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Osorio D, Vraka A, Moreno-Arribas J, Bertomeu-González V, Alcaraz R, Rieta JJ. Comparative Study of Methods for Cycle Length Estimation in Fractionated Electrograms of Atrial Fibrillation. J Pers Med 2022; 12:jpm12101712. [PMID: 36294851 PMCID: PMC9604643 DOI: 10.3390/jpm12101712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/04/2022] [Accepted: 10/11/2022] [Indexed: 11/07/2022] Open
Abstract
Atrial cycle length (CL) is an important feature for the analysis of electrogram (EGM) characteristics acquired during catheter ablation (CA) of atrial fibrillation (AF), the commonest cardiac arrhythmia. Nevertheless, a robust ACL estimator requires the precise detection of local activation waves (LAWs), which still remains a challenge. This work aims to compare the performance in (CL) estimation, especially under fractionated EGMs, of three different LAW detection methods relying on different operation strategies. The methods are based on the hyperbolic tangent (HT) function, an adaptive amplitude threshold (AAT) and a (CL) iteration (ACLI), respectively. For each method, LAW detection has been assessed with respect to manual annotations made by two experts and performance has been estimated by confusion matrix and mean and individual (CL) error calculation by EGM types of fractionation. The influence of EGM length on the individual (CL) error has been additionally considered. For the HT method, accuracy, sensitivity and precision were 92.77–100%, while for the AAT and ACLI methods they were 78.89–99.91% for all EGM types. The CL error on the HT method was lower than AAT and ACLI methods (up to 12 ms versus up to 20 ms), with the difference being more prominent in complex EGMs. The HT method also showed the lowest dependency on EGM length, presenting the lowest and least variable error values. Therefore, the HT method achieves higher performance in (CL) estimation in comparison with previous LAW detection techniques. The high robustness and precision demonstrated by this method suggest its implementation on CA mapping devices for a more successful location of ablation targets and improved results during CA procedures.
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Affiliation(s)
- Diego Osorio
- BioMIT.org, Electronic Engineering Department, Universitat Politecnica de Valencia, 46022 Valencia, Spain
| | - Aikaterini Vraka
- BioMIT.org, Electronic Engineering Department, Universitat Politecnica de Valencia, 46022 Valencia, Spain
| | - José Moreno-Arribas
- Cardiology Department, Saint John’s University Hospital, 03550 Alicante, Spain
| | | | - Raúl Alcaraz
- Research Group in Electronic, Biomedical and Telecommunication Engineering, University of Castilla-La Mancha, 16071 Cuenca, Spain
| | - José J. Rieta
- BioMIT.org, Electronic Engineering Department, Universitat Politecnica de Valencia, 46022 Valencia, Spain
- Correspondence:
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Osorio D, Vraka A, Quesada A, Hornero F, Alcaraz R, Rieta JJ. An Efficient Hybrid Methodology for Local Activation Waves Detection under Complex Fractionated Atrial Electrograms of Atrial Fibrillation. Sensors (Basel) 2022; 22:s22145345. [PMID: 35891025 PMCID: PMC9316244 DOI: 10.3390/s22145345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/06/2022] [Accepted: 07/15/2022] [Indexed: 05/04/2023]
Abstract
Local activation waves (LAWs) detection in complex fractionated atrial electrograms (CFAEs) during catheter ablation (CA) of atrial fibrillation (AF), the commonest cardiac arrhythmia, is a complicated task due to their extreme variability and heterogeneity in amplitude and morphology. There are few published works on reliable LAWs detectors, which are efficient for regular or low fractionated bipolar electrograms (EGMs) but lack satisfactory results when CFAEs are analyzed. The aim of the present work is the development of a novel optimized method for LAWs detection in CFAEs in order to assist cardiac mapping and catheter ablation (CA) guidance. The database consists of 119 bipolar EGMs classified by AF types according to Wells' classification. The proposed method introduces an alternative Botteron's preprocessing technique targeting the slow and small-ampitude activations. The lower band-pass filter cut-off frequency is modified to 20 Hz, and a hyperbolic tangent function is applied over CFAEs. Detection is firstly performed through an amplitude-based threshold and an escalating cycle-length (CL) analysis. Activation time is calculated at each LAW's barycenter. Analysis is applied in five-second overlapping segments. LAWs were manually annotated by two experts and compared with algorithm-annotated LAWs. AF types I and II showed 100% accuracy and sensitivity. AF type III showed 92.77% accuracy and 95.30% sensitivity. The results of this study highlight the efficiency of the developed method in precisely detecting LAWs in CFAEs. Hence, it could be implemented on real-time mapping devices and used during CA, providing robust detection results regardless of the fractionation degree of the analyzed recordings.
