Concomitant Spatiotemporal Electrogram Dispersion and Low Voltage During Atrial Fibrillation Is Associated With Refractory Atrial Fibrillation After Catheter Ablation
2022; Lippincott Williams & Wilkins; Volume: 15; Issue: 5 Linguagem: Inglês
10.1161/circep.121.010707
ISSN1941-3149
AutoresTetsuma Kawaji, Takanori Aizawa, Shun Hojo, Akihiro Kushiyama, Hidenori Yaku, Kenji Nakatsuma, Kazuhisa Kaneda, Masashi Kato, Takafumi Yokomatsu, Shinji Miki,
Tópico(s)Cardiac Arrhythmias and Treatments
ResumoHomeCirculation: Arrhythmia and ElectrophysiologyVol. 15, No. 5Concomitant Spatiotemporal Electrogram Dispersion and Low Voltage During Atrial Fibrillation Is Associated With Refractory Atrial Fibrillation After Catheter Ablation Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBConcomitant Spatiotemporal Electrogram Dispersion and Low Voltage During Atrial Fibrillation Is Associated With Refractory Atrial Fibrillation After Catheter Ablation Tetsuma Kawaji, MD, PhD, Takanori Aizawa, MD, Shun Hojo, MD, Akihiro Kushiyama, MD, Hidenori Yaku, MD, PhD, Kenji Nakatsuma, MD, PhD, Kazuhisa Kaneda, MD, Masashi Kato, MD, Takafumi Yokomatsu, MD and Shinji Miki, MD Tetsuma KawajiTetsuma Kawaji Correspondence: Tetsuma Kawaji, MD, PhD, Department of Cardiology, Mitsubishi Kyoto Hospital, 1 Katsura Gosho-cho, Nishikyo-ku, Kyoto 615-8087, Japan. Email E-mail Address: [email protected] https://orcid.org/0000-0001-9929-902X Department of Cardiology, Mitsubishi Kyoto Hospital (T.K., S.H., A.K., H.Y., K.N., K.K., M.K., T.Y., S.M.). Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Japan (T.K., T.A.). , Takanori AizawaTakanori Aizawa Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Japan (T.K., T.A.). , Shun HojoShun Hojo Department of Cardiology, Mitsubishi Kyoto Hospital (T.K., S.H., A.K., H.Y., K.N., K.K., M.K., T.Y., S.M.). , Akihiro KushiyamaAkihiro Kushiyama Department of Cardiology, Mitsubishi Kyoto Hospital (T.K., S.H., A.K., H.Y., K.N., K.K., M.K., T.Y., S.M.). , Hidenori YakuHidenori Yaku Department of Cardiology, Mitsubishi Kyoto Hospital (T.K., S.H., A.K., H.Y., K.N., K.K., M.K., T.Y., S.M.). , Kenji NakatsumaKenji Nakatsuma Department of Cardiology, Mitsubishi Kyoto Hospital (T.K., S.H., A.K., H.Y., K.N., K.K., M.K., T.Y., S.M.). , Kazuhisa KanedaKazuhisa Kaneda https://orcid.org/0000-0002-4329-5975 Department of Cardiology, Mitsubishi Kyoto Hospital (T.K., S.H., A.K., H.Y., K.N., K.K., M.K., T.Y., S.M.). , Masashi KatoMasashi Kato https://orcid.org/0000-0002-3515-5526 Department of Cardiology, Mitsubishi Kyoto Hospital (T.K., S.H., A.K., H.Y., K.N., K.K., M.K., T.Y., S.M.). , Takafumi YokomatsuTakafumi Yokomatsu https://orcid.org/0000-0002-5700-5422 Department of Cardiology, Mitsubishi Kyoto Hospital (T.K., S.H., A.K., H.Y., K.N., K.K., M.K., T.Y., S.M.). and Shinji MikiShinji Miki Department of Cardiology, Mitsubishi Kyoto Hospital (T.K., S.H., A.K., H.Y., K.N., K.K., M.K., T.Y., S.M.). Originally published26 Apr 2022https://doi.org/10.1161/CIRCEP.121.010707Circulation: Arrhythmia and Electrophysiology. 2022;15Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: April 26, 2022: Ahead of Print Spatiotemporal electrogram dispersion, which has been reported as a novel sign of atrial fibrillation (AF) drivers, is a cluster of electrograms that displayed interelectrode time and space dispersion, which was described by Seitz et al.1 The aim of the present study was to elucidate clinical impact of atrial low voltage and spatiotemporal dispersion during AF rhythm on refractory AF.AF was mapped in both atria of 62 consecutive patients undergoing catheter ablation for persistent AF. Spatiotemporal dispersion and low voltage were evaluated in each mapping point during AF rhythm. Low voltage during AF rhythm was defined as maximum bipolar voltage during 230 milliseconds 30 seconds or those requiring repeat ablation procedures. The event-free rate was