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CLINICAL RESEARCH: HEART RHYTHM DISORDER

Functional Characterization of Atrial Electrograms in Sinus Rhythm Delineates Sites of Parasympathetic Innervation in Patients With Paroxysmal Atrial Fibrillation

UCLA Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California.

Manuscript received February 5, 2007; revised manuscript received March 5, 2007, accepted March 14, 2007.

^_* Reprint requests and correspondence: Dr. Kalyanam Shivkumar, UCLA Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, 47-123 CHS, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, California 90095-1679. (Email: kshivkumar{at}mednet.ucla.edu).

Objectives: This study sought to characterize left atrial (LA) sinus rhythm electrogram (EGM) patterns and their relationship to parasympathetic responses during atrial fibrillation (AF) ablation.

Background: The mechanistic basis of fractionated LA EGMs in patients with paroxysmal AF is not well understood.

Methods: We analyzed 1,662 LA ablation sites from 30 patients who underwent catheter ablation for paroxysmal AF. Pre-ablation EGM characteristics (number of deflections, amplitude, and duration) were measured in sinus rhythm. Parasympathetic responses during radiofrequency application (increase of atrial-His interval by 10 ms or decrease of sinus rate by 20%) were assessed at all sites. We also prospectively studied the effect of adenosine, a pharmacological agent mimicking acetylcholine signaling in myocytes, on LA EGMs. Finally, we performed mathematical simulations of atrial tissue to delineate possible mechanisms of fractionated EGMs in sinus rhythm.

Results: A specific pattern of pre-ablation sinus rhythm EGM (deflections 4, amplitude 0.7 mV, and duration 40 ms) was strongly associated with parasympathetic responses (sensitivity 72%, specificity 91%). The sites associated with these responses were found to be located mainly in the posterior wall of the LA. Adenosine administration and mathematical simulation of the effect of acetylcholine were able to reproduce a similar EGM pattern.

Conclusions: Parasympathetic activation during AF ablation is associated with the presence of pre-ablation high-amplitude fractionated EGMs in sinus rhythm. Local acetylcholine release could potentially explain this phenomenon.

Abbreviations and Acronyms   AF = atrial fibrillation   A–H = atrial-His   CART = classification and regression tree   CFAE = complex fractionated atrial electrogram   EGM = electrogram   HAFE = high-amplitude fractionated electrogram   LA = left atrial/atrium   LAFE = low-amplitude fractionated electrogram   PV = pulmonary vein   RA = right atrial/atrium   RF = radiofrequency

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