Analysis of the driving mechanism in paroxysmal atrial fibrillation: comparison of the activation sequence between the left atrial body and pulmonary vein

Takuya Kiyama; Hisanori Kanazawa; Hiroshige Yamabe; Miwa Ito; Shozo Kaneko; Yusuke Kanemaru; Yusei Kawahara; Kenshi Yamanaga; Koichiro Fujisue; Daisuke Sueta; Seiji Takashio; Yuichiro Arima; Satoshi Araki; Hiroki Usuku; Taishi Nakamura; Yasuhiro Izumiya; Kenji Sakamoto; Satoru Suzuki; Eiichiro Yamamoto; Hirofumi Soejima; Koichi Kaikita; Kenichi Tsujita

doi:10.1016/j.jjcc.2020.01.004

Analysis of the driving mechanism in paroxysmal atrial fibrillation: comparison of the activation sequence between the left atrial body and pulmonary vein

J Cardiol. 2020 Jun;75(6):673-681. doi: 10.1016/j.jjcc.2020.01.004. Epub 2020 Feb 7.

Authors

Takuya Kiyama¹, Hisanori Kanazawa², Hiroshige Yamabe³, Miwa Ito¹, Shozo Kaneko¹, Yusuke Kanemaru¹, Yusei Kawahara¹, Kenshi Yamanaga¹, Koichiro Fujisue¹, Daisuke Sueta¹, Seiji Takashio¹, Yuichiro Arima¹, Satoshi Araki¹, Hiroki Usuku¹, Taishi Nakamura¹, Yasuhiro Izumiya¹, Kenji Sakamoto¹, Satoru Suzuki¹, Eiichiro Yamamoto¹, Hirofumi Soejima¹, Koichi Kaikita¹, Kenichi Tsujita¹

Affiliations

¹ Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
² Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; Department of Cardiac Arrhythmias, Kumamoto University, Kumamoto, Japan. Electronic address: kanaza-h@kumamoto-u.ac.jp.
³ Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; Department of Cardiac Arrhythmias, Kumamoto University, Kumamoto, Japan.

PMID: 32037253
DOI: 10.1016/j.jjcc.2020.01.004

Abstract

Background: It has been shown that most paroxysmal atrial fibrillation (AF) can be terminated by pulmonary vein (PV) isolation alone, suggesting that rapid discharges from PV drive AF. To define the driving mechanism of AF, we compared the activation sequence in the body of left atrium (LA) to that within PV.

Methods: Endocardial noncontact mapping of LA body (LA group; n = 16) and selective endocardial mapping of left superior PV (LSPV) (PV group; n = 13) were performed in 29 paroxysmal AF patients. The frequency of pivoting activation, wave breakup, and wave fusion observed in LA were compared to those in LSPV to define the driving mechanism of AF. Circumferential ablation lesion around left PV was performed after right PV isolation to examine the effect of linear lesion around PV on AF termination both in LA and PV groups.

Results: The frequency of pivoting activation, wave breakup, and wave fusion in PV group were significantly higher than those in LA group (36.5 ± 17.7 vs 5.0 ± 2.2 times/seconds, p < 0.001, 10.1 ± 4.3 vs 5.0 ± 2.2 times/seconds, p = 0.004, 18.1 ± 5.7 vs 11.0 ± 5.2, p = 0.002). Especially in the PV group, the frequency of pivoting activation was significantly higher than that of wave breakup and wave fusion (36.5 ± 17.7 vs 10.1 ± 4.3 times/seconds, p < 0.001, 36.5 ± 17.7 vs 18.1 ± 5.7 times/seconds, p < 0.001). These disorganized activations in LSPV were eliminated by the circumferential ablation lesion around left PV (pivoting activation; 36.5 ± 17.7 vs 9.3 ± 2.3 times/seconds, p < 0.001, wave breakup; 10.1±1.3 times/seconds, p = 0.003, wave fusion; 18.1 ± 5.7 vs 5.7 ± 1.8, p < 0.001), resulted in AF termination in all patients in both LA and PV groups.

Conclusions: Activation sequence within PV was more disorganized than that in LA body. Frequent episodes of pivoting activation rather than wave breakup and fusion observed within PV acted as the driving sources of paroxysmal AF.

Keywords: Atrial fibrillation; Catheter ablation; Driver; Noncontact mapping; Pulmonary vein.

MeSH terms

Aged
Atrial Fibrillation / physiopathology*
Atrial Fibrillation / surgery
Catheter Ablation
Female
Heart Atria / physiopathology*
Heart Atria / surgery
Humans
Male
Middle Aged
Pulmonary Veins / physiopathology*
Pulmonary Veins / surgery