estimated by the Kaplan-Meier method, and the differences were assessed by the log-rank test. To evaluate adjusted risk for recurrent atrial tachyarrhythmia after the procedure by each arrhythmogenic substrate, we conducted multivariable analyses using the Cox proportional hazard models with variables with P<0.10 in full adjustment model because of the limited number of events. Written informed consent for the catheter ablation procedure and follow-up was obtained from all patients. Follow-up information was obtained by review of hospital-chart. The study protocol was approved by the institutional review board of Mitsubishi Memorial Kyoto Hospital. The data that support the findings of this study are available from the corresponding author upon reasonable request.Mean age of the current study population was 68.1 years and median AF duration was 0.7 (0.4–3.5) years including long-standing AF of 32.3%. Electroanatomic mapping with total 524±99 points (344 and 170 points in left and right atrium) was achieved in each patient. The mean prevalence of spatiotemporal dispersion and low voltage during AF rhythm were 5.6% and 35.1%. As arrhythmogenic substrate, large dispersion (≥8.0%) and low voltage (≥40.0%) were observed in 29.0% and 37% of the study patients.Median follow-up duration was 2.1 (1.9–2.4) years. After ablation procedure based on pulmonary vein isolation, the 2-year arrhythmia-free survival in patients with severe low voltage (≥40.0%) was significantly lower than those without (43.5% versus 79.5%, Log-rank P=0.003). The arrhythmia-free survival was also relatively but not significantly lower in patients with severe dispersion (≥8.0%) (55.6% versus 70.5% at 2 years, Log-rank P=0.23). Moreover, severe dispersion was associated with significantly lower arrhythmia-free survival even in patients with severe low voltage (0.0% versus 52.6% at 2 years, Log-rank P=0.01; Figure [A]). Spatiotemporal electrogram dispersion was rarely coexisting in low voltage during AF rhythm (0.5%). The concomitant dispersion and low voltage was also associated with significantly lower arrhythmia-free survival (40.0% [area≥0.8%] versus 69.2% [area<0.8%] versus 81.0% [none] at 2 years, Log-rank P=0.02; Figure [B]). Moreover, concomitant dispersion and low voltage area became an independent predictor for recurrent atrial tachyarrhythmia in multivariable analysis (adjusted hazard ratio, 4.36 [95% CI, 1.49–13.6], P=0.008). Representative cases of dispersion with and without low voltage were shown in Figure [C].Download figureDownload PowerPointFigure. Study results. A, The event-free survival from recurrent atrial tachyarrhythmias after procedure according to large spatiotemporal electrogram dispersion and/or low voltage, (B) according to concomitant spatiotemporal electrogram dispersion and low voltage, and (C) the representative examples of spatiotemporal electrogram dispersion: although persistent atrial fibrillation (AF) with isolated dispersion (small dispersion of 3.9% including 0.1% of concomitant dispersion and low voltage) could be restored by the ablation procedure based on pulmonary vein isolation, long-standing AF with concomitant dispersion and low voltage (large dispersion of 11.9% including 2.2% of concomitant dispersion and low voltage) was recurred after procedure. AP indicates anterior-posterior; LA, left atrium; and PA, posterior-anterior.In the present study, we focused spatiotemporal electrogram dispersion in low voltage area during AF rhythm, which was associated with refractory AF. Qin et al3 reported large dispersion distribution was associated with AF progression, left atrial enlargement, and short AF cycle length, which indicates AF drivers may play an important role for AF maintenance. We, furthermore, demonstrated large concomitant dispersion and low voltage area was associated with significantly higher risk for arrhythmia recurrence rate