Functional Characterization of Atrial Electrograms in Sinus Rhythm Delineates Sites of Parasympathetic Innervation in Patients With Paroxysmal Atrial Fibrillation
Nicolas Lellouche, MD,
Eric Buch, MD,
Andrew Celigoj, BS,
Carin Siegerman, PhD,
David Cesario, MD, PhD,
Carlos De Diego, MD,
Aman Mahajan, MD, PhD,
Noel G. Boyle, MD, PhD,
Isaac Wiener, MD,
Alan Garfinkel, PhD and
Kalyanam Shivkumar, MD, PhD*
UCLA Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
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Figure 1 Classification and Regression Tree Model
Likelihood of parasympathetic response (PR) according to pre-ablation electrogram characteristics. The total number of ablation sites (n = 1,662) is represented by the pie diagram at the top. The shaded area of each pie diagram is proportional to the number of sites in that group showing a parasympathetic response to ablation. According to this tree analysis, we defined 3 electrogram patterns: normal, low-amplitude fractionated electrogram (LAFE), and high-amplitude fractionated electrogram (HAFE).
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Figure 2 Three EGM Patterns Seen in the LA and Typical Responses to Ablation
A = atrial deflection; EGM = electrogram; H = His bundle deflection; LA = left atrium; other abbreviations as in Figure 1.
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Figure 4 Atrial EGM Recording During Adenosine Infusion
(A) Fluoroscopic image in the left anterior oblique view of typical intracardiac catheter locations during adenosine infusion. (B) Superimposition of the surface electrocardiogram P-wave in lead V1 and atrial EGM. CS = coronary sinus catheter; ICE = intracardiac echocardiography catheter; LA = left atrial catheter; RA = right atrial catheter; RV = right ventricular catheter; other abbreviations as in Figure 2.
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Figure 6 Adenosine-Induced Changes in Atrial EGMs
(A) Average number of deflections by patient. (B) Change in deflections from baseline. (C) Effects of adenosine on atrial electrograms. EGM = electrogram; LA = left atrial; RA = right atrial.
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Figure 7 Mathematical Modeling
(Left) (A) Electrograms from normal tissue; (B) fibrotic tissue showing low-amplitude fractionation; (C) tissue exposed to acetylcholine, showing high-amplitude fractionation. (Right) Tissue pattern followed by snapshots of the advancing wavefront. In normal tissue (A), the pattern is homogeneous. In fibrosis (B), gray areas represent inexcitable scar tissue. In tissue exposed to acetylcholine (C), darker shaded areas indicate patches of IKACh and lowered diffusion.
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