Effect of the electrograms density in detecting and ablating the tip of the rotor during chronic atrial fibrillation: an<i>in silico</i>study

Ugarte, Juan; Tobón, Catalina; Duque, Andrés; Becerra, Miguel A.; Bustamante, John

doi:10.1093/europace/euv244

Cited by 17 publications

(20 citation statements)

References 30 publications

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“…Besides rotor ablation, sites of local electrical dyssynchrony have recently been studied as potential targets for ablation in silico (Kuklik et al, 2016 ). Compared to previous in silico studies of rotor ablation (McDowell et al, 2012 , 2015 ; Gonzales et al, 2014 ; Krueger et al, 2014 ; Ugarte et al, 2015 ; Bayer et al, 2016 ; Hwang et al, 2016 ; Zahid et al, 2016 ; Lim et al, 2017 ), the work presented here is, to the best of our knowledge, the first which considers the full workflow from signal acquisition using realistic catheter models via rotor tip estimation to virtual ablation.…”

Section: Discussionmentioning

confidence: 83%

A Computational Framework to Benchmark Basket Catheter Guided Ablation in Atrial Fibrillation

et al. 2018

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Catheter ablation is a curative therapeutic approach for atrial fibrillation (AF). Ablation of rotational sources based on basket catheter measurements has been proposed as a promising approach in patients with persistent AF to complement pulmonary vein isolation. However, clinically reported success rates are equivocal calling for a mechanistic investigation under controlled conditions. We present a computational framework to benchmark ablation strategies considering the whole cycle from excitation propagation to electrogram acquisition and processing to virtual therapy. Fibrillation was induced in a patient-specific 3D volumetric model of the left atrium, which was homogeneously remodeled to sustain reentry. The resulting extracellular potential field was sampled using models of grid catheters as well as realistically deformed basket catheters considering the specific atrial anatomy. The virtual electrograms were processed to compute phase singularity density maps to target rotor tips with up to three circular ablations. Stable rotors were successfully induced in different regions of the homogeneously remodeled atrium showing that rotors are not constrained to unique anatomical structures or locations. Density maps of rotor tip trajectories correctly identified and located the rotors (deviation < 10 mm) based on catheter recordings only for sufficient resolution (inter-electrode distance ≤3 mm) and proximity to the wall (≤10 mm). Targeting rotor sites with ablation did not stop reentries in the homogeneously remodeled atria independent from lesion size (1–7 mm radius), from linearly connecting lesions with anatomical obstacles, and from the number of rotors targeted sequentially (≤3). Our results show that phase maps derived from intracardiac electrograms can be a powerful tool to map atrial activation patterns, yet they can also be misleading due to inaccurate localization of the rotor tip depending on electrode resolution and distance to the wall. This should be considered to avoid ablating regions that are in fact free of rotor sources of AF. In our experience, ablation of rotor sites was not successful to stop fibrillation. Our comprehensive simulation framework provides the means to holistically benchmark ablation strategies in silico under consideration of all steps involved in electrogram-based therapy and, in future, could be used to study more heterogeneously remodeled disease states as well.

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Section: Discussionmentioning

confidence: 83%

A Computational Framework to Benchmark Basket Catheter Guided Ablation in Atrial Fibrillation

et al. 2018

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“…However, our simulations provide high spatial resolution that places the same limitation as phase maps. In a recent report [137], we tested the influence of the spatial resolution over the ApEn electroanatomical maps in detecting rotors, using a two-dimensional atrial fibrillation model. Our results indicate that the ApEn maps can identify the rotor tip with spatial resolutions close to those available in commercial mapping catheters.…”

Section: Discussionmentioning

confidence: 99%

Complexity of Atrial Fibrillation Electrograms Through Nonlinear Signal Analysis: In Silico Approach

Tobón¹,

Duque²,

Ugarte³

et al. 2017

Interpreting Cardiac Electrograms - From Skin to Endocardium

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Identification of atrial fibrillation (AF) mechanisms could improve the rate of ablation success. However, the incomplete understanding of those mechanisms makes difficult the decision of targeting sites for ablation. This work is focused on the importance of EGM analysis for detecting and modulating rotors to guide ablation procedures and improve its outcomes. Virtual atrial models are used to show how nonlinear measures can be used to generate electroanatomical maps to detect critical sites in AF. A description of the atrial cell mathematical models, and the procedure of coupling them within two-dimensional and three-dimensional virtual atrial models in order to simulate arrhythmogenic mechanisms, is given. Mathematical modeling of unipolar and bipolar electrogramas (EGM) is introduced. It follows a discussion of EGM signal processing. Nonlinear descriptors, such as approximate entropy and multifractal analysis, are used to study the dynamical behavior of EGM signals, which are not well described by a linear law. Our results evince that nonlinear analysis of EGM can provide information about the dynamics of rotors and other mechanisms of AF. Furthermore, these fibrillatory patterns can be simulated using virtual models. The combination of features using machine learning tools can be used for identifying arrhythmogenic sources of AF.

