Human Recordings of Left Atrial Epicardial-Endocardial Asynchrony During Persistent Atrial Fibrillation

Tung, Roderick; Burris, Ryan; Salazar, Pablo; Aziz, Zaid

doi:10.1161/circep.121.010605

Cited by 6 publications

(5 citation statements)

References 5 publications

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“…It is likely that CB enhances endo-epicardial delay (EED), although this relationship has so far not been confirmed. Recently, it has been suggested that AF can be treated by ablation therapy of areas of endo-epicardial asynchrony [17]. We hypothesize that the degree of EED is more pronounced in areas of T-CB than SS-CB at either the endo-or epicardium.…”

Section: Introductionmentioning

confidence: 84%

“…Using the suggested potential morphology parameters, areas of T-CB can thus be targeted with these procedures, which may eventually improve ablation outcomes. Recently, Tung et al described four cases in which endo-epicardial mapping of the left atrium during AF showed a significant degree of EEA and areas of T-CB [17]. It was suggested that ablation therapies that achieve complete transmurality may be necessary to specifically direct treatment at the epicardium.…”

Section: Discussionmentioning

confidence: 99%

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Identification of Atrial Transmural Conduction Inhomogeneity Using Unipolar Electrogram Morphology

Zhang,

van Schie,

Xiang

et al. 2024

JCM

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(1) Background: Structural remodeling plays an important role in the pathophysiology of atrial fibrillation (AF). It is likely that structural remodeling occurs transmurally, giving rise to electrical endo-epicardial asynchrony (EEA). Recent studies have suggested that areas of EEA may be suitable targets for ablation therapy of AF. We hypothesized that the degree of EEA is more pronounced in areas of transmural conduction block (T-CB) than single-sided CB (SS-CB). This study examined the degree to which SS-CB and T-CB enhance EEA and which specific unipolar potential morphology parameters are predictive for SS-CB or T-CB. (2) Methods: Simultaneous endo-epicardial mapping in the human right atrium was performed in 86 patients. Potential morphology parameters included unipolar potential voltages, low-voltage areas, potential complexity (long double and fractionated potentials: LDPs and FPs), and the duration of fractionation. (3) Results: EEA was mostly affected by the presence of T-CB areas. Lower potential voltages and more LDPs and FPs were observed in T-CB areas compared to SS-CB areas. (4) Conclusion: Areas of T-CB could be most accurately predicted by combining epicardial unipolar potential morphology parameters, including voltages, fractionation, and fractionation duration (AUC = 0.91). If transmural areas of CB indeed play a pivotal role in the pathophysiology of AF, they could theoretically be used as target sites for ablation.

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Section: Introductionmentioning

confidence: 84%

Section: Discussionmentioning

confidence: 99%

Identification of Atrial Transmural Conduction Inhomogeneity Using Unipolar Electrogram Morphology

Zhang,

van Schie,

Xiang

et al. 2024

JCM

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“…Recent studies have suggested that there is discordance in electrical activity during AF between the endocardium and epicardium in LA 28–31 . However, there may be a limitation in the evaluation by endocardial mapping for the transmural electrical activity.…”

Section: Discussionmentioning

confidence: 99%

“…26,27 Recent studies have suggested that there is discordance in electrical activity during AF between the endocardium and epicardium in LA. [28][29][30][31] However, there may be a limitation in the evaluation F I G U R E 3 Patients were divided to three groups based on the voltage criteria in LA-PW: (A) no area of UV < 3.0 mV, (B) area size over 2.0 cm 2 of UV < 3.0 mV, (C) area size over 2.0cm 2 of UV < 2.0 mV. Group (B) did not include group (C): group (B) had the area size over 2.0 cm 2 of UV 2.0 mV≤ and <3.0 mV.…”

Section: Impact Of Unipolar Voltage Criteria Of La-pw On Af Recurrencementioning

confidence: 99%

Impact of unipolar voltage criteria for left atrial posterior wall on atrial fibrillation recurrence after pulmonary vein isolation

