Wavefront Direction Research Articles

Conduction velocity-based functional substrate mapping during atrial fibrillation (AF) enhances identification of AF drivers compared to mapping during sinus rhythm

Abstract Background Conduction velocity (CV) heterogeneity is known to play a role in the initiation and maintenance of atrial fibrillation (AF) [1,2]. CV has been shown to decrease with cycle lengths (CLs) <600ms in low voltage areas (LVAs) [3,4], and with CLs <300ms in non-LVAs [4]. Yet, the impact of rhythm and CL on voltage-independent, CV-based atrial substrate mapping remains uncertain. Purpose This study evaluates CV differences based on mapping protocol and explores the relationship between CV and AF pathologic conduction patterns (PCPs) identified through global, non-contact, charge density mapping (CDM) [5]. Methods CDM was performed in twelve patients with persistent AF, presenting for de novo ablation. All mapping was performed prior to any ablation. Sinus rhythm (SR) CV was assessed during atrial pacing at two CLs (380ms and 800ms). To mitigate the impact of wavefront direction, pacing was performed at three sites: mid coronary sinus, left atrial appendage, and right atrial appendage. AF CV was determined from a 20-second continuous recording of global propagation. PCPs were identified as: focal firing (FF), rotational propagation (Localised Rotational Activation [LRA]), and pivoting propagation (Localised Irregular Activity [LIA]) [5]. Patients’ left atrial geometries consisted of approximately 3000 vertices, facilitating paired comparisons of spatial data. At each vertex, values for median CV dependent on mapping protocol and frequency of PCPs were utilised for analysis. Variables are presented as mean±standard deviation, median (interquartile range), and count (percentage) as appropriate. All analyses were performed using R (version 4.1.2). CV distributions were compared using the Analysis of Variance test. Results Mean age was 64±12 years, eight (67%) were male, median time since AF diagnosis was 3.1 (2-3.5) years, and median CHA2DS2-VASc score was 2 (2-4). Median CV across our cohort was significantly lower during AF than SR with either long or short CL pacing (0.37mm/ms vs 0.66mm/ms vs 0.61mm/ms, p<0.001). Histograms of CV vs left atrial surface area demonstrated similar distributions for both CLs. However, there was poor overlap with AF, which was prominently skewed towards slower CVs (Figure 1). Slower CVs during AF were associated with an increased frequency of PCPs (Figure 2), particularly FF with CVs <0.2mm/ms, and LRA and LIA with CVs <0.4mm/ms. This association was absent during SR. Conclusions Rhythm has a significant impact on CV-based functional substrate mapping. Slower CVs observed during AF likely result from the presence of CLs shorter than 300ms, which impact both LVA and non-LVA areas. Crucially, areas of slow CV during AF were associated with the location of PCPs. Mapping performed during AF may improve identification of areas where functional remodelling has preceded structural. Such areas, characterised by CV heterogeneity, may serve as promising targets for catheter ablation.Figure 1.Figure 2.

Omnipolar mapping and vector mapping in premature ventricular contractions ablation: a comparison with bipolar mapping

Abstract Background Omnipolar Mapping, with HD Grid high-density mapping catheter, overcomes the dependency of EGM characteristics to wavefront orientation, reconstructing the highest peak-to-peak voltage attainable within the electric field and the real wavefront direction, displayed in the form of a local activation vector [1][2]. Methods Consecutive patients who underwent radiofrequency ablation of PVCs from October 2021 to August 2023 at the Hospital Clinic of Barcelona were included in the study. EAM was performed with EnsiteX mapping system, Advisor HDgrid was used as mapping catheter. An activation map was performed if enough PVC burden. The area of interest was determined by earliest activation time combined with the morphology of unipolar electrogram during activation mapping. RF was delivered at the area of interest with target temperature of 45°C and maximum power of 50W. Both bipolar and omnipolar maps were analysed retrospectively. The reviewer was blinded to the ablation set for this analysis. A window of interest was created uniformally for all maps by defining a caliper within 15 ms before the onset of PVC. Activation vectors were displayed on the map and visually analysed. Three specific patterns were identified: Starburst, Homogeneous and Chaotic. Area of the earliest activation was measured. Earliest site of bipolar and omnipolar maps and specific location of star burst pattern were tagged. The site of the effective RF ablation was identified and the distance between points was determined. Results 18 patients were included. Overall, 11(61%) were males; age: 57,9±15,2 ys, 6(33%) patients haven't structural heart disease, 4(22%) presented PVC-induced cardiomyopathy. Mean left ventricular ejection fraction was 46±10. Mean PVC burden was 27±10%. In 9(50%) patients, PVCs were ablated from RVOT, 4(22%) in LVOT, 1(5%) in the left superior fascicle, 1(5%) in the antero-lateral papillary muscle, 2(10%) in the perihissian area and 1(5%) in the aortomitral continuity. Compared with bipolar, omnipolar mapping showed a smaller area of earliest activation(2,13±1,9mm2 vs 3,34±2,1 mm2,p<0,001), a shorter distance of the earliest point to starburst region(4,2±4,1mm vs 7,8±4,2mm,p<0,001) and shorter distance to the effective ablation site(6,1±3,9 mm vs 8,33±4,2mm, p<0,07). No significative difference was found between the effective RF ablation site and the starburst area compared to the distance between the effective RF ablation site and the omnipolar earliest deflection (6,11±3,9mm vs 6,5±4,3mm, p=0,6). No statistical significative difference was found between the timing of the earliest deflection in both settings (33,2±12,5 ms vs 31,5±12 ms, p=0,2) Conclusions Omnipolar mapping allows a better identification of the area of interest in PVC’s ablation compared to bipolar mapping. Vector mapping is a valuable asset to identify the earliest activation point to guide PVCs catheter ablation.Retrospective EAM analysisArea/distance measurements

