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van Schie MS, Liao R, Ramdat Misier NL, Knops P, Heida A, Taverne YJHJ, de Groot NMS. Atrial extrasystoles enhance low-voltage fractionation electrograms in patients with atrial fibrillation. Europace 2023; 25:euad223. [PMID: 37477953 PMCID: PMC10401323 DOI: 10.1093/europace/euad223] [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: 05/02/2023] [Accepted: 07/14/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND AND AIMS Atrial extrasystoles (AES) provoke conduction disorders and may trigger episodes of atrial fibrillation (AF). However, the direction- and rate-dependency of electrophysiological tissue properties on epicardial unipolar electrogram (EGM) morphology is unknown. Therefore, this study examined the impact of spontaneous AES on potential amplitude, -fractionation, -duration, and low-voltage areas (LVAs), and correlated these differences with various degrees of prematurity and aberrancy. METHODS AND RESULTS Intra-operative high-resolution epicardial mapping of the right and left atrium, Bachmann's Bundle, and pulmonary vein area was performed during sinus rhythm (SR) in 287 patients (60 with AF). AES were categorized according to their prematurity index (>25% shortening) and degree of aberrancy (none, mild/opposite, moderate and severe). In total, 837 unique AES (457 premature; 58 mild/opposite, 355 moderate, and 154 severe aberrant) were included. The average prematurity index was 28% [12-45]. Comparing SR and AES, average voltage decreased (-1.1 [-1.2, -0.9] mV, P < 0.001) at all atrial regions, whereas the amount of LVAs and fractionation increased (respectively, +3.4 [2.7, 4.1] % and +3.2 [2.6, 3.7] %, P < 0.001). Only weak or moderate correlations were found between EGM morphology parameters and prematurity indices (R2 < 0.299, P < 0.001). All parameters were, however, most severely affected by either mild/opposite or severely aberrant AES, in which the effect was more pronounced in AF patients. Also, there were considerable regional differences in effects provoked by AES. CONCLUSION Unipolar EGM characteristics during spontaneous AES are mainly directional-dependent and not rate-dependent. AF patients have more direction-dependent conduction disorders, indicating enhanced non-uniform anisotropy that is uncovered by spontaneous AES.
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Affiliation(s)
- Mathijs S van Schie
- Department of Cardiology, Erasmus Medical Center, Dr. Molewaterplein 40, 3015GD Rotterdam, the Netherlands
| | - Rongheng Liao
- Department of Cardiology, Erasmus Medical Center, Dr. Molewaterplein 40, 3015GD Rotterdam, the Netherlands
| | - Nawin L Ramdat Misier
- Department of Cardiology, Erasmus Medical Center, Dr. Molewaterplein 40, 3015GD Rotterdam, the Netherlands
| | - Paul Knops
- Department of Cardiology, Erasmus Medical Center, Dr. Molewaterplein 40, 3015GD Rotterdam, the Netherlands
| | - Annejet Heida
- Department of Cardiology, Erasmus Medical Center, Dr. Molewaterplein 40, 3015GD Rotterdam, the Netherlands
| | - Yannick J H J Taverne
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Natasja M S de Groot
- Department of Cardiology, Erasmus Medical Center, Dr. Molewaterplein 40, 3015GD Rotterdam, the Netherlands
- Department of Microelectronics, Signal Processing Systems, Faculty of Electrical Engineering, Mathematics and Computer Sciences, Delft University of Technology, Mekelweg 4, 2628CD Delft, the Netherlands
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van Schie MS, Ramdat Misier NL, Razavi Ebrahimi P, Heida A, Kharbanda RK, Taverne YJHJ, de Groot NMS. Premature atrial contractions promote local directional heterogeneities in conduction velocity vectors. Europace 2023; 25:1162-1171. [PMID: 36637110 PMCID: PMC10062298 DOI: 10.1093/europace/euac283] [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: 09/22/2022] [Accepted: 12/15/2022] [Indexed: 01/14/2023] Open
Abstract
AIMS Loss of cell-to-cell communication results in local conduction disorders and directional heterogeneity (LDH) in conduction velocity (CV) vectors, which may be unmasked by premature atrial contractions (PACs). We quantified LDH and examined differences between sinus rhythm (SR) and spontaneous PACs in patients with and without atrial fibrillation (AF). METHODS AND RESULTS Intra-operative epicardial mapping of the right and left atrium (RA, LA), Bachmann's bundle (BB) and pulmonary vein area (PVA) was performed in 228 patients (54 with AF). Conduction velocity vectors were computed at each electrode using discrete velocity vectors. Directions and magnitudes of individual vectors were compared with surrounding vectors to identify LDH. Five hundred and three PACs [2 (1-3) per patient; prematurity index of 45 ± 12%] were included. During SR, most LDH were found at BB and LA [11.9 (8.3-14.9) % and 11.3 (8.0-15.2) %] and CV was lowest at BB [83.5 (72.4-94.3) cm/s, all P < 0.05]. Compared with SR, the largest increase in LDH during PAC was found at BB and PVA [+13.0 (7.7, 18.3) % and +12.5 (10.8, 14.2) %, P < 0.001]; CV decreased particularly at BB, PVA and LA [-10.0 (-13.2, -6.9) cm/s, -9.3 (-12.5, -6.2) cm/s and -9.1 (-11.7, -6.6) cm/s, P < 0.001]. Comparing patients with and without AF, more LDH were found during SR in AF patients at PVA and BB, although the increase in LDH during PACs was similar for all sites. CONCLUSION Local directional heterogeneity is a novel methodology to quantify local heterogeneity in CV as a possible indicator of electropathology. Intra-operative high-resolution mapping indeed revealed that LDH increased during PACs particularly at BB and PVA. Also, patients with AF already have more LDH during SR, which becomes more pronounced during PACs.
