In patients with atrial fibrillation, intracardiac electrogram signal amplitude is known to decrease with increased structural tissue remodeling, referred to as fibrosis. In addition to the isolation of the pulmonary veins, fibrotic sites are considered a suitable target for catheter ablation. However, it remains an open challenge to find fibrotic areas and to differentiate their density and transmurality. This study aims to identify the volume fraction and transmurality of fibrosis in the atrial substrate. Simulated cardiac electrograms, combined with a generalized model of clinical noise, reproduce clinically measured signals. Our hybrid dataset approach combines and clinical electrograms to train a decision tree classifier to characterize the fibrotic atrial substrate. This approach captures different dynamics of the electrical propagation reflected on healthy electrogram morphology and synergistically combines it with synthetic fibrotic electrograms from experiments. The machine learning algorithm was tested on five patients and compared against clinical voltage maps as a proof of concept, distinguishing non-fibrotic from fibrotic tissue and characterizing the patient's fibrotic tissue in terms of density and transmurality. The proposed approach can be used to overcome a single voltage cut-off value to identify fibrotic tissue and guide ablation targeting fibrotic areas.
Under persistent atrial fibrillation (peAF), cardiac tissue experiences electrophysiological and structural remodeling. Fibrosis in the atrial tissue has an important impact on the myocyte action potential and its propagation. The objective of this work is to explore the effect of heterogeneities present in the fibrotic tissue and their impact on the intracardiac electrogram (EGM). Human atrial myocyte and fibroblast electrophysiology was simulated using mathematical models proposed by Koivumäki et al. to represent electrical remodeling under peAF and the paracrine effect of the transforming grow factor 1 (TGF-1). 2D tissue simulations were computed varying the density of fibrosis (10%, 20% and 40%), myofibroblasts and collagen were randomly distributed with different ratios (0%-100%, 50%-50% and 100%- 0%). Results show that increasing the fibrosis density changes the re-entry dynamics from functional to anatomical due to a block in conduction in regions with high fibrosis density (40%). EGM morphology was affected by different ratios of myofibroblasts-collagen. For low myofibroblast densities (below 50%) the duration of active segments was shorter compared to higher myofibroblasts densities (above 50%). Our results show that fibrosis heterogeneities can alter the dynamics of the re-entry and the morphology of the EGM.
There is evidence that rotors could be drivers that maintain atrial fibrillation. Complex fractionated atrial electrograms have been located in rotor tip areas. However, the concept of electrogram fractionation, defined using time intervals, is still controversial as a tool for locating target sites for ablation. We hypothesize that the fractionation phenomenon is better described using non-linear dynamic measures, such as approximate entropy, and that this tool could be used for locating the rotor tip. The aim of this work has been to determine the relationship between approximate entropy and fractionated electrograms, and to develop a new tool for rotor mapping based on fractionation levels. Two episodes of chronic atrial fibrillation were simulated in a 3D human atrial model, in which rotors were observed. Dynamic approximate entropy maps were calculated using unipolar electrogram signals generated over the whole surface of the 3D atrial model. In addition, we optimized the approximate entropy calculation using two real multi-center databases of fractionated electrogram signals, labeled in 4 levels of fractionation. We found that the values of approximate entropy and the levels of fractionation are positively correlated. This allows the dynamic approximate entropy maps to localize the tips from stable and meandering rotors. Furthermore, we assessed the optimized approximate entropy using bipolar electrograms generated over a vicinity enclosing a rotor, achieving rotor detection. Our results suggest that high approximate entropy values are able to detect a high level of fractionation and to locate rotor tips in simulated atrial fibrillation episodes. We suggest that dynamic approximate entropy maps could become a tool for atrial fibrillation rotor mapping.
This work uses a highly detailed computational model of human atria to investigate the effect of spatial gradient and smoothing of atrial wall thickness on inducibility and maintenance of atrial fibrillation (AF) episodes. An atrial model with homogeneous thickness (HO) was used as baseline for the generation of different atrial models including either a low (LG) or high thickness gradient between left/right atrial free wall and the other regions. Since the model with high spatial gradient presented non-natural sharp edges between regions, either 1 (HG1) or 2 (HG2) Laplacian smoothing iterations were applied. Arrhythmic episodes were initiated using a rapid pacing protocol and long-living rotors were detected and tracked over time. Thresholds optimised with receiver operating characteristic analysis were used to define high gradient/curvature regions. Greater spatial gradients increased the atrial model inducibility and unveiled additional regions vulnerable to maintain AF drivers. In the models with heterogeneous wall thickness (LG, HG2 and HG1), 73.5 ± 8.7% of the long living rotors were found in areas within 1.5 mm from nodes with high thickness gradient, and 85.0 ± 3.4% in areas around high endocardial curvature. These findings promote wall thickness gradient and endocardial curvature as measures of AF vulnerability.
Atrial myofiber orientation is complex and has multiple discrete layers and bundles. A novel robust semi-automatic method to incorporate atrial anisotropy and heterogeneities into patient-specific models is introduced. The user needs to provide 22 distinct seed-points from which a network of auxiliary lines is constructed. These are used to define fiber orientation and myocardial bundles. The method was applied to 14 patient-specific volumetric models derived from CT, MRI and photographic data. Initial electrophysiological simulations show a significant influence of anisotropy and heterogeneity on the excitation pattern and P-wave duration (20.7% shortening). Fiber modeling results show good overall correspondence with anatomical data. Minor modeling errors are observed if more than four pulmonary veins exist in the model. The method is an important step towards creating realistic patient-specific atrial models for clinical applications.