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Ganesan P, Deb B, Feng R, Rodrigo M, Ruiperez-Campillo S, Rogers AJ, Clopton P, Wang PJ, Zeemering S, Schotten U, Rappel WJ, Narayan SM. Quantifying a spectrum of clinical response in atrial tachyarrhythmias using spatiotemporal synchronization of electrograms. Europace 2023; 25:euad055. [PMID: 36932716 PMCID: PMC10227659 DOI: 10.1093/europace/euad055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 02/09/2023] [Indexed: 03/19/2023] Open
Abstract
AIMS There is a clinical spectrum for atrial tachyarrhythmias wherein most patients with atrial tachycardia (AT) and some with atrial fibrillation (AF) respond to ablation, while others do not. It is undefined if this clinical spectrum has pathophysiological signatures. This study aims to test the hypothesis that the size of spatial regions showing repetitive synchronized electrogram (EGM) shapes over time reveals a spectrum from AT, to AF patients who respond acutely to ablation, to AF patients without acute response. METHODS AND RESULTS We studied n = 160 patients (35% women, 65.0 ± 10.4 years) of whom (i) n = 75 had AF terminated by ablation propensity matched to (ii) n = 75 without AF termination and (iii) n = 10 with AT. All patients had mapping by 64-pole baskets to identify areas of repetitive activity (REACT) to correlate unipolar EGMs in shape over time. Synchronized regions (REACT) were largest in AT, smaller in AF termination, and smallest in non-termination cohorts (0.63 ± 0.15, 0.37 ± 0.22, and 0.22 ± 0.18, P < 0.001). Area under the curve for predicting AF termination in hold-out cohorts was 0.72 ± 0.03. Simulations showed that lower REACT represented greater variability in clinical EGM timing and shape. Unsupervised machine learning of REACT and extensive (50) clinical variables yielded four clusters of increasing risk for AF termination (P < 0.01, χ2), which were more predictive than clinical profiles alone (P < 0.001). CONCLUSION The area of synchronized EGMs within the atrium reveals a spectrum of clinical response in atrial tachyarrhythmias. These fundamental EGM properties, which do not reflect any predetermined mechanism or mapping technology, predict outcome and offer a platform to compare mapping tools and mechanisms between AF patient groups.
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Affiliation(s)
- Prasanth Ganesan
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Brototo Deb
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Ruibin Feng
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Miguel Rodrigo
- Electronic Engineering Department, Universitat de Valencia, Av. de Blasco Ibáñez, 13, 46010 València, Spain
| | - Samuel Ruiperez-Campillo
- Electronic Engineering Department, Universitat de Valencia, Av. de Blasco Ibáñez, 13, 46010 València, Spain
- Department of Bioengineering, University of California, Berkeley, CA 94720, USA
| | - Albert J Rogers
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Paul Clopton
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Paul J Wang
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Stef Zeemering
- Department of Physiology, Maastricht University, 6211 LK Maastricht, 616 6200, Netherlands
| | - Ulrich Schotten
- Department of Physiology, Maastricht University, 6211 LK Maastricht, 616 6200, Netherlands
| | - Wouter-Jan Rappel
- Department of Physics, University of California, 9500 Gilman Dr, La Jolla, CA 92093, USA
| | - Sanjiv M Narayan
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
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Özgül O, Hermans BJ, van Hunnik A, Verheule S, Schotten U, Bonizzi P, Zeemering S. High-density and high coverage composite mapping of repetitive atrial activation patterns. Comput Biol Med 2023; 159:106920. [PMID: 37119551 DOI: 10.1016/j.compbiomed.2023.106920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 03/18/2023] [Accepted: 04/13/2023] [Indexed: 05/01/2023]
Abstract
BACKGROUND Repetitive atrial activation patterns (RAAPs) during atrial fibrillation (AF) may be associated with localized mechanisms that maintain AF. Current electro-anatomical mapping systems are unsuitable for analyzing RAAPs due to the trade-off between spatial coverage and electrode density in clinical catheters. This work proposes a technique to overcome this trade-off by constructing composite maps from spatially overlapping sequential recordings. METHODS High-density epicardial contact mapping was performed during open-chest surgery in goats (n=16, left and right atria) with 3 or 22 weeks of sustained AF (249-electrode array, electrode distance 2.4 mm). A dataset mimicking sequential recordings was generated by segmenting the grid into four spatially overlapping regions (each region 6.5 cm2, 48±10% overlap) without temporal overlap. RAAPs were detected in each region using recurrence plots of activation times. RAAPs in two different regions were joined in case of RAAP cross-recurrence between overlapping electrodes. We quantified the reconstruction success rate and quality of the composite maps. RESULTS Of 1021 RAAPs found in the full mapping array (32±13 per recording), 328 spatiotemporally stable RAAPs were analyzed. 247 composite maps were generated (75% success) with a quality of 0.86±0.21 (Pearson correlation). Success was significantly affected by the RAAP area. Quality was weakly correlated with the number of repetitions of RAAPs (r=0.13, p<0.05) and not affected by the atrial side (left or right) or AF duration (3 or 22 weeks of AF). CONCLUSIONS Constructing composite maps by combining spatially overlapping sequential recordings is feasible. Interpretation of these maps can play a central role in ablation planning.
