Abstract
Electrocardiographic mapping (ECGI) detects reentrant drivers (RDs) that perpetuate arrhythmia in persistent AF (PsAF). Patient-specific computational models derived from late gadolinium-enhanced magnetic resonance imaging (LGE-MRI) identify all latent sites in the fibrotic substrate that could potentially sustain RDs, not just those manifested during mapped AF. The objective of this study was to compare RDs from simulations and ECGI (RDsim/RDECGI) and analyze implications for ablation. We considered 12 PsAF patients who underwent RDECGI ablation. For the same cohort, we simulated AF and identified RDsim sites in patient-specific models with geometry and fibrosis distribution from pre-ablation LGE-MRI. RDsim- and RDECGI-harboring regions were compared, and the extent of agreement between macroscopic locations of RDs identified by simulations and ECGI was assessed. Effects of ablating RDECGI/RDsim were analyzed. RDsim were predicted in 28 atrial regions (median [inter-quartile range (IQR)] = 3.0 [1.0; 3.0] per model). ECGI detected 42 RDECGI-harboring regions (4.0 [2.0; 5.0] per patient). The number of regions with RDsim and RDECGI per individual was not significantly correlated (R = 0.46, P = ns). The overall rate of regional agreement was fair (modified Cohen's κ0 statistic = 0.11), as expected, based on the different mechanistic underpinning of RDsim- and RDECGI. nineteen regions were found to harbor both RDsim and RDECGI, suggesting that a subset of clinically observed RDs was fibrosis-mediated. The most frequent source of differences (23/32 regions) between the two modalities was the presence of RDECGI perpetuated by mechanisms other than the fibrotic substrate. In 6/12 patients, there was at least one region where a latent RD was observed in simulations but was not manifested during clinical mapping. Ablation of fibrosis-mediated RDECGI (i.e., targets in regions that also harbored RDsim) trended toward a higher rate of positive response compared to ablation of other RDECGI targets (57 vs. 41%, P = ns). Our analysis suggests that RDs in human PsAF are at least partially fibrosis-mediated. Substrate-based ablation combining simulations with ECGI could improve outcomes.
Highlights
Atrial fibrillation (AF) is the most prevalent sustained arrhythmia, affecting 1–2% of the population (Andrade et al, 2014)
For the present follow-up study, which has distinct aims and scope, we considered the subset of 12 cases in which at least one reentrant driver (RD) was identified by electrocardiographic mapping (ECGI) (RDECGI) and at least one RD was induced in the corresponding patient-specific model (RDsim)
Two thirds of all RDsim observed were in three regions: the left Pulmonary Vein (PV) (25.0%), posterior left atrium (LA) (21.4%), and the superior right atrium (RA) (21.4%)
Summary
Atrial fibrillation (AF) is the most prevalent sustained arrhythmia, affecting 1–2% of the population (Andrade et al, 2014). A promising non-invasive approach uses electrocardiographic mapping (ECGI) to reconstruct atrial activations from body surface potentials and approximate the locations of reentrant drivers (RDs; i.e., rotors) sustaining AF, which are targeted for ablation (Haissaguerre et al, 2014; Lim et al, 2017). In cases of failed ablation, AF is typically sustained by persistent RDs at different locations (Lalani et al, 2016). This indicates that ECGI-driven RD ablation did not modify the arrhythmogenic substrate sufficiently to eliminate its capacity to Abbreviations: AT, Atrial Tachycardia; LGE-MRI, Late Gadolinium-Enhanced Magnetic Resonance Imaging; LA, Left Atrium; PsAF, Persistent Atrial Fibrillation; PV, Pulmonary Vein; RA, Right Atrium; SR, Sinus Rhythm
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