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Time-Averaged Wavefront Analysis Demonstrates Preferential Pathways of Atrial Fibrillation, Predicting Pulmonary Vein Isolation Acute Response

Research output: Contribution to journalArticlepeer-review

Original languageEnglish
Article number707189
JournalFrontiers in Physiology
Volume12
Early online date27 Sep 2021
DOIs
Accepted/In press24 Aug 2021
E-pub ahead of print27 Sep 2021
Published27 Sep 2021

Bibliographical note

Funding Information: CHR acknowledges a Medical Research Council Skills Development Fellowship (MR/S015086/1). This study was supported by the UK Engineering and Physical Sciences Research Council (EP/P010741/1, EP/F043929/1, EP/P01268X/1). This study was supported by the Wellcome Trust Center for Medical at King’s College London, and the Department of Health via the National Institute for Health Research Biomedical Research Centre award to Guy’s & St Thomas’ NHS Foundation Trust in partnership with King’s College London and King’s College Hospital NHS Foundation Trust; the London Medical Imaging and AI Centre for Value-Based Healthcare and the King’s College London BHF centre of research excellence. This work Publisher Copyright: © Copyright © 2021 Roney, Child, Porter, Sim, Whitaker, Clayton, Laughner, Shuros, Neuzil, Williams, Razavi, O'Neill, Rinaldi, Taggart, Wright, Gill and Niederer.

King's Authors

Abstract

Electrical activation during atrial fibrillation (AF) appears chaotic and disorganised, which impedes characterisation of the underlying substrate and treatment planning. While globally chaotic, there may be local preferential activation pathways that represent potential ablation targets. This study aimed to identify preferential activation pathways during AF and predict the acute ablation response when these are targeted by pulmonary vein isolation (PVI). In patients with persistent AF (n = 14), simultaneous biatrial contact mapping with basket catheters was performed pre-ablation and following each ablation strategy (PVI, roof, and mitral lines). Unipolar wavefront activation directions were averaged over 10 s to identify preferential activation pathways. Clinical cases were classified as responders or non-responders to PVI during the procedure. Clinical data were augmented with a virtual cohort of 100 models. In AF pre-ablation, pathways originated from the pulmonary vein (PV) antra in PVI responders (7/7) but not in PVI non-responders (6/6). We proposed a novel index that measured activation waves from the PV antra into the atrial body. This index was significantly higher in PVI responders than non-responders (clinical: 16.3 vs. 3.7%, p = 0.04; simulated: 21.1 vs. 14.1%, p = 0.02). Overall, this novel technique and proof of concept study demonstrated that preferential activation pathways exist during AF. Targeting patient-specific activation pathways that flowed from the PV antra to the left atrial body using PVI resulted in AF termination during the procedure. These PV activation flow pathways may correspond to the presence of drivers in the PV regions.

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