Reconsidering the multiple wavelet hypothesis of atrial fibrillation

Lee, Seungyup; Khrestian, Celeen M.; Sahadevan, Jayakumar; Waldo, Albert L.

doi:10.1016/j.hrthm.2020.06.017

Cited by 22 publications

(24 citation statements)

References 23 publications

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“…During the late 20th century, researchers had little doubt that AF was largely maintained by multiple simultaneous reentrant wavelets. 65 – 67 , 73 – 75 In the 21st century, with more advanced mapping technologies and increased numbers of groups investigating AF with mapping techniques, multiple simultaneous reentries during AF were not observed, 76 – 85 with rare exceptions. 86 Nowadays, although some groups consistently observe relatively stable or unstable rotors during AF, 87 – 89 the other groups either do not record rotors at all or record them rarely and only short-lived.…”

Section: Electrophysiological Mechanisms Of Af: Reentry or Focal?mentioning

confidence: 99%

“… 86 Nowadays, although some groups consistently observe relatively stable or unstable rotors during AF, 87 – 89 the other groups either do not record rotors at all or record them rarely and only short-lived. 76 , 77 , 79 , 80 , 82 , 83 , 85 , 90 – 93 Using simultaneous epicardial and endocardial surface mapping, some researches consistently observed an intramural, anatomically determined reentrant circuit during AF (without any reentry on the surfaces), 84 while other groups did not detect reentry at all (intramurally or on the surface). 78 , 81 Importantly, most of those who consistently demonstrated sustained or frequent short-lived rotors during AF used the phase mapping approach for rotor detection 87 – 89 that was recently reported to have a low specificity, usually interpreting conduction blocks as rotors.…”

Section: Electrophysiological Mechanisms Of Af: Reentry or Focal?mentioning

confidence: 99%

“… 78 , 81 Importantly, most of those who consistently demonstrated sustained or frequent short-lived rotors during AF used the phase mapping approach for rotor detection 87 – 89 that was recently reported to have a low specificity, usually interpreting conduction blocks as rotors. 93 This may explain mutually exclusive mapping AF data, ie, “consistent reentry” 87 – 89 and “no or rare reentry.” 76 – 83 , 85 , 90 – 93 …”

Section: Electrophysiological Mechanisms Of Af: Reentry or Focal?mentioning

confidence: 99%

“…Focal activations during AF are observed by practically all groups (short-lived, sustained, or both), and these activations can be real focal source(s) or breakthrough(s) from any remote sources (reentry or focal). 80 – 85 , 87 , 89 , 95 – 97 It was long ago postulated that AF can be maintained by focal sources, 98 , 99 and there has been an increasing amount data supporting this hypothesis, particularly during the past 10 years. 76 , 79 , 80 , 82 , 83 , 90 , 97 , 100 Interestingly, although the data from 1960 to 2000 almost universally supported reentry as the only mechanism of AF maintenance, 65 – 67 starting from about the beginning of the 21st century, an increasing number of studies have not or rarely observed reentry 77 , 78 , 81 and/or have consistently detected focal activations as either predominant or the only mechanism of AF maintenance.…”

Section: Electrophysiological Mechanisms Of Af: Reentry or Focal?mentioning

confidence: 99%

“… 76 , 79 , 80 , 82 , 83 , 90 , 97 , 100 Interestingly, although the data from 1960 to 2000 almost universally supported reentry as the only mechanism of AF maintenance, 65 – 67 starting from about the beginning of the 21st century, an increasing number of studies have not or rarely observed reentry 77 , 78 , 81 and/or have consistently detected focal activations as either predominant or the only mechanism of AF maintenance. 76 , 79 , 80 , 82 , 83 , 85 , 90 , 100 In short, the prime mechanism of AF maintenance is rather debatable in 2020, and as a result (at least partly), the search for novel anti-AF pharmacological drugs/approaches remains largely empirical.…”

Section: Electrophysiological Mechanisms Of Af: Reentry or Focal?mentioning

confidence: 99%

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Investigational Anti–Atrial Fibrillation Pharmacology and Mechanisms by Which Antiarrhythmics Terminate the Arrhythmia: Where Are We in 2020?

Burashnikov

2020

Journal of Cardiovascular Pharmacology

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: Antiarrhythmic drugs remain the mainstay therapy for patients with atrial fibrillation (AF). A major disadvantage of the currently available anti-AF agents is the risk of induction of ventricular proarrhythmias. Aiming to reduce this risk, several atrial-specific or -selective ion channel block approaches have been introduced for AF suppression, but only the atrial-selective inhibition of the sodium channel has been demonstrated to be valid in both experimental and clinical studies. Among the other pharmacological anti-AF approaches, “upstream therapy” has been prominent but largely disappointing, and pulmonary delivery of anti-AF drugs seems to be promising. Major contradictions exist in the literature about the electrophysiological mechanisms of AF (ie, reentry or focal?) and the mechanisms by which anti-AF drugs terminate AF, making the search for novel anti-AF approaches largely empirical. Drug-induced termination of AF may or may not be associated with prolongation of the atrial effective refractory period. Anti-AF drug research has been largely based on the “suppress reentry” ideology; however, results of the AF mapping studies increasingly indicate that nonreentrant mechanism(s) plays an important role in the maintenance of AF. Also, the analysis of anti-AF drug-induced electrophysiological alterations during AF, conducted in the current study, leans toward the focal source as the prime mechanism of AF maintenance. More effort should be placed on the investigation of pharmacological suppression of the focal mechanisms.

