Relationship Between Fractionated Signal Areas in the Atrial Muscle During Sinus Rhythm and Atrial Pacing and Non-Pulmonary Vein Foci
2020; Lippincott Williams & Wilkins; Volume: 13; Issue: 8 Linguagem: Inglês
10.1161/circep.120.008667
ISSN1941-3149
AutoresJun Hirokami, Kenichi Hiroshima, Kyohei Yamaji, Kengo Korai, Michio Nagashima, Masato Fukunaga, Junji Morita, Kei Yamamoto, Kenji Andò, Masahiko Goya,
Tópico(s)Cardiac electrophysiology and arrhythmias
ResumoHomeCirculation: Arrhythmia and ElectrophysiologyVol. 13, No. 8Relationship Between Fractionated Signal Areas in the Atrial Muscle During Sinus Rhythm and Atrial Pacing and Non-Pulmonary Vein Foci Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsFree AccessReview ArticlePDF/EPUBRelationship Between Fractionated Signal Areas in the Atrial Muscle During Sinus Rhythm and Atrial Pacing and Non-Pulmonary Vein FociNovel Mapping Strategy Jun Hirokami, MD, Kenichi Hiroshima, MD, Kyohei Yamaji, MD, PhD, Kengo Korai, MD, Michio Nagashima, MD, Masato Fukunaga, MD, Junji Morita, MD, Kei Yamamoto, MD, Kenji Ando, MD and Masahiko Goya, MD Jun HirokamiJun Hirokami Correspondence to: Jun Hirokami, MD, Department of Cardiology, Kokura Memorial Hospital, 1-2-3 Asano, N of Kokura, Kitakyushu, Fukuoka 802-8555, Japan. Email E-mail Address: [email protected] https://orcid.org/0000-0001-5588-0533 Department of Cardiology, Kokura Memorial Hospital, Kitakyushu (J.H., K.H., K.Y., K.K., M.N., M.F., J.M., K.Y., K.A., M.G.). , Kenichi HiroshimaKenichi Hiroshima Department of Cardiology, Kokura Memorial Hospital, Kitakyushu (J.H., K.H., K.Y., K.K., M.N., M.F., J.M., K.Y., K.A., M.G.). , Kyohei YamajiKyohei Yamaji https://orcid.org/0000-0002-8798-9186 Department of Cardiology, Kokura Memorial Hospital, Kitakyushu (J.H., K.H., K.Y., K.K., M.N., M.F., J.M., K.Y., K.A., M.G.). , Kengo KoraiKengo Korai https://orcid.org/0000-0001-9676-7684 Department of Cardiology, Kokura Memorial Hospital, Kitakyushu (J.H., K.H., K.Y., K.K., M.N., M.F., J.M., K.Y., K.A., M.G.). , Michio NagashimaMichio Nagashima Department of Cardiology, Kokura Memorial Hospital, Kitakyushu (J.H., K.H., K.Y., K.K., M.N., M.F., J.M., K.Y., K.A., M.G.). , Masato FukunagaMasato Fukunaga https://orcid.org/0000-0002-0230-4556 Department of Cardiology, Kokura Memorial Hospital, Kitakyushu (J.H., K.H., K.Y., K.K., M.N., M.F., J.M., K.Y., K.A., M.G.). , Junji MoritaJunji Morita Department of Cardiology, Kokura Memorial Hospital, Kitakyushu (J.H., K.H., K.Y., K.K., M.N., M.F., J.M., K.Y., K.A., M.G.). , Kei YamamotoKei Yamamoto Department of Cardiology, Kokura Memorial Hospital, Kitakyushu (J.H., K.H., K.Y., K.K., M.N., M.F., J.M., K.Y., K.A., M.G.). , Kenji AndoKenji Ando Department of Cardiology, Kokura Memorial Hospital, Kitakyushu (J.H., K.H., K.Y., K.K., M.N., M.F., J.M., K.Y., K.A., M.G.). and Masahiko GoyaMasahiko Goya https://orcid.org/0000-0002-7210-0671 Department of Cardiology, Kokura Memorial Hospital, Kitakyushu (J.H., K.H., K.Y., K.K., M.N., M.F., J.M., K.Y., K.A., M.G.). Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan (M.G.). Originally published6 Jul 2020https://doi.org/10.1161/CIRCEP.120.008667Circulation: Arrhythmia and Electrophysiology. 2020;13:e008667Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: July 6, 2020: Ahead of Print Pulmonary vein isolation is the preferred treatment strategy for atrial fibrillation (AF) that involves electrically isolating pulmonary vein (PV) foci from the left atrium.1 While non-PV foci during or after pulmonary vein isolation were observed in ≈20% of patients,2,3 frequent activation of multiple arrhythmogenic non-PV foci was reported to be associated with the perpetuation of AF.4 Additionally, postpulmonary vein isolation AF recurrence rates remain high in cases with unsuccessful ablation for non-PV foci and/or non-PV triggers that did not induce AF3.Fractionated signals consist of multiple high-frequency components and may play a role in the structural remodeling of myocardium. Fractionated signals in atrial muscle cause repetitive atrial firing which increases susceptibility to AF and has been used as an indicator of atrial vulnerability.5 The recently introduced Lumipoint software (Boston Scientific, Marlborough, MA) enabled the visualization of fractionated signals within geographic regions of interest. We aimed to clarify the spatial correlation between fractionated potentials detected by