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Affiliation(s)
- Diego Osorio
- BioMIT.org, Electronic Engineering Department, Universitat Politecnica de Valencia, 46022 Valencia, Spain; (D.O.); (A.V.)
| | - Aikaterini Vraka
- BioMIT.org, Electronic Engineering Department, Universitat Politecnica de Valencia, 46022 Valencia, Spain; (D.O.); (A.V.)
| | - Aurelio Quesada
- Arrhythmia Unit, Cardiology Department, General University Hospital Consortium of Valencia, 46014 Valencia, Spain;
| | - Fernando Hornero
- Cardiovascular Surgery Department, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain;
| | - Raúl Alcaraz
- Research Group in Electronic, Biomedical and Telecommunication Engineering, University of Castilla-La Mancha, 16071 Cuenca, Spain;
| | - José J. Rieta
- BioMIT.org, Electronic Engineering Department, Universitat Politecnica de Valencia, 46022 Valencia, Spain; (D.O.); (A.V.)
- Correspondence:
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Vraka A, Hornero F, Bertomeu-González V, Osca J, Alcaraz R, Rieta JJ. Short-Time Estimation of Fractionation in Atrial Fibrillation with Coarse-Grained Correlation Dimension for Mapping the Atrial Substrate. Entropy (Basel) 2020; 22:e22020232. [PMID: 33286006 PMCID: PMC7516661 DOI: 10.3390/e22020232] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/14/2020] [Accepted: 02/15/2020] [Indexed: 11/16/2022]
Abstract
Atrial fibrillation (AF) is currently the most common cardiac arrhythmia, with catheter ablation (CA) of the pulmonary veins (PV) being its first line therapy. Ablation of complex fractionated atrial electrograms (CFAEs) outside the PVs has demonstrated improved long-term results, but their identification requires a reliable electrogram (EGM) fractionation estimator. This study proposes a technique aimed to assist CA procedures under real-time settings. The method has been tested on three groups of recordings: Group 1 consisted of 24 highly representative EGMs, eight of each belonging to a different AF Type. Group 2 contained the entire dataset of 119 EGMs, whereas Group 3 contained 20 pseudo-real EGMs of the special Type IV AF. Coarse-grained correlation dimension (CGCD) was computed at epochs of 1 s duration, obtaining a classification accuracy of 100% in Group 1 and 84.0–85.7% in Group 2, using 10-fold cross-validation. The receiver operating characteristics (ROC) analysis for highly fractionated EGMs, showed 100% specificity and sensitivity in Group 1 and 87.5% specificity and 93.6% sensitivity in Group 2. In addition, 100% of the pseudo-real EGMs were correctly identified as Type IV AF. This method can consistently express the fractionation level of AF EGMs and provides better performance than previous works. Its ability to compute fractionation in short-time can agilely detect sudden changes of AF Types and could be used for mapping the atrial substrate, thus assisting CA procedures under real-time settings for atrial substrate modification.
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Affiliation(s)
- Aikaterini Vraka
- BioMIT.org, Electronic Engineering Department, Universitat Politecnica de Valencia, 46022 Valencia, Spain;
| | - Fernando Hornero
- Cardiac Surgery Department, Hospital Universitari i Politecnic La Fe, 46026 Valencia, Spain;
| | | | - Joaquín Osca
- Electrophysiology Section, Hospital Universitari i Politecnic La Fe, 46026 Valencia, Spain;
| | - Raúl Alcaraz
- Research Group in Electronic, Biomedical and Telecommunication Engineering, University of Castilla-La Mancha, 16071 Cuenca, Spain;
| | - José J. Rieta
- BioMIT.org, Electronic Engineering Department, Universitat Politecnica de Valencia, 46022 Valencia, Spain;
- Correspondence:
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Abstract
Ablation occupies an increasing role in the contemporary management of atrial fibrillation (AF), but results are suboptimal, particularly for persistent AF. While an anatomic approach to ablation is a highly efficacious and safe method to isolate pulmonary vein (PV) triggers, recurrence of AF is not always associated with PV reconnection, and there is compelling evidence that non-PV sites sustain AF after it is triggered. Recent developments in wide-area mapping and signal processing now identify rotors in the vast majority of AF patients that sustain AF and whose elimination improves long-term freedom from AF in multicenter studies. Investigators have now demonstrated rotor and focal sources for AF that show many analogous properties between approaches: they lie in spatially reproducible regions temporally over hours to days, and they are amenable to targeted ablation. This review outlines the rationale and technical developments supporting this mechanistic paradigm for human AF, and discusses how rotor mapping may be implemented for individual patient customization of lesion sets. Mechanistic studies are required to explain why rotor elimination (or other ablation approaches) producing long-term elimination of AF may not always terminate AF acutely, how AF correlates with structural changes on magnetic resonance imaging, and how these findings can be integrated clinically with current ablation strategies to improve patient outcomes.
