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Impact of Ischemic and Valvular Heart Disease on Atrial Excitation:A High-Resolution Epicardial Mapping Study.

ABSTRACT: BACKGROUND:The influence of underlying heart disease or presence of atrial fibrillation (AF) on atrial excitation during sinus rhythm (SR) is unknown. We investigated atrial activation patterns and total activation times of the entire atrial epicardial surface during SR in patients with ischemic and/or valvular heart disease with or without AF. METHODS AND RESULTS:Intraoperative epicardial mapping (N=128/192 electrodes, interelectrode distances: 2 mm) of the right atrium, Bachmann's bundle (BB), left atrioventricular groove, and pulmonary vein area was performed during SR in 253 patients (186 male [74%], age 66±11 years) with ischemic heart disease (N=132, 52%) or ischemic valvular heart disease (N=121, 48%). As expected, SR origin was located at the superior intercaval region of the right atrium in 232 patients (92%). BB activation occurred via 1 wavefront from right-to-left (N=163, 64%), from the central part (N=18, 7%), or via multiple wavefronts (N=72, 28%). Left atrioventricular groove activation occurred via (1) BB: N=108, 43%; (2) pulmonary vein area: N=9, 3%; or (3) BB and pulmonary vein area: N=136, 54%; depending on which route had the shortest interatrial conduction time (P<0.001). Ischemic valvular heart disease patients more often had central BB activation and left atrioventricular groove activation via pulmonary vein area compared with ischemic heart disease patients (N=16 [13%] versus N=2 [2%]; P=0.009 and N=86 [71%] versus N=59 [45%]; P<0.001, respectively). Total activation times were longer in patients with AF (AF: 136±20 [92-186] ms; no AF: 114±17 [74-156] ms; P<0.001), because of prolongation of right atrium (P=0.018) and BB conduction times (P<0.001). CONCLUSIONS:Atrial excitation during SR is affected by underlying heart disease and AF, resulting in alternative routes for BB and left atrioventricular groove activation and prolongation of total activation times. Knowledge of atrial excitation patterns during SR and its electropathological variations, as demonstrated in this study, is essential to further unravel the pathogenesis of AF.

SUBMITTER: Mouws EMJP

PROVIDER: S-EPMC5907575 | biostudies-literature | 2018 Mar

REPOSITORIES: biostudies-literature

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Impact of Ischemic and Valvular Heart Disease on Atrial Excitation:A High-Resolution Epicardial Mapping Study.

Mouws Elisabeth M J P EMJP Lanters Eva A H EAH Teuwen Christophe P CP van der Does Lisette J M E LJME Kik Charles C Knops Paul P Yaksh Ameeta A Bekkers Jos A JA Bogers Ad J J C AJJC de Groot Natasja M S NMS

Journal of the American Heart Association 20180308 6

<h4>Background</h4>The influence of underlying heart disease or presence of atrial fibrillation (AF) on atrial excitation during sinus rhythm (SR) is unknown. We investigated atrial activation patterns and total activation times of the entire atrial epicardial surface during SR in patients with ischemic and/or valvular heart disease with or without AF.<h4>Methods and results</h4>Intraoperative epicardial mapping (N=128/192 electrodes, interelectrode distances: 2 mm) of the right atrium, Bachmann ...[more]

