Korean J Physiol Pharmacol.  2016 Sep;20(5):507-514. 10.4196/kjpp.2016.20.5.507.

Spatial reproducibility of complex fractionated atrial electrogram depending on the direction and configuration of bipolar electrodes: an in-silico modeling study

• Song JS
• Lee YS
• Hwang M
• Lee JK
• Li C
• Joung B
• Lee MH
• Shim EB
• Pak HN

• KMID: 2350507
• DOI: http://doi.org/10.4196/kjpp.2016.20.5.507

Abstract

Although 3D-complex fractionated atrial electrogram (CFAE) mapping is useful in radiofrequency catheter ablation for persistent atrial fibrillation (AF), the directions and configuration of the bipolar electrodes may affect the electrogram. This study aimed to compare the spatial reproducibility of CFAE by changing the catheter orientations and electrode distance in an in-silico left atrium (LA). We conducted this study by importing the heart CT image of a patient with AF into a 3D-homogeneous human LA model. Electrogram morphology, CFAE-cycle lengths (CLs) were compared for 16 different orientations of a virtual bipolar conventional catheter (conv-cath: size 3.5 mm, inter-electrode distance 4.75 mm). Additionally, the spatial correlations of CFAE-CLs and the percentage of consistent sites with CFAE-CL<120 ms were analyzed. The results from the conv-cath were compared with that obtained using a mini catheter (mini-cath: size 1 mm, inter-electrode distance 2.5 mm). Depending on the catheter orientation, the electrogram morphology and CFAE-CLs varied (conv-cath: 11.5±0.7% variation, mini-cath: 7.1±1.2% variation), however the mini-cath produced less variation of CFAE-CL than conv-cath (p<0.001). There were moderate spatial correlations among CFAE-CL measured at 16 orientations (conv-cath: r=0.3055±0.2194 vs. mini-cath: 0.6074±0.0733, p<0.001). Additionally, the ratio of consistent CFAE sites was higher for mini catheter than conventional one (38.3±4.6% vs. 22.3±1.4%, p<0.05). Electrograms and CFAE distribution are affected by catheter orientation and electrode configuration in the in-silico LA model. However, there was moderate spatial consistency of CFAE areas, and narrowly spaced bipolar catheters were less influenced by catheter direction than conventional catheters.

Keyword

Atrial fibrillation; Bipolar electrogram; Complex fractionated atrial electrogram; Computational modeling

MeSH Terms

Atrial Fibrillation
Catheter Ablation
Catheters
Electrodes*
Electrophysiologic Techniques, Cardiac*
Heart
Heart Atria
Humans

Figure

• 

  Fig. 1 Design and configuration of the virtual bipolar catheter(A) Design of the conventional bipolar catheter (conv-cath). (B) Design of the mini catheter (mini-cath). The recording site (red point) is defined as the center of the distal electrode. (C) Configuration of the virtual bipolar catheter for 16 different orientations at each point of the tangent plane on the left atrial surface.

• 

  Fig. 2 Morphological similarity index and coefficient of variation of CFAE-CL among virtual bipolar electrograms of 16 different directions.(A) Morphological similarity index of bipolar electrogram between conventional catheter (conv-cath) and mini catheter (minicath). (B) Coefficient of variation of complex fractionated atrial electrogram-cycle length (CFAE-CL) between conv-cath and mini-cath. Both indices were calculated at each of the 400,000 nodes of the left atrial surface, and those from conv-cath were compared to mini-cath (p<0.001). Mean and SD are presented.

• 

  Fig. 3 Color-coded CFAE-CL map recorded by the conventional catheter (3.5mm tip, inter-electrode distance 4.75mm) at different catheter directions (θ=0° and 90°).(A) CFAE-CL map at catheter direction of θ=0°. (B) CFAE-CL map at catheter direction of θ=90°. Onesecond recordings of virtual bipolar electrograms at the tip of the distal electrode are presented.

• 

  Fig. 4 Color-coded CFAE-CL map recorded by the mini catheter (1.0 mm tip, inter-electrode distance 2.5 mm) at different catheter directions (θ=0° and 90°).((A) CFAE-CL map at catheter direction of θ=0°. (B) CFAE-CL map at catheter direction of θ=90°. One-second recordings of virtual bipolar electrograms at the tip of the distal electrode are presented.

