Electrophysiological Characteristics of Atrial Fibrillation Trigger Sites During Ongoing Atrial Fibrillation Using Ultra‐High‐Resolution Mapping

Figures

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  FIGURE 1. Schematic representations of the segmentation of the PVs and LA in the posteroanterior view (left panels) and the SVC and RA in the anteroposterior view (right panel). The PVs and LA were segmented at the level of the PV antrum, and the SVC and RA were segmented at the level of the RA‐SVC junction (black dotted lines). IVC, inferior vena cava; LA, left atrium; LAA, LA appendage; LCPV, left common pulmonary vein (PV); LIPV, left inferior PV; LSPV, left superior PV; RIPV, right inferior PV; RSPV, right superior PV; RA, right atrium; RAA, RA appendage; SVC, superior vena cava; TA, tricuspid annulus.

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  FIGURE 2. A representative case with LSPV and LIPV triggers. (A) Whole‐region mapping of the PVs, LA, SVC, and RA is shown. Bipolar voltage maps and scatter plots of the L‐CL and DC are presented for the PVs and LA (upper pairs of panels) and for the SVC and RA (lower pairs of panels) in the posteroanterior (left panels) and anteroposterior (right panels) views. When the Ockham software module was set to highlight areas with an L‐CL of 115–125 ms, highlighted areas were observed in the posterior LSPV and LIPV (white arrowheads), whereas no highlighted areas were observed in the RSPV, RIPV, LA, SVC, or RA. (B) Twelve‐lead and intracardiac electrocardiograms at AF onset induced by triggers originating from the LSPV (left panel) and LIPV (right panel) are shown (red arrowheads). (C) Local electrograms recorded by the mini‐basket catheter at sites with the minimum L‐CL within each segmented anatomical region (left panels), corresponding bipolar voltage maps (middle panels), and scatter plots of the L‐CL and DC (right panels). To demonstrate the minimum L‐CL within each region, Panel C selectively displays the anatomical region used for calculation of the minimum, quartile, and maximum L‐CL and…

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  FIGURE 3. A representative case with an SVC trigger. (A) Whole‐region mapping of the PVs, LA, SVC, and RA is shown. Bipolar voltage maps and scatter plots of the L‐CL and DC are presented for the PVs and LA (upper pairs of panels) and for the SVC and RA (lower pairs of panels) in the posteroanterior (left panels) and anteroposterior (right panels) views. When the Ockham software module was set to highlight areas with an L‐CL of 115–120 ms, a highlighted area was observed in the septal SVC (white arrowhead), whereas no highlighted areas were observed in the PVs, LA, or RA. (B) Twelve‐lead and intracardiac electrocardiograms at AF onset induced by a trigger originating from the SVC are shown (red arrowhead). (C) Local electrograms recorded by the mini‐basket catheter at sites with the minimum L‐CL within each segmented anatomical region (left panels), corresponding bipolar voltage maps (middle panels), and scatter plots of the L‐CL and DC (right panels). To demonstrate the minimum L‐CL within each region, Panel C selectively displays the anatomical region used for calculation of the minimum, quartile, and maximum L‐CL and DC values. The Ockham software module highlighted the sites with the…

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  FIGURE 4. Comparison of the (A) L‐CL and (B) DC among the trigger veins, non‐trigger PVs, LA, non‐trigger SVC, and RA. In the box‐and‐whisker plots, the center line indicates the median, the box represents the IQR, the whiskers indicate the range excluding outliers, and the circles represent outliers. (C) The table shows the minimum, quartile, and maximum values of the L‐CL and DC in the trigger veins, non‐trigger PVs, LA, non‐trigger SVC, and RA, respectively. **Significantly different from the trigger veins at p < 0.01, *p < 0.05. ††Significantly different from the non‐trigger PVs at p < 0.01, †p < 0.05. ‡‡Significantly different from the LA at p < 0.01, ‡p < 0.05. §§Significantly different from the RA at p < 0.01, §p < 0.05. The abbreviations are as in Figure 1 and Figure 2.

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  FIGURE 5. Association of the L‐CL and DC with AF trigger sites. The upper panels represent the ROC curves for the (A) L‐CL and (B) DC. The dots on the ROC curves indicate the optimal cutoffs. (C) The table shows the AUC with a 95% CI, optimal cutoff, sensitivity, specificity, and positive and negative predictive values for the minimum, quartile, and maximum values of the L‐CL and DC. Abbreviations: AUC, area under the curve; CI, confidence interval; PPV, positive predictive value; NPV, negative predictive value. The other abbreviations are as in Figure 2.