10840-021-01101-z] [Citation(s) in RCA: 1] [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] [Received: 08/09/2021] [Accepted: 12/01/2021] [Indexed: 12/17/2022]
Abstract
Purpose Effective identification of electrical drivers within remodeled tissue is a key for improving ablation treatment for atrial fibrillation. We have developed a mutual information, graph-based approach to identify and propose fault tolerance metric of local efficiency as a distinguishing feature of rotational activation and remodeled atrial tissue. Methods Voltage data were extracted from atrial tissue simulations (2D Karma, 3D physiological, and the Multiscale Cardiac Simulation Framework (MSCSF)) using multi-spline open and parallel regional mapping catheter geometries. Graphs were generated based on varied mutual information thresholds between electrode pairs and the local efficiency for each graph was calculated. Results High-resolution mapping catheter geometries can distinguish between rotational and irregular activation patterns using the derivative of local efficiency as a function of increasing mutual information threshold. The derivative is decreased for rotational activation patterns comparing to irregular activations in both a simplified 2D model (0.0017 ± 1 × 10−4 vs. 0.0032 ± 1 × 10−4, p < 0.01) and a more realistic 3D model (0.00092 ± 5 × 10−5 vs. 0.0014 ± 4 × 10−5, p < 0.01). Average local efficiency derivative can also distinguish between degrees of remodeling. Simulations using the MSCSF model, with 10 vs. 90% remodeling, display distinct derivatives in the grid design parallel spline catheter configuration (0.0015 ± 5 × 10−5 vs. 0.0019 ± 6 × 10−5, p < 0.01) and the flower shaped open spline configuration (0.0011 ± 5 × 10−5 vs. 0.0016 ± 4 × 10−5, p < 0.01). Conclusion A decreased derivative of local efficiency characterizes rotational activation and varies with atrial remodeling. This suggests a distinct communication pattern in cardiac rotational activation detectable via high-resolution regional mapping and could enable identification of electrical drivers for targeted ablation. Supplementary Information The online version contains supplementary material available at 10.1007/s10840-021-01101-z.
Collapse
|
12
|
Cycle Length Evaluation in Persistent Atrial Fibrillation Using Kernel Density Estimation to Identify Transient and Stable Rapid Atrial Activity. Cardiovasc Eng Technol 2021; 13:219-233. [PMID: 34453278 PMCID: PMC9114079 DOI: 10.1007/s13239-021-00568-1] [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: 04/14/2021] [Accepted: 07/20/2021] [Indexed: 11/18/2022]
Abstract
Purpose Left atrial (LA) rapid AF activity has been shown to co-localise with areas of successful atrial fibrillation termination by catheter ablation. We describe a technique that identifies rapid and regular activity. Methods Eight-second AF electrograms were recorded from LA regions during ablation for psAF. Local activation was annotated manually on bipolar signals and where these were of poor quality, we inspected unipolar signals. Dominant cycle length (DCL) was calculated from annotation pairs representing a single activation interval, using a probability density function (PDF) with kernel density estimation. Cumulative annotation duration compared to total segment length defined electrogram quality. DCL results were compared to dominant frequency (DF) and averaging. Results In total 507 8 s AF segments were analysed from 7 patients. Spearman’s correlation coefficient was 0.758 between independent annotators (P < 0.001), 0.837–0.94 between 8 s and ≥ 4 s segments (P < 0.001), 0.541 between DCL and DF (P < 0.001), and 0.79 between DCL and averaging (P < 0.001). Poorer segment organization gave greater errors between DCL and DF. Conclusion DCL identifies rapid atrial activity that may represent psAF drivers. This study uses DCL as a tool to evaluate the dynamic, patient specific properties of psAF by identifying rapid and regular activity. If automated, this technique could rapidly identify areas for ablation in psAF.
Collapse
|
13
|
Rosa GL, Quintanilla JG, Salgado R, González-Ferrer JJ, Cañadas-Godoy V, Pérez-Villacastín J, Pérez-Castellano N, Jalife J, Filgueiras-Rama D. Mapping Technologies for Catheter Ablation of Atrial Fibrillation Beyond Pulmonary Vein Isolation. Eur Cardiol 2021; 16:e21. [PMID: 34093742 PMCID: PMC8157391 DOI: 10.15420/ecr.2020.39] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 01/25/2021] [Indexed: 11/17/2022] Open
Abstract
Catheter ablation remains the most effective and relatively minimally invasive therapy for rhythm control in patients with AF. Ablation has consistently shown a reduction of arrhythmia-related symptoms and significant improvement in patients’ quality of life compared with medical treatment. The ablation strategy relies on a well-established anatomical approach of effective pulmonary vein isolation. Additional anatomical targets have been reported with the aim of increasing procedure success in complex substrates. However, larger ablated areas with uncertainty of targeting relevant regions for AF initiation or maintenance are not exempt from the potential risk of complications and pro-arrhythmia. Recent developments in mapping tools and computational methods for advanced signal processing during AF have reported novel strategies to identify atrial regions associated with AF maintenance. These novel tools – although mainly limited to research series – represent a significant step forward towards the understanding of complex patterns of propagation during AF and the potential achievement of patient-tailored AF ablation strategies for the near future.