Lumipoint with non-PV triggers.The data that support the findings of this study are available from the corresponding author upon reasonable request.We enrolled 30 symptomatic AF patients who underwent non-PV foci ablation via the ultra-high density Rhythmia system at Kokura Memorial Hospital between April 2017 and October 2019: 4 patients underwent first procedure, 17 underwent second procedure, 8 underwent third procedure, and 1 underwent fourth procedure. All patients were refractory or intolerant to >1 antiarrhythmic drug before catheter ablation. This retrospective study was approved by an institutional review committee and the subjects gave informed consent. We excluded patients with allergy to antiarrhythmic drugs, severe valvular disease, severe sleep apnea syndrome, and bronchial asthma.We analyzed non-PV triggers with electrode catheters when spontaneous ectopic beats were observed. If spontaneous ectopic beats did not occur, we intravenously administered a bolus injection of adenosine triphosphate (20–60 mg) during a continuous infusion of isoproterenol (1–10 μg/kg per minute) to search for non-PV foci. If AF was not initiated by adenosine triphosphate and isoproterenol infusion, we induced sustained AF via rapid atrial pacing (50 ms/30 mA/5 second) at the high right atrium during isoproterenol infusion. This pacing-induced AF was terminated via intracardiac defibrillation, and after recovery to sinus rhythm, we checked for any spontaneous non-PV triggers.The dedicated visualization system which provided by the Lumipoint software highlighted the fractionated signal area in atrial muscle (FAAM) during sinus rhythm and atrial pacing, thereby producing a digital FAAM map. FAAM maps were assigned by peaks slider which is original parameter of Lumipoint. Peaks slider indicates the number of components of fractionated signals and range from 1 to 15. If peaks slider was set large, Lumipoint highlighted small area which only had high fractionated signals; the larger the peaks slider is, the smaller the FAAM is (Figure II in the Data Supplement). We defined non-PV foci as atrial firing or atrial premature beat observed at least 10× per minute presumably from the same origin, regardless of AF induction.3 Non-PV foci was assessed by combining the 12-lead ECG morphology of triggers and their earliest local intracardiac electrograms recorded on the catheters (Figure I in the Data Supplement). We retrospectively applied Lumipoint to 30 patients to clarify the relationship between FAAM and non-PV foci (Figure).Download figureDownload PowerPointFigure. These fractionated signal area in atrial muscle (FAAM) maps show that all non-pulmonary vein (PV) foci were found within peaks slider 7 area (A) and peaks slider 10 area (B). The locations of non-PV foci are shown in red (yellow arrow). The Lumipoint software highlights fractionated signal areas. Peaks slider indicates the number of components of fractionated signals and range from 1 to 15. The larger the peaks slider is, the smaller the FAAM is.Non-PV foci were successfully identified in all patients (age, 68.8±7.2 years; male, 21; Data Supplement). We observed 4 patients with multiple non-PV foci. Of these 4 patients, one had non-PV foci at the superior vena cava (SVC) and left atrial anterior wall, one had non-PV foci at the SVC and left atrial bottom wall, and 2 had non-PV foci at the SVC and interatrial septum. We only analyzed 30 non-PV foci unrelated to the SVC because SVC isolation was routinely performed for non-PV foci at the SVC. To analyze the correlation between FAAM and location of non-PV triggers, we determined the cutoff point of peaks slider which non-PV triggers were completely located within the FAAM in. The accuracy of predicting location of non-PV triggers was summarized using the area under the receiver operating characteristic curves. The optimal cutoff point of peak sliders to predict the locations of non-PV foci was determined by the Youden index, that is, J=max (sensitivity + specificity −1). Youden index established that the optimal cutoff point of the maximum peaks slider was 7; sensitivity and specificity were 0.906 and 0.770, respectively. The peaks slider 7 was most accurate predictor of fractionated signals area to the location of non-PV triggers (area under the receiver operating characteristic 0.902) (Figures III and IV in the Data Supplement). The mean area of peaks