Inverse relationship between fractionated electrograms and atrial fibrosis in persistent atrial fibrillation: combined magnetic resonance imaging and high-density mapping

J Am Coll Cardiol. 2013 Aug 27;62(9):802-12. doi: 10.1016/j.jacc.2013.03.081. Epub 2013 May 30.


Objectives: This study sought to evaluate the relationship between fibrosis imaged by delayed-enhancement (DE) magnetic resonance imaging (MRI) and atrial electrograms (Egms) in persistent atrial fibrillation (AF).

Background: Atrial fractionated Egms are strongly related to slow anisotropic conduction. Their relationship to atrial fibrosis has not yet been investigated.

Methods: Atrial high-resolution MRI of 18 patients with persistent AF (11 long-lasting persistent AF) was registered with mapping geometry (NavX electro-anatomical system (version 8.0, St. Jude Medical, St. Paul, Minnesota)). DE areas were categorized as dense or patchy, depending on their DE content. Left atrial Egms during AF were acquired using a high-density, 20-pole catheter (514 ± 77 sites/map). Fractionation, organization/regularity, local mean cycle length (CL), and voltage were analyzed with regard to DE.

Results: Patients with long-lasting persistent versus persistent AF had larger left atrial (LA) surface area (134 ± 38 cm(2) vs. 98 ± 9 cm(2), p = 0.02), a higher amount of atrial DE (70 ± 16 cm(2) vs. 49 ± 10 cm(2), p = 0.01), more complex fractionated atrial Egm (CFAE) extent (54 ± 16 cm(2) vs. 28 ± 15 cm(2), p = 0.02), and a shorter baseline AF CL (147 ± 10 ms vs. 182 ± 14 ms, p = 0.01). Continuous CFAE (CFEmean [NavX algorithm that quantifies Egm fractionation] <80 ms) occupied 38 ± 19% of total LA surface area. Dense DE was detected at the left posterior left atrium. In contrast, the right posterior left atrium contained predominantly patchy DE. Most CFAE (48 ± 14%) occurred at non-DE LA sites, followed by 41 ± 12% CFAE at patchy DE and 11 ± 6% at dense DE regions (p = 0.005 and p = 0.008, respectively); 19 ± 6% CFAE sites occurred at border zones of dense DE. Egms were less fractionated, with longer CL and lower voltage at dense DE versus non-DE regions: CFEmean: 97 ms versus 76 ms, p < 0.0001; local CL: 153 ms versus 143 ms, p < 0.0001; mean voltage: 0.63 mV versus 0.86 mV, p < 0.0001.

Conclusions: Atrial fibrosis as defined by DE MRI is associated with slower and more organized electrical activity but with lower voltage than healthy atrial areas. Ninety percent of continuous CFAE sites occur at non-DE and patchy DE LA sites. These findings are important when choosing the ablation strategy in persistent AF.

Keywords: AF; CFAE; CFEmean; CL; CS; DE; Egm; LA; MRI; NavX algorithm that quantifies electrogram fractionation; PV; PVI; aDE; ablation; atrial delayed enhancement; atrial fibrillation; atrial fibrosis; complex fractionated atrial electrogram; coronary sinus; cycle length; delayed enhancement; electrogram; left atrial; magnetic resonance imaging; pulmonary vein; pulmonary vein isolation.

MeSH terms

  • Aged
  • Atrial Fibrillation / complications
  • Atrial Fibrillation / physiopathology*
  • Atrial Fibrillation / surgery
  • Catheter Ablation
  • Electrophysiologic Techniques, Cardiac*
  • Female
  • Fibrosis
  • Heart Atria / physiopathology*
  • Heart Atria / surgery
  • Humans
  • Magnetic Resonance Imaging / methods
  • Male
  • Middle Aged
  • Prospective Studies