• 

  Fig. 5 Analysis of the reproducibility of the CFAE map depending on the catheter direction.(A) Point-to-point linear correlation of CFAE-CL between the 0°-CFAE map and the 90°-CFAE map. (B) Pairwise correlation coefficients (r) between the θ1-CFAE and θ2-CFAE maps. The mean r values were 0.3055 ± 0.2194 (p<0.001) and 0.6074±0.0733 (p<0.001) for the conventional catheter (conv-cath) and mini catheter (mini-cath), respectively.

• 

  Fig. 6 Regional distribution of the CFAE area in the virtual CFAE map and the clinical CFAE map.The distribution of the consistent CFAE sites (CFAE-CL<120 ms) was calculated. LAA, left atrial appendage; PV, pulmonary veins; Roof, roof wall; Sep, septal wall; Lat, lateral wall; Ant, anterior wall; Post, posterior wall.

Reference

1. January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC Jr, Conti JB, Ellinor PT, Ezekowitz MD, Field ME, Murray KT, Sacco RL, Stevenson WG, Tchou PJ, Tracy CM, Yancy CW. ACC/AHA Task Force Members. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation. 2014; 130:e199–e267. PMID: 24682347.

2. Oral H, Knight BP, Tada H, Ozaydin M, Chugh A, Hassan S, Scharf C, Lai SW, Greenstein R, Pelosi F Jr, Strickberger SA, Morady F. Pulmonary vein isolation for paroxysmal and persistent atrial fibrillation. Circulation. 2002; 105:1077–1081. PMID: 11877358.

3. Tilz RR, Chun KR, Schmidt B, Fuernkranz A, Wissner E, Koester I, Baensch D, Boczor S, Koektuerk B, Metzner A, Zerm T, Ernst S, Antz M, Kuck KH, Ouyang F. Catheter ablation of long-standing persistent atrial fibrillation: a lesson from circumferential pulmonary vein isolation. J Cardiovasc Electrophysiol. 2010; 21:1085–1093. PMID: 20487116.

4. Nademanee K, McKenzie J, Kosar E, Schwab M, Sunsaneewitayakul B, Vasavakul T, Khunnawat C, Ngarmukos T. A new approach for catheter ablation of atrial fibrillation: mapping of the electrophysiologic substrate. J Am Coll Cardiol. 2004; 43:2044–2053. PMID: 15172410.

5. Brooks AG, Stiles MK, Laborderie J, Lau DH, Kuklik P, Shipp NJ, Hsu LF, Sanders P. Outcomes of long-standing persistent atrial fibrillation ablation: a systematic review. Heart Rhythm. 2010; 7:835–846. PMID: 20206320.

6. Oral H, Chugh A, Good E, Wimmer A, Dey S, Gadeela N, Sankaran S, Crawford T, Sarrazin JF, Kuhne M, Chalfoun N, Wells D, Frederick M, Fortino J, Benloucif-Moore S, Jongnarangsin K, Pelosi F Jr, Bogun F, Morady F. Radiofrequency catheter ablation of chronic atrial fibrillation guided by complex electrograms. Circulation. 2007; 115:2606–2612. PMID: 17502567.

7. Habel N, Znojkiewicz P, Thompson N, Müller JG, Mason B, Calame J, Calame S, Sharma S, Mirchandani G, Janks D, Bates J, Noori A, Karnbach A, Lustgarten DL, Sobel BE, Spector P. The temporal variability of dominant frequency and complex fractionated atrial electrograms constrains the validity of sequential mapping in human atrial fibrillation. Heart Rhythm. 2010; 7:586–593. PMID: 20156614.

8. Lau DH, Maesen B, Zeemering S, Verheule S, Crijns HJ, Schotten U. Stability of complex fractionated atrial electrograms: a systematic review. J Cardiovasc Electrophysiol. 2012; 23:980–987. PMID: 22554025.

9. Lin YJ, Tai CT, Kao T, Chang SL, Lo LW, Tuan TC, Udyavar AR, Wongcharoen W, Hu YF, Tso HW, Tsai WC, Chang CJ, Ueng KC, Higa S, Chen SA. Spatiotemporal organization of the left atrial substrate after circumferential pulmonary vein isolation of atrial fibrillation. Circ Arrhythm Electrophysiol. 2009; 2:233–241. PMID: 19808473.

