Paroxysmal Cycle Length Shortening in the Pulmonary Veins During Atrial Fibrillation Correlates with Arrhythmogenic Triggering Foci in Sinus Rhythm

Abstract Introduction Twenty years ago, pulmonary veins (PV) ostia were identified as the left atrium (LA) areas with the shortest refractory period during sinus rhythm. Pulmonary veins isolation (PVI) became standard of care, but clinical results are still suboptimal. Today, a special tool using the Carto® electroanatomical mapping (EAM) allows for AF cycle length mapping (CLM), to identify the areas in the left atria with shortest refractory period, during atrial fibrillation. Using this EAM tool, our study aimed to find the LA areas with the shortest refractory period to better recognize electrical targets for catheter ablation. Methods Retrospective analysis of an unicentric registry of individuals with symptomatic drug-refractory AF who underwent PVI with Carto® EAM. CLM was performed with a high-density mapping Pentaray® catheter before and after PVI and in 4 redo procedures. We assessed areas of short cycle length (SCL) (defined as 120 to 250ms), and their relationships with complex fractionated atrial electrograms (CFAE), and low-voltage zones (from 0.1 to 0.3mV). Results A total of 18 patients (8 men, median age 63 IQR 58–71 years) were included. Most patients presented with persistent AF (n=12, 67%), and 4 patients (22%) had a previous PVI. The mean shortest measured cycle length in AF was 140ms (SD ±27ms). All patients presented areas of SCL located in the PVs or their insertion, 70% in the posterior/roof region adjacent to the left superior pulmonary vein (LSPV) (figure 1) and 60% in the anterior region of the right superior pulmonary vein (RSPV). These two areas remained the fastest even after PVI. The anterior mitral region rarely presented SCL (17%). SCL were related to low-voltage areas in 94% and were adjacent to CFAE. Low-voltage areas and CFAE were more frequent and had a larger LA dispersion than SCL. Conclusion We confirmed in 3D mapping that PVs are the LA zones with shortest refractory period, not only in sinus rhythm but also during AF. The persistence of SCL areas in the border zones of the PVI lines suggest the benefit of a more extensive CLM guided ablation. Larger studies are needed. FUNDunding Acknowledgement Type of funding sources: None. Short cycle length mapping

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Electrical anatomy of the left atrium during atrial fibrillation

EP Europace ◽

10.1093/europace/euab116.239 ◽

2021 ◽

Vol 23 (Supplement_3) ◽

Author(s):

P Adragao ◽

D Nascimento Matos ◽

F Costa ◽

P Galvao Santos ◽

G Rodrigues ◽

...

Keyword(s):

Atrial Fibrillation ◽

Sinus Rhythm ◽

Left Atrium ◽

Pulmonary Vein ◽

Refractory Period ◽

Cycle Length ◽

Low Voltage ◽

Pulmonary Veins ◽

Density Mapping ◽

Superior Pulmonary Vein

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Twenty years ago, pulmonary veins (PV) ostia were identified as the left atrium (LA) areas with the shortest refractory period during sinus rhythm. Pulmonary veins isolation (PVI) became standard of care, but clinical results are still suboptimal. Today, a special tool using the Carto® electroanatomical mapping (EAM) allows for AF cycle length mapping (CLM), to identify the areas in the left atria with shortest refractory period, during atrial fibrillation. Using this EAM tool, our study aimed to find the LA areas with the shortest refractory period to better recognize electrical targets for catheter ablation. Methods Retrospective analysis of an unicentric registry of individuals with symptomatic drug-refractory AF who underwent PVI with Carto® EAM. CLM was performed with a high-density mapping Pentaray® catheter before and after PVI and in 4 redo procedures. We assessed areas of short cycle length (SCL) (defined as 120 to 250ms), and their relationships with complex fractionated atrial electrograms (CFAE), and low-voltage zones (from 0.1 to 0.3mV). Results A total of 18 patients (8 men, median age 63 IQR 58-71 years) were included. Most patients presented with persistent AF (n = 12, 67%), and 4 patients (22%) had a previous PVI. The mean shortest measured cycle length in AF was 140ms (SD ±27ms). All patients presented areas of SCL located in the PVs or their insertion, 70% in the posterior/roof region adjacent to the left superior pulmonary vein (LSPV) (figure 1) and 60% in the anterior region of the right superior pulmonary vein (RSPV). These two areas remained the fastest even after PVI. The anterior mitral region rarely presented SCL (17%). SCL were related to low-voltage areas in 94% and were adjacent to CFAE. Low-voltage areas and CFAE were more frequent and had a larger LA dispersion than SCL. Conclusion We confirmed in 3D mapping that PVs are the LA zones with shortest refractory period, not only in sinus rhythm but also during AF. The persistence of SCL areas in the border zones of the PVI lines suggest the benefit of a more extensive CLM guided ablation. Larger studies are needed. Abstract Figure 1