Influence of Heart Rate and Change in Wavefront Direction through Pacing on Conduction Velocity and Voltage Amplitude in a Porcine Model: A High-Density Mapping Study.

Understanding the dynamics of conduction velocity (CV) and voltage amplitude (VA) is crucial in cardiac electrophysiology, particularly for substrate-based catheter ablations targeting slow conduction zones and low voltage areas. This study utilizes ultra-high-density mapping to investigate the impact of heart rate and pacing location on changes in the wavefront direction, CV, and VA of healthy pig hearts. We conducted in vivo electrophysiological studies on four healthy juvenile pigs, involving various pacing locations and heart rates. High-resolution electroanatomic mapping was performed during intrinsic normal sinus rhythm (NSR) and electrical pacing. The study encompassed detailed analyses at three levels: entire heart cavities, subregions, and localized 5-mm-diameter circular areas. Linear mixed-effects models were used to analyze the influence of heart rate and pacing location on CV and VA in different regions. An increase in heart rate correlated with an increase in conduction velocity and a decrease in voltage amplitude. Pacing influenced conduction velocity and voltage amplitude. Pacing also influenced conduction velocity and voltage amplitude, with varying effects observed based on the pacing location within different heart cavities. Pacing from the right atrium (RA) decreased CV in all heart cavities. The overall CV and VA changes in the whole heart cavities were not uniformly reflected in all subregions and subregional CV and VA changes were not always reflected in the overall analysis. Overall, there was a notable variability in absolute CV and VA changes attributed to pacing. Heart rate and pacing location influence CV and VA within healthy juvenile pig hearts. Subregion analysis suggests that specific regions of the heart cavities are more susceptible to pacing. High-resolution mapping aids in detecting regional changes, emphasizing the substantial physiological variations in CV and VA.

Distinct Electrogram Features and Ventricular Arrhythmia Induction Modes Between Repolarization and Conduction Heterogeneities

BackgroundRecent clinical studies have indicated the presence of localized electrical abnormalities in idiopathic ventricular fibrillation and J-wave syndrome patients. ObjectivesThis study aims to characterize the specific electrical signatures of localized repolarization and conduction heterogeneities and their respective role in vulnerability to arrhythmias. MethodsOptical mapping was performed in porcine right ventricles with local: 1) repolarization shortening; 2) conduction slowing; or 3) structural heterogeneity induced by locally perfusing: 1) pinacidil (20 μmol/L, n = 13); or 2) flecainide (2 μmol/L, n = 13) via an epicardial catheter; or 3) by local epicardial tissue destruction (9 radiofrequency lesions n = 12). Electrograms were recorded (n = 5 in each group) and spontaneous and induced arrhythmias were quantified and optically mapped. ResultsElectrograms were normal in (1) but showed local fragmentation in 40% of preparations in (2) with greater effects observed at high pacing frequencies dependent on the wavefront direction. In (3), the structural substrate alone increased the width and number of peaks in the electrograms, and addition of flecainide induced pronounced fragmentation (≥3 peaks and ≥70 ms) in all cases. Occurrence of spontaneous arrhythmias was significantly increased in (1) and (2) (P < 0.0001 and 0.05, respectively, vs baseline) and were triggered by ectopies. Vulnerability to arrhythmias at high pacing frequencies (≥2 Hz) was the lowest in (1) and greatest in (2). ConclusionsMicrostructural substrates have the most pronounced impact on electrograms, especially when combined with sodium channel blockers, whereas local action potential duration shortening does not lead to electrogram fragmentation even though it is associated with the highest prevalence of spontaneous arrhythmias.