after ablation procedure. The correlation between AF drivers and low voltage zone was also reported in several studies. Nakahara et al4 reported circular activities during AF rhythm were frequently documented at or around left atrial contact area representing low voltage zone. Qin et al3 also demonstrated patchy low voltage zone was related to dispersion region. It may be because localized rotated activity driving AF needs slow conduction isthmus representing low voltage. The other possible reason is that changes of the local tissue characteristics with low voltage represent as pivoting of AF wavefronts. Although the current study did not assess the utility of the substrate ablation targeting concomitant dispersion and low voltage area, previous study reported by Jadidi et al5 showed significantly higher arrhythmia-free survival in patients with AF (N=85) receiving pulmonary vein isolation and selective voltage-guided ablation targeting low voltage zone with repetitive rotational activity than pulmonary vein isolation only.In the present study assessing the prognostic impact of the arrhythmogenic substrate on refractory AF, severe low voltage during AF rhythm, especially with coexisting spatiotemporal dispersion, was strongly associated with the higher arrhythmia-recurrence rate after ablation procedure.Article InformationAcknowledgmentWe appreciated all the members of the cardiac catheterization laboratory in Mitsubishi Kyoto Hospital for their contribution to this study.Sources of FundingNone.Nonstandard Abbreviations and AcronymsAFatrial fibrillationDisclosures None.FootnotesFor Sources of Funding and Disclosures, see page 341.Correspondence: Tetsuma Kawaji, MD, PhD, Department of Cardiology, Mitsubishi Kyoto Hospital, 1 Katsura Gosho-cho, Nishikyo-ku, Kyoto 615-8087, Japan. Email [email protected]kyoto-u.ac.jpReferences1. Seitz J, Bars C, Théodore G, Beurtheret S, Lellouche N, Bremondy M, Ferracci A, Faure J, Penaranda G, Yamazaki M, et al.. AF ablation guided by spatiotemporal electrogram dispersion without pulmonary vein isolation: a wholly patient-tailored approach.J Am Coll Cardiol. 2017; 69:303–321. doi: 10.1016/j.jacc.2016.10.065CrossrefMedlineGoogle Scholar2. Kawaji T, Hojo S, Kushiyama A, Nakatsuma K, Kaneda K, Kato M, Yokomatsu T, Miki S. Optimal cutoff value of bipolar low-voltage in electroanatomic voltage mapping during atrial fibrillation rhythm.Pacing Clin Electrophysiol. 2019; 42:663–669. doi: 10.1111/pace.13661CrossrefMedlineGoogle Scholar3. Qin M, Jiang WF, Wu SH, Xu K, Liu X. Electrogram dispersion-guided driver ablation adjunctive to high-quality pulmonary vein isolation in atrial fibrillation of varying durations.J Cardiovasc Electrophysiol. 2020; 31:48–60. doi: 10.1111/jce.14268CrossrefMedlineGoogle Scholar4. Nakahara S, Yamaguchi T, Hori Y, Anjo N, Hayashi A, Kobayashi S, Komatsu T, Sakai Y, Fukui A, Tsuchiya T, et al.. Spatial relation between left atrial anatomical contact areas and circular activation in persistent atrial fibrillation.J Cardiovasc Electrophysiol. 2016; 27:515–523. doi: 10.1111/jce.12907CrossrefMedlineGoogle Scholar5. Jadidi AS, Lehrmann H, Keyl C, Sorrel J, Markstein V, Minners J, Park CI, Denis A, Jaïs P, Hocini M, et al.. Ablation of persistent atrial fibrillation targeting low-voltage areas with selective activation characteristics.Circ Arrhythm Electrophysiol. 2016; 9:e002962. doi: 10.1161/CIRCEP.115.002962LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails May 2022Vol 15, Issue 5 Advertisement Article InformationMetrics © 2022 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.121.010707PMID: 35471037 Originally publishedApril 26, 2022 Keywordsinformed consentatrial fibrillationcatheter ablationtachycardiahospitalPDF download Advertisement SubjectsAtrial FibrillationCatheter Ablation and Implantable Cardioverter-Defibrillator
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