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Simultaneous Catheter and Epicardial Ablations Enable a Comprehensive Atrial Fibrillation Procedure

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1097/imi.0b013e31822ca15c ◽

2011 ◽

Vol 6 (4) ◽

pp. 243-247 ◽

Cited By ~ 11

Author(s):

Andy C. Kiser ◽

Mark D. Landers ◽

Ker Boyce ◽

Matjaž šinkovec ◽

Andrej Pernat ◽

...

Keyword(s):

Atrial Fibrillation ◽

Radiofrequency Ablation ◽

Sinus Rhythm ◽

Pulmonary Veins ◽

Persistent Atrial Fibrillation ◽

Chronic Atrial Fibrillation ◽

Lesion Pattern ◽

Atrial Size ◽

Cardiac Surgeon ◽

Successful Collaboration

Objective Transmural and contiguous ablations and a comprehensive lesion pattern are difficult to create from the surface of a beating heart but are critical to the successful treatment of persistent, isolated atrial fibrillation. A codisciplinary simultaneous epicardial (surgical) and endocardial (catheter) procedure (Convergent procedure) addresses these issues. Methods Patients with symptomatic atrial fibrillation who failed medical treatment were evaluated. Using only pericardioscopy, the surgeon performed near-complete epicardial isolation of the pulmonary veins and a “box” lesion on the posterior left atrium using unipolar radiofrequency ablation. Simultaneous endocardial catheter radiofrequency ablation completed pulmonary vein isolation, performed a mitral annular and cavotricuspid isthmus line of block, and debulked the coronary sinus. Twelve-month results for the Convergent procedure were compared with 12-month results for concomitant and pericardioscopic (stand-alone transdiaphragmatic/thoracoscopic) atrial fibrillation procedures using unipolar radiofrequency ablation. Results Sixty-five patients underwent the Convergent procedure (mean age, 62 y; mean body surface area, 2.17 m2; mean atrial fibrillation duration, 4.8 y; mean left atrial size, 5.2 cm). Ninety-two percent were in persistent or long-standing persistent atrial fibrillation. At 12 months, evaluation with 24-hour Holter monitors found 82% of patients in sinus rhythm, while only 47% of pericardioscopic and 77% of concomitant patients treated with unipolar radiofrequency ablation were in sinus rhythm. Conclusions Simultaneous epicardial and endocardial ablation improves outcomes for patients with persistent or longstanding persistent atrial fibrillation. This successful collaboration between cardiac surgeon and electrophysiologist is an important treatment option for patients with large left atriums and chronic atrial fibrillation.

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Termination of atrial fibrillation during pharmacological cardioversion in the goat requires inter-atrial synchronisation of conduction

EP Europace ◽

10.1093/europace/euab116.563 ◽

2021 ◽

Vol 23 (Supplement_3) ◽

Author(s):

V Sobota ◽

A Van Hunnik ◽

S Zeemering ◽

G Gatta ◽

D Opacic ◽

...

Keyword(s):