10. Lin YJ, Tai CT, Kao T, Chang SL, Wongcharoen W, Lo LW, Tuan TC, Udyavar AR, Chen YJ, Higa S, Ueng KC, Chen SA. Consistency of complex fractionated atrial electrograms during atrial fibrillation. Heart Rhythm. 2008; 5:406–412. PMID: 18313599.

11. Blauer JJ, Swenson D, Higuchi K, Plank G, Ranjan R, Marrouche N, Macleod RS. Sensitivity and specificity of substrate mapping: an in silico framework for the evaluation of electroanatomical substrate mapping strategies. J Cardiovasc Electrophysiol. 2014; 25:774–780. PMID: 24762029.

12. Keller MW, Schuler S, Luik A, Seemann G, Schilling C, Schmitt C, Dössel O. Comparison of simulated and clinical intracardiac electrograms. Conf Proc IEEE Eng Med Biol Soc. 2013; 2013:6858–6861. PMID: 24111320.

13. Hwang M, Kwon SS, Wi J, Park M, Lee HS, Park JS, Lee YS, Shim EB, Pak HN. Virtual ablation for atrial fibrillation in personalized in-silico three-dimensional left atrial modeling: comparison with clinical catheter ablation. Prog Biophys Mol Biol. 2014; 116:40–47. PMID: 25261813.

14. Courtemanche M, Ramirez RJ, Nattel S. Ionic mechanisms underlying human atrial action potential properties: insights from a mathematical model. Am J Physiol. 1998; 275:H301–H321. PMID: 9688927.

15. Clayton RH, Bernus O, Cherry EM, Dierckx H, Fenton FH, Mirabella L, Panfilov AV, Sachse FB, Seemann G, Zhang H. Models of cardiac tissue electrophysiology: progress, challenges and open questions. Prog Biophys Mol Biol. 2011; 104:22–48. PMID: 20553746.

16. Brignole M, Menozzi C, Sartore B, Barra M, Monducci I. The use of atrial pacing to induce atrial fibrillation and flutter. Int J Cardiol. 1986; 12:45–54. PMID: 3733266.

17. Zozor S, Blanc O, Jacquemet V, Virag N, Vesin JM, Pruvot E, Kappenberger L, Henriquez C. A numerical scheme for modeling wavefront propagation on a monolayer of arbitrary geometry. IEEE Trans Biomed Eng. 2003; 50:412–420. PMID: 12723052.

18. Yun Y, Hwang M, Park JH, Shin H, Shim EB, Pak HN. The relationship among complex fractionated electrograms, wavebreak, phase singularity, and local dominant frequency in fibrillation wave-dynamics: a modeling comparison study. J Korean Med Sci. 2014; 29:370–377. PMID: 24616586.

19. Potse M, Vinet A, Opthof T, Coronel R. Validation of a simple model for the morphology of the T wave in unipolar electrograms. Am J Physiol Heart Circ Physiol. 2009; 297:H792–H801. PMID: 19465555.

20. Plonsey R, Barr RC. Current flow patterns in two-dimensional anisotropic bisyncytia with normal and extreme conductivities. Biophys J. 1984; 45:557–571. PMID: 6713068.

21. Faes L, Nollo G, Antolini R, Gaita F, Ravelli F. A method for quantifying atrial fibrillation organization based on wave-morphology similarity. IEEE Trans Biomed Eng. 2002; 49:1504–1513. PMID: 12549732.

22. Park JH, Park SW, Kim JY, Kim SK, Jeoung B, Lee MH, Hwang C, Kim YH, Kim SS, Pak HN. Characteristics of complex fractionated atrial electrogram in the electroanatomically remodeled left atrium of patients with atrial fibrillation. Circ J. 2010; 74:1557–1563. PMID: 20562494.

23. Konings KT, Smeets JL, Penn OC, Wellens HJ, Allessie MA. Configuration of unipolar atrial electrograms during electrically induced atrial fibrillation in humans. Circulation. 1997; 95:1231–1241. PMID: 9054854.

