Epicardial wave mapping in human long-lasting persistent atrial fibrillation: Transient rotational circuits, complex wavefronts, and disorganized activity

Geoffrey Lee, Saurabh Kumar, Andrew Teh, Andrew Madry, Steven Spence, Marco Larobina, John Goldblatt, Robin Brown, Victoria Atkinson, Simon Moten, Joseph B. Morton, Prashanthan Sanders, Peter M. Kistler, Jonathan M. Kalman

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Objectives To characterize the nature of atrial fibrillation (AF) activation in human persistent AF (PerAF) using modern tools including activation, directionality analyses, complex-fractionated electrogram, and spectral information.BackgroundThe mechanism of PerAF in humans is uncertain.Methods and resultsHigh-density epicardial mapping (128 electrodes/6.75 cm2) of the posterior LA wall (PLAW), LA and RA appendage (LAA, RAA), and RSPV-LA junction was performed in 18 patients with PerAF undergoing open heart surgery. Continuous 10 s recordings were analysed offline. Activation patterns were characterized into four subtypes (i) wavefronts (broad or multiple), (ii) rotational circuits (≥2 rotations of 360), (iii) focal sources with centrifugal activation of the entire mapping area, or (iv) disorganized activity [isolated chaotic activation(s) that propagate ≤3 bipoles or activation(s) that occur as isolated beats dissociated from the activation of adjacent bipole sites].Activation at a total of 36 regions were analysed (14 PLAW, 3 RSPV-LA, 12 LAA, and 7 RAA) creating a database of 2904 activation patterns. In the majority of maps, activation patterns were highly heterogeneous with multiple unstable activation patterns transitioning from one to another during each recording. A mean of 3.8 ± 1.6 activation subtypes was seen per map. The most common patterns seen were multiple wavefronts (56.2 ± 32%) and disorganized activity (24.2 ± 30.3%). Only 2 of 36 maps (5.5%) showed a single stable activation pattern throughout the 10-s period. These were stable planar wavefronts. Three transient rotational circuits were observed. Two of the transient circuits were located in the posterior left atrium, while the third was located on the anterior surface of the LAA. Focal activations accounted for 11.3 ± 14.2% of activations and were all short-lived (≤2 beats), with no site demonstrating sustained focal activity.ConclusionHuman long-lasting PerAF is characterized by heterogeneous and unstable patterns of activation including wavefronts, transient rotational circuits, and disorganized activity.

Original languageEnglish
Pages (from-to)86-97
Number of pages12
JournalEuropean Heart Journal
Issue number2
Publication statusPublished - 7 Jan 2014
Externally publishedYes


  • Atrial fibrillation

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