Aims Atrial flutter (AFlut) is a common re-entrant atrial tachycardia driven by self-sustainable mechanisms that cause excitations to propagate along pathways different from sinus rhythm. Intra-cardiac electrophysiological mapping and catheter ablation are often performed without detailed prior knowledge of the mechanism perpetuating AFlut, likely prolonging the procedure time of these invasive interventions. We sought to discriminate the AFlut location [cavotricuspid isthmus-dependent (CTI), peri-mitral, and other left atrium (LA) AFlut classes] with a machine learning-based algorithm using only the non-invasive signals from the 12-lead electrocardiogram (ECG). Methods and results Hybrid 12-lead ECG dataset of 1769 signals was used (1424 in silico ECGs, and 345 clinical ECGs from 115 patients—three different ECG segments over time were extracted from each patient corresponding to single AFlut cycles). Seventy-seven features were extracted. A decision tree classifier with a hold-out classification approach was trained, validated, and tested on the dataset randomly split after selecting the most informative features. The clinical test set comprised 38 patients (114 clinical ECGs). The classifier yielded 76.3% accuracy on the clinical test set with a sensitivity of 89.7%, 75.0%, and 64.1% and a positive predictive value of 71.4%, 75.0%, and 86.2% for CTI, peri-mitral, and other LA class, respectively. Considering majority vote of the three segments taken from each patient, the CTI class was correctly classified at 92%. Conclusion Our results show that a machine learning classifier relying only on non-invasive signals can potentially identify the location of AFlut mechanisms. This method could aid in planning and tailoring patient-specific AFlut treatments.
OBJECTIVE: Atrial flutter (AFl) is a common arrhythmia that can be categorized according to different self-sustained electrophysiological mechanisms. The non-invasive discrimination of such mechanisms would greatly benefit ablative methods for AFl therapy as the driving mechanisms would be described prior to the invasive procedure, helping to guide ablation. In the present work, we sought to implement recurrence quantification analysis (RQA) on 12-lead ECG signals from a computational framework to discriminate different electrophysiological mechanisms sustaining AFl. METHODS: 20 different AFl mechanisms were generated in 8 atrial models and were propagated into 8 torso models via forward solution, resulting in 1,256 sets of 12-lead ECG signals. Principal component analysis was applied on the 12-lead ECGs, and six RQA-based features were extracted from the most significant principal component scores in two different approaches: individual component RQA and spatial reduced RQA. RESULTS: In both approaches, RQA-based features were significantly sensitive to the dynamic structures underlying different AFl mechanisms. Hit rate as high as 67.7% was achieved when discriminating the 20 AFl mechanisms. RQA-based features estimated for a clinical sample suggested high agreement with the results found in the computational framework. CONCLUSION: RQA has been shown an effective method to distinguish different AFl electrophysiological mechanisms in a non-invasive computational framework. A clinical 12-lead ECG used as proof of concept showed the value of both the simulations and the methods. SIGNIFICANCE: The non-invasive discrimination of AFl mechanisms helps to delineate the ablation strategy, reducing time and resources required to conduct invasive cardiac mapping and ablation procedures.
The outcomes of ablation targeting either reentry activations or fractionated activity during persistent atrial fibrillation (AF) therapy remain suboptimal due to, among others, the intricate underlying AF dynamics. In the present work, we sought to investigate such AF dynamics in a heterogeneous simulation setup using recurrence quantification analysis (RQA). AF was simulated in a spherical model of the left atrium, from which 412 unipolar atrial electrograms (AEGs) were extracted (2 s duration; 5 mm spacing). The phase was calculated using the Hilbert transform, followed by the identification of points of singularity (PS). Three regions were defined according to the occurrence of PSs: 1) no rotors; 2) transient rotors and; 3) long-standing rotors. Bipolar AEGs (1114) were calculated from pairs of unipolar nodes and bandpass filtered (30-300 Hz). The CARTO criterion (Biosense Webster) was used for AEGs classification (normal vs. fractionated). RQA attributes were calculated from the filtered bipolar AEGs: determinism (DET); recurrence rate (RR); laminarity (LAM). Sample entropy (SampEn) and dominant frequency (DF) were also calculated from the AEGs. Regions with longstanding rotors have shown significantly lower RQA attributes and SampEn when compared to the other regions, suggesting a higher irregular behaviour (P≤0.01 for all cases). Normal and fractionated AEGs were found in all regions (respectively; Region 1: 387 vs. 15; Region 2: 221 vs. 13; Region 3: 415 vs. 63). Region 1 vs. Region 3 have shown significant differences in normal AEGs (P≤0.0001 for all RQA attributes and SampEn), and significant differences in fractionated AEGs for LAM, RR and SampEn (P=0.0071, P=0.0221 and P=0.0086, respectively). Our results suggest the co-existence of normal and fractionated AEGs within long-standing rotors. RQA has unveiled distinct dynamic patterns–irrespective of AEGs classification–related to regularity structures and their nonstationary behaviour in a rigorous deterministic context.
Atrial fibrillation (AF) is the most frequent irregular heart rhythm due to disorganized atrial electrical activity, often sustained by rotational drivers called rotors. The non-invasive localization of AF drivers can lead to improved personalized ablation strategy, suggesting pulmonary vein (PV) isolation or more complex extra- PV ablation procedures in case the driver is on other atrial regions. We used a Machine Learning approach to characterize and discriminate simulated single stable rotors (1R) location: PVs, left atrium (LA) excluding the PVs, and right atrium (RA), utilizing solely non-invasive signals (i.e., the 12-lead ECG). 1R episodes sustaining AF were simulated. 128 features were extracted from the signals. Greedy forward algorithm was implemented to select the best feature set which was fed to a decision tree classifier with hold-out cross-validation technique. All tested features showed significant discriminatory power, especially those based on recurrence quantification analysis (up to 80.9% accuracy with single feature classification). The decision tree classifier achieved 89.4% test accuracy with 18 features on simulated data, with sensitivities of 93.0%, 82.4%, and 83.3% for RA, LA, and PV classes, respectively. Our results show that a machine learning approach can potentially identify the location of 1R sustaining AF using the 12-lead ECG.
Changes in atrial fibrillation cycle length (AF-CL) are broadly used as a ‘ground truth’ to assess the effect of substrate modification during AF ablation. This work sought to optimize thresholds for changes in coronary sinus CL (CS-CL) after local ablation using different atrial electrogram (AEG)-derived markers. 834 AEGs were collected from 11 patients undergoing persAF ablation. CS-CL was measured before and after each ablation point. Five AEG-derived markers were tested as classifiers for CS-CL changes: ICL (Biosense Webster), CFE-Mean (St. Jude Medical), Wave Similarity, Shannon Entropy and AEG-CL. The area under the receiver operating characteristic (AUROC) curve was used to assess the quality of classification for each marker. Maximum AUROC was found at threshold values between 9 and 14 ms in all markers, except for Shannon Entropy. The average AUROC of the five markers reached a maximum of 0.60 at a threshold value of 10 ms. The 10 ms threshold is suggested as a starting setpoint for future studies seeking to identify AF ablation targets based on an objective 'ground truth'.