Different characteristics of complex fractionated atrial electrograms in acute paroxysmal versus long-standing persistent atrial fibrillation

Abstract

Background: Complex fractionated atrial electrograms (CFAEs) may represent a phenomenon associated with sources of atrial fibrillation (AF) and are being used increasingly as targets of catheter ablation. However, current methods have limited efficacy for characterizing CFAEs important to substrate arrhythmogenicity and do not measure electrogram morphology.

Objective: The purpose of this study was to develop a methodology for quantifying the degree of morphologic heterogeneity in CFAE deflections, and to determine whether there are differences in this measurement between paroxysmal and persistent AF patients.

Methods: Two successive bipolar CFAEs of length 8.4 seconds each were acquired during AF from two sites each at the ostia of the four pulmonary veins (PVs) and from the anterior and posterior left atrial free wall in patients with paroxysmal AF (N = 10) and long-standing persistent AF (N = 10). Extrinsic and intrinsic features of electrogram shape were used to characterize fractionation in CFAE sequences. The extrinsic parameters were the amplitude, upslope, downslope, and width of each deflection. The intrinsic parameter was the voltage profile as characterized by the sum of absolute values. These measurements were compared to the mean interval between CFAE deflections, a standard fractionation indicator.

Results: The variability of intrinsic/extrinsic morphologic parameters was higher in paroxysmal than persistent AF at the left superior PV (P < or =.003), the posterior left atrial free wall, anterior left atrial free wall, left inferior PV, and right superior PV (P <.05 for most parameters), and the right inferior PV (not significant). Mean CFAE deflection intervals were longer at all locations in paroxysmal AF but were significant only at the left superior PV and posterior left atrial free wall (P <.05). Quantitative morphologic parameters were not well correlated with dominant frequency (r(2) <0.32); thus, our new measures are robust to changes in activation rate.

Conclusion: A novel method for quantifying CFAEs, independent of activation rate, has been developed. The method demonstrates greater significance in the difference between CFAE morphology in paroxysmal and long-standing AF compared with mean interval between CFAE deflections. The differences identified suggest that CFAE morphology may evolve as AF persists.

Figure 1

Phase plot descriptions. Left panels: Simulated signals varying in amplitude over time. Right panels: Corresponding phase plots for these signals.

Figure 2

Schematic diagrams showing positive and negative rectangular pulses with increasing disparity in amplitude but constant power and energy from A to D.

Figure 3

Signals and phase plots from paroxysmal (A, B) and long-standing persistent (C, D) atrial fibrillation (AF).

Figure 4

Summary plots of the coefficient of variation (COV) for the four different complex fractionated atrial electrogram morphologic parameters (amplitude, upslope, downslope, and peak width) for paroxysmal and long-standing atrial fibrillation. ANT = anterior left atrial free wall; LIPV = left inferior pulmonary vein; LSPV = left superior pulmonary vein; POST = posterior left atrial free wall; RIPV = right inferior pulmonary vein; RSPV = right superior pulmonary vein.

Figure 5

Plots of mean sum of absolute values measured in complex fractionated atrial electrograms recorded from different anatomic sites. ANT = anterior left atrial free wall; LIPV = left inferior pulmonary vein; LSPV = left superior pulmonary vein; POST = posterior left atrial free wall; RIPV = right inferior pulmonary vein; RSPV = right superior pulmonary vein.