Volume 16, Issue 1, Pages (January 2019)

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Volume 16, Issue 1, Pages 18-25 (January 2019) Structural remodeling and conduction velocity dynamics in the human left atrium: Relationship with reentrant mechanisms sustaining atrial fibrillation Shohreh Honarbakhsh, MRCP, BSc, Richard J. Schilling, MRCP, MD, Michele Orini, PhD, Rui Providencia, MD, Emily Keating, BAppSc, Malcolm Finlay, MRCP, PhD, Simon Sporton, FRCP, MD, BSc, Anthony Chow, FRCP, MD, Mark J. Earley, MRCP, MD, Pier D. Lambiase, FRCP, PhD, Ross J. Hunter, FESC, PhD Heart Rhythm Volume 16, Issue 1, Pages 18-25 (January 2019) DOI: 10.1016/j.hrthm.2018.07.019 Copyright © 2018 Terms and Conditions

Figure 1 Anterior (A) and posterior (B) views of the left atrium showing the distribution of the low-voltage zones and rate-dependent conduction velocity slowing sites (percentage in brackets) in the patients involved in the study. Red indicates septum; green indicates lateral; blue indicates anterior; yellow indicates posterior; purple indicates roof. Heart Rhythm 2019 16, 18-25DOI: (10.1016/j.hrthm.2018.07.019) Copyright © 2018 Terms and Conditions

Figure 2 A: Change in CV over the 4 pacing intervals in non-LVZs ≥0.5 mV (black triangles), LVZs (0.2–0.5 mV) (light gray circles), and LVZs (0–0.2 mV) (dark gray triangles). B, C: Bar chart showing the percentage of rate-dependent CV slowing sites in non-LVZs ≥0.5 mV, LVZs (0.2–0.5 mV), and LVZs (0–0.2 mV) (B) and the proportion of non-LVZs ≥0.5 mV, LVZs (0.2–0.5 mV), and LVZs (0–0.2 mV) demonstrating rate-dependent CV slowing (C). CV = conduction velocity; LVZ = low-voltage zone; RD-CV = rate-dependent conduction velocity. Heart Rhythm 2019 16, 18-25DOI: (10.1016/j.hrthm.2018.07.019) Copyright © 2018 Terms and Conditions

Figure 3 Relationship between mean CV for each patient at pacing interval of 600 ms (the average of all the CV measured between all pole pairs in each patient) and mean bipolar voltage including all bipolar voltage points in each patient (A) and the proportion of non-LVZs in each patient (B). CV = conduction velocity; LVZ = low-voltage zone. Heart Rhythm 2019 16, 18-25DOI: (10.1016/j.hrthm.2018.07.019) Copyright © 2018 Terms and Conditions

Figure 4 A: i–iv: Still CARTOFINDER map demonstrating a rotational driver at the anterior roof (B) in an area of LVZ as shown on the bipolar voltage map (C), where ablation resulted in atrial fibrillation termination to sinus rhythm on the Bard electrograms. D: i: Replicated CARTO geometry created in MATLAB demonstrating site of rate-dependent conduction velocity (CV) slowing at the anterior roof in an area of LVZ (0.2–0.5 mV) (F3–F5 electrodes; vertical and F4–E4 electrode: horizontal). ii: Electrograms obtained at F3 and F5 electrodes during left atrial appendage pacing at PI 600–250 ms show an increase in activation time difference of 12 ms (80% increase) between the 2 electrodes when reaching PI of 250 ms. (iii) Electrograms obtained at F4 and E4 electrodes during roof pacing at PI 600–250 ms show an increase in activation time difference of 13 ms (163% increase). LVZ = low-voltage zone; PI = pacing interval; V = far-field ventricular signal. Heart Rhythm 2019 16, 18-25DOI: (10.1016/j.hrthm.2018.07.019) Copyright © 2018 Terms and Conditions

Supplemental Figure 1 Ai–Aii: LA geometry in AP (Ai) and PA (Aii) position that show the distribution of potential drivers with rotational activity (circles) and sites of rate-dependent CV slowing (arrows) on the anatomical LA surface. The figure also demonstrates whether these sites co-locate (with red circles and arrows indicating co-location whilst blue circles and arrows indicate that they do not collate). The numbers refer to the patient ID. Each potential driver and the specific response to ablation is further detailed in Supplementary Table 3. Heart Rhythm 2019 16, 18-25DOI: (10.1016/j.hrthm.2018.07.019) Copyright © 2018 Terms and Conditions