Abstract

This editorial refers to ‘Epicardial wave mapping in human long-lasting persistent atrial fibrillation: transient rotational circuits, complex wavefronts, and disorganized activity’, by G. Lee et al. doi:10.1093/eurheartj/eht267 In the study of Lee and co-workers,1 in 18 patients undergoing open heart surgery for mitral or aortic valve disease, high-density mapping of the atria was performed (128 electrodes/6.75 cm2). The mapping plaque was positioned consecutively on the left and right atrial appendages, the posterior wall of the left atrium, and the right superior pulmonary vein (RSPV)–left atrial (LA) junction. In the majority of maps, activation patterns were highly heterogeneous, with multiple unstable activation patterns transitioning from one to another during each recording. The most common patterns seen were multiple wavefronts (56.2 ± 32%) and disorganized activity (24.2 ± 30.3%). Focal activations accounted for 11.3 ± 14.2% of activations and were all short lived ( ≤2 beats), with no site demonstrating sustained focal activity. Two of 36 maps (5.5%) showed a stable activation pattern, consisting of consecutive planar wavefronts propagating in the same direction. Only three transient rotational circuits were observed [two in the posterior left atrium and one on the anterior surface of the left atrial appendage (LAA)]. Two of these circuits lasted for only 5–7 revolutions, whereas the third broke up within < 5 s. On the basis of these observations, the authors conclude that: ‘Human long-lasting persistent AF is characterized by heterogeneous and unstable patterns of activation including multiple wavefronts, transient rotational circuits, and disorganized activity’. The investigators have to be complimented on their efforts carefully to visualize and dissect the complex activation patterns during long-standing human atrial fibrillation (AF). Studies like these are quite scarce, because attempts to diagnose the underlying substrate of AF are very time-consuming and usually considered less attractive than evaluating the rate of …

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