Collapse
Affiliation(s)
- Giulio La Rosa
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Myocardial Pathophysiology Area Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute Madrid, Spain
| | - Jorge G Quintanilla
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Myocardial Pathophysiology Area Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV) Madrid, Spain
| | - Ricardo Salgado
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute Madrid, Spain
| | - Juan José González-Ferrer
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV) Madrid, Spain
| | - Victoria Cañadas-Godoy
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV) Madrid, Spain
| | - Julián Pérez-Villacastín
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV) Madrid, Spain.,Fundación Interhospitalaria para la Investigación Cardiovascular (FIC) Madrid, Spain
| | - Nicasio Pérez-Castellano
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV) Madrid, Spain.,Fundación Interhospitalaria para la Investigación Cardiovascular (FIC) Madrid, Spain
| | - José Jalife
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Myocardial Pathophysiology Area Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV) Madrid, Spain
| | - David Filgueiras-Rama
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Myocardial Pathophysiology Area Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV) Madrid, Spain
| |
Collapse
|
14
|
Kowalewski C. Mapping atrial fibrillation : An overview of potential mechanisms underlying atrial fibrillation. Herz 2021; 46:305-311. [PMID: 34104977 DOI: 10.1007/s00059-021-05045-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2021] [Indexed: 11/24/2022]
Abstract
Mechanisms sustaining atrial fibrillation are yet to be clarified. This article focuses on milestones in the theory of atrial fibrillation and addresses the different leading hypotheses concerning atrial fibrillation mechanisms. We start off with electric potential originating from the pulmonary vein, which triggers atrial fibrillation, discuss classic activation mapping and phase mapping as well as computer models, which have contributed to the our understanding of atrial fibrillation, and end with new mapping methods and studies highlighting the advantages and disadvantages of current mechanistic hypotheses. The technical evolution of mapping atrial fibrillation has led to new insights into the potential mechanisms underlying atrial fibrillation. A comparison between methods is essential for understanding the advantages and disadvantages of each method when mapping atrial fibrillation. Ultimately, the combination of several methods might shed light on the underlying mechanisms of atrial fibrillation and lead to a better understanding of atrial fibrillation and subsequently improve treatment of this condition.
Collapse
|
15
|
Hemam ME, Dave AS, Rodríguez-Mañero M, Valderrábano M. Epiphenomenal Re-Entry and Spurious Focal Activation Detection by Atrial Fibrillation Mapping Algorithms. JACC Clin Electrophysiol 2021; 7:923-932. [PMID: 33812838 DOI: 10.1016/j.jacep.2020.12.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/28/2020] [Accepted: 12/10/2020] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The purpose of this study was to validate the ability of mapping algorithms to detect rotational activations (RoA) and focal activations (FoA) during fibrillatory conduction (FC) and atrial fibrillation (AF) and understand their mechanistic relevance. BACKGROUND Mapping algorithms have been proposed to detect RoA and FoA to guide AF ablation. METHODS Rapid left atrial pacing created FC-fibrillatory electrograms-with and without AF induction in dogs (n = 17). Activation maps were constructed using Topera (Abbott, St. Paul, Minnesota) or CARTOFINDER (Biosense Webster, Irvine, California) algorithms. Mapping strategies included: panoramic noncontact mapping with a basket catheter (CARTOFINDER n = 6, Topera n = 5); and sequential contact mapping using 8-spline OctaRay catheter (Biosense Webster) (n = 6). Offline frequency and spectral analysis were also performed. Algorithm-detected RoA was manually verified. RESULTS The right atrium (RA) consistently exhibited fibrillatory signals during FC. FC with and without AF had similar left-to-right frequency gradients. Basket maps were either uninterpretable (847 of 990 Topera, 132 of 148 Cartofinder) or had unverifiable RoA. OctaRay contact mapping showed 4% RoA (n = 30 of 679) and 63% FoA (n = 429 of 679). Verified RoA clustered at consistent sites, was more common in the RA than left atrium (odds ratio: 3.5), and colocalized with sites of frequency breakdown in the crista terminalis and RA appendage. During pacing, spurious FoA sites were identified around the atria, but not at the actual pacing sites. RoA and FoA site distribution was similar during pacing with and without induction, and during induced AF. CONCLUSIONS Mapping algorithms were unable to detect pacing sites as true drivers of FC, and detected epiphenomenal RoA and FoA sites unrelated to AF induction or maintenance. Algorithm-detected RoA and FoA did not identify true AF drivers.
Collapse
Affiliation(s)
- Majd E Hemam
- Division of Cardiac Electrophysiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA; Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Amish S Dave
- Division of Cardiac Electrophysiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Moisés Rodríguez-Mañero
- Complexo Hospitalario Universitario de Santiago de Compostela (CHUS), Santiago de Compostela, Spain
| | - Miguel Valderrábano
- Division of Cardiac Electrophysiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA.
