Circ Arrhythm Electrophysiol

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Circ Arrhythm Electrophysiol Identification and Characterization of Sites Where Persistent Atrial Fibrillation Is Terminated by Localized Ablation by Junaid A.B. Zaman, William H. Sauer, Mahmood I. Alhusseini, Tina Baykaner, Ryan T. Borne, Christopher A.B. Kowalewski, Sonia Busch, Paul C. Zei, Shirley Park, Mohan N. Viswanathan, Paul J. Wang, Johannes Brachmann, David E. Krummen, John M. Miller, Wouter Jan Rappel, Sanjiv M. Narayan, and Nicholas S. Peters Circ Arrhythm Electrophysiol Volume 11(1):e005258 January 12, 2018 Copyright © American Heart Association, Inc. All rights reserved.

Junaid A.B. Zaman et al. Circ Arrhythm Electrophysiol. 2018;11:e005258 Copyright © American Heart Association, Inc. All rights reserved.

Acute termination in patients with persistent atrial fibrillation (AF) by first ablation at sites marked (*). Acute termination in patients with persistent atrial fibrillation (AF) by first ablation at sites marked (*). A, Acute termination of AF in a 60-y-old man to sinus rhythm by ablation, depicted on the electroanatomic right atrial shell (i). B, Acute termination of AF in a 61-y-old with the first ablation lesion applied in the left atrium (ii). This study was designed to investigate these scenarios. IVC indicates inferior vena cava; LA indicates left atrium; LSPV, left superior pulmonary vein; RA, right atrium; and SVC, superior vena cava. Junaid A.B. Zaman et al. Circ Arrhythm Electrophysiol. 2018;11:e005258 Copyright © American Heart Association, Inc. All rights reserved.

Consecutive isochronal maps at sites of atrial fibrillation (AF) termination. Consecutive isochronal maps at sites of atrial fibrillation (AF) termination. A, Partial rotational circuit with a termination site near the left pulmonary vein carina. B, Repetitive focal activity from site of termination on the left atrial (LA) roof. C, Complete rotational circuit with a termination site near the mitral valve. Isochronal maps (iia, iib, iic) are shown for 3 consecutive cycles of AF. LAA indicates left atrial appendage; LIPV, left inferior pulmonary vein; LSPV, left superior pulmonary vein; MV, mitral valve; RIPV, right inferior pulmonary vein; and RSPV, right superior pulmonary vein. Junaid A.B. Zaman et al. Circ Arrhythm Electrophysiol. 2018;11:e005258 Copyright © American Heart Association, Inc. All rights reserved.

Complete rotational circuits at sites of termination of persistent atrial fibrillation (AF). Complete rotational circuits at sites of termination of persistent atrial fibrillation (AF). A, Three cycles of AF in a 66-y-old man, with unipolar electrograms spanning 100% of the AF cycle length (160 ms). Dashed line shows the first derivative (−dv/dt), with red vertical lines indicating activation at each AF cycle (maximum –dv/dt). Blue boxes highlight a 50-ms window used to detect local activation. Numbered traces on left atrial isochrones (i) show rotational circuits with head-meets-tail interaction. B, Three cycles of AF in a 54-y-old man with persistent AF annotated using blue vertical lines (local peak-to-peak amplitude). Coronary sinus recording confirms AF. (ii) Isochronal activation map shows rotational activation in right atrium. Junaid A.B. Zaman et al. Circ Arrhythm Electrophysiol. 2018;11:e005258 Copyright © American Heart Association, Inc. All rights reserved.

Phase mapping and isochronal mapping of atrial fibrillation. Phase mapping and isochronal mapping of atrial fibrillation. A, Snapshot of a computer simulation of a spiral wave with period 180 ms and a meandering tip trajectory in red. B, Isochronal map using the activation times at the 8×8 grid shown in yellow in (A), identifying the spiral wave. C, As in (B) but now with variations of the relative timing of each electrode chosen at random between ±20 ms (±10% of cycle length 180 ms). Altered activation times alter the spiral wave in the isochronal map. D, Sequence of phase maps spanning the time interval of (B). Phase singularities reveal a counterclockwise rotation at these same activation times. See Data Supplement for phase methods. Junaid A.B. Zaman et al. Circ Arrhythm Electrophysiol. 2018;11:e005258 Copyright © American Heart Association, Inc. All rights reserved.

Importance of timing assignment in multiple component electrograms in atrial fibrillation (AF). Importance of timing assignment in multiple component electrograms in atrial fibrillation (AF). A, Persistent AF in a 54-y-old man, with electrode D3 indicating 3 possible deflections. Annotating the first (minimum dv/dt; red lines) portrays a focal source at the termination site (i). Annotating the middle deflection (green) indicates a partial rotation (green box, ii). Annotating the third deflection (blue) gives a complete rotational circuit (blue box, iii). B, Termination of AF with ablation at D3. Junaid A.B. Zaman et al. Circ Arrhythm Electrophysiol. 2018;11:e005258 Copyright © American Heart Association, Inc. All rights reserved.

Importance of selection of time window for analysis in computer simulation. Importance of selection of time window for analysis in computer simulation. A, Snapshot of a computer simulation of a spiral wave and a meandering tip trajectory in red. Tissue is heterogeneous with a larger (smaller) conductivity above (below) the dashed line. Membrane potential is indicated using a gray scale with activated/deactivated tissue shown in white/black. B, Isochronal map using activation times on the 8×8 grid shown in yellow in (A). No rotation is seen. C, As in (B) using a time window shifted by 50 ms. Rotation is identified. D, Phase maps spanning the time interval of (B) using the activation times of the grid, with phase singularities shown as black (clockwise rotations) or white (counterclockwise rotations) symbols. Junaid A.B. Zaman et al. Circ Arrhythm Electrophysiol. 2018;11:e005258 Copyright © American Heart Association, Inc. All rights reserved.

Clinical Impact of timing window on atrial fibrillation (AF) maps. Clinical Impact of timing window on atrial fibrillation (AF) maps. A, Three consecutive cycles of AF are shown in a 70-y-old female, as voltages and –dv/dt. The blue box represents 1 AF cycle (190 ms), with electrograms spanning 100% of the AF cycle in all channels in a rotational circuit (i). Moving this box 15 ms earlier (orange box) now shows focal activity (starting with F6) with activity spanning only 140 ms (ii). Morphology (qS) did not indicate focal activity (cycles 2 and 3). Ablation at FG34 (from blue window) acutely terminated AF. Junaid A.B. Zaman et al. Circ Arrhythm Electrophysiol. 2018;11:e005258 Copyright © American Heart Association, Inc. All rights reserved.