Abstract
In both clinical and computational studies, different pacing protocols are used to induce arrhythmia and non-inducibility is often considered as the endpoint of treatment. The need for a standardized methodology is urgent since the choice of the protocol used to induce arrhythmia could lead to contrasting results, e.g., in assessing atrial fibrillation (AF) vulnerabilty. Therefore, we propose a novel method—pacing at the end of the effective refractory period (PEERP)—and compare it to state-of-the-art protocols, such as phase singularity distribution (PSD) and rapid pacing (RP) in a computational study. All methods were tested by pacing from evenly distributed endocardial points at 1 cm inter-point distance in two bi-atrial geometries. Seven different atrial models were implemented: five cases without specific AF-induced remodeling but with decreasing global conduction velocity and two persistent AF cases with an increasing amount of fibrosis resembling different substrate remodeling stages. Compared with PSD and RP, PEERP induced a larger variety of arrhythmia complexity requiring, on average, only 2.7 extra-stimuli and 3 s of simulation time to initiate reentry. Moreover, PEERP and PSD were the protocols which unveiled a larger number of areas vulnerable to sustain stable long living reentries compared to RP. Finally, PEERP can foster standardization and reproducibility, since, in contrast to the other protocols, it is a parameter-free method. Furthermore, we discuss its clinical applicability. We conclude that the choice of the inducing protocol has an influence on both initiation and maintenance of AF and we propose and provide PEERP as a reproducible method to assess arrhythmia vulnerability.
Highlights
Atrial fibrillation (AF) is the most frequent cardiac arrhythmia and a progressive pathology associated with high morbidity and mortality (Hindricks et al, 2020)
We would like to recall that RPB300,200 and RPE300,200 were used for the models H1, H2, H3, H4, H4B, and RPB200,130 and RPE200,130 for the models Utah stage II case (UII) and Utah stage IV (UIV)
The application of the rapid pacing (RP) protocol resulted in inducing a majority of atrial flutter mechanisms in the model UII and no multi-frontal episode in either model with fibrosis
Summary
Atrial fibrillation (AF) is the most frequent cardiac arrhythmia and a progressive pathology associated with high morbidity and mortality (Hindricks et al, 2020). The modest efficacy reflects the complexity of the underlying phenomena and our incomplete understanding of the mechanisms of initiation, maintenance and progression of AF episodes (Andrade et al, 2014; Mann et al, 2018). Electrical stimulation has been widely used to diagnose and guide therapy of arrhythmias. PEERP to Assess Arrhythmia Vulnerability rhythm disorders, the sensitivity, specificity and reproducibility of mostly ventricular stimulation has been investigated (DiCarlo et al, 1985; Kudenchuk et al, 1986). An critical evaluation of protocols for induction of AF and atrial flutter is currently lacking
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