PMID: 29519812

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Project description:BACKGROUND:Cardiovascular magnetic resonance (CMR) T1? mapping can be used to detect ischemic or non-ischemic cardiomyopathy without the need of exogenous contrast agents. Current 2D myocardial T1? mapping requires multiple breath-holds and provides limited coverage. Respiratory gating by diaphragmatic navigation has recently been exploited to enable free-breathing 3D T1? mapping, which, however, has low acquisition efficiency and may result in unpredictable and long scan times. This study aims to develop a fast respiratory motion-compensated 3D whole-heart myocardial T1? mapping technique with high spatial resolution and predictable scan time. METHODS:The proposed electrocardiogram (ECG)-triggered T1? mapping sequence is performed under free-breathing using an undersampled variable-density 3D Cartesian sampling with spiral-like order. Preparation pulses with different T1? spin-lock times are employed to acquire multiple T1?-weighted images. A saturation prepulse is played at the start of each heartbeat to reset the magnetization before T1? preparation. Image navigators are employed to enable beat-to-beat 2D translational respiratory motion correction of the heart for each T1?-weighted dataset, after which, 3D translational registration is performed to align all T1?-weighted volumes. Undersampled reconstruction is performed using a multi-contrast 3D patch-based low-rank algorithm. The accuracy of the proposed technique was tested in phantoms and in vivo in 11 healthy subjects in comparison with 2D T1? mapping. The feasibility of the proposed technique was further investigated in 3 patients with suspected cardiovascular disease. Breath-hold late-gadolinium enhanced (LGE) images were acquired in patients as reference for scar detection. RESULTS:Phantoms results revealed that the proposed technique provided accurate T1? values over a wide range of simulated heart rates in comparison to a 2D T1? mapping reference. Homogeneous 3D T1? maps were obtained for healthy subjects, with septal T1? of 58.0 ± 4.1?ms which was comparable to 2D breath-hold measurements (57.6 ± 4.7?ms, P?=?0.83). Myocardial scar was detected in 1 of the 3 patients, and increased T1? values (87.4 ± 5.7?ms) were observed in the infarcted region. CONCLUSIONS:An accelerated free-breathing 3D whole-heart T1? mapping technique was developed with high respiratory scan efficiency and near-isotropic spatial resolution (1.7 × 1.7 × 2?mm3) in a clinically feasible scan time of ~?6 mins. Preliminary patient results suggest that the proposed technique may find applications in non-contrast myocardial tissue characterization.

Project description:BackgroundAlthough atrial fibrillation (AF), a common arrhythmia, frequently presents in patients with underlying valvular disease, its hemodynamic contributions are not fully understood. The present work aimed to computationally study how physical conditions imposed by pathologic valvular anatomy act on AF hemodynamics.MethodsWe simulated AF with different severity grades of left-sided valvular diseases and compared the cardiovascular effects that they exert during AF, compared to lone AF. The fluid dynamics model used here has been recently validated for lone AF and relies on a lumped parameterization of the four heart chambers, together with the systemic and pulmonary circulation. The AF modelling involves: (i) irregular, uncorrelated and faster heart rate; (ii) atrial contractility dysfunction. Three different grades of severity (mild, moderate, severe) were analyzed for each of the four valvulopathies (AS, aortic stenosis, MS, mitral stenosis, AR, aortic regurgitation, MR, mitral regurgitation), by varying-through the valve opening angle-the valve area.ResultsRegurgitation was hemodynamically more relevant than stenosis, as the latter led to inefficient cardiac flow, while the former introduced more drastic fluid dynamics variation. Moreover, mitral valvulopathies were more significant than aortic ones. In case of aortic valve diseases, proper mitral functioning damps out changes at atrial and pulmonary levels. In the case of mitral valvulopathy, the mitral valve lost its regulating capability, thus hemodynamic variations almost equally affected regions upstream and downstream of the valve. In particular, the present study revealed that both mitral and aortic regurgitation strongly affect hemodynamics, followed by mitral stenosis, while aortic stenosis has the least impact among the analyzed valvular diseases.DiscussionThe proposed approach can provide new mechanistic insights as to which valvular pathologies merit more aggressive treatment of AF. Present findings, if clinically confirmed, hold the potential to impact AF management (e.g., adoption of a rhythm control strategy) in specific valvular diseases.

Dataset Information

Impact of Ischemic and Valvular Heart Disease on Atrial Excitation:A High-Resolution Epicardial Mapping Study.

Publications

Impact of Ischemic and Valvular Heart Disease on Atrial Excitation:A High-Resolution Epicardial Mapping Study.

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