Watanabe

Sato

et al. 2023

Cardiovasc electrophysiol

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Introduction Beyond pulmonary vein isolation (PVI), additional therapeutic strategies for atrial fibrillation (AF) have not been established. Remodeling of the left atrium (LA) could impact AF recurrence post‐PVI. We investigated the impact of unipolar voltage (UV) criteria for the LA posterior wall (LA‐PW) on AF recurrence post‐PVI. Methods We reviewed the cases of 106 AF patients (mean age 63.8 years, nonparoxysmal AF: 59%) who underwent extensive encircling PVI by radiofrequency ablation guided by a 3‐dimension mapping system, investigating the impact on AF recurrence of the UV criteria of the LA. Results Out of all patients, 26 patients had AF recurrence during post‐PVI follow‐up [median 603 days]. They showed a higher percentage of nonparoxysmal AF (80.8 vs. 52.5%, p = .011), longer AF duration (2.9 ± 2.7 vs. 1.0 ± 1.7 years, p = .002), and larger area size of UV < 2.0 mV in LA‐PW (2.8 ± 1.8 vs. 1.0 ± 1.5 cm2, p < .001) than those without recurrence. Cox Hazard analysis for AF recurrence adjusted by age, gender, AF duration, body mass index and left atrial volume index revealed that an area size over 2.0 cm2 of UV < 2.0 mV in LA‐PW (HR 6.9 [95% CI:1.3–35.5], p = .021) posed independent risks for AF recurrence post‐PVI. The atrial arrhythmia‐free survival rate was higher in those with no area of UV < 3.0 mV in LA‐PW compared to those with a sizable area (>2.0 cm2) of UV < 3.0 mV and <2.0 mV (95.0% vs. 74.2% vs. 57.1%, Log‐Rank: p < .001). In the AF etiology of patients with AF recurrence, 9 of 14 patients who underwent the 2nd procedure had no PV reconnection, and 8 patients required the LA‐PW isolation for their non‐PV AF. Conclusion UV criteria of LA‐PW is a useful parameter for AF‐recurrence post‐PVI. Lower UV in LA‐PW as an indication of electrical remodeling could indicate a higher risk of AF recurrence and the need for further therapeutic strategies.

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“…The LAPW is a complex structure consisting of variable fiber orientation and wall thickness ranging from 1.5 mm to 6.5 mm, and is more similar embryologically and electrophysiologically to PV tissue than atrial tissue [76,77]. The bundles of LAPW myocytes, fibrosis, LA stretching, and adipose infiltration associated with LA remodeling during advanced AF lead to complex LAPW physiology in which there are epicardial to endocardial bundle connections and a physiological separation between the endocardial and epicardial layer that enables the two layers to act independently [78]. This epicardial-endocardial LAPW electrical dissociation can lead to electrically isolated endocardium, while the adjacent LAPW epicardium can still maintain AF (Figure 2) [79,80].…”

Section: Factors Leading To Failure Of Catheter Ablation In Advanced Afmentioning

confidence: 99%

Hybrid Endo-Epicardial Therapies for Advanced Atrial Fibrillation

Wong,

Buch,

Beygui

et al. 2024

JCM

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Atrial fibrillation (AF) is a growing health problem that increases morbidity and mortality, and in most patients progresses to more advanced diseases over time. Recent research has examined the underlying mechanisms, risk factors, and progression of AF, leading to updated AF disease classification schemes. Although endocardial catheter ablation is effective for early-stage paroxysmal AF, it consistently achieves suboptimal outcomes in patients with advanced AF. Identification of the factors that lead to the increased risk of treatment failure in advanced AF has spurred the development and adoption of hybrid ablation therapies and collaborative heart care teams that result in higher long-term arrhythmia-free survival. Patients with non-paroxysmal AF, atrial remodeling, comorbidities, or AF otherwise deemed difficult to treat may find hybrid treatment to be the most effective option. Future research of hybrid therapies in advanced AF patient populations, including those with dual diagnoses, may provide further evidence establishing the safety and efficacy of hybrid endo-epicardial ablation as a first line treatment.

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Human Recordings of Left Atrial Epicardial-Endocardial Asynchrony During Persistent Atrial Fibrillation

Cited by 6 publications

References 5 publications

Identification of Atrial Transmural Conduction Inhomogeneity Using Unipolar Electrogram Morphology

Identification of Atrial Transmural Conduction Inhomogeneity Using Unipolar Electrogram Morphology

Impact of unipolar voltage criteria for left atrial posterior wall on atrial fibrillation recurrence after pulmonary vein isolation

Hybrid Endo-Epicardial Therapies for Advanced Atrial Fibrillation

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