Atrial Fibrillation ◽

Sinus Rhythm ◽

Left Atrium ◽

Conduction Velocity ◽

Right Atrium ◽

Path Length ◽

Cycle Length ◽

Final Phase ◽

Periodic Activity ◽

Bachmann’S Bundle

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): ITN Networks PersonalizeAF: Personalized Therapies for Atrial Fibrillation. A Translational Approach, No. 860974; CATCH ME: Characterizing Atrial fibrillation by Translating its Causes into Health Modifiers in the Elderly, No. 633196; MAESTRIA: Machine Learning and Artificial Intelligence for Early Detection of Stroke and Atrial Fibrillation, No. 965286; AFib-TrainNet: EU Training Network on Novel Targets and Methods in Atrial Fibrillation, No. 675351 Netherlands Heart Foundation: CVON2014-09, RACE V Reappraisal of Atrial Fibrillation: Interaction between hyperCoagulability, Electrical remodeling, and Vascular Destabilization in the Progression of Atrial Fibrillation Background Few studies report on mechanisms leading to termination of atrial fibrillation (AF). Purpose To characterise electrophysiological parameters and conduction patterns during the transition from AF to sinus rhythm under various conditions of AF termination. Methods A retrospective evaluation of 6 goat studies was performed. AF was maintained for 3-4 weeks in 29 animals. Four animals were in SR. Unipolar electrograms were acquired with one 249-electrode array/atrium. Pharmacological termination of AF was evoked by various drugs; AP14145 (n = 5), PA6 (n = 7), XAF-1407 (n = 9) vernakalant (n = 8). In animals with sinus rhythm, AF was acutely induced and terminated spontaneously. Baseline AF and ≤3 recordings of the last 10 seconds preceding AF termination were analysed. Intervals with temporal continuous and periodic activity were distinguished in the recordings. AF cycle length (AFCL), conduction velocity and path length were determined for each interval. Results In total, 85 AF terminations were recorded. Switches between temporal continuous and periodic activity were seen frequently during AF. However, termination of AF was always preceded by a phase of periodic activity (PA). The final phase of PA persisted for a median number of 21 [IQR 10-28] cycles in the left atrium and somewhat shorter in the right atrium, Table 1. This final phase of PA was accompanied by a profound bi-atrial increase of AFCL, conduction velocity and path length and a disappearance of inter-atrial cycle length differences. Equipotent changes were not observed in the preceding PAs. During the final AF beats, the number of wave fronts were low, 1 or 2. Interestingly, 92% of the patterns during the last beats of AF involved the Bachmann’s bundle as main source of atrial conduction. Conclusion AF termination is preceded by an increased organisation of fibrillatory conduction, associated with abrupt prolongation of the path length. Propagation in atrial free walls regularly originated from the Bachmann’s bundle. These findings suggest that AF termination was not a random process but follows common spatiotemporal patterns. Final period of temporal organisation Left atrium Right atrium Final PA start Final PA end Final PA start Final PA end Af cycle length (ms) 163 ± 37 204 ± 50* 146 ± 44 207 ± 49* Conduction velocity (cm/s) 77 ± 15 96 ± 25* 83 ± 20 103 ± 24* Path Length (cm) 12.2 ± 2.7 19.3 ± 6.3* 12.0 ± 4.1 21.2 ± 6.4* Length of final periodic activity (beats) NA 21 [IQR 10-28] NA 15 [IQR 10- 25] Electrophysiological changes during the final period periodic activity (PA). Wilcoxon signed rank test. *p <0.05NA= not available

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Repetitive Evaluation of Fibrillation Cycle Length Predicts the Effect of Bepridil for Conversion of Long-Lasting Persistent Atrial Fibrillation to Sinus Rhythm

Journal of Arrhythmia ◽

10.4020/jhrs.27.op51_4 ◽

2011 ◽

Vol 27 (Supplement) ◽

pp. OP51_4

Author(s):

Yuya Aoyama ◽

Shinichi Niwano ◽

Hiroe Niwano ◽

Yoshihiro Yumoto ◽

Akira Sato ◽

...

Keyword(s):

Atrial Fibrillation ◽

Sinus Rhythm ◽

Cycle Length ◽

Persistent Atrial Fibrillation

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Abstract 15977: Comparison of Clinical and Procedural Outcomes Between High-power Short-duration, Standard-power Standard-duration, and Temperature-controlled Non-contact Force Guided Ablation for Atrial Fibrillation

Circulation ◽

10.1161/circ.142.suppl_3.15977 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Sean J Dikdan ◽

Joey Junarta ◽

Sairamya Bodempudi ◽

Naman Upadhyay ◽

Zachary Pang ◽

...

Keyword(s):