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“…Virtual voltage data were created by an interpolation of the clinical voltage mapping. We used the inverse distance weighting (IDW) method for signal interpolation 14 . We collected the data within a radius of 10 mm from the point where we wanted to Definition of fiber orientation from atlases.…”

Section: Alignment Of Electro-anatomical Maps Onto Ct Derived Mesh Momentioning

confidence: 99%

In situ procedure for high-efficiency computational modeling of atrial fibrillation reflecting personal anatomy, fiber orientation, fibrosis, and electrophysiology

Lim

Kim

Hwang

et al. 2020

Sci Rep

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We previously reported the feasibility and efficacy of a simulation-guided clinical catheter ablation of atrial fibrillation (AF) in an in-silico AF model. We developed a highly efficient realistic AF model reflecting the patient endocardial voltage and local conduction and tested its clinical feasibility. We acquired > 500 endocardial bipolar electrograms during right atrial pacing at the beginning of the AF ablation procedures. Based on the clinical bipolar electrograms, we generated simulated voltage maps by applying fibrosis and local activation maps adjusted for the fiber orientation. The software's accuracy (CUVIA2.5) was retrospectively tested in 17 patients and feasibility prospectively in 10 during clinical AF ablation. Results: We found excellent correlations between the clinical and simulated voltage maps (R = 0.933, p < 0.001) and clinical and virtual local conduction (R = 0.958, p < 0.001). The proportion of virtual local fibrosis was 15.4, 22.2, and 36.9% in the paroxysmal AF, persistent AF, and post-pulmonary vein isolation (PVI) states, respectively. The reconstructed virtual bipolar electrogram exhibited a relatively good similarities of morphology to the local clinical bipolar electrogram (R = 0.60 ± 0.08, p < 0.001). Feasibility testing revealed an in situ procedural computing time from the clinical data acquisition to wave-dynamics analyses of 48.2 ± 4.9 min. All virtual analyses were successfully achieved during clinical PVI procedures. We developed a highly efficient, realistic, in situ procedural simulation model reflective of individual anatomy, fiber orientation, fibrosis, and electrophysiology that can be applied during AF ablation. Catheter ablation (CA) is an effective approach for rhythm control management of atrial fibrillation (AF) 1,2. However, the recurrence rate after AF ablation procedures is still substantial 3. Although pulmonary vein isolation (PVI) is a well-established target of AF ablation, extra-pulmonary vein (PV) foci or drivers maintain AF in some patients, and extra-PV foci are more commonly found in AF patients with significant left atrial (LA) remodeling 4,5. The Substrate and Trigger Ablation for Reduction of Atrial Fibrillation trial part 2 (STAR AF2) demonstrated that an empirical extra-PV ablation did not improve the rhythm outcome compared with a circumferential PVI alone in patients with persistent AF (PeAF) 6. However, the one-year recurrence rate was higher than 40% regardless of any additional extra-PV ablation after the PVI, and the outcome of the invasive interventional catheter procedure was not adequate. Therefore, an innovative mapping technology to identify the core target of AF is needed in AF catheter ablation (AFCA). Simulation is a very useful computer-aided method for identifying appropriate intervention targets. We recently reported the feasibility of a simulation-guided PeAF ablation by applying a personalized heart computed tomography (CT) image-integrated AF simulation 7,8. To further this method, we developed a more realistic AF simulation r...

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Effect of the electrograms density in detecting and ablating the tip of the rotor during chronic atrial fibrillation: anin silicostudy

Cited by 17 publications

References 30 publications

A Computational Framework to Benchmark Basket Catheter Guided Ablation in Atrial Fibrillation

A Computational Framework to Benchmark Basket Catheter Guided Ablation in Atrial Fibrillation

Complexity of Atrial Fibrillation Electrograms Through Nonlinear Signal Analysis: In Silico Approach

In situ procedure for high-efficiency computational modeling of atrial fibrillation reflecting personal anatomy, fiber orientation, fibrosis, and electrophysiology

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