24. Takahashi Y, O'Neill MD, Hocini M, Dubois R, Matsuo S, Knecht S, Mahapatra S, Lim KT, Jaïs P, Jonsson A, Sacher F, Sanders P, Rostock T, Bordachar P, Clémenty J, Klein GJ, Haïssaguerre M. Characterization of electrograms associated with termination of chronic atrial fibrillation by catheter ablation. J Am Coll Cardiol. 2008; 51:1003–1010. PMID: 18325439.

25. Lin J, Scherlag BJ, Zhou J, Lu Z, Patterson E, Jackman WM, Lazzara R, Po SS. Autonomic mechanism to explain complex fractionated atrial electrograms (CFAE). J Cardiovasc Electrophysiol. 2007; 18:1197–1205. PMID: 17916143.

26. Atienza F, Calvo D, Almendral J, Zlochiver S, Grzeda KR, Martínez-Alzamora N, González-Torrecilla E, Arenal A, Fernández-Avilés F, Berenfeld O. Mechanisms of fractionated electrograms formation in the posterior left atrium during paroxysmal atrial fibrillation in humans. J Am Coll Cardiol. 2011; 57:1081–1092. PMID: 21349400.

27. Jalife J, Berenfeld O, Mansour M. Mother rotors and fibrillatory conduction: a mechanism of atrial fibrillation. Cardiovasc Res. 2002; 54:204–216. PMID: 12062327.

28. Jacquemet V, Henriquez CS. Genesis of complex fractionated atrial electrograms in zones of slow conduction: a computer model of microfibrosis. Heart Rhythm. 2009; 6:803–810. PMID: 19467508.

29. Zlochiver S, Yamazaki M, Kalifa J, Berenfeld O. Rotor meandering contributes to irregularity in electrograms during atrial fibrillation. Heart Rhythm. 2008; 5:846–854. PMID: 18534369.

30. Chen X, Hu Y, Fetics BJ, Berger RD, Trayanova NA. Unstable QT interval dynamics precedes ventricular tachycardia onset in patients with acute myocardial infarction: a novel approach to detect instability in QT interval dynamics from clinical ECG. Circ Arrhythm Electrophysiol. 2011; 4:858–866. PMID: 21841208.

31. Vadakkumpadan F, Arevalo H, Ceritoglu C, Miller M, Trayanova N. Image-based estimation of ventricular fiber orientations for personalized modeling of cardiac electrophysiology. IEEE Trans Med Imaging. 2012; 31:1051–1060. PMID: 22271833.

32. Ng J, Jacobson JT, Ng JK, Gordon D, Lee DC, Carr JC, Goldberger JJ. Virtual electrophysiological study in a 3-dimensional cardiac magnetic resonance imaging model of porcine myocardial infarction. J Am Coll Cardiol. 2012; 60:423–430. PMID: 22633654.

33. Ruchat P, Virag N, Dang L, Schlaepfer J, Pruvot E, Kappenberger L. A biophysical model of atrial fibrillation ablation: what can a surgeon learn from a computer model? Europace. 2007; 9(Suppl 6):vi71–vi76. PMID: 17959696.

34. Ryu K, Khrestian CM, Matsumoto N, Sahadevan J, Goldstein RN, Dorostkar PC, Waldo AL. Characterization of the critical cycle length of a left atrial driver which causes right atrial fibrillatory conduction. Conf Proc IEEE Eng Med Biol Soc. 2004; 6:3960–3963.

35. Sanders P, Berenfeld O, Hocini M, Jaïs P, Vaidyanathan R, Hsu LF, Garrigue S, Takahashi Y, Rotter M, Sacher F, Scavée C, Ploutz-Snyder R, Jalife J, Haïssaguerre M. Spectral analysis identifies sites of high-frequency activity maintaining atrial fibrillation in humans. Circulation. 2005; 112:789–797. PMID: 16061740.

36. Ashihara T, Haraguchi R, Nakazawa K, Namba T, Ikeda T, Nakazawa Y, Ozawa T, Ito M, Horie M, Trayanova NA. The role of fibroblasts in complex fractionated electrograms during persistent/permanent atrial fibrillation: implications for electrogram-based catheter ablation. Circ Res. 2012; 110:275–284. PMID: 22179057.

37. Weinberg S, Iravanian S, Tung L. Representation of collective electrical behavior of cardiac cell sheets. Biophys J. 2008; 95:1138–1150. PMID: 18469085.