Maintenance Mechanism of Paroxysmal Atrial Fibrillation from the Activation Occurring Within the Pulmonary Vein: Analysis Using Non-contact Mapping

Overview

Journal Heart Vessels

Specialty Cardiology & Vascular Diseases

Date 2024 Dec 7

PMID 39644400

Authors

Hiroshige Yamabe

Toshiya Soejima

Yurie Fukami

Kazuki Haraguchi

Taichi Okonogi

Keisuke Hirai

Ryota Fukuoka

Kyoko Umeji

Yoshiya Orita

Hisashi Koga

Tomohiro Kawasaki

Affiliations

Soon will be listed here.

Abstract

It is unclear how pulmonary veins (PVs) maintain paroxysmal atrial fibrillation (AF). To clarify the PV's arrhythmogenic role, we examined PV activation sequences during paroxysmal AF. Left superior PV (LSPV) endocardial non-contact mapping was performed after a right PV isolation in 13 paroxysmal AF patients. Activation sequences within the LSPV before and during left-sided PVs ablation were analyzed, and those in complex fractionated atrial electrogram (CFAE) areas were compared with those in non-CFAE areas. CFAEs were observed in the LSPV's proximal half (area; 8.8 ± 3.2cm) occupying 19.9 ± 6.0% of LSPV. The number of pivoting activations, wave breaks, and fusions over CFAE areas were significantly higher than those over non-CFE areas (25.5 ± 9.3 vs. 4.5 ± 4.8 times/s, p < 0.0001; 9.1 ± 5.3 vs. 1.4 ± 1.8 times/s, p < 0.0001; 13.0 ± 4.6 vs. 5.4 ± 4.4 times/s, p < 0.0001). The conduction velocities in CFAE areas were significantly slower than in non-CFAE areas (0.6 ± 0.2 vs. 1.7 ± 0.8 m/s, p < 0.001). After delivery of ablation lesions around the left-sided PVs (13.2 ± 7.4 applications), the PV activation became organized with a loss of CFAE areas, and the frequency of the LSPV's pivoting activation, wave break, and fusion significantly decreased compared to that pre-ablation (7.3 ± 10.9 vs. 30.0 ± 11.6 times/s, p < 0.001; 2.1 ± 5.3 vs. 10.5 ± 6.2 times/s, p < 0.002; 6.0 ± 6.6 vs. 18.4 ± 8.2 times/s, p < 0.001). Subsequently, AF terminated before the left-sided PV isolation in all patients. In conclusion, high-frequency random reentry associated with pivoting activation, wave break, and fusion within the LSPV, observed mostly over CFAE areas, maintained AF. Linear ablation lesions around the PV suppressed random reentry, resulting in the loss of CFAEs and AF termination.

References

Haissaguerre M, Jais P, Shah D, Takahashi A, Hocini M, Quiniou G . Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998; 339(10):659-66. DOI: 10.1056/NEJM199809033391003. View

Haissaguerre M, Sanders P, Hocini M, Jais P, Clementy J . Pulmonary veins in the substrate for atrial fibrillation: the "venous wave" hypothesis. J Am Coll Cardiol. 2004; 43(12):2290-2. DOI: 10.1016/j.jacc.2004.03.036. View

Oral H, Knight B, Tada H, Ozaydin M, Chugh A, Hassan S . Pulmonary vein isolation for paroxysmal and persistent atrial fibrillation. Circulation. 2002; 105(9):1077-81. DOI: 10.1161/hc0902.104712. View

Yano M, Egami Y, Kawanami S, Sugae H, Ukita K, Kawamura A . Acute myocardial injury after radiofrequency catheter ablation: impact on pulmonary vein reconnection and relevant factors. Heart Vessels. 2021; 37(5):812-820. DOI: 10.1007/s00380-021-01972-2. View

Aoyama D, Miyazaki S, Amaya N, Tama N, Hasegawa K, Nomura R . Treatment with catheter ablation for patients with arrhythmia-induced cardiomyopathy caused by atrial fibrillation promises a good prognosis. Heart Vessels. 2023; 39(3):240-251. DOI: 10.1007/s00380-023-02329-7. View

Kuck K, Hoffmann B, Ernst S, Wegscheider K, Treszl A, Metzner A . Impact of Complete Versus Incomplete Circumferential Lines Around the Pulmonary Veins During Catheter Ablation of Paroxysmal Atrial Fibrillation: Results From the Gap-Atrial Fibrillation-German Atrial Fibrillation Competence Network 1 Trial. Circ Arrhythm Electrophysiol. 2016; 9(1):e003337. DOI: 10.1161/CIRCEP.115.003337. View

