References
1. Piccini JP, Fauchier L. Rhythm control in atrial
fibrillation. The Lancet 2016;388:829-840.
2. Khurram IM, Habibi M, Gucuk Ipek E, et al. Left Atrial LGE
and Arrhythmia Recurrence Following Pulmonary Vein Isolation for
Paroxysmal and Persistent AF. JACC Cardiovasc Imaging Feb
2016;9:142-148.
3. Zahid S, Cochet H, Boyle PM, Schwarz EL, Whyte KN, Vigmond
EJ, Dubois R, Hocini M, Haissaguerre M, Jais P, Trayanova NA.
Patient-derived models link re-entrant driver localization in atrial
fibrillation to fibrosis spatial pattern. Cardiovasc Res Jun 1
2016;110:443-454.
4. Dzeshka MS, Lip GY, Snezhitskiy V, Shantsila E. Cardiac
Fibrosis in Patients With Atrial Fibrillation: Mechanisms and Clinical
Implications. J Am Coll Cardiol Aug 25 2015;66:943-959.
5. Sakata K, Okuyama Y, Ozawa T, Haraguchi R, Nakazawa K,
Tsuchiya T, Horie M, Ashihara T. Not all rotors, effective ablation
targets for nonparoxysmal atrial fibrillation, are included in areas
suggested by conventional indirect indicators of atrial fibrillation
drivers: ExTRa Mapping project. J Arrhythm Apr 2018;34:176-184.
6. Tomii N, Asano K, Seno H, Ashihara T, Sakuma I, Yamazaki M.
Validation of Intraoperative Catheter Phase Mapping Using a Simultaneous
Optical Measurement System in Rabbit Ventricular Myocardium. Circ J Mar
25 2020;84:609-615.
7. Nakamura T, Kiuchi K, Fukuzawa K, et al. Late-gadolinium
enhancement properties associated with atrial fibrillation rotors in
patients with persistent atrial fibrillation. J Cardiovasc
Electrophysiol Feb 8 2021.
8. Roy A, Varela M, Aslanidi O. Image-Based Computational
Evaluation of the Effects of Atrial Wall Thickness and Fibrosis on
Re-entrant Drivers for Atrial Fibrillation. Front Physiol 2018;9:1352.
9. Kiuchi K, Okajima K, Shimane A, et al. Visualization of the
radiofrequency lesion after pulmonary vein isolation using delayed
enhancement magnetic resonance imaging fused with magnetic resonance
angiography. J Arrhythm Jun 2015;31:152-158.
10. Kiuchi K, Okajima K, Shimane A, Shigenaga Y. Visualization
of pulmonary vein-left atrium reconduction site on delayed-enhancement
magnetic resonance imaging in the second atrial fibrillation catheter
ablation. Circ J 2014;78:2993-2995.
11. McGann C, Akoum N, Patel A, et al. Atrial fibrillation
ablation outcome is predicted by left atrial remodeling on MRI. Circ
Arrhythm Electrophysiol Feb 2014;7:23-30.
12. Kiuchi K, Fukuzawa K, Takami M, et al. Feasibility of
catheter ablation in patients with persistent atrial fibrillation guided
by fragmented late-gadolinium enhancement areas. J Cardiovasc
Electrophysiol 2020.
13. Kiuchi K, Kircher S, Watanabe N, Gaspar T, Rolf S, Arya A,
Piorkowski C, Hindricks G, Sommer P. Quantitative analysis of isolation
area and rhythm outcome in patients with paroxysmal atrial fibrillation
after circumferential pulmonary vein antrum isolation using the
pace-and-ablate technique. Circ Arrhythm Electrophysiol Aug 1
2012;5:667-675.
14. Nakamura K, Funabashi N, Uehara M, Ueda M, Murayama T,
Takaoka H, Komuro I. Left atrial wall thickness in paroxysmal atrial
fibrillation by multislice-CT is initial marker of structural remodeling
and predictor of transition from paroxysmal to chronic form. Int J
Cardiol Apr 14 2011;148:139-147.
15. Zuo K, Li K, Liu M, Li J, Liu X, Liu X, Zhong J, Yang X.
Correlation of left atrial wall thickness and atrial remodeling in
atrial fibrillation: Study based on low-dose-ibutilide-facilitated
catheter ablation. Medicine (Baltimore) Apr 2019;98:e15170.