Atrial Fibrillation ◽

Sinus Rhythm ◽

Clinical Outcomes ◽

Contact Force ◽

High Power ◽

Pulmonary Veins ◽

Standard Duration ◽

Temperature Controlled ◽

Sinus Rhythm Maintenance ◽

Power Standard

Introduction: High-power short-duration (HPSD) ablation via the St. Jude EnSite™ Velocity™ system (St. Paul, MN) utilizes 50W delivered for up to 15s, guided by a Lesion Size Index of 5-6 specific to the Velocity™ system. HPSD is a novel way to use a contact force-sensing catheter optimized for power-controlled radiofrequency ablation of atrial fibrillation (AF). Procedural and clinical outcomes of HPSD compared to standard-power standard-duration (SPSD; 20-25W until 400-500 gram seconds, up to 60s) and temperature-controlled non-contact (TCNC; 20-40W up to 60s of ablation) settings would inform this strategy. Methods: We studied consecutive cases of patients with paroxysmal or persistent AF undergoing pulmonary vein isolation (PVI) with TCNC, SPSD, and HPSD between 7/1/13 to 11/1/19. Procedural data collected include total radiofrequency time (RFT), time to isolate the left pulmonary veins (LPVT), time to isolate the right pulmonary veins (RPVT), and safety outcomes. Clinical data collected include sinus rhythm maintenance 3 and 12-months post-procedure. Results: A total of 171 patients were studied (44 TCNC, 51 SPSD, 76 HPSD). There was no difference in age, sex, or AF type between groups. RFT was shorter when comparing HPSD to SPSD (71 vs 101 min; p<0.01), HPSD to TCNC (71 vs 146 min; p<0.01), and SPSD to TCNC groups (101 vs 146 min; p<0.01). This was driven by decreases in LPVT between the HPSD vs SPSD (34 vs 46 min; p=0.04), HPSD vs TCNC (34 vs 72 min; p<0.01), and SPSD vs TCNC groups (46 vs 72 min; p<0.01), as well as decreases in RPVT between the HPSD vs SPSD (42 vs 54 min; p=0.03), HPSD vs TCNC (42 vs 75 min; p<0.01), and SPSD vs TCNC groups (54 vs 75 min; p<0.01). There was no difference in sinus rhythm maintenance after 3 or 12-months between groups overall, and when stratified by AF type, left atrial volume, CHA 2 DS 2 -VASc score, or left ventricular EF. There was a numerical difference in safety with no adverse events in HPSD (0/76 in HPSD vs 1/51 in SPSD vs 3/44 in TCNC; p=0.06). Conclusion: AF ablation with contact force utilizing an HPSD ablation strategy reduced procedure times with similar sinus rhythm maintenance compared to SPSD and TCNC approaches. Further research is needed to determine whether clinical outcomes differ with a larger population and longer follow-up.

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Abstract 16896: Electrogram Morphology Recurrence to Characterize Drivers of Persistent Atrial Fibrillation: Findings at Initial versus Redo Catheter Ablation

Circulation ◽

10.1161/circ.142.suppl_3.16896 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Ghaith Zaatari ◽

Jorge Bohorquez ◽

Raul Mitrani ◽

Jason Ng ◽

Justin Ng ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Cycle Length ◽

Cross Correlation ◽

Pulmonary Veins ◽

Persistent Atrial Fibrillation ◽

Success Rates ◽

Mapping Tool ◽

Group 2 ◽

Group 1

Background: Electrogram (EGM) morphology recurrence (EMR) mapping of persistent atrial fibrillation (PeAF) quantifies consistency of activation at each site and is expected to be high and rapid near drivers of PeAF. Objective: To compare EMR in the left (LA) and right atrium (RA) in patients undergoing first- vs second-time PeAF catheter ablation (CA). Methods: Multisite bipolar EGM mapping of the LA (265±153 sites) and RA (224±148 sites) prior to CA for PeAF was performed in 40 patients (29 males, age 63±9 yrs, CHA2DS2-VASc 2.4±1.5, LVEF 48±12%) undergoing first (Group 1, n=31) or second-time (Group 2, n=9) CA. After cross-correlation of each automatically detected EGM with every other EGM in the recording, the most recurrent EGM morphology was identified and its frequency (Rec%) and cycle length of recurrence (CL R ) were computed (figure). The minimum CL R sites were identified. Results: In group 1, shortest CL R was in the LA in 26 patients (84%) and RA in 5 patients (16%). In the LA, there were 1 (n=23), 2 (n=2), or 3 (n=1) areas of shortest CL R , most commonly in the pulmonary veins (PV; n=19). In the RA, there was only 1 area of shortest CL R . Minimum CL R was 174.1±25.4 ms (LA-179.6±37.4 vs RA-207.9±34.5, p=0.0004), with Rec% 95±10%. In group 2, shortest CL R was in the LA in 5 patients and RA in 5 patients (56%)– one had both LA and RA. In the LA/RA, there were 1 (n=3/4) or 2 (n=2/1) areas of shortest CL R . The most common LA site was non-PV (6/7, 85.7%). The minimum CL R was 182.1±26.2ms (LA-190.8±36.2 vs RA-196.0±30.5, p=0.6), with Rec% 96±5%. Conclusion: In 61% of patients undergoing initial CA for PeAF, EMR identified LA drivers in the PVs which may explain why PV isolation has been reported to have 50-60% success rates in PeAF. In patients undergoing a 2 nd ablation for PeAF, EMR identified predominantly nonPV drivers with even distribution of shortest CL R between RA and LA and diminished CL R gradient between the LA and RA. EMR may be a useful mapping tool to characterize potential drivers of PeAF.