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Affiliation(s)
- Junaid A B Zaman
- Stanford University, Palo Alto, California ; Imperial College London, London, United Kingdom
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Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide and represents a major burden to health care systems. Atrial fibrillation is associated with a 4- to 5-fold increased risk of thromboembolic stroke. The pulmonary veins have been identified as major sources of atrial triggers for AF. This is particularly true in patients with paroxysmal AF but not always the case for those with long-standing persistent AF (LSPAF), in which other locations for ectopic beats have been well recognized. Structures with foci triggering AF include the coronary sinus, the left atrial appendage (LAA), the superior vena cava, the crista terminalis, and the ligament of Marshall. More than 30 studies reporting results on radiofrequency ablation of LSPAF have been published to date. Most of these are observational studies with very different methodologies using different strategies. As a result, there has been remarkable variation in short- and long-term success, which suggests that the optimal ablation technique for LSPAF is still to be elucidated. In this review we discuss the different approaches to LSPAF catheter ablation, starting with pulmonary vein isolation (PVI) through ablation lines in different left atrial locations, the role of complex fractionated atrial electrograms, focal impulses and rotor modulation, autonomic modulation (ganglionated plexi), alcohol ablation, and the future of epicardial mapping and ablation for this arrhythmia. A stepwise ablation approach requires several key ablation techniques, such as meticulous PVI, linear ablation at the roof and mitral isthmus, electrogram-targeted ablation with particular attention to triggers in the coronary sinus and LAA, and discretionary right atrial ablation (superior vena cava, intercaval, or cavotricuspid isthmus lines).
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Affiliation(s)
- Jorge Romero
- Albert Einstein College of Medicine at Montefiore Hospital, Bronx, New York ; Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Carola Gianni
- St. David's Medical Center, Austin, Texas ; University of Milan, Milan, Italy
| | - Luigi Di Biase
- Albert Einstein College of Medicine at Montefiore Hospital, Bronx, New York ; St. David's Medical Center, Austin, Texas ; University of Texas, Austin, Texas ; University of Foggia, Foggia, Italy
| | - Andrea Natale
- St. David's Medical Center, Austin, Texas ; University of Texas, Austin, Texas ; California Pacific Medical Center, San Francisco, California ; Stanford University, Palo Alto, California ; Case Western Reserve University, Cleveland, Ohio ; Scripps Clinic, San Diego, California
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Wright M. Ablation of Persistent AF: Have We Come Full Circle, or Are We Chasing Our Tails? J Am Coll Cardiol 2015; 66:2753-2756. [PMID: 26700837 DOI: 10.1016/j.jacc.2015.07.089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 07/13/2015] [Indexed: 11/19/2022]
Affiliation(s)
- Matthew Wright
- Division of Imaging Sciences and Biomedical Engineering, King's College London and Department of Cardiology, St. Thomas' Hospital, London, United Kingdom.
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Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice, yet our understanding of the mechanisms that initiate and sustain this arrhythmia remains quite poor. Over the last 50 years, various mechanisms of AF have been proposed, yet none has been consistently observed in both experimental studies and in humans. Recently, there has been increasing interest in understanding how spiral waves or rotors - which are specific, organised forms of functional reentry - sustain human AF and how they might be therapeutic targets for catheter-based ablation. The following review describes the historical understanding of reentry and AF mechanisms from earlier in the 20th century, advances in our understanding of mechanisms that are able to sustain AF with a focus on rotors and complex fractionated atrial electrograms (CFAEs), and how the study of AF mechanisms has resulted in new strategies for treating AF with novel forms of catheter ablation.
