Termination of persistent atrial fibrillation by ablating sites that control large atrial areas

Rogers, Albert J.; Krummen, David E.; Hossainy, Syed; Sauer, William H.; Miller, John M.; Alhusseini, Mahmood; Peszek, Adam; Armenia, Erin; Baykaner, Tina; Brachmann, Johannes; Turakhia, Mintu P.; Clopton, Paul; Wang, Paul J.; Rappel, Wouter‐Jan; Narayan, Sanjiv M.

doi:10.1093/europace/euaa018

Cited by 15 publications

(10 citation statements)

References 19 publications

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“…It represents fibrillatory conduction at one end, and pivoting, wavefront propagation through an isthmus (acceleration) as well as source‐sink mismatch in other aspects. Further studies on delineating anatomical areas of LIA would offer the opportunity to determine whether it is of mechanistic importance or a bystander phenomena of AF as shown in the latest results of panoramic AF recordings 21 …”

Section: Discussionmentioning

confidence: 99%

Diverse activation patterns during persistent atrial fibrillation by noncontact charge‐density mapping of human atrium

Shi

Chen

Butcher

et al. 2020

Journal of Arrhythmia

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Background Global simultaneous recording of atrial activation during atrial fibrillation (AF) can elucidate underlying mechanisms contributing to AF maintenance. A better understanding of these mechanisms may allow for an individualized ablation strategy to treat persistent AF. The study aims to characterize left atrial endocardial activation patterns during AF using noncontact charge‐density mapping. Methods Twenty‐five patients with persistent AF were studied. Activation patterns were characterized into three subtypes: (i) focal with centrifugal activation (FCA); (ii) localized rotational activation (LRA); and (iii) localized irregular activation (LIA). Continuous activation patterns were analyzed and distributed in 18 defined regions in the left atrium. Results A total of 144 AF segments with 1068 activation patterns were analyzed. The most common pattern during AF was LIA (63%) which consists of four disparate features of activation: slow conduction (45%), pivoting (30%), collision (16%), and acceleration (7%). LRA was the second‐most common pattern (20%). FCA accounted for 17% of all activations, arising frequently from the pulmonary veins (PVs)/ostia. A majority of patients (24/25; 96%) showed continuous and highly dynamic patterns of activation comprising multiple combinations of FCA, LRA, and LIA, transitioning from one to the other without a discernible order. Preferential conduction areas were typically seen in the mid‐anterior (48%) and lower‐posterior (40%) walls. Conclusion Atrial fibrillation is characterized by heterogeneous activation patterns identified in PV‐ostia and non‐PV regions throughout the LA at varying locations between individuals. Clinical implications of individualized ablation strategies guided by charge‐density mapping need to be determined.

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Section: Discussionmentioning

confidence: 99%

Diverse activation patterns during persistent atrial fibrillation by noncontact charge‐density mapping of human atrium

Shi

Chen

Butcher

et al. 2020

Journal of Arrhythmia

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“…The majority of the cases have more than one driver and are of types II and III. Previous studies have shown that AF is organized into interacting areas, 9,22 which may shrink, enlarge, or even merge during ablation and are similar to the driver regions in this paper.…”

Section: Discussionmentioning

confidence: 58%

Weakly-Coupled Oscillators with Long-Distance Correlation as a Model of Human Atrial Fibrillation

Iravanian

2021

Preprint

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I.ABSTRACTAtrial Fibrillation (AF) is a chronic, progressive, and heterogeneous disease, which exhibits irregular and chaotic atrial electrical activity. The exact mechanisms of AF have remained elusive. The complexity of the atrial signals, irregular period, and the non-local nature of AF make it very difficult to characterize its spatiotemporal organization. This paper presents a set of data-processing tools to find and evaluate the intracardiac signals in AF based on synchronization theory. Specifically, a graph-theoretical algorithm is developed to prune spurious detections of atrial complexes (spikes). The processing pipeline was applied to 10 intracardiac recordings obtained during ablation procedures in patients with paroxysmal or persistent AF. The AF cases were classified into three main types. Type I (n=3) is defined as the presence of a single driver that dominates both atria and is consistent with the mother rotor hypothesis. The majority of the cases had more than one driver and were classified as types II (n=4) and III (n=3). The drivers, i.e., the interacting organized areas, in type II have significantly different peak frequencies and are only weakly coupled. The drivers in type III have close frequencies, are moderately interacting, and show evidence of transient intermittent phase-locking (intermittency). In addition, a long-distance correlation between channels from the left and right atria was observed. The theory of synchronization is a useful conceptual framework to process and analyze AF and can provide mechanistic insight into AF and the effect of various interventions.

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“…From the activation fronts we determined a wavefront field (WFF) describing conduction propagation using stream lines. These streamlines can be used to determine rotational activity within the mapped domain using the vector curl of the flow velocity (Vidmar et al, 2016;Bhatia et al, 2020). Specifically, the rotational activity can be quantified by the vorticity Ω, which takes on values between -1 and +1, with negative/positive values corresponding to counterclockwise/ clockwise rotating spiral waves.…”

Section: Clinical Mapping and Ablationmentioning

confidence: 99%

Stochastic Termination of Spiral Wave Dynamics in Cardiac Tissue

Rappel

Krummen

Baykaner

et al. 2022

Front. Netw. Physiol.

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Rotating spiral waves are self-organized features in spatially extended excitable media and may play an important role in cardiac arrhythmias including atrial fibrillation (AF). In homogeneous media, spiral wave dynamics are perpetuated through spiral wave breakup, leading to the continuous birth and death of spiral waves, but have a finite probability of termination. In non-homogeneous media, however, heterogeneities can act as anchoring sources that result in sustained spiral wave activity. It is thus unclear how and if AF may terminate following the removal of putative spiral wave sources in patients. Here, we address this question using computer simulations in which a stable spiral wave is trapped by an heterogeneity and is surrounded by spiral wave breakup. We show that, following ablation of spatial heterogeneity to render that region of the medium unexcitable, termination of spiral wave dynamics is stochastic and Poisson-distributed. Furthermore, we show that the dynamics can be accurately described by a master equation using birth and death rates. To validate these predictions in vivo, we mapped spiral wave activity in patients with AF and targeted the locations of spiral wave sources using radiofrequency ablation. Targeted ablation was indeed able to terminate AF, but only after a variable delay of up to several minutes. Furthermore, and consistent with numerical simulations, termination was not accompanied by gradual temporal or spatial organization. Our results suggest that spiral wave sources and tissue heterogeneities play a critical role in the maintenance of AF and that the removal of sources results in spiral wave dynamics with a finite termination time, which could have important clinical implications.

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Termination of persistent atrial fibrillation by ablating sites that control large atrial areas

Cited by 15 publications

References 19 publications

Diverse activation patterns during persistent atrial fibrillation by noncontact charge‐density mapping of human atrium

Diverse activation patterns during persistent atrial fibrillation by noncontact charge‐density mapping of human atrium

Weakly-Coupled Oscillators with Long-Distance Correlation as a Model of Human Atrial Fibrillation

Stochastic Termination of Spiral Wave Dynamics in Cardiac Tissue

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