Statistical Analysis of Low‐Latitude Boundary of Polar‐Type Medium‐Scale Traveling Ionospheric Disturbances Observed by a 630‐nm Airglow Imager at Nyrölä, Finland

AbstractMedium‐scale traveling ionospheric disturbances (MSTIDs) are one of the ionospheric plasma density structures and are observable through 630‐nm airglow images. Previous studies using airglow images at Tromsø (69.6°N, 19.2°E; magnetic latitude: 66.7°N), Norway, reported high‐latitude MSTIDs (here we call them as polar‐type MSTIDs) whose propagation direction changes associated with auroral brightening and magnetic field disturbances. However, there has been little statistical analysis on the connection of MSTIDs occurring at high and middle latitudes. In this study, we statistically analyzed the MSTIDs observed by an airglow imager at Nyrölä (62.3°N, 25.5°E; magnetic latitude: 59.4°N), Finland, which is located ∼7° south of Tromsø, corresponding to subauroral latitudes. The period analyzed was from 23 January 2017, to 30 September 2021. We found 11 cases of MSTIDs during this period. Eight cases were found to be the polar‐type MSTIDs whose motion changes associated with auroral brightening and magnetic field disturbances. We found that 9 cases of MSTID show the low‐latitude boundary at 61° ± 2°N for geographic latitude and 58° ± 2°N for magnetic latitude, indicating disconnection between high‐ and mid‐latitude MSTIDs. We also derived occurrence probability, velocity, wavelength, period, wave front direction, and propagation direction of these MSTIDs. The occurrence probability of MSTIDs at Nyrölä is 1.9%, which is much lower than those at high (Tromsoe, more than 50%) and middle (Japan, ∼30%) latitudes. We discuss these MSTID characteristics at subauroral latitudes based on possible difference of generation mechanisms of nighttime MSTIDs at high and middle latitudes.

Optimal cardiac rhythm during substrate mapping in scar-related ventricular tachycardia: Significance of wavefront direction on identifying critical sites

BackgroundA rotational activation pattern (RAP) around the localized line of a conduction block often correlates with sites specific to the critical zones of ventricular tachycardia (VT). The wavefront direction during substrate mapping affects manifestation of the RAP and line of block. ObjectiveThe purpose of this study was to investigate the most optimal cardiac rhythm for identifying RAP and line of block in substrate mapping. MethodsWe retrospectively evaluated 71 maps (median 3205 points/map) in 46 patients (65 ± 15 years; 33% with ischemic cardiomyopathy) who underwent high-density substrate mapping and ablation of scar-related VT. Appearance of a RAP during sinus, right ventricular (RV)-paced, left ventricular (LV)-paced, and biventricular-paced rhythms was investigated. ResultsRAP was identified in 24 of 71 maps (34%) in the region where wavefronts from a single direction reached but not in the region where wavefronts from multiple directions centripetally collided. The probability of identifying the RAP depended on scar location; that is, anteroseptal and inferoseptal, inferior and apical, and basal lateral RAPs were likely to be identified during sinus/atrial, RV-paced, and LV-paced rhythms, respectively. In 13 patients, the RAP was not evident in the baseline map but became apparent during remapping in the other rhythm, in which the wavefront reached the site earlier within the entire activation time. ConclusionThe optimal rhythm for substrate mapping depends on the spatial distribution of the area of interest. A paced rhythm with pacing sites near the scar may facilitate the identification of critical VT zones.

Abstract 14374: The Atrium Conduction Mappings Using Omnipolar Technology for Detecting Epicardial Connection in Patients With Atrial Fibrillation

Background: Epicardial connection (Epi-connection) between the right atrium (RA) and right pulmonary vein (RPV) has been known to complicate pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF). Meanwhile, the omnipolar voltage detected using EnSite™ Omnipolar Technology (OT) has been reported to facilitate the recognition of wavefront direction and see every signal in 360 degrees. Purpose: We investigated whether epicardial RA-RPV connection can be evaluated with OT mapping before PVI. Methods: We prospectively studied 113 consecutive patients (74 males, age 71±10 years, 68 paroxysmal AF) who underwent initial pulmonary vein isolation (PVI) for AF. The RA-RPV connections before PVI were assessed using OT mappings during right atrial pacing. True Epi-connections were defined as cases that required additional ablation medial to the PV more than 1 cm from the ablation line after the right PVI. Results: RA-RPV connections before PVI were detected in 7 out of 113 patients (6.2%). True Epi-connections were confirmed in 7 out of 113 patients (6.2%, 6 patients with carina and 1 with right superior PV) and were not related to any other clinical data, blood samples, or echocardiographic findings. Only 5 out of 7 patients with RA-RPV connections before PVI showed True Epi-connections (Figure). Conclusion: The prevalence of Epi-connections is not high, however, the conduction mapping using OT could be useful for detecting Epi-connection (especially non-carina Epi-connection) before PVI.

Hybrid Artificial Boundary Conditions for the Application of Blunt-Body Aerodynamic Noise Prediction

A hybrid artificial boundary condition (HABC) that combines the volume-based acoustic damping layer (ADL) and the local face-based characteristic boundary condition (CBC) is presented to enhance the absorption of acoustic waves near the computational boundaries. This method is applied to the prediction of aerodynamic noise from a circular cylinder immersed in uniform compressible viscous flow. Different ADLs are designed to assess their effectiveness whereby the effect of the mesh-stretch direction on wave absorption in the ADL is analysed. Large eddy simulation (LES) and FW-H acoustic analogy method are implemented to predict the far-field noise, and the sensitivities of each approach to the HABC are compared. In the LES computed propagation field of the fluctuation pressure and the frequency-domain results, the spurious reflections at edges are found to be significantly eliminated by the HABC through the effective dissipation of incident waves along the wave-front direction in the ADL. Thereby, the LES results are found to be in a good agreement with the acoustic pressure predicted using FW-H method, which is observed to be just affected slightly by reflected waves.