| |
Collapse
|
16
|
Quintanilla JG, Shpun S, Jalife J, Filgueiras-Rama D. Novel approaches to mechanism-based atrial fibrillation ablation. Cardiovasc Res 2021; 117:1662-1681. [PMID: 33744913 PMCID: PMC8208747 DOI: 10.1093/cvr/cvab108] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 02/12/2021] [Accepted: 03/18/2021] [Indexed: 01/23/2023] Open
Abstract
Modern cardiac electrophysiology has reported significant advances in the understanding of mechanisms underlying complex wave propagation patterns during atrial fibrillation (AF), although disagreements remain. One school of thought adheres to the long-held postulate that AF is the result of randomly propagating wavelets that wonder throughout the atria. Another school supports the notion that AF is deterministic in that it depends on a small number of high-frequency rotors generating three-dimensional scroll waves that propagate throughout the atria. The spiralling waves are thought to interact with anatomic and functional obstacles, leading to fragmentation and new wavelet formation associated with the irregular activation patterns documented on AF tracings. The deterministic hypothesis is consistent with demonstrable hierarchical gradients of activation frequency and AF termination on ablation at specific (non-random) atrial regions. During the last decade, data from realistic animal models and pilot clinical series have triggered a new era of novel methodologies to identify and ablate AF drivers outside the pulmonary veins. New generation electroanatomical mapping systems and multielectrode mapping catheters, complimented by powerful mathematical analyses, have generated the necessary platforms and tools for moving these approaches into clinical procedures. Recent clinical data using such platforms have provided encouraging evidence supporting the feasibility of targeting and effectively ablating driver regions in addition to pulmonary vein isolation in persistent AF. Here, we review state-of-the-art technologies and provide a comprehensive historical perspective, characterization, classification, and expected outcomes of current mechanism-based methods for AF ablation. We discuss also the challenges and expected future directions that scientists and clinicians will face in their efforts to understand AF dynamics and successfully implement any novel method into regular clinical practice.
Collapse
Affiliation(s)
- Jorge G Quintanilla
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Myocardial Pathophysiology Area, Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | | | - José Jalife
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Myocardial Pathophysiology Area, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Department of Internal Medicine, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI 48109, USA
| | - David Filgueiras-Rama
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Myocardial Pathophysiology Area, Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| |
Collapse
|
17
|
Parameswaran R, Al-Kaisey AM, Kalman JM. Catheter ablation for atrial fibrillation: current indications and evolving technologies. Nat Rev Cardiol 2020; 18:210-225. [PMID: 33051613 DOI: 10.1038/s41569-020-00451-x] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/07/2020] [Indexed: 12/12/2022]
Abstract
Catheter ablation for atrial fibrillation (AF) has emerged as an important rhythm-control strategy and is by far the most common cardiac ablation procedure performed worldwide. Current guidelines recommend the procedure in symptomatic patients with paroxysmal or persistent AF who are refractory or intolerant to antiarrhythmic drugs. The procedure might also be considered as a first-line approach in selected asymptomatic patients. Data from large registries indicate that AF ablation might reduce mortality and the risk of heart failure and stroke, but evidence from randomized controlled trials is mixed. Pulmonary vein isolation using point-by-point radiofrequency or with the cryoballoon remains the cornerstone technique in AF ablation. Additional atrial ablation can be performed in patients with persistent AF, but its benefits are largely unproven. Technological advances in the past decade have focused on achieving durable vein isolation, reducing procedure duration and improving safety. Numerous exciting new technologies are in various stages of development. In this Review, we discuss the relevant data to support the recommended and evolving indications for catheter ablation of AF, describe the different ablation techniques, and highlight the latest advances in technology that aim to improve its safety and efficacy. We also discuss lifestyle modification strategies to improve ablation outcomes.
Collapse
Affiliation(s)
- Ramanathan Parameswaran
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Ahmed M Al-Kaisey
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Jonathan M Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia. .,Department of Medicine, University of Melbourne, Melbourne, Australia.
| |
Collapse
|
18
|
Honarbakhsh S, Schilling RJ, Finlay M, Keating E, Hunter RJ. Prospective STAR-Guided Ablation in Persistent Atrial Fibrillation Using Sequential Mapping With Multipolar Catheters. Circ Arrhythm Electrophysiol 2020; 13:e008824. [PMID: 32903033 PMCID: PMC7566307 DOI: 10.1161/circep.120.008824] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [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
BACKGROUND A novel stochastic trajectory analysis of ranked signals (STAR) mapping approach to guide atrial fibrillation (AF) ablation using basket catheters recently showed high rates of AF termination and subsequent freedom from AF. METHODS This study aimed to determine whether STAR mapping using sequential recordings from conventional pulmonary vein mapping catheters could achieve similar results. Patients with persistent AF<2 years were included. Following pulmonary vein isolation AF drivers (AFDs) were identified on sequential STAR maps created with PentaRay, IntellaMap Orion, or Advisor HD Grid catheters. Patients had a minimum of 10 multipolar recordings of 30 seconds each. These were processed in real-time and AFDs were targeted with ablation. An ablation response was defined as AF termination or cycle length slowing ≥30 ms. RESULTS Thirty patients were included (62.4±7.8 years old, AF duration 14.1±4.3 months) of which 3 had AF terminated on pulmonary vein isolation, leaving 27 patients that underwent STAR-guided AFD ablation. Eighty-three potential AFDs were identified (3.1±1.1 per patient) of which 70 were targeted with ablation (2.6±1.2 per patient). An ablation response was seen at 54 AFDs (77.1% of AFDs; 21 AF termination and 33 cycle length slowing) and occurred in all 27 patients. No complications occurred. At 17.3±10.1 months, 22 out of 27 (81.5%) patients undergoing STAR-guided ablation were free from AF/atrial tachycardia off antiarrhythmic drugs. CONCLUSIONS STAR-guided AFD ablation through sequential mapping with a multipolar catheter effectively achieved an ablation response in all patients. AF terminated in a majority of patients, with a high freedom from AF/atrial tachycardia off antiarrhythmic drugs at long-term follow-up. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02950844.
