Abstract:

AIMS: The effective refractory period (ERP) is one of the main electrophysiological properties governing arrhythmia, yet ERP personalization is rarely performed when creating patient-specific computer models of the atria to inform clinical decision-making. This study evaluates the impact of integrating clinical ERP measurements into personalized in silico models on arrhythmia vulnerability. METHODS AND RESULTS: Clinical ERP measurements were obtained in seven patients from multiple locations in the atria. Atrial geometries from the electroanatomical mapping system were used to generate personalized anatomical atrial models. The Courtemanche M. et al. cellular model was adjusted to reproduce patient-specific ERP. Four modeling approaches were compared: homogeneous (A), heterogeneous (B), regional (C), and continuous (D) ERP distributions. Non-personalized approaches (A and B) were based on literature data, while personalized approaches (C and D) were based on patient measurements. Modeling effects were assessed on arrhythmia vulnerability and tachycardia cycle length, with sensitivity analysis on ERP measurement uncertainty. Mean vulnerability was 3.4 ± 4.0%, 7.7 ± 3.4%, 9.0 ± 5.1%, and 7.0 ± 3.6% for scenarios A-D, respectively. Mean tachycardia cycle length was 167.1 ± 12.6 ms, 158.4 ± 27.5 ms, 265.2 ± 39.9 ms, and 285.9 ± 77.3 ms for scenarios A-D, respectively. Incorporating perturbations to the measured ERP in the range of 2, 5, 10, 20, and 50 ms changed the vulnerability of the model to 5.8 ± 2.7%, 6.1 ± 3.5%, 6.9 ± 3.7%, 5.2 ± 3.5%, and 9.7 ± 10.0%, respectively. CONCLUSION: Increased ERP dispersion had a greater effect on re-entry dynamics than on vulnerability. Inducibility was higher in personalized scenarios compared with scenarios with uniformly reduced ERP; however, this effect was reversed when incorporating fibrosis informed by low-voltage areas. Effective refractory period measurement uncertainty up to 20 ms slightly influenced vulnerability. Electrophysiological personalization of atrial in silico models appears essential and requires confirmation in larger cohorts.

Abstract:

Background: Computer models for simulating cardiac electrophysiology are valuable tools for research and clinical applications. Traditional reaction-diffusion (RD) models used for these purposes are computationally expensive. While eikonal models offer a faster alternative, they are not well-suited to study cardiac arrhythmias driven by reentrant activity. The present work extends the diffusion-reaction eikonal alternant model (DREAM), incorporating conduction velocity (CV) restitution for simulating complex cardiac arrhythmias. Methods: The DREAM modifies the fast iterative method to model cyclical behavior, dynamic boundary conditions, and frequency-dependent anisotropic CV. Additionally, the model alternates with an approximated RD model, using a detailed ionic model for the reaction term and a triple-Gaussian to approximate the diffusion term. The DREAM and monodomain models were compared, simulating reentries in 2D manifolds with different resolutions. Results: The DREAM produced similar results across all resolutions, while experiments with the monodomain model failed at lower resolutions. CV restitution curves obtained using the DREAM closely approximated those produced by the monodomain simulations. Reentry in 2D slabs yielded similar results in vulnerable window and mean reentry duration for low CV in both models. In the left atrium, most inducing points identified by the DREAM were also present in the high-resolution monodomain model. DREAM's reentry simulations on meshes with an average edge length of 1600$\mu$m were 40x faster than monodomain simulations at 200$\mu$m. Conclusion: This work establishes the mathematical foundation for using the accelerated DREAM simulation method for cardiac electrophysiology. Cardiac research applications are enabled by a publicly available implementation in the openCARP simulator.