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Affiliation(s)
- Mathijs S van Schie
- Department of Cardiology, Erasmus Medical Center, Dr. Molewaterplein 40, 3015GD Rotterdam, the Netherlands
| | - Nawin L Ramdat Misier
- Department of Cardiology, Erasmus Medical Center, Dr. Molewaterplein 40, 3015GD Rotterdam, the Netherlands
| | - Payam Razavi Ebrahimi
- Department of Cardiology, Erasmus Medical Center, Dr. Molewaterplein 40, 3015GD Rotterdam, the Netherlands
| | - Annejet Heida
- Department of Cardiology, Erasmus Medical Center, Dr. Molewaterplein 40, 3015GD Rotterdam, the Netherlands
| | - Rohit K Kharbanda
- Department of Cardiology, Erasmus Medical Center, Dr. Molewaterplein 40, 3015GD Rotterdam, the Netherlands
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Dr. Molewaterplein 40, 3015GD Rotterdam, the Netherlands
| | - Yannick J H J Taverne
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Dr. Molewaterplein 40, 3015GD Rotterdam, the Netherlands
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Novel insights in pathophysiology of postoperative atrial fibrillation. JTCVS OPEN 2021; 6:120-129. [PMID: 36003566 PMCID: PMC9390318 DOI: 10.1016/j.xjon.2021.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 01/08/2021] [Indexed: 11/29/2022]
Abstract
Objectives Atrial extrasystoles are usually benign; however, they can also trigger atrial fibrillation. It is most likely that if atrial extrasystoles provoke a larger amount of conduction disorders and a greater degree of endo-epicardial asynchrony, the risk of postoperative atrial fibrillation increases. To test this hypothesis, we investigated the effect of programmed atrial extrasystoles on endo-epicardial conduction and postoperative atrial fibrillation. Methods Twelve patients (58% male, age 68 ± 7 years) underwent simultaneous endo-epicardial mapping (256 electrodes) of the right atrium during sinus rhythm and programmed atrial extrasystoles provoked from the right atrial free wall. Areas of conduction block were defined as conduction delays of ≥12 milliseconds and endo-epicardial asynchrony as activation time differences of exact opposite electrodes of ≥15 milliseconds. Results Endo-epicardial mapping data of all programmed atrial extrasystoles were analyzed and compared with sinus rhythm (median preceding cycle length = 531 milliseconds [345-787] and median sinus rhythm cycle length = 843 milliseconds [701-992]). All programmed atrial extrasystoles were aberrant (severe, moderate, and mildly aberrant, respectively, n = 6, 3, and 3) and had a mean prematurity index of 50.1 ± 11.9%. The amount of endo-epicardial asynchrony (1% [1-2] vs 6.7 [2.7-16.9], P = .006) and conduction block (1.4% [0.6-2.6] vs 8.5% [4.2-10.4], P = .005) both increased during programmed atrial extrasystoles. Interestingly, conduction block during programmed atrial extrasystoles was more severe in patients (n = 4, 33.3%) who developed postoperative atrial fibrillation (5.1% [2.9-8.8] vs 11.3% [10.1-12.1], P = .004). Conclusions Atrial conduction disorders and endo-epicardial asynchrony, which play an important role in arrhythmogenesis, are enhanced during programmed atrial extrasystoles compared with sinus rhythm. The findings of this pilot study provide a possible explanation for enhanced vulnerability for postoperative atrial extrasystoles to induce postoperative atrial fibrillation in patients after cardiac surgery.