Association of Sinus Wavefront Activation and Ventricular Extrastimuli Mapping With Ventricular Tachycardia Re-Entrant Circuits

BackgroundSubstrate-based ablation targets areas of delayed and fractionated electrograms during sinus rhythm, which are sensitive for identifying the ventricular tachycardia (VT) isthmus but is influenced by the activation wavefront direction and decremental pacing. ObjectivesThe aim of this study was to correlate the areas of latest activation during varying wavefront activation mapping and decremental pacing mapping with sites critical to the VT isthmus. MethodsThree high-density electroanatomical substrate maps were created in patients presenting for ablation of monomorphic VT: 1) native sinus rhythm; 2) right ventricular (RV) apical pacing; and 3) an RV apical S2 map following the S1 drive train at 20 ms above the ventricular effective refractory period. Areas corresponding to the latest activation were compared with the VT isthmus identified by conventional mapping. ResultsTwenty patients with structural heart disease with a mean age of 55.6 ± 16.9 years were included. The majority of the cohort consisted of patients with ischemic heart disease (50%) and arrhythmogenic RV cardiomyopathy (35%). Epicardial ablation was performed in 45% of patients. The concordance of the site of latest activation in sinus rhythm with the VT isthmus was 75%. The location of the latest activation during RV apical pacing corresponded with the VT isthmus in 85% of cases. However, in 95% of cases, the site of the latest activation following the S2 stimulus colocalized to the VT isthmus. ConclusionsIn a mix of underlying myocardial substrates, regions of conduction slowing during decremental pacing colocalize with the VT isthmus more frequently than sinus rhythm activation mapping and may have a role in substrate-based ablation where VT induction is undesirable.

Evaluation and assessment of clique arrangements for the estimation of omnipolar electrograms in high density electrode arrays: an experimental animal model study

High-density catheters combined with Orientation Independent Sensing (OIS) methods have emerged as a groundbreaking technology for cardiac substrate characterisation. In this study, we aim to assess the arrangements and constraints to reliably estimate the so-called omnipolar electrogram (oEGM). Performance was evaluated using an experimental animal model. Thirty-eight recordings from nine retrospective experiments on isolated perfused rabbit hearts with an epicardial HD multielectrode were used. We estimated oEGMs according to the classic triangular clique (4 possible orientations) and a novel cross-orientation clique arrangement. Furthermore, we tested the effects of interelectrode spacing from 1 to 4 mm. Performance was evaluated by means of several parameters that measured amplitude rejection ratios, electric field loop area, activation pulse width and morphology distortion. Most reliable oEGM estimations were obtained with cross-configurations and interelectrode spacings le 2 mm. Estimations from triangular cliques resulted in wider electric field loops and unreliable detection of the direction of the propagation wavefront. Moreover, increasing interelectrode distance resulted in increased pulse width and morphology distortion. The results prove that current oEGM estimation techniques are insufficiently accurate. This study opens a new standpoint for the design of new-generation HD catheters and mapping software.

The omnipolar mapping technology-a new mapping tool to overcome "bipolar blindness" resulting in true high-density maps.

Omnipolar mapping (OT) is a novel tool to acquire omnipolar signals for electro-anatomical mapping, displaying true voltage and real-time wavefront direction and speed independent of catheter orientation. The aim was to analyze previously performed left atrial (LA) and left ventricular (LV) maps for differences using automated OT vs. standard bipolar settings (SD) and HD wave (HDW) algorithm. Previously obtained SD and HDW maps of the LA and LV using a 16-electrode, grid-shaped catheter were retrospectively analyzed by applying automated OT, comparing voltage, point density, pulmonary vein (PV) gaps, and LV scar area. In this analysis, 135 maps of 45 consecutive patients (30 treated for LA, 15 for LV arrhythmia) were included. Atrial maps revealed significantly higher point densities using OT (21471) vs. SD (6682) or HDW (12189, p < 0.001). Mean voltage was significantly higher using OT (0.75 mV) vs. SD (0.61 mV) or HDW (0.64 mV, p < 0.001). OT maps detected significantly more PV gaps per patient vs. SD (4 vs. 2), p = 0.001. In LV maps, OT revealed significantly higher point densities (25951) vs. SD (8582) and HDW (17071), p < 0.001. Mean voltage was significantly higher for OT (1.49 mV) vs. SD (1.19 mV) and HDW (1.2 mV), p < 0.001. Detected scar area was significantly smaller using OT (25.3%) vs. SD (33.9%, p < 0.001). OT mapping leads to significantly different substrate display, map density, voltage, detection of PV gaps, and scar size, compared to SD and HDW in LA and LV procedures. Successful CA might be facilitated due to true HD maps.