Abstract:

Atrial fibrillation (AF) is one of the most commoncardiac diseases. However, a complete understanding of howto treat patients suffering from AF is still not achieved. Asthe isolation of the pulmonary veins in the left atrium (LA)is the standard treatment for AF, the role of the right atrium(RA) in AF is rarely considered. We investigated the impactof including the RA on arrhythmia vulnerability in silico. Wegenerated a dataset of five mono-atrial (LA) and five bi-atrialmodels with three different electrophysiological (EP) setupseach, regarding different states of AF-induced remodelling.For every model, a pacing protocol was run to induce reen-tries from a set of stimulation points. The average share ofinducing points across all EP setups was 0.0, 0.8 and 6.7 %for the mono-atrial scenario, 0.5, 27.3 and 37.9 % for the bi-atrial scenario. The increase in inducibility of LA stimula-tion points from mono- to bi-atrial scenario was 0.91 ± 2.03%,34.55 ± 14.9 % and 44.2 ± 14.9 %, respectively. In this study,the RA had a marked impact on the results of the vulnerabilityassessment that needs to be further investigated.

Abstract:

IntroductionThe role of the right atrium (RA) in atrial fibrillation (AF) has long been overlooked. Computer models of the atria can aid in assessing how the RA influences arrhythmia vulnerability and in studying the role of RA drivers in the induction of AF, both aspects challenging to assess in living patients until now. It remains unclear whether the incorporation of the RA influences the propensity of the model to reentry induction. As personalized ablation strategies rely on non-inducibility criteria, the adequacy of left atrium (LA)-only models for developing such ablation tools is uncertain.AimTo evaluate the effect of incorporating the RA in 3D patient-specific computer models on arrhythmia vulnerability.MethodsImaging data from 8 subjects were obtained to generate patient-specific computer models. For each subject, we created 2 models: one monoatrial consisting only of the LA, and one biatrial model consisting of both the RA and LA. We considered 3 different states of substrate remodeling: healthy (H), mild (M), and severe (S). The Courtemanche et al. cellular model was modified from control conditions to a setup representing AF-induced remodeling with 0%, 50%, and 100% changes for H, M, and S, respectively. Conduction velocity along the myocyte preferential direction was set to 1.2, 1.0, and 0.8m/s for each remodeling level. To incorporate fibrotic substrate, we manually placed six seeds on each biatrial model, 3 in the LA and 3 in the RA, corresponding to regions with the most frequent enhancement (IIR>1.2) in LGE-MRI. The extent of the fibrotic substrate corresponded to the Utah 2 (5-20%) and Utah 4 (>35%) stages, for M and S respectively, while the H state was modeled without fibrosis. Electrical propagation in the atria was modeled using the monodomain equation solved with openCARP. Arrhythmia vulnerability was assessed by virtual S1S2 pacing from different points separated by 2cm. A point was classified as inducing arrhythmia if reentry was initiated and maintained for at least 1s. The vulnerability ratio was defined as the number of inducing points divided by the number of stimulation points. The mean tachycardia cycle length (TCL) of the induced arrhythmia was assessed at the stimulation site. We compared the vulnerability ratio of the LA in monoatrial and biatrial configurations.ResultsThe incorporation of the RA increased the mean LA vulnerability ratio by 115.79% (0.19±0.13 to 0.41±0.22, p=0.033) in state M, and 29.03% in state S (0.31±0.14 to 0.40±0.15, p=0.219) as illustrated in Figure 1. No arrhythmia was induced in the H models. RA inclusion increased the TCL of LA reentries by 5.51% (186.9±13.3ms to 197.2±18.3ms, p=0.006) in M scenario, and decreased it by 7.17% (224.3±27.6ms to 208.2±34.8ms, p=0.010) in scenario S. RA inclusion resulted in an elevated LA inducibility, revealing 4.9±3.3 additional points per patient in the LA for the biatrial model that did not induce reentry in the monoatrial model. ConclusionsThe LA vulnerability in a biatrial model differs from the LA vulnerability in a monoatrial model. Incorporating the RA in patient-specific computational models unmasked potential inducing points in the LA. The RA had a substrate-dependent effect on reentry dynamics, altering the TCL of LA-induced reentries. Our results provide evidence for an important role of the RA in the maintenance and induction of arrhythmia in patient-specific computational models, thus suggesting the use of biatrial models.