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Affiliation(s)
- Jonathan W Waks
- Clinical Fellow in Cardiac Electrophysiology, Harvard Medical School, Harvard-Thorndike Electrophysiology Institute and Arrhythmia Service, Beth Israel Deaconess Medical Center, Boston, US
| | - Mark E Josephson
- Herman C. Dana Professor of Medicine, Harvard Medical School, Chief of the Cardiovascular Division, Beth Israel Deaconess Medical Center and Director, Harvard-Thorndike Electrophysiology Institute and Arrhythmia Service, Beth Israel Deaconess Medical Center, Boston, US
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Lin YJ, Chang SL, Lo LW, Hu YF, Chong E, Chao TF, Chung FP, Liao J, Li CH, Tsao HM, Kao T, Chen YY, Huang JL, Chen SA. A prospective and randomized comparison of limited versus extensive atrial substrate modification after circumferential pulmonary vein isolation in nonparoxysmal atrial fibrillation. J Cardiovasc Electrophysiol 2014; 25:803-812. [PMID: 24628987 DOI: 10.1111/jce.12407] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 02/27/2014] [Accepted: 03/02/2014] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The optimal substrate ablation approach in patients with persistent atrial fibrillation (Per AF) remains unclear. This was a prospective randomized study comparing the efficacy of limited (continuous complex fractionated atrial electrogram, CFAE: <60 milliseconds) versus extensive (continuous CFAE plus variable CFAE: <120 milliseconds) atrial substrate modification in Per AF patients. METHODS AND RESULTS We enrolled 120 Per AF patients in the study, and 30 patients with AF termination after pulmonary vein isolation (PVI) were excluded. In the remaining 90 patients, 45 were treated with limited approach (Group 1) and 45 with an extensive approach (Group 2). The end point of the study was the incidence of an atrial arrhythmia recurrence postblanking period. The patients were followed up for 15 months with 3-month clinical reviews, electrograms (ECGs), Holter recordings, and echocardiographic monitoring. Procedural AF termination and the single procedural efficacy were statistically comparable between the 2 groups (48.9% vs. 63.4% in Groups 1 and 2, respectively, P = 0.289). During the follow-up, patients who received limited ablation had a lower incidence of recurrent AFL (P = 0.04), and better reverse remodeling of the left atrium (LA, P = 0.04). After 2 procedures, the freedom from any atrial arrhythmia was better in Group 2 (62.2% vs. 87.8%, P = 0.009). Those with longstanding AF and a larger baseline LA size responded better to the extensive ablation. CONCLUSIONS In the Per AF patients who failed to achieve AF termination after PVI alone, a specific atrial substrate modification approach targeting only continuous CFAEs could be considered as an initial ablation strategy.
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Affiliation(s)
- Yenn-Jiang Lin
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Shih-Lin Chang
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Li-Wei Lo
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Yu-Feng Hu
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Eric Chong
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Fa-Po Chung
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jonan Liao
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Cheng-Hung Li
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hsuan-Ming Tsao
- Cardiology, National Yang Ming University Hospital, I-Lan, Taiwan
| | - Tsair Kao
- Department of Biomedical Engineering, Hungkuang University, Taichung, Taiwan
| | - Yun-Yu Chen
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jin-Long Huang
- Faculty of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan.,Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shih-Ann Chen
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
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Kumagai K, Sakamoto T, Nakamura K, Nishiuchi S, Hayano M, Hayashi T, Sasaki T, Aonuma K, Oshima S. Combined dominant frequency and complex fractionated atrial electrogram ablation after circumferential pulmonary vein isolation of atrial fibrillation. J Cardiovasc Electrophysiol 2013; 24:975-83. [PMID: 23691953 DOI: 10.1111/jce.12166] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2012] [Revised: 03/09/2013] [Accepted: 03/29/2013] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Atrial substrates with high-dominant frequency (DF) and complex fractionated atrial electrogram (CFAE) sites have sources maintaining atrial fibrillation (AF) and are potential AF ablation targets. This study aimed to evaluate an approach of circumferential pulmonary vein isolation (PVI) followed by a DF and CFAE site ablation. METHODS AND RESULTS Fifty consecutive AF patients (23 paroxysmal, 9 persistent, and 18 longstanding persistent) underwent ablation, using NavX. When AF continued after circumferential PVI, high-DF sites of ≥ 8 Hz and then continuous left atrial (LA) CFAE sites defined by fractionated intervals (FI) of ≤50 milliseconds including the coronary sinus and right atrium were targeted. A total of 45.1% of high-DF and 48.1% of continuous CFAE sites significantly decreased after PVI (P < 0.001). The mean LA DF and FI significantly decreased and prolonged, respectively, after PVI (P < 0.001). Only 14.1% of all high-DF sites after PVI overlapped with continuous CFAE sites. AF terminated at high-DF sites in 11 (22%) patients and continuous CFAE sites in 1 (2%). AF could be induced in only 8% of patients after the procedure. The mean LA DF value before ablation was significantly lower in those without recurrence (P = 0.003). AF freedom on antiarrhythmic drugs was 96% and 59%, respectively, in the paroxysmal and nonparoxysmal AF patients (89% persistent and 44% longstanding persistent) after 1 procedure over a 12-month follow-up. CONCLUSIONS A combined high-DF and continuous CFAE site ablation in all chambers after circumferential PVI may be effective in the paroxysmal and persistent AF patients.
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Affiliation(s)
- Koji Kumagai
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Gunma, Japan
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