Double rhythm mapping for coherent electrophysiological substrate characterization in atrial fibrillation patients

Abstract Funding Acknowledgements Type of funding sources: None. Background Atrial fibrillation (AF) progresses with a cascade of combined structural, functional, and systemic dysfunctions. Electro-anatomical maps are employed to investigate pro-arrhythmic areas, characterized by abnormal electrical properties. However, single rhythm maps provide only a partial reconstruction: rhythm and wavefront directionality might mask some of these areas. Purpose To demonstrate that the combined quantitative analysis of different rhythm maps (i.e., parallel sinus rhythm and paced maps) could allow consistent identification of structural and functional defects sustaining AF. Methods Thirty AF clinical procedures have been performed with mapping system support. In particular, a sinus rhythm activation map and a paced map have been created with a multipolar catheter exploiting the parallel mapping feature by setting an extra beat (pacing interval = ERP + 40 ms) every three sinus beats. Areas of abnormal conduction have been identified and a comparison of electrophysiological biomarkers (EGMs voltage and fractionation) among the two rhythms has been performed. Results This comparative analysis allowed us to identify both structural and functional electrophysiological phenomena. Specifically, we distinguished: (i) abnormal conduction zones confirmed in both maps, both characterized by signal fractionation and a lower voltage (0,56 ± 0,18 mV) with respect to healthy atrial tissue (2,40 ± 0,41 mV), and (ii) abnormal conduction zones visible in only one of the two maps. In the latter, we distinguished whether the absence of the phenomena was due to wavefront orthogonality to the diseased area (revealed in paced rhythm thanks to a change in wavefront direction) or due to the presence of a functional phenomenon induced by the pacing. In the first group signal fractionation has been detected in both rhythms and a lower voltage has been found (1,79 ± 1,1 mV) with respect to normal conduction zones (3,26 ± 0,98 mV), while in functional cases EGMs fractionation has been identified only in paced maps and no significant difference has been observed in terms of voltage. Conclusion Double rhythm mapping provides a more robust characterization of atrial abnormal conduction phenomena. In fact, it allowed the distinction of true structural dysfunctions from dynamic (functional) ones thanks to the different wavefront directionality and rhythm. Moreover, the structural defects have been confirmed by EGMs analysis, which revealed both low voltage amplitude and high fractionation, characteristics that have not been reported in functional cases.

Multi-modal physiological parameter for mapping ablation lesions

Abstract Funding Acknowledgements Type of funding sources: None. Background In addition to variety of force time indices, electrophysiologist use peak to peak voltage (Vpp) and or S wave on unipolar electrogram to assess RF lesions they deliver. This strategy ignores cardiac conduction speed, direction, and wave curvature, all of which are affected by delivered lesion. Electrode array catheters such as the Advisor HD Grid allow individual cardiac wavefronts from sites to be characterized simultaneously in two dimensions from which vectorcardiograms can be derived. This underappreciated attribute of electrograms when integrated into activation mapping may provide new insights into the electrophysiologic state of tissue including wavefront amplitude, direction and velocity. Objective We tested the hypothesis that intracardiac vectorcardiogram loops contain aspects of properties that may better detect lesions compared to Vpp reduction and that a novel multi-modal approach will provide additional insights on wavefront interaction with substrate. Methods In 5 ex-vivo Langendorff perfused swine hearts, 56-pole (7 x 8 configuration) electrode arrays were sutured to the anterior epicardial left ventricle. Unipolar electrograms were acquired with UHN mapping system during programmed stimulation from all cardinal directions before and after creating RF ablation lesions. Vector loop maps were derived from orthogonal bipole pairs to study wavefront organization and voltage. Isochrone maps were generated from unipolar local activation times. Vector loop eccentricity was defined for each 4-electrode group as a function of loop’s major and minor axis lengths. Low values denote less eccentricity (more circular). Results An illustrative example of vector, loop and isochrone maps before and after ablation is shown in figures 1 and 2. Pre-ablation conditions show activation from a point stimulation on the left side with slender vector loops indicative of a relatively homogeneous linear conduction. In contrast, post-ablation vector loops are much less eccentric near the ablated area and smaller reflecting attenuated amplitude. Interestingly, near border zone locations large round loops are observed, suggesting curved or nonlinear wave propagation. Figure 2 shows that vector loops recorded from scar areas were diminished in size following ablation with a mean Vpp of 3.76 vs 2.18mV (p=0.0001) and exhibited less mean eccentricity, 0.925 vs 0.848 (p&amp;lt;0.0001), with more round loops (eccentricity &amp;lt; 0.7) found after ablation (12% of sites vs 4% pre-ablation, p &amp;lt; 0.0001). Conclusions Significant changes in loop characteristics were observed even when ablation induced voltage attenuation was minimal. This suggests that vectorial loop eccentricity may provide information in addition to omnipolar Vpp. Wavefront propagation disruption near ablation border zones is thus potentially valuable to detect lesion gaps. This information along with wave amplitude and direction can now be integrated into a novel multi-modal map.