16. Bunch TJ, Day JD. Adverse Remodeling of the Left Atrium in
Patients with Atrial Fibrillation: When Is the Tipping Point in Which
Structural Changes Become Permanent? J Cardiovasc Electrophysiol Jun
2015;26:606-607.
17. Hansen BJ, Zhao J, Csepe TA, et al. Atrial fibrillation
driven by micro-anatomic intramural re-entry revealed by simultaneous
sub-epicardial and sub-endocardial optical mapping in explanted human
hearts. Eur Heart J Sep 14 2015;36:2390-2401.
18. Handa BS, Li X, Baxan N, Roney CH, Shchendrygina A,
Mansfield CA, Jabbour RJ, Pitcher DS, Chowdhury RA, Peters NS, Ng FS.
Ventricular fibrillation mechanism and global fibrillatory organization
are determined by gap junction coupling and fibrosis pattern. Cardiovasc
Res Mar 21 2021;117:1078-1090.
19. Eckstein J, Zeemering S, Linz D, Maesen B, Verheule S, van
Hunnik A, Crijns H, Allessie MA, Schotten U. Transmural conduction is
the predominant mechanism of breakthrough during atrial fibrillation:
evidence from simultaneous endo-epicardial high-density activation
mapping. Circ Arrhythm Electrophysiol Apr 2013;6:334-341.
20. Parameswaran R, Kalman JM, Royse A, et al.
Endocardial-Epicardial Phase Mapping of Prolonged Persistent Atrial
Fibrillation Recordings: High Prevalence of Dissociated Activation
Patterns. Circ Arrhythm Electrophysiol Aug 2020;13:e008512.
21. Ashihara T, Haraguchi R, Nakazawa K, Namba T, Ikeda T,
Nakazawa Y, Ozawa T, Ito M, Horie M, Trayanova NA. The role of
fibroblasts in complex fractionated electrograms during
persistent/permanent atrial fibrillation: implications for
electrogram-based catheter ablation. Circ Res Jan 20 2012;110:275-284.
22. Ali RL, Hakim JB, Boyle PM, Zahid S, Sivasambu B, Marine
JE, Calkins H, Trayanova NA, Spragg DD. Arrhythmogenic propensity of the
fibrotic substrate after atrial fibrillation ablation: a longitudinal
study using magnetic resonance imaging-based atrial models. Cardiovasc
Res Oct 1 2019;115:1757-1765.
Figure 1 The measurement of the atrial wall thickness in our
representative case. A, B) Axial, C, D) coronal and E, F) sagittal views
of the atria from one representative subject overlaid, in the bottom
row, with the performed manual segmentations. Ao, aorta; LA, left
atrium; LAA, left atrial appendage; PA, pulmonary artery; LV, left
ventricle; RA, right atrium.
Figure 2 The mean AWT in each segment of the whole left atrium
(A) and mean AWT in the NPAs and PAs in lesser LGE and all LGE areas
(B). AWT, atrial wall thickness; LAA, left atrial appendage; LGE, late
gadolinium enhancement; NPA, non-passively activated area; PA, passively
activated area. PV, pulmonary vein.
Figure 3 The distribution of the NPAs and PAs according to the
AWT and LGE-volume ratio. The NPAs (red) and PAs (blue). The AWT
correlated negatively with the LGE-volume ratio in the total areas (A).
This correlation was stronger in the NPAs (B) than PAs (C). AWT, atrial
wall thickness; LGE, late gadolinium enhancement; NPA, non-passively
activated area; PA, passively activated area.
Figure 4 Representative case in our study. ExTRa Mapping with
the NavX system in the AP (A) and PA (B) views. The red, yellow, green,
and light blue circles indicate the NPAs with a high %NP of 73, 59, 57,
and 55%, respectively. The 3D LGE-MRI of the LA in the AP (C) and PA
(D) views. The red, yellow, green, and light blue circles correspond to
those in panel A. Despite the low value of the LGE-volume ratio, these 5
areas were determined to be NPAs and their AWT was thick.
AP, anterior-posterior; AWT, atrial wall thickness; LA, left atrium.
LGE-MRI, late-gadolinium enhancement magnetic resonance imaging; LSI,
lesion size index; NPA, non-passively activated area; PA,
posterior-anterior; %NP, non-passively activated ratio.
Figure 5 The proportion of MRs and MWs in the %NP of NPAs in
lesser LGE and heterogenous LGE areas. LGE, late gadolinium enhancement;
MR, meandering rotors; MW, multiple wavelets; NPA, non-passively
activated area; %NP, non-passively activated ratio.