Unipolar atrial electrogram morphology from an epicardial and endocardial perspective

Does, Lisette J.M.E. van der; Knops, Paul; Teuwen, Christophe P.; Serban, C.; Starreveld, Roeliene; Lanters, Eva A.H.; Mouws, Elisabeth M.J.P.; Kik, Charles; Bogers, Ad J.J.C.

doi:10.1016/j.hrthm.2018.02.020

Cited by 34 publications

(26 citation statements)

References 16 publications

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“…30 To assess whether endo-epicardial asynchrony contributes to electrogram fractionation, van der Does et al carried out epicardial mapping during sinus rhythm in patients undergoing cardiac surgery. 31 Activation time, electrogram amplitude, RS ratio, and fractionation were assessed in the right atrial free wall of patients operated for coronary artery disease or valvular heart disease. The authors showed that during sinus rhythm, epi-endo differences in electrogram fractionation occurred.…”

Section: Fractionation and Late Potentialsmentioning

confidence: 99%

Electrogram recording and analyzing techniques to optimize selection of target sites for ablation of cardiac arrhythmias

Bakker

2019

Pacing Clinical Electrophis

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The extracellular electrogram is caused by transmembrane currents that flow into extracellular space during propagation of the electrical impulse. Electrograms are usually recorded in unipolar or bipolar mode that have different characteristics, but provide complementary information. Both recording modes have specific advantages, but also suffer from disadvantages. Techniques to circumvent some of the weaknesses are reviewed. The origin of remote and fractionated deflections and their relation with electrode characteristics are discussed. Epicardial and endocardial sites of origin and breakthrough sites as well as the effect of fatty tissue on extracellular electrograms are presented. Induction of tachycardia to assess the arrhythmogenic area is not always possible because of hemodynamic instability of the patient. Techniques to assess sites with high reentry vulnerability without induction of arrhythmias are outlined such as activation‐repolarization mapping and decremental stimulation. Pitfalls of substrate mapping and techniques to avoid them as omnipolar mapping and characterization of complex electrograms by entropy are presented. Technical aspects that influence electrogram morphology as electrode size, filtering, contact force, and catheter position are delineated. Data from the various publications suggest that a combination of unipolar and bipolar electrogram analysis techniques is helpful to optimize determination of target sites for ablation.

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Section: Fractionation and Late Potentialsmentioning

confidence: 99%

Electrogram recording and analyzing techniques to optimize selection of target sites for ablation of cardiac arrhythmias

Bakker

2019

Pacing Clinical Electrophis

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“…of fractionated potentials, providing a possible explanation of the low success rate of ablation therapy targeting these complex fractionated potentials. 19 Furthermore, recent studies have revealed that aside from the well-known effects of increased renin-angiotensin-system activation, cardiac endothelin-1 levels may play an in important role in AF pathogenesis. 20 Endothelin-1 expression, promoting myocyte hypertrophy and interstitial fibrosis, was increased during AF compared to SR. 20 Particularly, endothelin-1 levels were higher at the LA and in patients with VHD, leading to the presumption that this may play a substantial role in the vulnerability of these patients for AF development.…”

Section: The Future Of Af Therapymentioning

confidence: 99%

Impact of the arrhythmogenic potential of long lines of conduction slowing at the pulmonary vein area

et al. 2019

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BACKGROUND Areas of conduction delay (CD) or conduction block (CB) are associated with higher recurrence rates after ablation therapy for atrial fibrillation (AF). OBJECTIVE Thus far, there are no reports on the quantification of the extensiveness of CD and CB at the pulmonary vein area (PVA) and their clinical relevance. METHODS Intraoperative high-density epicardial mapping of the PVA (interelectrode distance 2 mm) was performed during sinus rhythm in 268 patients (mean 6 SD [minimum-maximum] 67 6 11 [21-84] years) with and without preoperative AF. For each patient, extensiveness of CD (conduction velocity 17-29 cm/s) and CB (conduction velocity ,17 cm/s) was assessed and related to the presence and type of AF. RESULTS CD and CB occurred in, respectively, 242 (90%) and 183 (68%) patients. Patients with AF showed a higher incidence of continuous conduction delay and block (CDCB) lines (AF: n 5 37 [76%]; no AF: n 5 132 [60%]; P 5 .046), a 2-fold number of lines per patient (CD: 7 [0-30] vs 4 [0-22], P , .001; CB: 3 [0-11] vs 1 [0-12], P 5 .003; CDCB: 2 [0-6] vs 1 [0-8], P 5 .004), and a higher incidence of CD or CB lines 6 mm and CDCB lines 16 mm (P 5 .011, P 5 .025, and P 5 .027). The extensiveness of CD, CB, and CDCB could not distinguish between the different AF types. CONCLUSION Patients with AF more often present with continuous lines of adjacent areas of CD and CB, whereas in patients without AF, lines of CD and CB are shorter and more often separated by areas with normal intra-atrial conduction. However, a considerable overlap in the amount of conduction abnormalities at the PVA was observed between patients with a history of paroxysmal and persistent AF.

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“…At the endocardium, the mapping area is activated by wavefronts entering the array from different directions, separated by long lines of conduction block. Hence, this example illustrates the complexity of atrial activation, even during SR [Color figure can be viewed at wileyonlinelibrary.com] wall simultaneously during SR 17. From these data, it appeared that EEA during SR indeed exists and could even be as large as 50 ms.…”

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confidence: 70%

Pathophysiology of atrial fibrillation: Focal patterns of activation

Groot

Allessie

2019

Pacing Clinical Electrophis

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For decades, electrical activity recorded has been investigated to unravel pathophysiology of cardiac arrhythmias, such as atrial fibrillation (AF). Particularly high‐resolution mapping studies have significantly contributed to novel insights into AF mechanisms. From these mapping studies, it appeared that persistence of AF is associated with a high incidence of focal patterns of activation. Features of these focal activation patterns indicated that they could be attributed to transmural propagation of fibrillation waves. However, “focal fibrillation waves” can only appear when there is electrical asynchrony between the endocardial and epicardial layer. By performing simultaneous high‐resolution mapping of the endo‐ and epicardial wall of the right atrium in humans during AF, the existence of electrical asynchrony (endo‐epicardial asynchrony [EEA]) between the endo‐ and epicardial layer was indeed confirmed. During sinus rhythm, focal patterns of activation are most frequently observed at the right atrium and a considerable degree of EEA—as large as 50 ms—may occur. Furthermore, prematurely aberrant atrial extrasystoles emerging as focal waves caused the highest degree of conduction disorders, particularly in patients with left atrial dilatation and diabetes mellitus. These observations emphasize the contribution of atrial anatomy to EEA and the role of focal patterns of activation in development AF.

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Unipolar atrial electrogram morphology from an epicardial and endocardial perspective

Cited by 34 publications

References 16 publications

Electrogram recording and analyzing techniques to optimize selection of target sites for ablation of cardiac arrhythmias

Electrogram recording and analyzing techniques to optimize selection of target sites for ablation of cardiac arrhythmias

Impact of the arrhythmogenic potential of long lines of conduction slowing at the pulmonary vein area

Pathophysiology of atrial fibrillation: Focal patterns of activation

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