The Omnipolar Mapping Technology - a new mapping tool to overcome bipolar blindness resulting in true high-density maps

Abstract Funding Acknowledgements Type of funding sources: None. Background Mapping, using the novel omnipolar technology (OT) obtains omnipolar signals displaying true voltage, real-time wavefront direction and speed, independent of catheter orientation and external reference. Employment of OT potentially overcomes so called "bipolar blindness" (conventional bipolar electroanatomic mapping). Hence, OT potentially improves substrate assessment, comprehension of tachycardia mechanisms and gap detection after previous catheter ablation (CA). Purpose Purposes of our study was to analyze previously performed left atrial (LA) and left ventricular (LV) maps for differences using automated OT vs. SD vs. the previously published HD Wave (HDW) algorithm. Methods Maps of patients undergoing CA for atrial or ventricular arrhythmia were initially acquired using HDW settings in conjunction with the Advisor HD Grid mapping catheter. These maps were then analyzed retrospectively applying the automated OT algorithm vs. SD vs. HDW. to reveal differences in voltage and point density. Additionally, detection of pulmonary vein (PV) gaps and LV scar area was evaluated. Results In 45 consecutive patients 135 maps were analyzed. The study population undergoing CA consisted of: 30 (22.2%) patients undergoing repeated CA for recurrence of persistent atrial fibrillation (persAF)/left atrial tachycardia (AT) and 15 (11.1%) patients with ventricular tachycardia (VT) or premature ventricular contractions (PVC). Atrial maps revealed a significantly higher point density using OT (21471) vs. SD (6682) or HDW (12189, p&amp;lt;0.001). Mean voltage was significantly higher using OT (0.75mV) vs. SD (0.61mV) or HDW (0.64mV, p&amp;lt;0.001). OT maps detected significantly more PV gaps vs. SD (4 vs. 2, p=0.001). In LV maps, OT revealed a significantly higher point density (25951) vs. SD (8582) and HDW (17071), p&amp;lt;0.001. Mean voltage was significantly higher for OT (1.49mV) vs. SD (1.19mV) and HDW (1.2mV), p&amp;lt;0.001. Detected scar area was significantly smaller using OT (25.3%) vs. SD (33.9%, p&amp;lt;0.001). Conclusion Using OT results in a higher voltage and point density compared to SD and HDW. Therefore displayed scar extend is significantly smaller in atrial and ventricular maps. Also, more PV gaps were detected using OT. The OT algorithm potentially improves scar delineation, facilitates substrate characterization, and may improve procedural outcome.

C4 DOUBLE RHYTHM MAPPING FOR COHERENT ELECTROPHYSIOLOGICAL SUBSTRATE CHARACTERIZATION IN ATRIAL FIBRILLATION PATIENTS

Abstract Background Atrial fibrillation (AF) progresses with a cascade of combined structural, functional, and systemic dysfunctions. Electro–anatomical maps are employed to investigate pro–arrhythmic areas. However, single rhythm maps provide only a partial reconstruction: rhythm and wavefront directionality might mask some of these areas. Purpose. To demonstrate that the combined quantitative analysis of different rhythm maps (i.e., parallel sinus rhythm and paced maps) could allow consistent identification of structural and functional defects sustaining AF. Methods Thirty AF clinical procedures have been performed with mapping system support. In particular, a sinus rhythm activation map and a paced map have been created with a multipolar catheter by setting an extra beat every three sinus beats. Areas of abnormal conduction have been identified and a comparison of electrophysiological biomarkers (EGMs voltage and fractionation) among the two rhythms has been performed. Results This comparative analysis allowed us to identify both structural and functional electrophysiological phenomena. Specifically, we distinguished: (i) abnormal conduction zones confirmed in both maps, both characterized by signal fractionation and a lower voltage (0,56 ± 0,18 mV) with respect to healthy atrial tissue (2,40 ± 0,41 mV), and (ii) abnormal conduction zones visible in only one of the two maps. In the latter, we distinguished whether the absence of the phenomena was due to wavefront orthogonality to the diseased area (revealed thanks to a change in wavefront direction) or due to the presence of a functional phenomenon induced by the pacing. In the first group signal fractionation has been detected in both rhythms and a lower voltage has been found (1,79 ± 1,1 mV) with respect to normal conduction zones (3,26 ± 0,98 mV), while in functional cases EGMs fractionation has been identified only in paced maps and no significant difference has been observed in terms of voltage. Conclusion Double rhythm mapping provides a more robust characterization of atrial abnormal conduction phenomena which better represent AF electrical substrate. It allows the distinction of true structural dysfunctions from dynamic ones thanks to the different wavefront directionality and paced rhythm. Moreover, the structural defects have been confirmed by EGMs analysis, which revealed both low voltage amplitude and high fractionation, characteristics that have not been reported in functional cases.

