Objectives: The goal of this study was to describe functional endocardial–epicardial dissociation (FEED), signal complexities, and three-dimensional activation dynamics of the human atrium with structural heart disease (SHD). Background: SHD commonly predisposes to arrhythmias. Although progressive remodeling is implicated, direct demonstration of FEED in the human atrium has not been reported previously. Methods: Simultaneous intraoperative mapping of the endocardial and epicardial lateral right atrial wall was performed by using 2 high-density grid catheters during sinus rhythm, pacing drive (600 ms and 400 ms cycle length), and premature extrastimulation (PES). Unipolar electrograms (EGMs) were exported into custom-made software for activation and phase mapping. Difference of ≥20 ms between paired endocardial and epicardial electrodes defined dissociation. EGMs with ≥3 deflections were classified as fractionated. Results: Sixteen patients (mean age 60.5 ± 4.1 years; 18.7% with a history of atrial fibrillation) with SHD (43% ischemia, 57% valvular disease) were included. A total of 9,218 EGMs were analyzed. Compared with sinus rhythm, phase and activation analyses showed significant FEED during pacing at 600 ms and 400 ms (phase mapping 22.4% vs. 10% [p < 0.0001] and 25.8% vs. 10% [p < 0.0001], respectively; activation mapping 25.4% vs. 7.8% [p < 0.0001] and 27.7% vs. 7.8% [p < 0.0001]) and PES (phase mapping 34% vs. 10% [p < 0.0001]; activation mapping 29.5% vs. 7.8% [p < 0.0001]). Fractionated EGMs occurred significantly more during PES compared with sinus rhythm (50.2% vs. 39.5%; p < 0.0001). Activation patterns differed significantly during pacing drive and PES, with preferential epicardial exit during the latter (15.9% vs. 13.8%; p = 0.046). Conclusions: Simultaneous endocardial–epicardial mapping revealed significant FEED with signal fractionation and preferential epicardial breakthroughs with PES. Such complex three-dimensional interaction in electrical activation provides mechanistic insights into atrial arrhythmogenesis with SHD.

arrhythmogenesis, electrogram morphology, epicardial–endocardial mapping, fractionation, functional dissociation, structural heart disease
dx.doi.org/10.1016/j.jacep.2019.08.016, hdl.handle.net/1765/123793
JACC: Clinical Electrophysiology
Department of Cardiology

Parameswaran, R. (Ramanathan), Teuwen, C.P, Watts, T. (Troy), Nalliah, C.J. (Chrishan J.), Royse, A. (Alistair), Goldblatt, J. (John), … Kalman, J.M. (Jonathan M.). (2020). Functional Atrial Endocardial–Epicardial Dissociation in Patients With Structural Heart Disease Undergoing Cardiac Surgery. JACC: Clinical Electrophysiology, 6(1), 34–44. doi:10.1016/j.jacep.2019.08.016