Anti-atrial Fibrillation Effects of Pulmonary Vein Isolation With or Without Ablation Gaps: A Computational Modeling Study

Figures

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  Figure 1. Study protocol of the computational atrial modeling and AF simulation. (A) CT merged 3D-clinical electroanatomical map. (B) Clinical map integrated computational modeling. (C) Baseline AF induction in activation map. (D) Application of CPVI and PVI-gap. The yellow arrows indicate gaps in the PVI. (E) DF-based wave-dynamics analyses. (F) Study protocol. CT indicates computed tomography; EP, electrophysiology; LAT, local activation time; PVI-gap, pulmonary vein isolation with gap; CPVI, complete pulmonary vein isolation; DF, dominant frequency; AF, atrial fibrillation; AT, atrial tachycardia.

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  Figure 2. Wave-dynamic changes after the virtual PVI-gap and CPVI. (A) The ECGs were obtained at the blue * sites in the DF maps. (B) The red arrows indicate gaps in the PVI. (C) The 3D DF maps and ECGs indicate that the CPVI reduced the mean DF, increased the AF cycle lengths, and defragmented the AF, but the PVI-gap did not. However, neither the CPVI nor PVI-gap changed the Smax. DF indicates dominant frequency; Smax, the maximal slope of the restitution curves; PVI-gap, pulmonary vein isolation with gaps; CPVI, complete pulmonary vein isolation; AF, atrial fibrillation; AT, atrial tachycardia; ECG, electrocardiogram.

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  Figure 3. Wave-dynamic interactions between the PVs and extra-PVs in 35 ongoing AF episodes after the PVI-gap intervention. DF indicates dominant frequency; PV, pulmonary vein.

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  Figure 4. Wave-break at the wavelet exit of the gaps by a source-sink mismatch. (A) The 3D DF map indicates that the extra-PV DFs was greater than the PV-DFs. The activation map and ECG indicate that a regular wavelet turned into a wave-break when moving from the posterior wall of the LA to inside the PV through the gap. (B) The 3D DF map indicates that the inside PV-DF was greater than the extra-PV DF. The activation map and ECG indicate that a regular wavelet turned into a wave-break when moving from inside the PV to the lateral wall of the LA through the gap. DF indicates dominant frequency; PV, pulmonary vein; LA, left atrium; LSPV, left superior pulmonary vein; LIPV, left inferior pulmonary vein; ECG, Electrocardiogram.

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  Figure 5. Wave-dynamic changes after filling the wave-breaking PVI-gaps, ablating the highest DF sites, and adding virtual flecainide. ECGs were obtained at the green * sites in the DF map, and the green arrows indicate the gaps in the PVI. (A) AF terminated after ablating the two gaps on the posterior wall of the LA. (B) AF terminated after ablating the high DF site (white areas indicated by black arrows). (C) AF converted to AT after adding virtual flecainide without additional ablation. PVI-gap indicates pulmonary vein isolation with gaps; PV, pulmonary vein; DF, dominant frequency; AF, atrial fibrillation; AT, atrial tachycardia; ECG, Electrocardiogram.