PO-04-134 STAR MAPPING METHOD TO IDENTIFY ENDO-EPICARDIAL DISSOCIATION AND DRIVING SITES IN PERSISTENT ATRIAL FIBRILLATION

Recurrence rates following ablation for persistent AF (psAF) remain high with the underlying mechanisms complex and poorly understood. Asynchronous activation of the endocardial and epicardial surfaces during AF, defined as endo-epicardial dissociation (EED) may be a driver for AF. We aim to investigate whether using the novel vector mapping approach, Stochastic Trajectory Analysis of Ranked (STAR) signals, endo- epicardial dissociation and early sites of activation (ESA) can be identified. Six (6) patients underwent endo-epicardial AF ablation utilizing the pericardial percutaneous CO2 insufflation technique. Two AdvisorTM HD Grid mapping catheters were placed in corresponding endocardial and epicardial positions in the left atrium. During AF, 30 second segments were recorded at the base of the left atrial appendage, anterior, inferior, left lateral and posterior LA wall. Fifteen (15) corresponding endo-epicardial segments were analysed using STAR maps and assessed for ESA and variation in direction of activation wavefront between the endocardium and epicardium. Activation wavefront direction was defined as dissociated if there was >40-degree difference between activation direction of simultaneous endo-epicardial wavefronts on STAR mapping. For each 30 second recording if there was more than 1 dominant wavefront direction, the 2 most common were used and an average taken. The overall mean difference in angulation of wavefront between the endocardium and epicardium was 71 ± 55 degrees. Nine (9) of 15 STAR maps (53%) showed activation angulation difference of >40 degrees between the endocardial and epicardial wavefront activation. Of these 9, 3 were on the posterior wall, 3 were at the base of the appendage, 2 were on the left lateral wall and 1 was on the anterior wall. ESA was identified in 6 STAR mapped endo and epicardial segments of AF, with 4 of these 6 (67%) ESAs in the epicardium. STAR mapping identifies activation wavefront discrepancy showing EED in multiple sites of the atrium with the majority of ESAs in the epicardial atrial surface.

PO-05-065 HIGH DENSITY PACE-MAPPING TO IDENTIFY FUNCTIONAL ARRHYTHMOGENIC SUBSTRATE IN SCAR-MEDIATED VENTRICULAR TACHYCARDIA

The location of conduction abnormality including activation slowing and wavefront discontinuity, which often corresponds to the critical zones of reentrant circuit in scar-mediated ventricular tachycardia (VT), is affected by the wavefront direction during substrate mapping. We hypothesized that an abrupt change in paced-QRS morphologies may occur at the region with conduction abnormality. This study assessed the conduction velocity in substrate mapping during at least two rhythms at the region where an abrupt change in paced-QRS morphologies was obtained. In a retrospective review of 57 patients who underwent functional substrate mapping for scar-mediated VT, 21 patients underwent it during multiple rhythms, that is intrinsic rhythm and paced rhythm with high-density pace-mapping in the area of interest. In 10 of these patients, those critical sites, as determined by direct termination during ablation (4 VTs, 33%) or pace-mapping findings (8 VTs, 67%) were identified in a total of 12 VTs. Conduction velocities during an intrinsic rhythm or paced rhythm at the isthmus area were assessed based on the difference of local activation time between two sites along the site where pace-mapping scores changed abruptly. Pace-mapping scores, which were obtained at two adjacent sites along the presumed isthmus, showed 92% [interquartile range [IQR] 89-96%] at the exit side and 48% [IQR 41-56%] at the adjacent entrance side. Ten patients (71±9 years, 9 (90%) male, 6 (60%) nonischemic) underwent high-density substrate mapping during multiple rhythms, that is intrinsic rhythm including sinus rhythm (n=7) or right ventricular pacing (n=5) and paced rhythm including right (n=5) or left ventricular pacing (n=7). Conduction velocity during intrinsic rhythm at the location of abrupt pacemap change was 0.37m/sec [IQR 0.19-0.43 m/sec], which was no slower than 0.25 m/sec, defined as activation slowing in previous studies. However, conduction velocity at abrupt pacemap change site that was faster in one of the multiple rhythms, was significantly slowed down when changing to the other rhythm (0.41 m/sec [IQR 0.25-1.05 m/sec] vs. 0.09 m/sec [IQR0.07-0.22 m/sec], P<0.01) (Fig.1). The abrupt change in paced-QRS morphology in a novel high-density pace-mapping strategy, which is shown independent of wavefront direction during substrate mapping, can identify the high-yield regions with conduction abnormality being critical for reentry.

