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. 2020 Aug 31;13(2):2304.
doi: 10.4022/jafib.2304. eCollection 2020 Aug.

The Arrhythmic Substrate for Atrial Fibrillation in Patients with Mitral Regurgitation

Matthew R Schill  1 , Phillip S Cuculich  2 , Christopher M Andrews  3 , Ramya Vijayakumar  3 , Chawannuch Ruaengsri  1 , Matthew C Henn  1 , Timothy S Lancaster  1 , Spencer J Melby  1 , Richard B Schuessler  1   3 , Yoram Rudy  2   3 , Ralph J Damiano  1
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The Arrhythmic Substrate for Atrial Fibrillation in Patients with Mitral Regurgitation

Matthew R Schill et al. J Atr Fibrillation. .

Abstract

Objective: Patients with severe mitral regurgitation commonly develop atrial fibrillation. The precise mechanisms of this relationship remain unknown. The objective of this study was to apply noninvasive electrocardiographic imaging of the atria during sinus rhythm to identify changes in atrial electrophysiology that may contribute to development of atrial fibrillation in patients with severe mitral regurgitation referred for mitral valve surgery.

Methods: Twenty subjects (9 atrial fibrillation and mitral regurgitation, 11 mitral regurgitation alone) underwent electrocardiographic imaging. Biatrial electrophysiology was imaged with activation maps in sinus rhythm. The reconstructed unipolar electrograms were analyzed for voltage amplitude, number of deflections and conduction heterogeneity. In subjects with mitral regurgitation, left atrial biopsies were obtained at the time of surgery. Results: Subjects with history of atrial fibrillation demonstrated prolonged left atrial conduction times (110±25 ms vs. mitral regurgitation alone (85±21), p=0.025); right atrial conduction times were unaffected. Variable patterns of conduction slowing were imaged in the left atria of most subjects, but those with prior history of atrial fibrillation had more complex patterns of conduction slowing or unidirectional block. The presence of atrial fibrillation was not associated with the extent of fibrosis in atrial biopsies.

Conclusions: Detailed changes in sinus rhythm atrial electrophysiology can be imaged noninvasively and can be used to assess the impact and evolution of atrial fibrillation on atrial conduction properties in patients with mitral regurgitation. If replicated in larger studies, electrocardiographic imaging may identify patients with mitral regurgitation at risk for atrial fibrillation and could be used to guide treatment strategies.

Keywords: Atrial Fibrillation; Electrocardiographic Imaging; Inferior Vena Cava.

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Figures

Figure 1.
Figure 1.. Data processing scheme. Data shown are from a normal volunteer imaged previously. A. Usable torso signals identified after low-and high-pass filtering and semi-automated rejection. B. Rejected torso signals. C. Scatterplot showing torso positions of used (blue) and rejected (red) nodes. D. Final torso potentials after P-wave selection and semi-automated rejection. E. Epicardial potentials calculated using inverse reconstruction. F. Epicardial potentials (initial time point) projected onto bi-atrial mesh.
Figure 2.
Figure 2.. Activation maps: (A) MR (B) AF and MR. Earliest activation is set as time zero; activation times are shown in ms. Amplitude maps: (C) MR (D) AF and MR. AF and MR displays increased variation in electrogram amplitude. Number of deflections: (E) MR (F) AF and MR. MR displays higher numbers of deflections in a consistent location in the left atrial posterior wall; in AF and MR, the pattern is less predictable. Inhomogeneity maps: (G) MR (H) AF and MR. Calculated inhomogeneity delineates lines of conduction slowing or block. The pattern of conduction slowing is much more complex in AF and MR than in MR. IVC, inferior vena cava. LAA, left atrial appendage. LIPV, left inferior pulmonary vein. RAA, right atrial appendage. RSPV, right superior pulmonary vein.
Figure 3.
Figure 3.. Electrogram progression across line of conduction block from a normal volunteer. Four electrograms crossing a line of conduction block in the left atrial posterior wall are shown in blue; activation time is shown by red vertical lines. Electrograms A and B display significantly earlier activation than C and D, and there is a progression of electrogram morphology across the line of block.
Figure 4.
Figure 4.. Histopathology: (A) MR (B) AF and MR. Masson’s trichrome. MR exhibits normal muscle fiber architecture and orientation; AF and MR exhibits interstitial fibrosis.
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