Collapse
Affiliation(s)
| | | | - Malcolm Finlay
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Emily Keating
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Ross J Hunter
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| |
Collapse
|
19
|
Roy A, Varela M, Chubb H, MacLeod R, Hancox JC, Schaeffter T, Aslanidi O. Identifying locations of re-entrant drivers from patient-specific distribution of fibrosis in the left atrium. PLoS Comput Biol 2020; 16:e1008086. [PMID: 32966275 PMCID: PMC7535127 DOI: 10.1371/journal.pcbi.1008086] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 10/05/2020] [Accepted: 06/22/2020] [Indexed: 11/18/2022] Open
Abstract
Clinical evidence suggests a link between fibrosis in the left atrium (LA) and atrial fibrillation (AF), the most common sustained arrhythmia. Image-derived fibrosis is increasingly used for patient stratification and therapy guidance. However, locations of re-entrant drivers (RDs) sustaining AF are unknown and therapy success rates remain suboptimal. This study used image-derived LA models to explore the dynamics of RD stabilization in fibrotic regions and generate maps of RD locations. LA models with patient-specific geometry and fibrosis distribution were derived from late gadolinium enhanced magnetic resonance imaging of 6 AF patients. In each model, RDs were initiated at multiple locations, and their trajectories were tracked and overlaid on the LA fibrosis distributions to identify the most likely regions where the RDs stabilized. The simulations showed that the RD dynamics were strongly influenced by the amount and spatial distribution of fibrosis. In patients with fibrosis burden greater than 25%, RDs anchored to specific locations near large fibrotic patches. In patients with fibrosis burden below 25%, RDs either moved near small fibrotic patches or anchored to anatomical features. The patient-specific maps of RD locations showed that areas that harboured the RDs were much smaller than the entire fibrotic areas, indicating potential targets for ablation therapy. Ablating the predicted locations and connecting them to the existing pulmonary vein ablation lesions was the most effective in-silico ablation strategy.
Collapse
Affiliation(s)
- Aditi Roy
- Department of Biomedical Engineering, School of Biomedical Engineering & Imaging Sciences, King’s College London, St Thomas’ Hospital, London, United Kingdom
| | - Marta Varela
- Department of Biomedical Engineering, School of Biomedical Engineering & Imaging Sciences, King’s College London, St Thomas’ Hospital, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Henry Chubb
- Cardiothoracic Surgery, Stanford University, United States of America
| | - Robert MacLeod
- Bioengineering Department, University of Utah, Salt Lake City, Utah, United States of America
| | - Jules C. Hancox
- School of Physiology and Pharmacology, Cardiovascular Research Laboratories, University of Bristol, Bristol, United Kingdom
| | | | - Oleg Aslanidi
- Department of Biomedical Engineering, School of Biomedical Engineering & Imaging Sciences, King’s College London, St Thomas’ Hospital, London, United Kingdom
| |
Collapse
|
20
|
Honarbakhsh S, Schilling RJ, Keating E, Finlay M, Hunter RJ. Drivers in AF colocate to sites of electrogram organization and rapidity: Potential synergy between spectral analysis and STAR mapping approaches in prioritizing drivers for ablation. J Cardiovasc Electrophysiol 2020; 31:1340-1349. [PMID: 32219906 DOI: 10.1111/jce.14456] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 02/27/2020] [Accepted: 03/16/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Stochastic trajectory analysis of ranked signals (STAR) mapping has recently been used to ablate persistent atrial fibrillation (AF) with high rates of AF termination and long-term freedom from AF in small, single-arm studies. We hypothesized that rapidity and organization markers would correlate with early sites of activation (ESA). METHODS Patients undergoing persistent AF ablation as part of the STAR mapping study were included. Five-minute unipolar basket recordings used to create STAR maps were used to determine the minimum-cycle length (Min-CL) and CL variability (CLV) at each electrode to identify the site of the fastest Min-CL and lowest CLV across the left atrium (LA). The location of ESA targeted with ablation was compared with these sites. Dominant frequency was assessed at ESA and compared with that of neighboring electrodes to assess for regional gradients. RESULTS Thirty-two patients were included with 83 ESA ablated, with an ablation response at 73 sites (24 AF termination and 49 CL slowing ≥30 ms). Out of these, 54 (74.0%) and 56 (76.7%) colocated to sites of fastest Min-CL and lowest CLV, respectively. Regional CL and frequency gradients were demonstrable at majority of ESA. ESA colocating to sites of fastest Min-CL and lowest CLV were more likely to terminate AF with ablation (odds ratio, 34 and 29, respectively, P = .02). These showed a moderate sensitivity (74.0% Min-CL and 75.3% CLV) and specificity (66.7% Min-CL and 76.9% CLV) in predicting ESA with an ablation response. CONCLUSIONS ESA correlate with rapidity and organization markers. Further work is needed to clarify any role for spectral analysis in prioritizing driver ablation.