Abstract:

Introduction: Although the effective refractory period (ERP) is one of the main electrophysiological properties governing atrial tachycardia (AT) maintenance, ERP personalization is rarely performed when creating patient-specifi c computer models of the atria to inform clinical decision-making. State-of-the-art models usually do not consider physiological ERP gradients but assume a homogeneous ERP distribution. This assumption might have an influence on the ability to induce reentries in the model.Aim: To evaluate the impact of incorporating clinical ERP measurements when creating in silico personalized models to predict vulnerability to atrial fibrillation (AF).Methods: Clinical ERP measurements were obtained from three patients from multiple locations in the atria. The protocol for ERP identification consisted of trains of 7 S1 stimuli with a basic cycle length of 500ms followed by an S2 stimulus with a coupling interval between 300 and 200ms in decrements of 10ms until loss of capture. The atrial geometries from the electroanatomical mapping system were used to generate personalized atrial models. To reproduce patient-specific ERP, the established Courtemanche cellular model was gradually reparameterized from control conditions to a setup representing AF-induced remodeling. Three different approaches were studied:1) a control scenario with no ERP personalization 2) a discrete split where each region had a single ERP value and3) a continuous ERP distribution by interpolation of measured ERP data (Fig. 1). Arrhythmia vulnerability was assessed by virtual S1S2 pacing from different locations separated by 3cm. The number and location of inducing points and type of arrhythmia were determined for the three approaches. The mean conduction velocity was setto 0.7 m/s and the electrical propagation in the atria was modeled by the monodomain equation and solved withopenCARP.Results: Incorporating patient-specific ERP as a continuous distribution did not induce any reentrant activity. A summary of induced ATs is shown in Table 1. For patient A, AF was induced from 3 different locations with the control setup, whereas 9 ATs were induced with the regional method, of which 4 were AF and 5 macro reentries. For patient B, AF was induced from 1 point with the control setup; whereas with the regional approach, AF was induced at 4 points. For patient C, only one macro reentry was induced with the regional method.Conclusion: The incorporation of patient-specifi c ERP values has an impact on the assessment of AF vulnerability. Furthermore, the type of personalization affects the likelihood of AF inducibility. The incorporation of more detailed ERP distributions may lead to a more accurate prediction of AF trigger points and could in the future inform patient-specifi c therapy planning. Larger cohorts need to follow to demonstrate the role of incorporating clinical patient-specifi c ERP values into personalized models for predicting AF vulnerability.

Abstract:

Atrial fibrillation (AF) is the most common sus- tained arrhythmia posing a significant burden to patients and leading to an increased risk of stroke and heart failure. Additional ablation of areas of arrhythmogenic substrate in the atrial body detected by either late gadolinium enhance- ment magnetic resonance imaging (LGE-MRI) or electro- anatomical mapping (EAM) may increase the success rate of restoring and maintaining sinus rhythm compared to the stan- dard treatment procedure of pulmonary vein isolation (PVI). To evaluate if LGE-MRI and EAM identify equivalent sub- strate as potential ablation targets, we divided the left atrium (LA) into six clinically important regions in ten patients. Then, we computed the correlation between both modalities by ana- lyzing the regional extents of identified pathological tissue. In this regional analysis, we observed no correlation between late gadolinium enhancement (LGE) and low voltage areas (LVA), neither in any region nor with regard to the entire atrial surface (−0.3 < 𝑟 < 0.3). Instead, the regional extents identified as pathological tissue varied significantly between both modali- ties. An increased extent of LVA compared to LGE was ob- served in the septal wall of the LA (𝑎 ̃sept.,LVA = 19.63 % and 𝑎 ̃sept.,LGE = 3.94 %, with 𝑎 ̃ = median of the extent of patho- logical tissue in the corresponding region). In contrast, in the inferior and lateral wall, the extent of LGE was higher than the extent of LVA for most geometries (𝑎 ̃inf.,LGE = 27.22% and 𝑎 ̃lat.,LGE = 32.70 % compared to 𝑎 ̃inf .,LVA = 9.21 % and 𝑎 ̃lat.,LVA = 6.69 %). Since both modalities provided dis- crepant results regarding the detection of arrhythmogenic sub- strate using clinically established thresholds, further investiga- tions regarding their constraints need to be performed in order to use these modalities for patient stratification and treatment planning.