The impact of the atrial wall thickness in normal/mild late‐gadolinium enhancement areas on atrial fibrillation rotors in persistent atrial fibrillation patients

Figures

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  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; LV, left ventricle; PA, pulmonary artery; RA, right atrium

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  FIGURE 2. An example of ExTRa Mapping. White lines indicate the head of the wavefronts, and white arrows indicate the direction of the wavefronts. The panel (A) and (B) show the representative case of non‐passive activation where counterclockwise rotational activations with meandering the center of the activation was found. The panel (C) shows the representative case of passive activation where planar wave is found

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  FIGURE 3. The mean AWT in each segment of the whole left atrium (A) and mean AWT in the NPAs and PAs in normal/mild 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

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  FIGURE 4. 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 area

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  FIGURE 5. Optimal AWT of normal/mild LGE areas predicting AF rotor. An ROC curve analysis yielded an optimal cutoff value of 2.3 mm and the AUC was 0.77 (0.66–0.88) for predicting the presence of an NPA in normal/mild LGE areas. AF, atrial fibrillation; AWT, atrial wall thickness; LGE, late‐gadolinium enhancement

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  FIGURE 6. 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 three areas were determined to be NPAs and their AWT was thick. %NP, non‐passively activated ratio; 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

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  FIGURE 7. The proportion of MRs and MWs in the %NP of NPAs in normal/mild LGE and heterogenous LGE areas. %NP, non‐passively activated ratio; LGE, late gadolinium enhancement; MR, meandering rotors; MW, multiple wavelets; NPA, non‐passively activated area