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Affiliation(s)
- Ozan Özgül
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Ben Jm Hermans
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Arne van Hunnik
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Sander Verheule
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Ulrich Schotten
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands.
| | - Pietro Bonizzi
- Department of Advanced Computing Sciences, Maastricht University, Maastricht, the Netherlands
| | - Stef Zeemering
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
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Masè M, Cristoforetti A, Del Greco M, Ravelli F. A Divergence-Based Approach for the Identification of Atrial Fibrillation Focal Drivers From Multipolar Mapping: A Computational Study. Front Physiol 2021; 12:749430. [PMID: 35002755 PMCID: PMC8740027 DOI: 10.3389/fphys.2021.749430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 11/30/2021] [Indexed: 11/13/2022] Open
Abstract
The expanding role of catheter ablation of atrial fibrillation (AF) has stimulated the development of novel mapping strategies to guide the procedure. We introduce a novel approach to characterize wave propagation and identify AF focal drivers from multipolar mapping data. The method reconstructs continuous activation patterns in the mapping area by a radial basis function (RBF) interpolation of multisite activation time series. Velocity vector fields are analytically determined, and the vector field divergence is used as a marker of focal drivers. The method was validated in a tissue patch cellular automaton model and in an anatomically realistic left atrial (LA) model with Courtemanche-Ramirez-Nattel ionic dynamics. Divergence analysis was effective in identifying focal drivers in a complex simulated AF pattern. Localization was reliable even with consistent reduction (47%) in the number of mapping points and in the presence of activation time misdetections (noise <10% of the cycle length). Proof-of-concept application of the method to human AF mapping data showed that divergence analysis consistently detected focal activation in the pulmonary veins and LA appendage area. These results suggest the potential of divergence analysis in combination with multipolar mapping to identify AF critical sites. Further studies on large clinical datasets may help to assess the clinical feasibility and benefit of divergence analysis for the optimization of ablation treatment.
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Affiliation(s)
- Michela Masè
- Laboratory of Biophysics and Translational Cardiology, Department of Cellular, Computational and Integrative Biology – CIBIO, University of Trento, Trento, Italy
- Institute of Mountain Emergency Medicine, EURAC Research, Bolzano, Italy
| | - Alessandro Cristoforetti
- Laboratory of Biophysics and Translational Cardiology, Department of Cellular, Computational and Integrative Biology – CIBIO, University of Trento, Trento, Italy
| | - Maurizio Del Greco
- Division of Cardiology, Santa Maria del Carmine Hospital, Rovereto, Italy
| | - Flavia Ravelli
- Laboratory of Biophysics and Translational Cardiology, Department of Cellular, Computational and Integrative Biology – CIBIO, University of Trento, Trento, Italy
- CISMed – Centre for Medical Sciences, University of Trento, Trento, Italy
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Ozgul O, Maesen B, Schotten U, Bonizzi P, Zeemering S. State Space Embedding of Atrial Electrograms to Detect Repetitive Conduction Patterns During Atrial Fibrillation. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2021; 2021:508-511. [PMID: 34891344 DOI: 10.1109/embc46164.2021.9630766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Repetitive atrial conduction patterns are often observed during human atrial fibrillation (AF). Repetitive patterns may be associated with AF drivers such as focal and micro-reentrant mechanisms. Therefore, tools for repetitive activity detection are of great interest as they may allow to identify the leading electrophysiological AF mechanism in an individual patient. Recurrence plots (RP) are efficient tools for repetitive activity visualization. Construction of an RP requires embedding of epicardial atrial electrograms into a phase space. In this study, we compared the conventional Takens' embedding approach and three novel approaches based on a priori AF cycle length (AFCL) information. Approaches were bench-marked based on the similarity of the RPs they produce with a previously proposed technique, the sensitivity and specificity to detect the repetitive patterns, as well as the capability to estimate overall repetitive pattern prevalence. All techniques were applied to high-density epicardial direct contact mapping recordings in AF patients with paroxysmal AF (n=12) and persistent AF (n=9). Compared to a reference method the proposed novel techniques achieved significantly higher similarity and sensitivity values (p<0.01) than conventional embedding, in both paroxysmal and persistent patients. Moreover, estimated prevalences were robust against the various degrees of AF complexity present in the recordings.Clinical relevance- This study presents three novel approaches for detection of repetitive patterns of conduction during AF in atrial direct contact recordings, which may aid in the identification of the leading AF mechanism in an individual patient.