Collapse
Affiliation(s)
| | | | - Emily Keating
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Malcolm Finlay
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Ross J Hunter
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom.,QUML
| |
Collapse
|
21
|
Abstract
This review focusses on novel findings in atrial fibrillation mechanisms derived from mapping studies. Recent panoramic mapping techniques have identified 2 arrhythmic mechanisms of interest, namely, rotational (rotors) and ectopic focal activations as drivers of atrial fibrillation. Epicardial adipose tissue and fatty infiltration into the myocardium have been described as novel substrates for atrial fibrillation. There is increasing appreciation that the thin atrial walls harbor a complex 3-dimensional electrostructural substrate to contribute to atrial fibrillation sustenance. Further research is warranted to advance the field toward more targeted therapy.
Collapse
Affiliation(s)
- Dennis H Lau
- Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide, Royal Adelaide Hospital, 1 Port Road, Adelaide, South Australia 5000, Australia
| | - Dominik Linz
- Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide, Royal Adelaide Hospital, 1 Port Road, Adelaide, South Australia 5000, Australia
| | - Prashanthan Sanders
- Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide, Royal Adelaide Hospital, 1 Port Road, Adelaide, South Australia 5000, Australia.
| |
Collapse
|
22
|
Zaman J, Baykaner T, Narayan SM. Mapping and Ablation of Rotational and Focal Drivers in Atrial Fibrillation. Card Electrophysiol Clin 2020; 11:583-595. [PMID: 31706467 DOI: 10.1016/j.ccep.2019.08.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Drivers are increasingly studied ablation targets for atrial fibrillation (AF). However, results from ablation remain controversial. First, outcomes vary between centers and patients. Second, it is unclear how best to perform driver ablation. Third, there is a lack of practical guidance on how to identify critical from secondary sites using different AF mapping methods. This article addresses each of these issues.
Collapse
Affiliation(s)
- Junaid Zaman
- Stanford University, 780 Welch Road, Suite CJ250F, Stanford, CA 94305, USA; Imperial College London, London, UK
| | - Tina Baykaner
- Department of Medicine/Cardiovascular Medicine, Stanford University, 780 Welch Road, Suite CJ250F, Stanford, CA 94305, USA
| | - Sanjiv M Narayan
- Department of Medicine/Cardiovascular Medicine and Cardiovascular Institute, Stanford University, 780 Welch Road, Suite CJ250F, MC 5773, Stanford, CA 94305, USA.
| |
Collapse
|
23
|
Quintanilla JG, Alfonso-Almazán JM, Pérez-Castellano N, Pandit SV, Jalife J, Pérez-Villacastín J, Filgueiras-Rama D. Instantaneous Amplitude and Frequency Modulations Detect the Footprint of Rotational Activity and Reveal Stable Driver Regions as Targets for Persistent Atrial Fibrillation Ablation. Circ Res 2019; 125:609-627. [PMID: 31366278 PMCID: PMC6735936 DOI: 10.1161/circresaha.119.314930] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
RATIONALE Costly proprietary panoramic multielectrode (64-256) acquisition systems are being increasingly used together with conventional electroanatomical mapping systems for persistent atrial fibrillation (PersAF) ablation. However, such approaches target alleged drivers (rotational/focal) regardless of their activation frequency dynamics. OBJECTIVES To test the hypothesis that stable regions of higher than surrounding instantaneous frequency modulation (iFM) drive PersAF and determine whether rotational activity is specific for such regions. METHODS AND RESULTS First, novel single-signal algorithms based on instantaneous amplitude modulation (iAM) and iFM to detect rotational-footprints without panoramic multielectrode acquisition systems were tested in 125 optical movies from 5 ex vivo Langendorff-perfused PersAF sheep hearts (sensitivity/specificity, 92.6/97.5%; accuracy, 2.5-mm) and in computer simulations. Then, 16 pigs underwent high-rate atrial pacing to develop PersAF. After a median (interquartile range [IQR]) of 4.4 (IQR, 2.5-9.9) months of high-rate atrial pacing followed by 4.1 (IQR, 2.7-5.4) months of self-sustained PersAF, pigs underwent in vivo high-density electroanatomical atrial mapping (4920 [IQR, 4435-5855] 8-second unipolar signals per map). The first 4 out of 16 pigs were used to adapt ex vivo optical proccessing of iFM/iAM to in vivo electrical signals. In the remaining 12 out of 16 pigs, regions of higher than surrounding average iFM were considered leading-drivers. Two leading-driver + rotational-footprint maps were generated 2.6 (IQR, 2.4-2.9) hours apart to test leading-driver spatiotemporal stability and guide ablation. Leading-driver regions (2.5 [IQR, 2.0-4.0] regions/map) exactly colocalized (95.7%) in the 2 maps, and their ablation terminated PersAF in 92.3% of procedures (radiofrequency until termination, 16.9 [IQR, 9.2-35.8] minutes; until nonsustainability, 20.4 [IQR, 12.8-44.0] minutes). Rotational-footprints were found at every leading-driver region, albeit most (76.8% [IQR, 70.5%-83.6%]) were located outside. Finally, the translational ability of this approach was tested in 3 PersAF redo patients. CONCLUSIONS Both rotational-footprints and spatiotemporally stable leading-driver regions can be located using iFM/iAM algorithms without panoramic multielectrode acquisition systems. In pigs, ablation of leading-driver regions usually terminates PersAF and prevents its sustainability. Rotational activations are sensitive but not specific to such regions. Single-signal iFM/iAM algorithms could be integrated into conventional electroanatomical mapping systems to improve driver detection accuracy and reduce the cost of patient-tailored/mechanistic approaches.