slider 7 was 6.0±5.9 cm2 (5.4±4.3% of the atrium; Figure IV in the Data Supplement).In conclusion, our proof-of-concept observational study demonstrated that the novel visualization tool of FAAM map successfully identified non-PV triggers that did not induce AF and/or non-PV foci, which potentially serve as substrates of AF maintenance. Larger confirmatory studies are needed to clarify whether use of FAAM map reduce the recurrence rate of AF.Nonstandard Abbreviations and AcronymsAFatrial fibrillationATPadenosine triphosphateFAAMfractionated signal area in atrial musclePVpulmonary veinPVIpulmonary vein isolationSVCsuperior vena cavaSources of FundingNone.DisclosuresNone.FootnotesThe Data Supplement is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCEP.120.008667.For Sources of Funding and Disclosures, see page 867.Correspondence to: Jun Hirokami, MD, Department of Cardiology, Kokura Memorial Hospital, 1-2-3 Asano, N of Kokura, Kitakyushu, Fukuoka 802-8555, Japan. Email [email protected]or.jpReferences1. Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, Akar JG, Badhwar V, Brugada J, Camm J, et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation: executive summary.Heart Rhythm. 2017; 14:e445–e494. doi: 10.1016/j.hrthm.2017.07.009CrossrefMedlineGoogle Scholar2. Shah D, Haissaguerre M, Jais P, Hocini M. Nonpulmonary vein foci: do they exist?Pacing Clin Electrophysiol. 2003; 26(7 Pt 2):1631–1635. doi: 10.1046/j.1460-9592.2003.t01-1-00243.xCrossrefMedlineGoogle Scholar3. Elayi CS, Di Biase L, Bai R, Burkhardt JD, Mohanty P, Santangeli P, Sanchez J, Hongo R, Gallinghouse GJ, Horton R, et al. Administration of isoproterenol and adenosine to guide supplemental ablation after pulmonary vein antrum isolation.J Cardiovasc Electrophysiol. 2013; 24:1199–1206. doi: 10.1111/jce.12252CrossrefMedlineGoogle Scholar4. Kurotobi T, Iwakura K, Inoue K, Kimura R, Okamura A, Koyama Y, Tosyoshima Y, Ito N, Fujii K. Multiple arrhythmogenic foci associated with the development of perpetuation of atrial fibrillation.Circ Arrhythm Electrophysiol. 2010; 3:39–45. doi: 10.1161/CIRCEP.109.885095LinkGoogle Scholar5. Centurion OA, Shimizu A, Isomoto S, Konoe A, Hirata T, Hano O, Kaibara M, Yano K. Repetitive atrial firing and fragmented atrial activity elicited by extrastimuli in the sick sinus syndrome with and without abnormal atrial electrograms.Am J Med Sci. 1994; 307:247–254. doi: 10.1097/00000441-199404000-00001CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Kurata N, Masuda M, Kanda T, Asai M, Iida O, Okamoto S, Ishihara T, Nanto K, Tsujimura T, Matsuda Y, Hata Y, Uematsu H and Mano T (2022) Left Atrial Localized Low-Voltage Areas Indicate Whole Left Atrial Electrophysiological Degeneration in Atrial Fibrillation Patients, Circulation Journal, 10.1253/circj.CJ-21-0527, 86:2, (192-199), Online publication date: 25-Jan-2022. Xu B, Xu C, Sun Y, Peng J, Peng F, Tang W, Zhou Y, Wang S, Pan J and Xing Y (2022) Fixed complex electrograms during sinus rhythm and local pacing: potential ablation targets for persistent atrial fibrillation, Scientific Reports, 10.1038/s41598-022-14824-4, 12:1, Online publication date: 1-Dec-2022. Tohoku S, Fukunaga M, Nagashima M, Korai K, Hirokami J, Yamamoto K, Takeo A, Niu H, Ando K and Hiroshima K (2020) Clinical impact of eliminating nonpulmonary vein triggers of atrial fibrillation and nonpulmonary vein premature atrial contractions at initial ablation for persistent atrial fibrillation, Journal of Cardiovascular Electrophysiology, 10.1111/jce.14830, 32:2, (224-234), Online publication date: 1-Feb-2021. Ikenouchi T, Nitta J, Inaba O, Kono T, Murata K, Takamiya T, Inamura Y, Sato A, Matsumura Y, Takahashi Y, Goya M and Sasano T (2022) Effect of isolation feasibility of non-pulmonary vein foci on efficacy of ablation for atrial fibrillation: comparison of the isolation and focal ablation methods, Journal of Interventional Cardiac Electrophysiology, 10.1007/s10840-022-01217-w August 2020Vol 13, Issue 8 Advertisement Article InformationMetrics © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.120.008667PMID: 32628515 Originally publishedJuly 6, 2020 Keywordsatrial fibrillationelectrophysiologymyocardiumarrhythmiapulmonary veinPDF download Advertisement SubjectsArrhythmiasAtrial FibrillationCatheter Ablation and Implantable Cardioverter-DefibrillatorElectrophysiology
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