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Molero R, Soler Torro JM, Martínez Alzamora N, M Climent A, Guillem MS. Higher reproducibility of phase derived metrics from electrocardiographic imaging during atrial fibrillation in patients remaining in sinus rhythm after pulmonary vein isolation. Comput Biol Med 2021; 139:104934. [PMID: 34688171 DOI: 10.1016/j.compbiomed.2021.104934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 10/08/2021] [Accepted: 10/08/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Electrocardiographic imaging (ECGI) allows evaluating the complexity of the reentrant activity of atrial fibrillation (AF) patients. In this study, we evaluated the ability of ECGI metrics to predict the success of pulmonary vein isolation (PVI) to treat AF. METHODS ECGI of 24 AF patients (6 males, 13 paroxysmal, 61.8 ± 14 years) was recorded prior to PVI. Patients were distributed into two groups based on their PVI outcome 6 months after ablation (sinus vs. arrhythmia recurrence). Metrics derived from phase analysis of ECGI signals were computed for two different temporal segments before ablation. Correlation analysis and variability over time were studied between the two recorded segments and were compared between patient groups. RESULTS Temporal variability of both rotor duration and spatial entropy of the rotor histogram presented statistical differences between groups with different PVI outcome (p < 0.05). The reproducibility of reentrant metrics was higher (R2 > 0.8) in patients with good outcome rather than arrhythmia recurrence patients (R2 < 0.62). Prediction of PVI success based on ECGI temporal variability metrics allows for an increased specificity over the classification into paroxysmal or persistent (0.85 vs. 0.64). CONCLUSIONS Patients with favorable PVI outcome present ECGI metrics more reproducible over time than patients with AF recurrence. These results suggest that ECGI derived metrics may allow selecting which patients would benefit from ablation therapies.
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Affiliation(s)
- Rubén Molero
- ITACA Institute, Universitat Politècnica de València, València, Spain.
| | - José Manuel Soler Torro
- Department of Applied Statistics and Operational Research and Quality, Universitat Politècnica de València, València, Spain.
| | - Nieves Martínez Alzamora
- Department of Applied Statistics and Operational Research and Quality, Universitat Politècnica de València, València, Spain.
| | - Andreu M Climent
- ITACA Institute, Universitat Politècnica de València, València, Spain.
| | - María S Guillem
- ITACA Institute, Universitat Politècnica de València, València, Spain.
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van Rosmalen F, Maesen B, van Hunnik A, Hermans BJM, Bonizzi P, Bidar E, Nijs J, Maessen JG, Verheule S, Delhaas T, Schotten U, Zeemering S. Incidence, prevalence, and trajectories of repetitive conduction patterns in human atrial fibrillation. Europace 2021; 23:i123-i132. [PMID: 33751087 DOI: 10.1093/europace/euaa403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/11/2020] [Indexed: 11/12/2022] Open
Abstract
AIMS Repetitive conduction patterns in atrial fibrillation (AF) may reflect anatomical structures harbouring preferential conduction paths and indicate the presence of stationary sources for AF. Recently, we demonstrated a novel technique to detect repetitive patterns in high-density contact mapping of AF. As a first step towards repetitive pattern mapping to guide AF ablation, we determined the incidence, prevalence, and trajectories of repetitive conduction patterns in epicardial contact mapping of paroxysmal and persistent AF patients. METHODS AND RESULTS A 256-channel mapping array was used to record epicardial left and right AF electrograms in persistent AF (persAF, n = 9) and paroxysmal AF (pAF, n = 11) patients. Intervals containing repetitive conduction patterns were detected using recurrence plots. Activation movies, preferential conduction direction, and average activation sequence were used to characterize and classify conduction patterns. Repetitive patterns were identified in 33/40 recordings. Repetitive patterns were more prevalent in pAF compared with persAF [pAF: median 59%, inter-quartile range (41-72) vs. persAF: 39% (0-51), P < 0.01], larger [pAF: = 1.54 (1.15-1.96) vs. persAF: 1.16 (0.74-1.56) cm2, P < 0.001), and more stable [normalized preferentiality (0-1) pAF: 0.38 (0.25-0.50) vs. persAF: 0.23 (0-0.33), P < 0.01]. Most repetitive patterns were peripheral waves (87%), often with conduction block (69%), while breakthroughs (9%) and re-entries (2%) occurred less frequently. CONCLUSION High-density epicardial contact mapping in AF patients reveals frequent repetitive conduction patterns. In persistent AF patients, repetitive patterns were less frequent, smaller, and more variable than in paroxysmal AF patients. Future research should elucidate whether these patterns can help in finding AF ablation targets.
