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Volume 12, Issue 2, Pages 397-408 (February 2015) Fractionation of electrograms is caused by colocalized conduction block and connexin disorganization in the absence of fibrosis as AF becomes persistent in the goat model Senthil Kirubakaran, MD, MRCP, Rasheda A. Chowdhury, MSc, PhD, Mark C.S. Hall, MD, FRCP, Pravina M. Patel, BSc, Clifford J. Garratt, DM, FRCP, FESC, Nicholas S. Peters, MD, FRCP, FHRS Heart Rhythm Volume 12, Issue 2, Pages 397-408 (February 2015) DOI: 10.1016/j.hrthm.2014.10.027 Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 1 Method for calculating local conduction velocity. Diagram shows activation times of 3 neighboring electrodes (T1, T2, and T3). Interval X can then be calculated using trigonometry. The conduction velocity in the direction of propagation would then be the interelectrode distance divided by interval X. AF = atrial fibrillation. Heart Rhythm 2015 12, 397-408DOI: (10.1016/j.hrthm.2014.10.027) Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 2 A: Consecutive right atrial unipolar electrogram recordings during mapping of the right atrium during atrial pacing at a cycle length of 400 ms. Representative electrograms are shown as single, double, and fractionated. B: Consecutive right atrial unipolar electrogram recordings during mapping of the right atrium during AF in representative goats from each group. Atrial electrograms during AF in the control goat had discrete sharp negative deflections, with goats in the remaining groups displaying variable morphologies. AF = atrial fibrillation. Heart Rhythm 2015 12, 397-408DOI: (10.1016/j.hrthm.2014.10.027) Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 3 Tissue fiber orientation is indicated using double-headed dotted arrows. Examples of the Cx43 label in the region of the intercalated disc are shown by vertical arrows, and those of Cx43 along the lateral membrane are shown by horizontal arrows. A: In the image for score 1, the majority of Cx43 immunolabel is confined to the ends of the myocytes in the location of the intercalated disc. B: In the image for score 5, the immunolabel is found along the length of the lateral membrane. Cx43 = connexin 43. Heart Rhythm 2015 12, 397-408DOI: (10.1016/j.hrthm.2014.10.027) Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 4 Changes in mean duration of burst pacing required to induce AF episodes. Results are expressed as mean values obtained from all goats. AF = atrial fibrillation; ANOVA = analysis of variance. Heart Rhythm 2015 12, 397-408DOI: (10.1016/j.hrthm.2014.10.027) Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 5 Fragmentation maps of each goat, showing the distribution of single, double, and fractionated atrial electrograms and localized areas of conduction block and slow conduction during epicardial mapping of the right atrium during atrial pacing. AF = atrial fibrillation. Heart Rhythm 2015 12, 397-408DOI: (10.1016/j.hrthm.2014.10.027) Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 6 Fragmentation maps of each goat, showing the spatial distribution of atrial electrogram morphology and localized areas of conduction block and slow conduction during epicardial mapping of the right atrium during AF. AF = atrial fibrillation. Heart Rhythm 2015 12, 397-408DOI: (10.1016/j.hrthm.2014.10.027) Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 7 Isochronal maps of right atrial activation during AF in a representative goat from each group during 10 consecutive time frames. Isochronal lines are drawn at 10-ms intervals. Thick lines represent arcs of conduction block, and dashed lines represent arcs of collision. Arrows indicate the direction of activation. Asterisks represent areas of epicardial breakthrough. AF = atrial fibrillation. Heart Rhythm 2015 12, 397-408DOI: (10.1016/j.hrthm.2014.10.027) Copyright © 2015 Heart Rhythm Society Terms and Conditions

Figure 8 Correlation of Cx43 redistribution scores with both proportion of areas of conduction block fractionated electrograms during atrial pacing and AF, as well as with complexity scores of atrial activation during AF. AF = atrial fibrillation; Cx43 = connexin 43. Heart Rhythm 2015 12, 397-408DOI: (10.1016/j.hrthm.2014.10.027) Copyright © 2015 Heart Rhythm Society Terms and Conditions