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Published on: July 29, 2011
Impact of Ischemic and Valvular Heart Disease on Atrial Excitation:A High-Resolution Epicardial Mapping Study
Elisabeth M J P Mouws1,2, Eva A H Lanters1, Christophe P Teuwen1
1Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands.
Insights
Underlying heart disease and atrial fibrillation (AF) alter atrial activation during sinus rhythm (SR). This study reveals how these conditions affect excitation patterns and prolong total activation times, crucial for understanding AF pathogenesis.
Area of Science:
- Cardiology
- Electrophysiology
- Cardiac Anatomy
Background:
- The impact of heart disease and atrial fibrillation (AF) on atrial excitation during sinus rhythm (SR) remains unclear.
- Investigating these influences is vital for understanding AF development.
Purpose of the Study:
- To examine atrial activation patterns and total activation times during SR in patients with ischemic and/or valvular heart disease, with or without a history of AF.
- To identify how underlying cardiac conditions influence atrial electrophysiology.
Main Methods:
- Intraoperative epicardial mapping using high-density electrode arrays (128/192 electrodes) in 253 patients undergoing cardiac surgery.
- Mapping focused on the right atrium, Bachmann's bundle (BB), left atrioventricular groove, and pulmonary vein area during SR.
Main Results:
- Sinus rhythm origin was predominantly in the superior intercaval region (92%).
- Bachmann's bundle activation varied, with 28% showing multiple wavefronts.
- Left atrioventricular groove activation predominantly occurred via combined BB and pulmonary vein routes (54%).
- Ischemic valvular heart disease was associated with more central BB activation and pulmonary vein area-driven left atrioventricular groove activation compared to ischemic heart disease.
- Total atrial activation times were significantly longer in patients with AF (136±20 ms) versus those without (114±17 ms), primarily due to prolonged right atrial and BB conduction.
Conclusions:
- Underlying heart disease and AF significantly affect atrial excitation patterns during SR.
- Alternative activation routes and prolonged conduction times are observed, particularly in patients with AF.
- Understanding these electropathological variations in atrial excitation is essential for elucidating the pathogenesis of AF.
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.
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