Collapse
Affiliation(s)
- Jorge G Quintanilla
- From the Myocardial Pathophysiology Area, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (J.G.Q., J.M.A.-A., J.J., D.F.-R.).,Arrhythmia Unit, Cardiology Department, Cardiovascular Institute, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain (J.G.Q., N.P.-C., J.P.-V., D.F.-R.).,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (J.G.Q., N.P.-C., J.J., J.P.-V., D.F.-R.)
| | - José Manuel Alfonso-Almazán
- From the Myocardial Pathophysiology Area, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (J.G.Q., J.M.A.-A., J.J., D.F.-R.)
| | - Nicasio Pérez-Castellano
- Arrhythmia Unit, Cardiology Department, Cardiovascular Institute, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain (J.G.Q., N.P.-C., J.P.-V., D.F.-R.).,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (J.G.Q., N.P.-C., J.J., J.P.-V., D.F.-R.)
| | - Sandeep V Pandit
- Center for Arrhythmia Research, Department of Internal Medicine, University of Michigan, Ann Arbor (S.V.P., J.J.)
| | - José Jalife
- From the Myocardial Pathophysiology Area, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (J.G.Q., J.M.A.-A., J.J., D.F.-R.).,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (J.G.Q., N.P.-C., J.J., J.P.-V., D.F.-R.).,Center for Arrhythmia Research, Department of Internal Medicine, University of Michigan, Ann Arbor (S.V.P., J.J.)
| | - Julián Pérez-Villacastín
- From the Myocardial Pathophysiology Area, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (J.G.Q., J.M.A.-A., J.J., D.F.-R.).,Arrhythmia Unit, Cardiology Department, Cardiovascular Institute, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain (J.G.Q., N.P.-C., J.P.-V., D.F.-R.).,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (J.G.Q., N.P.-C., J.J., J.P.-V., D.F.-R.)
| | - David Filgueiras-Rama
- From the Myocardial Pathophysiology Area, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (J.G.Q., J.M.A.-A., J.J., D.F.-R.).,Arrhythmia Unit, Cardiology Department, Cardiovascular Institute, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain (J.G.Q., N.P.-C., J.P.-V., D.F.-R.).,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (J.G.Q., N.P.-C., J.J., J.P.-V., D.F.-R.)
| |
Collapse
|
24
|
Schade A, Costello-Boerrigter L, Deneke T. Mapping of persistent atrial fibrillation: Learning to walk, step by step. J Cardiovasc Electrophysiol 2018; 29:1489-1492. [PMID: 30334595 DOI: 10.1111/jce.13730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 08/29/2018] [Indexed: 12/01/2022]
Affiliation(s)
- Anja Schade
- Helios Clinic Erfurt, Clinic for Cardiology/Department of Interventional Electrophysiology, Erfurt, Germany
| | | | - Thomas Deneke
- Heart Center Bad Neustadt, Clinic for Interventional Electrophysiology, Bad Neustadt, Germany.,Faculty of Medicine, Ruhr-University Bochum, Bochum, Germany
| |
Collapse
|
25
|
Stiles MK, Sanders P, Lau DH. Targeting the Substrate in Ablation of Persistent Atrial Fibrillation: Recent Lessons and Future Directions. Front Physiol 2018; 9:1158. [PMID: 30279660 PMCID: PMC6154526 DOI: 10.3389/fphys.2018.01158] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 08/02/2018] [Indexed: 12/16/2022] Open
Abstract
While isolation of the pulmonary veins is firmly established as effective treatment for the majority of paroxysmal atrial fibrillation (AF) patients, there is recognition that patients with persistent AF have substrate for perpetuation of arrhythmia existing outside of the pulmonary veins. Various computational approaches have been used to identify targets for effective ablation of persistent AF. This paper aims to discuss the clinical aspects of computational approaches that aim to identify critical sites for treatment. Various analyses of electrogram characteristics have been performed with this aim. Leading techniques for electrogram analysis are Complex Fractionated Atrial Electrograms (CFAE) and Dominant Frequency (DF). These techniques have been the subject of clinical trials of which the results are discussed. Evaluation of the activation patterns of atria in AF has been another avenue of research. Focal Impulse and Rotor Modulation (FIRM) mapping and forms of Body Surface Mapping aim to characterize multiple atrial wavelets, macro-reentry and focal sources which have been proposed as basic mechanisms perpetuating AF. Both invasive and non-invasive activation mapping techniques are reviewed. The presence of atrial fibrosis causes non-uniform anisotropic impulse propagation. Therefore, identification of fibrosis by imaging techniques is an avenue of potential research. The leading contender for imaging-based techniques is Cardiac Magnetic Resonance (CMR). As this technology advances, improvements in resolution and scar identification have positioned CMR as the mode of choice for analysis of atrial structure. AF has been demonstrated to be associated with obesity, inactivity and diseases of modern life. An opportunity exists for detailed computational analysis of the impact of risk factor modification on atrial substrate. This ranges from microstructural investigation through to examination at a population level via registries and public health interventions. Computational analysis of atrial substrate has moved from basic science toward clinical application. Future directions and potential limitations of such analyses are examined in this review.