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Khan MS, Lange M, Ranjan R, Sharma V, Glotzbach JP, Selzman C, Dosdall DJ. Premature atrial stimulation accentuates conduction abnormalities in cardiac surgery patients that develop postoperative atrial fibrillation. J Electrocardiol 2021; 69:36-43. [PMID: 34555557 PMCID: PMC9265137 DOI: 10.1016/j.jelectrocard.2021.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 09/03/2021] [Accepted: 09/06/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND postoperative atrial fibrillation (POAF) is a common cardiac surgery complication that is associated with increased complications and negative outcomes, but the association between presurgical atrial conduction abnormalities and POAF has not been investigated clinically during premature atrial S1S2 stimulation. This clinical study sought to examine whether intraoperative premature atrial stimulation reveals increased areas of slowed and/or blocked conduction in patients that develop POAF. METHODS High-density intraoperative epicardial left atrial mapping was conducted in 20 cardiac surgery patients with no prior history of atrial fibrillation (AF). In 20 patients, 6 (30%) developed POAF. A flexible-array of 240-electrodes was placed on the posterior left atrial wall in between the pulmonary veins. Activation maps were generated for sinus and premature atrial S1S2 stimulated beats. The area of conduction block (CB), conduction delay (CD) and the combination of both (CDCB) for conduction velocity < 0.1, 0.1 ≤ x < 0.2 and < 0.2 m/s, respectively were quantified. RESULTS For a premature atrial S2 beat with shortest cycle length captured, conduction velocity maps revealed a significantly higher area for CD (13.19 ± 6.59 versus 6.06 ± 4.22 mm2, p = 0.028) and CDCB (17.36 ± 8.75 versus 7.41 ± 6.39 mm2, p = 0.034), and a trend toward a larger area for CB (4.17 ± 3.66 versus 1.34 ± 2.86 mm2, p = 0.063) in patients who developed POAF in comparison to those that remained in the sinus. Sinus and S1 paced beats did not show substantial differences in abnormal conduction areas between patients with and without POAF. CONCLUSION In comparison to sinus and S1 beats, premature atrial S2 beats accentuate conduction abnormalities in the posterior left atrial wall of cardiac surgery patients that developed POAF.
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Affiliation(s)
- Muhammad S. Khan
- Nora Eccles Harrison Cardiovascular Research and Training Institute, The University of Utah – Health, Salt Lake City, UT 84112, USA
| | - Matthias Lange
- Nora Eccles Harrison Cardiovascular Research and Training Institute, The University of Utah – Health, Salt Lake City, UT 84112, USA
| | - Ravi Ranjan
- Nora Eccles Harrison Cardiovascular Research and Training Institute, The University of Utah – Health, Salt Lake City, UT 84112, USA.,Division of Cardiovascular Medicine, Department of Internal Medicine, The University of Utah – Health, Salt Lake City, UT 84112, USA.,Department of Bioengineering, The University of Utah – Health, Salt Lake City, UT 84112, USA
| | - Vikas Sharma
- Division of Cardiothoracic Surgery, Department of Surgery, The University of Utah – Health, Salt Lake City, UT 84112, USA
| | - Jason P. Glotzbach
- Division of Cardiothoracic Surgery, Department of Surgery, The University of Utah – Health, Salt Lake City, UT 84112, USA
| | - Craig Selzman
- Nora Eccles Harrison Cardiovascular Research and Training Institute, The University of Utah – Health, Salt Lake City, UT 84112, USA.,Division of Cardiothoracic Surgery, Department of Surgery, The University of Utah – Health, Salt Lake City, UT 84112, USA
| | - Derek J. Dosdall
- Nora Eccles Harrison Cardiovascular Research and Training Institute, The University of Utah – Health, Salt Lake City, UT 84112, USA.,Division of Cardiovascular Medicine, Department of Internal Medicine, The University of Utah – Health, Salt Lake City, UT 84112, USA.,Department of Bioengineering, The University of Utah – Health, Salt Lake City, UT 84112, USA.,Division of Cardiothoracic Surgery, Department of Surgery, The University of Utah – Health, Salt Lake City, UT 84112, USA.,Address For Correspondence: Dr. Derek J. Dosdall, PhD, FHRS, FAHA, Associate Professor of Surgery, Division of Cardiothoracic Surgery, The University of Utah – Health, Salt Lake City, UT 84112 USA, / Ph: (+1) 801-587-2036
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Bhaskaran A, Fitzgerald J, Jackson N, Gizurarson S, Nanthakumar K, Porta-Sánchez A. Decrement Evoked Potential Mapping to Guide Ventricular Tachycardia Ablation: Elucidating the Functional Substrate. Arrhythm Electrophysiol Rev 2020; 9:211-218. [PMID: 33437489 PMCID: PMC7788395 DOI: 10.15420/aer.2020.25] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Empirical approaches to targeting the ventricular tachycardia (VT) substrate include mapping of late potentials, local abnormal electrogram, pace-mapping and homogenisation of the abnormal signals. These approaches do not try to differentiate between the passive or active role of local signals as the critical components of the VT circuit. By not considering the functional components, these approaches often view the substrate as a fixed anatomical barrier. Strategies to improve the success of VT ablation need to include the identification of critical functional substrate. Decrement-evoked potential (DeEP) mapping has been developed to elucidate this using an extra-stimulus added to a pacing drive train. With knowledge translation in mind, the authors detail the evolution of the DeEP concept by way of a study of simultaneous panoramic endocardial mapping in VT ablation; an in silico modelling study to demonstrate the factors influencing DeEPs; a multicentre VT ablation validation study; a practical approach to DeEP mapping; the potential utility of DeEPs to identify arrhythmogenic atrial substrate; and, finally, other functional mapping strategies.
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Affiliation(s)
| | | | | | | | | | - Andreu Porta-Sánchez
- Hospital Universitario Quirónsalud Madrid, Molecular Cardiology Laboratory, Centro Nacional de Investigaciones Cardiovasculares, Spain
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