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P1431Radiofrequency ablation of left atrium in patients with mitral valve replacement. The future of surgical treatment for atrial fibrillation in mitral valve disease?

EP Europace ◽

10.1093/europace/euaa162.116 ◽

2020 ◽

Vol 22 (Supplement_1) ◽

Author(s):

A Utyasheva ◽

I V Abdulyanov ◽

M A Sungatullin ◽

I I Vagizov

Keyword(s):

Atrial Fibrillation ◽

Surgical Treatment ◽

Mitral Valve ◽

Sinus Rhythm ◽

Left Atrium ◽

Pulmonary Veins ◽

Pacemaker Implantation ◽

Valve Prosthesis ◽

Diagnostic Center ◽

Valve Pathology

Abstract Aims The evaluation of sinus rhythm preservation after surgical treatment of atrial fibrillation by left-atrial RFA in patients with mitral valve prosthetics. Materials and methods A prospective, randomized study was performed in the interregional clinical and diagnostic center of Kazan in 2011-2018 which were included 136 patients with mitral valve pathology and persistent AF. The average age of patients was 57 ± 5, the gender division was dominated by female patients and made up 97 (58.4%). All patients underwent either mitral valve prosthesis with mechanical prosthesis Meding-2 which made up 96 (70.5%) or biological prosthesis Carpantier-Edwards which made up 40 (29.4%). Radiofrequency isolation of the left atrium and pulmonary veins was performed by standard procedure by Cox-IV which doesn’t include the right atrium tissue. Results and discussion: In the early post surgical period, recovery of sinus rhythm was observed in 111 (81.6%) patients. Cardiac Pacemaker Implantation was performed in 1 (0.73%) case. The results of the study were assessed after surgical treatment in 22 ± 5 months, the sinus rhythm was preserved in 99 patients from the study group and made up 72.7%. Conclusion Radiofrequency ablation the left atrium provides long-term preservation of sinus rhythm in the treatment of patients with atrial fibrillation and mitral valve pathology.

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Heartbeat Cycle Length Detection by a Ballistocardiographic Sensor in Atrial Fibrillation and Sinus Rhythm

BioMed Research International ◽

10.1155/2015/840356 ◽

2015 ◽

Vol 2015 ◽

pp. 1-10 ◽

Cited By ~ 9

Author(s):

Matthias Daniel Zink ◽

Christoph Brüser ◽

Patrick Winnersbach ◽

Andreas Napp ◽

Steffen Leonhardt ◽

...

Keyword(s):

Atrial Fibrillation ◽

Heart Rate ◽

Sinus Rhythm ◽

Quality Index ◽

Cycle Length ◽

Heart Rate Monitoring ◽

Mechanical Vibrations ◽

Before And After ◽

Registration Number ◽

Novel Algorithm

Background.Heart rate monitoring is especially interesting in patients with atrial fibrillation (AF) and is routinely performed by ECG. A ballistocardiography (BCG) foil is an unobtrusive sensor for mechanical vibrations. We tested the correlation of heartbeat cycle length detection by a novel algorithm for a BCG foil to an ECG in AF and sinus rhythm (SR).Methods.In 22 patients we obtained BCG and synchronized ECG recordings before and after cardioversion and examined the correlation between heartbeat characteristics.Results.We analyzed a total of 4317 heartbeats during AF and 2445 during SR with a correlation between ECG and BCG during AF ofr=0.70(95% CI 0.68–0.71,P<0.0001) andr=0.75(95% CI 0.73–0.77,P<0.0001) during SR. By adding a quality index, artifacts could be reduced and the correlation increased for AF to 0.76 (95% CI 0.74–0.77,P<0.0001,n=3468) and for SR to 0.85 (95% CI 0.83–0.86,P<0.0001,n=2176).Conclusion.Heartbeat cycle length measurement by our novel algorithm for BCG foil is feasible during SR and AF, offering new possibilities of unobtrusive heart rate monitoring. This trial is registered with IRB registration number EK205/11. This trial is registered with clinical trials registration numberNCT01779674.

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