Inverse ECG imaging as a novel solution for acute coronary syndrome classification from standard 12-lead ECG in the emergency department

Spiral wave reentry is a potential mechanism of atrial fibrillation (AF), but is difficult to differentiate clinically from multiple wavelet breakup using standard bipolar recordings. We developed a new methodology using bipolar recordings to estimate the direction of local activation wavefronts during AF by calculating the electrogram conformation (Egm-C). We subsequently used recurrence quantification analysis (RQA) of Egm-C to differentiate regions of spiral wave reentry from wavelet breakup.A 2D computer simulation was created with regions containing a stable spiral wave and also regions of wavebreak. A grid of 40 × 40 unipolar electrodes was superimposed. At each site, the actual wavefront direction (WD) was determined by comparing relative activation timings of the local intracellular recordings, and the estimated wavefront direction (Egm-C) was determined from the morphology of the local bipolar electrogram. RQA of Egm-C was compared to RQA of actual WD in order to differentiate AF mechanisms.RQA of actual WD and Egm-C both distinguished regions of spiral wave reentry from wavelet breakup with high correlation between the two methods (recurrence rate, r = 0.96; determinism, r = 0.61; line max, r = 0.95; entropy, r = 0.84; p < 0.001 for all). In areas of stable spiral wave reentry, the recurrence plots of both Egm-C and actual WD demonstrated stable, periodic dynamics, while regions of wavelet breakup demonstrated chaotic behavior largely devoid of repetitive activation patterns.Calculation of Egm-C allows RQA to be performed on bipolar electrograms during AF and differentiates regions of spiral wave reentry from multiple wavelet breakup.

Evaluation of RETRO-Mapping for electrophysiological features including direction of plane activity during atrial fibrillation using multipolar catheters in humans.

A quantifiable, automated standard of analyzing heart rhythm has long eluded cardiologists due, in part, to the limitations in technology and the ability to analyze large electrogram datasets. In this proof-of-concept study, we propose new measures to quantify plane activity in atrial fibrillation (AF) using our Representation of Electrical Tracking of Origin (RETRO)-Mapping software. We recorded 30 s segments of electrograms at the lower posterior wall of the left atrium using a 20-pole double loop catheter (AFocusII). The data were analyzed with the custom RETRO-Mapping algorithm in MATLAB. Thirty secondsegments were analyzed for number of activation edges, conduction velocity (CV), cycle length (CL), activation edge direction, and wavefront direction. These features were compared across 34 613 plane edges in three types of AF: persistent AF treated with amiodarone (11 906 wavefronts), persistent AF without amiodarone (14 959 wavefronts), and paroxysmal AF (7748 wavefronts). Change in activation edge direction between subsequent frames and change in overall wavefront direction between subsequent wavefronts were analyzed. All activation edge directions were represented across the lower posterior wall. The median change in activation edge direction followed a linear pattern for all three types of AF with R2 = 0.932 for persistent AF treated without amiodarone, R2 = 0.942 for paroxysmal AF, and R2 = 0.958 for persistent AF treated with amiodarone. All medians and the standard deviation error bars remained below 45° (suggesting all activation edges were traveling within a 90° sector, a criterion for plane activity). The directions of approximately half of all wavefronts (56.1% for persistent without amiodarone, 51.8% for paroxysmal, 48.8% for persistent with amiodarone) were predictive of the directions of the subsequent wavefront. RETRO-Mapping can measure electrophysiological features of activation activity and this proof-of-concept study suggests that this can be extended to the detection of plane activity in three types of AF. Wavefront direction may have a role in future work for predicting plane activity. For this study, we focused more on the ability of the algorithm to detect plane activity and less the differences between the types of AF. Future work should be in validating these results with a larger data set and comparing with other types of activation such as rotational, collision, and focal. Ultimately, this work can be implemented in real-time for prediction of wavefronts during ablation procedures.

Tandem Observations of Nighttime Mid‐Latitude Topside Ionospheric Perturbations

AbstractNighttime medium‐scale traveling ionospheric disturbances (MSTIDs) have been generally observed by ground‐based instruments. However, they provide 2‐dimensional images over only a limited field of view and are not distributed globally. The ground‐based observations reported that MSTID wavefronts exhibit backward‐C shapes virtually straddling the dip equator. In situ plasma density measurements onboard individual satellites could overcome the limited coverage of ground‐based MSTID observations. But, most of those spacecrafts could obtain only 1‐dimensional profiles of plasma density, which leaves uncertain whether the observed perturbations generally have the characteristic directivity of MSTIDs. This paper addresses this knowledge gap by statistically investigating nighttime perturbations in the mid‐latitude topside ionosphere observed by tandem satellites, Swarm A and C. We cross‐correlate the plasma density profiles observed by Swarm A and C. The correlation coefficient tends to increase as the two spacecraft move closer, allowing us to derive the disturbances' directivity whenever the Swarm A and C observations are correlated significantly. The directivity statistics agree well with the backward‐C shape. Furthermore, the wavefront directions have clear dependence on magnetic latitudes while they are not as well aligned with local time, which is also consistent with previous reports on nighttime MSTIDs using ground‐based observations and computer simulations. Additionally, we demonstrate that the nighttime MSTIDs can increase the topside Rate Of Total electron content Index above Swarm. All the above‐mentioned results support that the nighttime mid‐latitude perturbations observed by Swarm can be identified as MSTIDs on the whole, which is the most important finding of this paper.