Mujovic N, Marinkovic M, Lenarczyk R, Tilz R, Potpara T . Catheter Ablation of Atrial Fibrillation: An Overview for Clinicians. Adv Ther. 2017; 34(8):1897-1917. PMC: 5565661. DOI: 10.1007/s12325-017-0590-z. View

Scherr D, Dalal D, Cheema A, Cheng A, Henrikson C, Spragg D . Automated detection and characterization of complex fractionated atrial electrograms in human left atrium during atrial fibrillation. Heart Rhythm. 2007; 4(8):1013-20. DOI: 10.1016/j.hrthm.2007.04.021. View

Chen J, Off M, Solheim E, Hoff P, Schuster P, Ohm O . Spatial relationships between the pulmonary veins and sites of complex fractionated atrial electrograms during atrial fibrillation. Pacing Clin Electrophysiol. 2009; 32 Suppl 1:S190-3. DOI: 10.1111/j.1540-8159.2008.02282.x. View

10.

Yamabe H, Morihisa K, Tanaka Y, Uemura T, Enomoto K, Kawano H . Mechanisms of the maintenance of atrial fibrillation: role of the complex fractionated atrial electrogram assessed by noncontact mapping. Heart Rhythm. 2009; 6(8):1120-8. DOI: 10.1016/j.hrthm.2009.04.021. View

11.

Yamabe H, Morihisa K, Koyama J, Enomoto K, Kanazawa H, Ogawa H . Analysis of the mechanisms initiating random wave propagation at the onset of atrial fibrillation using noncontact mapping: role of complex fractionated electrogram region. Heart Rhythm. 2011; 8(8):1228-36. DOI: 10.1016/j.hrthm.2011.02.032. View

12.

Nademanee K, McKenzie J, Kosar E, Schwab M, Sunsaneewitayakul B, Vasavakul T . A new approach for catheter ablation of atrial fibrillation: mapping of the electrophysiologic substrate. J Am Coll Cardiol. 2004; 43(11):2044-53. DOI: 10.1016/j.jacc.2003.12.054. View

13.

MOE G, RHEINBOLDT W, Abildskov J . A COMPUTER MODEL OF ATRIAL FIBRILLATION. Am Heart J. 1964; 67:200-20. DOI: 10.1016/0002-8703(64)90371-0. View

14.

Jalife J . Rotors and spiral waves in atrial fibrillation. J Cardiovasc Electrophysiol. 2003; 14(7):776-80. DOI: 10.1046/j.1540-8167.2003.03136.x. View

15.

Kalifa J, Tanaka K, Zaitsev A, Warren M, Vaidyanathan R, Auerbach D . Mechanisms of wave fractionation at boundaries of high-frequency excitation in the posterior left atrium of the isolated sheep heart during atrial fibrillation. Circulation. 2006; 113(5):626-33. DOI: 10.1161/CIRCULATIONAHA.105.575340. View

16.

Yamabe H, Kanazawa H, Ito M, Kaneko S, Ogawa H . Prevalence and mechanism of rotor activation identified during atrial fibrillation by noncontact mapping: Lack of evidence for a role in the maintenance of atrial fibrillation. Heart Rhythm. 2016; 13(12):2323-2330. DOI: 10.1016/j.hrthm.2016.07.030. View

17.

Jais P, Hocini M, Macle L, Choi K, Deisenhofer I, Weerasooriya R . Distinctive electrophysiological properties of pulmonary veins in patients with atrial fibrillation. Circulation. 2002; 106(19):2479-85. DOI: 10.1161/01.cir.0000036744.39782.9f. View

18.

Arora R, Verheule S, Scott L, Navarrete A, Katari V, Wilson E . Arrhythmogenic substrate of the pulmonary veins assessed by high-resolution optical mapping. Circulation. 2003; 107(13):1816-21. PMC: 1995670. DOI: 10.1161/01.CIR.0000058461.86339.7E. View

19.

Hocini M, Ho S, Kawara T, Linnenbank A, Potse M, Shah D . Electrical conduction in canine pulmonary veins: electrophysiological and anatomic correlation. Circulation. 2002; 105(20):2442-8. DOI: 10.1161/01.cir.0000016062.80020.11. View

20.

Schotten U, Verheule S, Kirchhof P, Goette A . Pathophysiological mechanisms of atrial fibrillation: a translational appraisal. Physiol Rev. 2011; 91(1):265-325. DOI: 10.1152/physrev.00031.2009. View