Collapse
Affiliation(s)
- Martin K Stiles
- Waikato Clinical School, University of Auckland, Hamilton, New Zealand.,Department of Cardiology, Waikato District Health Board, Hamilton, New Zealand
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders (CHRD), South Australian Health and Medical Research Institute (SAHMRI), The University of Adelaide and Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders (CHRD), South Australian Health and Medical Research Institute (SAHMRI), The University of Adelaide and Royal Adelaide Hospital, Adelaide, SA, Australia
| |
Collapse
|
26
|
Li Q, Li H, Wang L, Liu C, Li S, Chen Y, Zhang Y, Gu C. Observation of local cardiac electrophysiological changes during off-pump coronary artery bypass grafting using epicardial mapping. Perfusion 2018; 34:116-124. [PMID: 30070175 DOI: 10.1177/0267659118787664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES At present, there is no effective method of evaluating the electrophysiological changes in cardiac myocytes during off-pump coronary artery bypass grafting (OPCAB). Therefore, we preliminarily explored the relationship between electrophysiological characteristics and the changes in cardiac function of 24 patients undergoing OPCAB. METHODS We used the CARTO3 system for epicardial electrophysiological mapping before surgery, during left anterior descending branch anastomosis, diagonal branch anastomosis and after surgery for 24 patients undergoing OPCAB. Data, including local activation time (LAT), bipolar voltage value (BV) and conduction velocity, were processed and analyzed by the system. Intraoperative invasive blood pressure, heart rate and arterial blood gas analysis data were recorded. Continuous electrocardiography (ECG) monitoring was performed three days after surgery. Routine resting myocardial perfusion imaging (MPI) and adenosine stress-gated MPI were performed before surgery. Patients were re-examined before discharge. RESULTS By analyzing the change in the LAT value, we found that the order of excitation of local myocardial cells changed after surgery. In addition, the LAT change in myocardial cells closer to the anastomosis was more significant. The earliest pacing point on the left anterior descending (LAD) coronary artery territory map was the third point (from the proximal to distal LAD) before OPCAB, but the earliest pacing point moved down to the fourth point (closer to the anastomosis) after the diagonal (DIA) anastomosis was complete. On the DIA territory map, the earliest pacing point was the fourth point before OPCAB; this moved up to the third point (closer to the anastomosis) after DIA bypass grafting. The voltages of all points were increased after myocardial revascularization. Compared with the preoperative period, the third, fourth and fifth points on the LAD territory map increased significantly after LAD anastomosis was complete (p=0.007, p=0.001, p=0.009, respectively). On the DIA territory map, the voltages of the first, second and third points were remarkably increased after completing the DIA anastomosis compared to before OPCAB and after LAD anastomosis completion (p=0.001, p=0.008, p<0.001 and p=0.006, p=0.032, p=0.002, respectively). The average conduction velocity (ACV) of all mapped points increased after OPCAB compared with before OPCAB (p<0.05). Postoperative resting MPI and adenosine stress-gated MPI showed that left ventricular global systolic function improved, the left ventricular ejection fraction (LVEF) increased significantly (p<0.05) and the left ventricular end systolic volume (LVESV) decreased significantly (p<0.05) compared to the preoperative MPI. CONCLUSIONS Adequate surgical coronary revascularization could lead to more stable electrical activity of local cardiomyocytes, thus, illustrating the specific mechanism of coronary revascularization for improving the cardiac function from an electrophysiological perspective.
Collapse
Affiliation(s)
- Qin Li
- 1 Department of Cardiac Surgery, Capital Medical University Affiliated Anzhen Hospital, Beijing, People's Republic of China
| | - Haiming Li
- 1 Department of Cardiac Surgery, Capital Medical University Affiliated Anzhen Hospital, Beijing, People's Republic of China
| | - Liangshan Wang
- 2 Center for Cardiac Intensive Care, Capital Medical University Affiliated Anzhen Hospital, Beijing, People's Republic of China
| | - Changcheng Liu
- 1 Department of Cardiac Surgery, Capital Medical University Affiliated Anzhen Hospital, Beijing, People's Republic of China
| | - Songnan Li
- 3 Department of Cardiology, Capital Medical University Affiliated Anzhen Hospital, Beijing, People's Republic of China
| | - Yingwei Chen
- 4 The First Affiliated Hospital of Zhengzhou University, Henan, People's Republic of China
| | - Yafei Zhang
- 5 People's Hospital of Zhengzhou, Henan, People's Republic of China
| | - Chengxiong Gu
- 1 Department of Cardiac Surgery, Capital Medical University Affiliated Anzhen Hospital, Beijing, People's Republic of China
| |
Collapse
|
27
|
Calvo D, Filgueiras-Rama D, Jalife J. Mechanisms and Drug Development in Atrial Fibrillation. Pharmacol Rev 2018; 70:505-525. [PMID: 29921647 PMCID: PMC6010660 DOI: 10.1124/pr.117.014183] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Atrial fibrillation is a highly prevalent cardiac arrhythmia and the most important cause of embolic stroke. Although genetic studies have identified an increasing assembly of AF-related genes, the impact of these genetic discoveries is yet to be realized. In addition, despite more than a century of research and speculation, the molecular and cellular mechanisms underlying AF have not been established, and therapy for AF, particularly persistent AF, remains suboptimal. Current antiarrhythmic drugs are associated with a significant rate of adverse events, particularly proarrhythmia, which may explain why many highly symptomatic AF patients are not receiving any rhythm control therapy. This review focuses on recent advances in AF research, including its epidemiology, genetics, and pathophysiological mechanisms. We then discuss the status of antiarrhythmic drug therapy for AF today, reviewing molecular mechanisms, and the possible clinical use of some of the new atrial-selective antifibrillatory agents, as well as drugs that target atrial remodeling, inflammation and fibrosis, which are being tested as upstream therapies to prevent AF perpetuation. Altogether, the objective is to highlight the magnitude and endemic dimension of AF, which requires a significant effort to develop new and effective antiarrhythmic drugs, but also improve AF prevention and treatment of risk factors that are associated with AF complications.