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Affiliation(s)
- Frank van Rosmalen
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Bart Maesen
- Department of Cardiothoracic Surgery, Maastricht University, Medical Center & Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Arne van Hunnik
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Ben J M Hermans
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Pietro Bonizzi
- Department of Data Science and Knowledge Engineering, Maastricht University, Maastricht, The Netherlands
| | - Elham Bidar
- Department of Cardiothoracic Surgery, Maastricht University, Medical Center & Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Jan Nijs
- Department of Cardiac Surgery, UZ Brussel, Brussels, Belgium
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University, Medical Center & Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Sander Verheule
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Tammo Delhaas
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Ulrich Schotten
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Stef Zeemering
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
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7
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Dharmaprani D, Jenkins E, Aguilar M, Quah JX, Lahiri A, Tiver K, Mitchell L, Kuklik P, Meyer C, Willems S, Clayton R, Nash M, Nattel S, McGavigan AD, Ganesan AN. M/M/Infinity Birth-Death Processes - A Quantitative Representational Framework to Summarize and Explain Phase Singularity and Wavelet Dynamics in Atrial Fibrillation. Front Physiol 2021; 11:616866. [PMID: 33519522 PMCID: PMC7841497 DOI: 10.3389/fphys.2020.616866] [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] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 12/16/2020] [Indexed: 01/25/2023] Open
Abstract
Rationale A quantitative framework to summarize and explain the quasi-stationary population dynamics of unstable phase singularities (PS) and wavelets in human atrial fibrillation (AF) is at present lacking. Building on recent evidence showing that the formation and destruction of PS and wavelets in AF can be represented as renewal processes, we sought to establish such a quantitative framework, which could also potentially provide insight into the mechanisms of spontaneous AF termination. Objectives Here, we hypothesized that the observed number of PS or wavelets in AF could be governed by a common set of renewal rate constants λ f (for PS or wavelet formation) and λ d (PS or wavelet destruction), with steady-state population dynamics modeled as an M/M/∞ birth-death process. We further hypothesized that changes to the M/M/∞ birth-death matrix would explain spontaneous AF termination. Methods and Results AF was studied in in a multimodality, multispecies study in humans, animal experimental models (rats and sheep) and Ramirez-Nattel-Courtemanche model computer simulations. We demonstrated: (i) that λ f and λ d can be combined in a Markov M/M/∞ process to accurately model the observed average number and population distribution of PS and wavelets in all systems at different scales of mapping; and (ii) that slowing of the rate constants λ f and λ d is associated with slower mixing rates of the M/M/∞ birth-death matrix, providing an explanation for spontaneous AF termination. Conclusion M/M/∞ birth-death processes provide an accurate quantitative representational architecture to characterize PS and wavelet population dynamics in AF, by providing governing equations to understand the regeneration of PS and wavelets during sustained AF, as well as providing insight into the mechanism of spontaneous AF termination.
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Affiliation(s)
- Dhani Dharmaprani
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.,College of Science and Engineering, Flinders University, Adelaide, SA, Australia
| | - Evan Jenkins
- College of Science and Engineering, Flinders University, Adelaide, SA, Australia
| | - Martin Aguilar
- The Research Center, Montréal Heart Institute and Université de Montréal, Montréal, QC, Canada
| | - Jing X Quah
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.,Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Anandaroop Lahiri
- Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Kathryn Tiver
- Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Lewis Mitchell
- School of Mathematical Sciences, University of Adelaide, Adelaide, SA, Australia
| | | | | | | | - Richard Clayton
- Insigneo Institute for in silico Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Martyn Nash
- Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Stanley Nattel
- The Research Center, Montréal Heart Institute and Université de Montréal, Montréal, QC, Canada
| | - Andrew D McGavigan
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.,Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Anand N Ganesan
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.,Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, SA, Australia
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