The Novel Electrophysiology of Complex Fractionated Atrial Electrograms: Insight from Noncontact Unipolar Electrograms

Lo, Li‐Wei; Higa, Satoshi; Lin, Yenn-Jiang; Chang, Shih‐Lin; Tuan, Ta‐Chuan; Hu, Yu‐Feng; Tsai, Wen-Chin; Tsao, Hsuan‐Ming; Tai, Ching‐Tai; Ishigaki, Shoichi; Oyakawa, Asuka; Maeda, Minetaka; Suenari, Kazuyoshi; Chen, Shih‐Ann

doi:10.1111/j.1540-8167.2009.01679.x

Cited by 20 publications

(20 citation statements)

References 38 publications

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“…Limited data exist as to the clinical relevance of CEA sites, but 1 human study did suggest that CEA sites may be more associated with sites of passive atrial activation compared with CFAE sites, demonstrating short CLs. 26 The better outcome in group I (the generalized arm), and the increased incidence of repeat procedures in group II (the selective arm), would certainly support this hypothesis. Interestingly, some studies have suggested that more extensive CFAE ablation could increase the risk of recurrent AT or AFL.…”

Section: Selective Versus Generalized Cfae Regionssupporting

confidence: 55%

Selective Complex Fractionated Atrial Electrograms Targeting for Atrial Fibrillation Study (SELECT AF)

Verma

Sanders

Champagne

et al. 2014

Circ: Arrhythmia and Electrophysiology

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Background-This study compared generalized complex fractionated atrial electrograms (CFAE) ablation versus a selective CFAE ablation strategy targeting areas of continuous electric activity. Methods and Results-Subjects with symptomatic, persistent/high-burden paroxysmal atrial fibrillation (AF) were enrolled at 6 centers (n=86) and randomized to 1 of 2 arms. For group I, all CFAE regions with an interval confidence level >7 were ablated followed by pulmonary vein isolation (PVI). For group II, only CFAE sites with continuous electric activity were ablated followed by PVI. For PVI, all 4 PV antra were isolated with confirmed entrance block. Subjects were followed for 1 year with a visit, ECG, and 48-hour Holter every 3 months. Symptoms were confirmed by loop recording. The primary end point was freedom from arrhythmia >30 seconds at 1 year. For both group I and II, CFAE ablation prolonged AF cycle length (25±33 versus 23±33 ms; P=0.78) and resulted in similar rates of AF termination (37% versus 28%; P=0.42). Radiofrequency duration during CFAE ablation was significantly less in group II (23±20 versus 38±20 minutes; P=0.002). At 1-year follow-up, freedom from AF/atrial flutter/atrial tachycardia recurrence was significantly higher in group I versus group II after 1 procedure (50% versus 28%; P=0.03). There were also significantly fewer repeat procedures in group I (13% versus 36%; P=0.021). Conclusions-Continuous electric activity ablation+PVI result in a similar incidence of acute AF termination with significantly less radiofrequency time. However, incidence of repeat procedures and long-term recurrence of AF/atrial flutter/atrial tachycardia are significantly lower using generalized CFAE ablation+PVI. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00926783 (Circ Arrhythm Electrophysiol. 2014;7:55-62.)

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Section: Selective Versus Generalized Cfae Regionssupporting

confidence: 55%

Selective Complex Fractionated Atrial Electrograms Targeting for Atrial Fibrillation Study (SELECT AF)

Verma

Sanders

Champagne

et al. 2014

Circ: Arrhythmia and Electrophysiology

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“…In AF, CFAE sites tend to have lower mean voltage than non-CFAE sites [13,22]. Furthermore, CFAEs with shorter cycle lengths (≤120 ms) or continuous electrical activity are associated with lower mean voltages than CFAEs with longer cycle lengths (Ͼ120 ms) [13,22]. These observations hold true when CFAE amplitudes are measured in terms of bipolar peak-to-peak voltage [13,20,22], unipolar peak negative voltage [22] and monophasic action potential voltage [20].…”

Section: Voltage Mapssupporting

confidence: 53%

“…While the initial report of CFAE ablation targeted only low voltage signals (≤0.15 mV) [5], subsequent reports have used numerous or even no voltage criteria. In AF, CFAE sites tend to have lower mean voltage than non-CFAE sites [13,22]. Furthermore, CFAEs with shorter cycle lengths (≤120 ms) or continuous electrical activity are associated with lower mean voltages than CFAEs with longer cycle lengths (Ͼ120 ms) [13,22].…”

Section: Voltage Mapsmentioning

confidence: 99%

Mapping of Atrial Fibrillation: Comparing Complex Fractionated Atrial Electrograms, Voltage Maps, Dominant Frequency Maps and Ganglionic Plexi

Al‐Ahmad

Schoenhard

2012

Cardiac Mapping

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Catheter-based radio-frequency ablation is an effective therapy for controlling atrial fibrillation (AF) in appropriately selected patients. While anatomic pulmonary vein isolation is typically sufficient for individuals with paroxysmal AF, adjunctive substrate modification within the body of the left atrium is often necessary in individuals with persistant AF. Several cardiac mapping strategies can be used to accurately target ablation for improved efficacy and limit unnecessary ablation for improved safety. These include identification of complex fractionated atrial electrograms, measurement of voltage in sinus rhythm and AF, assessment of dominant frequency and localization of ganglionic plexi. This chapter will compare these overlapping methodologies and provide recommendations with regard to their utilization.