Collapse
Affiliation(s)
- David Calvo
- Department of Cardiology, Arrhythmia Unit, Hospital Universitario Central de Asturias and Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain (D.C.); Fundación Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (D.F.-R., J.J.); Department of Cardiology, Arrhythmia Unit, Hospital Clínico Universitario San Carlos, Madrid, Spain (D.F.-R.); Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (D.F.-R., J.J.); and Center for Arrhythmia Research, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan (J.J.)
| | - David Filgueiras-Rama
- Department of Cardiology, Arrhythmia Unit, Hospital Universitario Central de Asturias and Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain (D.C.); Fundación Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (D.F.-R., J.J.); Department of Cardiology, Arrhythmia Unit, Hospital Clínico Universitario San Carlos, Madrid, Spain (D.F.-R.); Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (D.F.-R., J.J.); and Center for Arrhythmia Research, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan (J.J.)
| | - José Jalife
- Department of Cardiology, Arrhythmia Unit, Hospital Universitario Central de Asturias and Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain (D.C.); Fundación Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (D.F.-R., J.J.); Department of Cardiology, Arrhythmia Unit, Hospital Clínico Universitario San Carlos, Madrid, Spain (D.F.-R.); Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (D.F.-R., J.J.); and Center for Arrhythmia Research, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan (J.J.)
| |
Collapse
|
28
|
Ríos-Muñoz GR, Arenal Á, Artés-Rodríguez A. Real-Time Rotational Activity Detection in Atrial Fibrillation. Front Physiol 2018; 9:208. [PMID: 29593566 PMCID: PMC5859379 DOI: 10.3389/fphys.2018.00208] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 02/23/2018] [Indexed: 12/31/2022] Open
Abstract
Rotational activations, or spiral waves, are one of the proposed mechanisms for atrial fibrillation (AF) maintenance. We present a system for assessing the presence of rotational activity from intracardiac electrograms (EGMs). Our system is able to operate in real-time with multi-electrode catheters of different topologies in contact with the atrial wall, and it is based on new local activation time (LAT) estimation and rotational activity detection methods. The EGM LAT estimation method is based on the identification of the highest sustained negative slope of unipolar signals. The method is implemented as a linear filter whose output is interpolated on a regular grid to match any catheter topology. Its operation is illustrated on selected signals and compared to the classical Hilbert-Transform-based phase analysis. After the estimation of the LAT on the regular grid, the detection of rotational activity in the atrium is done by a novel method based on the optical flow of the wavefront dynamics, and a rotation pattern match. The methods have been validated using in silico and real AF signals.
Collapse
Affiliation(s)
- Gonzalo R Ríos-Muñoz
- Signal Theory and Communications Department, Universidad Carlos III de Madrid, Madrid, Spain.,Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Ángel Arenal
- Gregorio Marañón Health Research Institute, Madrid, Spain.,Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Antonio Artés-Rodríguez
- Signal Theory and Communications Department, Universidad Carlos III de Madrid, Madrid, Spain.,Gregorio Marañón Health Research Institute, Madrid, Spain
| |
Collapse
|
29
|
Zaman JAB, Rogers AJ, Narayan SM. Rotational Drivers in Atrial Fibrillation: Are Multiple Techniques Circling Similar Mechanisms? Circ Arrhythm Electrophysiol 2017; 10:CIRCEP.117.006022. [PMID: 29254949 DOI: 10.1161/circep.117.006022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Junaid A B Zaman
- From the Department of Medicine, Stanford University, CA (J.A.B.Z., A.J.R., S.M.N.); and Imperial Centre for Cardiac Engineering, Electrocardiomaths Programme, Imperial College London, United Kingdom (J.A.B.Z.)
| | - Albert J Rogers
- From the Department of Medicine, Stanford University, CA (J.A.B.Z., A.J.R., S.M.N.); and Imperial Centre for Cardiac Engineering, Electrocardiomaths Programme, Imperial College London, United Kingdom (J.A.B.Z.)
| | - Sanjiv M Narayan
- From the Department of Medicine, Stanford University, CA (J.A.B.Z., A.J.R., S.M.N.); and Imperial Centre for Cardiac Engineering, Electrocardiomaths Programme, Imperial College London, United Kingdom (J.A.B.Z.).
| |
Collapse
|