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Section: Electrophysiological Mechanisms Of Af: Reentry or Focal?mentioning

confidence: 99%

Section: Electrophysiological Mechanisms Of Af: Reentry or Focal?mentioning

confidence: 99%

Section: Electrophysiological Mechanisms Of Af: Reentry or Focal?mentioning

confidence: 99%

Section: Electrophysiological Mechanisms Of Af: Reentry or Focal?mentioning

confidence: 99%

Section: Electrophysiological Mechanisms Of Af: Reentry or Focal?mentioning

confidence: 99%

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Investigational Anti–Atrial Fibrillation Pharmacology and Mechanisms by Which Antiarrhythmics Terminate the Arrhythmia: Where Are We in 2020?

Burashnikov

2020

Journal of Cardiovascular Pharmacology

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Beyond pulmonary vein isolation for persistent atrial fibrillation: sequential high-resolution mapping to guide ablation

Małaczyńska-Rajpold

Jarman

Shi

et al. 2022

J Interv Card Electrophysiol

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Purpose We aimed to evaluate whether outcomes with ablation in persistent (PsAF) and long-standing persistent (LsPsAF) AF can be improved beyond what can be achieved with pulmonary vein isolation (PVI) alone, using individualized mapping to guide ablation. Methods We studied 20 pts (15 M, 68 ± 11y) with PsAF (14) or LsPsAF (6) referred for first-time AF ablation. Following antral PVI, individualized mapping (IM) was performed using a high-density mapping catheter stably and fully deployed for 30 s at each of 23 ± 9 sites per patient. Activation data were reviewed, and an ablation strategy designed to intersect areas of focal and rotational activity. Mean follow-up was 429 ± 131 days. The study population was compared to a matched contemporary control cohort (CC) of 20 consecutive patients undergoing conventional ablation. Results Despite the IM group having a higher median comorbidities score, 3.5 vs. 2.5 in the CC group, indicating potentially more complex patients and more advanced substrate, cumulative freedom from AF after a single procedure was achieved in 94% of patients in the IM group vs. 75% in the CC group at 1 year and remained the same in both groups at the conclusion of the study (p = 0.02). There was a similar trend in atrial arrhythmia-free survival between both groups (84% vs. 67% at 1 year) that did not reach statistical significance. The procedure duration was longer in the IM group by a median of 31.5 min (p = 0.004). Conclusions Individualized mapping to guide AF ablation appears to achieve significantly greater AF-free survival compared to conventional PVI when applied as a primary ablation treatment. The results of this pilot study need to be confirmed in a larger, randomized trial.

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Directed graph mapping exceeds phase mapping in discriminating true and false rotors detected with a basket catheter in a complex in-silico excitation pattern

Nieuwenhuyse

Martinez-Mateu

Sáiz

et al. 2021

Computers in Biology and Medicine

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Atrial fibrillation (AF) is the most frequently encountered arrhythmia in clinical practise. One of the major problems in the management of AF is the difficulty in identifying the arrhythmia sources from clinical recordings. That difficulty occurs because it is currently impossible to verify algorithms which determine these sources in clinical data, as high resolution true excitation patterns cannot be recorded in patients. Therefore, alternative approaches, like computer modelling are of great interest. In a recent published study such an approach was applied for the verification of one of the most commonly used algorithms, phase mapping (PM). A meandering rotor was simulated in the right atrium and a basket catheter was placed at 3 different locations: at the Superior Vena Cava (SVC), the Crista Terminalis (CT) and at the Coronary Sinus (CS). It was shown that although PM can identify the true source, it also finds several false sources due to the far-field effects and interpolation errors in all three positions. In addition, the detection efficiency strongly depended on the basket location. Recently, a novel tool was developed to analyse any arrhythmia called Directed Graph Mapping (DGM). DGM is based on network theory and creates a directed graph of the excitation pattern, from which the location and the source of the arrhythmia can be detected. Therefore, the objective of the current study was to compare the efficiency of DGM with PM on the basket dataset of this meandering rotor. The DGM-tool was applied for a wide variety of conduction velocities (minimal and maximal), which are input parameters of DGM. Overall we found that DGM was able to distinguish between the true rotor and false rotors for both the SVC and CT basket positions. For example, for the SVC position with a , DGM detected the true core with a prevalence of 82% versus 94% for PM. Three false rotors where detected for 39.16% (DGM) versus 100% (PM); 22.64% (DGM) versus 100% (PM); and 0% (DGM) versus 57% (PM). Increasing to had a stronger effect on the false rotors than on the true rotor. This led to a detection rate of for the true rotor, while all the other false rotors disappeared. A similar trend was observed for the CT position. For the CS position, DGM already had a low performance for the true rotor for (14.7%). For the false and the true rotors could therefore not be distinguished. We can conclude that DGM can overcome some of the limitations of PM by varying one of its input parameters ( ). The true rotor is less dependent on this parameter than the false rotors, which disappear at a . In order to increase to detection rate of the true rotor, one can decrease and discard the new rotors which also appear at lower values of .

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Reconsidering the multiple wavelet hypothesis of atrial fibrillation

Cited by 22 publications

References 23 publications

Investigational Anti–Atrial Fibrillation Pharmacology and Mechanisms by Which Antiarrhythmics Terminate the Arrhythmia: Where Are We in 2020?

Investigational Anti–Atrial Fibrillation Pharmacology and Mechanisms by Which Antiarrhythmics Terminate the Arrhythmia: Where Are We in 2020?

Beyond pulmonary vein isolation for persistent atrial fibrillation: sequential high-resolution mapping to guide ablation

Directed graph mapping exceeds phase mapping in discriminating true and false rotors detected with a basket catheter in a complex in-silico excitation pattern

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