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“…This modeling study of heterogenous tissue demonstrates that 1) structural heterogeneity in the border zone between well-coupled and poorly coupled tissue may actively facilitate the formation of reentrant circuits and 2) electrogram asymmetry, particularly a single negative deflection, combined with small, fractionated signals may be reliable indicator for locating the dynamic microscopic sites of wavefront breakthrough that lead to microreentry. This "S wave" electrogram morphology (negative deflection) has been observed clinically at recording sites in the arrhythmogenic pulmonary veins and at a site of ectopic activation and breakthrough (14,25). In a recent three-dimensional computational study (39) of a human atrial model with fiber orientation, electrode recordings using surface electrodes have shown negative deflections at the macroscopic level near sites of ectopic foci.…”

Section: Discussionmentioning

confidence: 78%

A microstructural model of reentry arising from focal breakthrough at sites of source-load mismatch in a central region of slow conduction

Hubbard

Henriquez

2014

American Journal of Physiology-Heart and Circulatory Physiology

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Hubbard ML, Henriquez CS. A microstructural model of reentry arising from focal breakthrough at sites of source-load mismatch in a central region of slow conduction. Am J Physiol Heart Circ Physiol 306: H1341-H1352, 2014. First published March 7, 2014; doi:10.1152/ajpheart.00385.2013.-Regions of cardiac tissue that have a combination of focal activity and poor, heterogeneous gap junction coupling are often considered to be arrhythmogenic; however, the relationship between the properties of the cardiac microstructure and patterns of abnormal propagation is not well understood. The objective of this study was to investigate the effect of microstructure on the initiation of reentry from focal stimulation inside a poorly coupled region embedded in more wellcoupled tissue. Two-dimensional discrete computer models of ventricular monolayers (1 ϫ 1 cm) were randomly generated to represent heterogeneity in the cardiac microstructure. A small, central poorly coupled patch (0.40 ϫ 0.40 cm) was introduced to represent the site of focal activity. Simulated unipolar electrogram recordings were computed at various points in the tissue. As the gap conductance of the patch decreased, conduction slowed and became increasingly complex, marked by fractionated electrograms with reduced amplitude. Near the limit of conduction block, isolated breakthrough sites occurred at single cells along the patch boundary and were marked by long cell-to-cell delays and negative deflections on electrogram recordings. The strongest determinant of the site of wavefront breakthrough was the connectivity of the brick wall architecture, which enabled current flow through small regions of overlapping cells to drive propagation into the well-coupled zone. In conclusion, breakthroughs at the size scale of a single cell can occur at the boundary of source-load mismatch allowing focal activations from slow conducting regions to produce reentry. These breakthrough regions, identifiable by distinct asymmetric, reduced amplitude electrograms, are sensitive to tissue architecture and may be targets for ablation. focal activity; source-load mismatch; cardiac reentry; gap junction uncoupling; unipolar electrogram recording PATHOLOGICAL CHANGES, such as decreased expression of connexin43 and high levels of fibrosis, create regions of slow conduction that can facilitate arrhythmogenesis in the heart (13,26,33). In regions of slow conduction, gap junction uncoupling reduces electrical load, making it easier for focal (ectopic) beats to form while at the same time increasing the likelihood of tortuous, "zig-zag" conduction and unidirectional conduction block, two major mechanisms underlying reentry in diseased cardiac tissue (8,20,35,40). In particular, the boundary between poorly coupled diseased tissue and wellcoupled healthy tissue has been identified as a critical region of high source-load mismatch, and a number of experimental studies (11,32,34,41) have been used to understand how the interplay between focal activations and the underlying tissue structure of th...

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The Novel Electrophysiology of Complex Fractionated Atrial Electrograms: Insight from Noncontact Unipolar Electrograms

Abstract: The bipolar repetitive and continuous fractionated CFAEs represented different activation patterns. The former was associated with an S wave predominant unipolar morphology which may represent an important focus for maintaining AF.

Cited by 20 publications

References 38 publications

Selective Complex Fractionated Atrial Electrograms Targeting for Atrial Fibrillation Study (SELECT AF)

Selective Complex Fractionated Atrial Electrograms Targeting for Atrial Fibrillation Study (SELECT AF)

Mapping of Atrial Fibrillation: Comparing Complex Fractionated Atrial Electrograms, Voltage Maps, Dominant Frequency Maps and Ganglionic Plexi

A microstructural model of reentry arising from focal breakthrough at sites of source-load mismatch in a central region of slow conduction

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