Predicting initiation and termination of atrial fibrillation from the ECG.

Atrial fibrillation is the most common cardiac arrhythmia, affecting more than two million people in the US. Several therapies for patients with atrial fibrillation are available, but methods to help physicians select the optimal therapy for an individual patient are still required. Knowledge of whether a patient with a normal ECG will exhibit atrial fibrillation in the future, as well as whether atrial fibrillation will terminate spontaneously, would be very useful in clinical routine. The paper presents a software system for predicting the initiation and termination of atrial fibrillation from the ECG. The algorithms have been validated on ECGs from several signal databases. Prediction of the initiation of atrial fibrillation was achieved by detecting premature heart beats and analyzing the morphology of their P waves. Prediction of the termination of atrial fibrillation was based on calculation of the major atrial frequency. This frequency has been shown to decrease significantly prior to the termination of atrial fibrillation. Nevertheless, the effect is much less distinct in the large data set used for this study compared to previous studies. The initiation of atrial fibrillation, however, could be correctly predicted in approximately 75% of the data analyzed.     

Frequency analysis of atrial fibrillation from the surface electrocardiogram

Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice. Neither the natural history of AF nor its response to therapy are sufficiently predictable by clinical and echocardiographic parameters. Atrial fibrillatory frequency (or rate) can reliably be assessed from the surface electrocardiogram (ECG) using digital signal processing (filtering, subtraction of averaged QRST complexes, and power spectral analysis) and shows large inter-individual variability. This measurement correlates well with intraatrial cycle length, a parameter which appears to have primary importance in AF domestication and response to therapy. AF with a low fibrillatory rate is more likely to terminate spontaneously, and responds better to antiarrhythmic drugs or cardioversion while high rate AF is more often persistent and refractory to therapy. In conclusion, frequency analysis of AF seems to be useful for non-invasive assessment of electrical remodeling in AF and may subsequently be helpful for guiding AF therapy.     

Nonreentrant focal activations in pulmonary veins in canine model of sustained atrial fibrillation

Repetitive rapid activities are present in the pulmonary veins (PVs) in dogs with pacing-induced sustained atrial fibrillation (AF). The mechanisms are unclear. We induced sustained (>48 h) AF by rapidly pacing the left atrium (LA) in six dogs. High-density computerized mapping was done in the PVs and atria. Results show repetitive focal activations in all dogs and in 12 of 18 mapped PVs. Activation originated from the middle of the PV and then propagated to the LA and distal PV with conduction blocks. The right atrium (RA) was usually activated by a single large wavefront. Mean AF cycle length in the PVs (left superior, 82 +/- 6 ms; left inferior, 83 +/- 6 ms; right inferior, 83 +/- 4 ms) and LA posterior wall (87 +/- 5 ms) were significantly (P < 0.05) shorter than those in the LA anterior wall (92 +/- 4 ms) and RA (107 +/- 5 ms). PVs in normal dogs did not have focal activations during induced AF. No reentrant wavefronts were demonstrated in the PVs. We conclude that nonreentrant focal activations are present in the PVs in a canine model of pacing-induced sustained AF.     

Atrial remodeling in atrial fibrillation and association between microRNA network and atrial fibrillation

Atrial fibrillation (AF) remains one of the leading causes of morbidity and mortality in the world which are related to palpitations, fainting, congestive heart failure or stroke. The mechanism for atrial fibrillation has been identified as electrical remodeling, structure remodeling and intracellular calcium handling remodeling. microRNAs (miRNAs) have recently emerged as one of the important factors in regulating gene expression. So far, thousands of miRNA genes have been found in diverse animals with the function of regulating cell death, cell proliferation, haematopoiesis and even participate in the processing of cardiovascular disease. In this review, we summarize the mechanism of AF and the association of microRNAs network with AF. We provide a potential perspective of miRNAs as the therapeutic target for AF.     

Nonlinear modeling of the atrioventricular node physiology in atrial fibrillation

A nonlinear model of the atrioventricular (AV) node physiology in atrial fibrillation (AF) is proposed based on three assumptions: (1) normal distribution of atrial impulses, (2) right-skewed distribution of R-R intervals, (3) increase in the refractory period of the AV node due to rapid bombardment from the atria. Simulation resulted in the following conclusions, all of which are in agreement with previous experience: (1) the entry speed of atrial impulses into the AV node in AF is inversely proportional to the ventricular rate, (2) the autocorrelation function of R-R intervals is zero at all delays, (3) a newly introduced index, sign of first difference, has a negative autocorrelation function at the first delay and zero ones at all others. In spite of its simplicity, the model is able to explain what happens in atrial premature complexes, sinus tachycardia and sinus bradycardia. Different rhythms, some of which rarely seen clinically, can be reproduced by changing input patterns or by slightly manipulating the model parameters. In order to make possible a long irregular time series of R-R interval, aperiodic changes in atrial signals are shown to be necessary. In conclusion, we proposed a simple model for the AV node physiology capable of explaining the previously known facts about AF as well as predicting interesting properties of some other supraventricular arrhythmias.     

Reduction of CPR artifacts in the ventricular fibrillation ECG by coherent line removal

Background  

Interruption of cardiopulmonary resuscitation (CPR) impairs the perfusion of the fibrillating heart, worsening the chance for successful defibrillation. Therefore ECG-analysis during ongoing chest compression could provide a considerable progress in comparison with standard analysis techniques working only during "hands-off" intervals.     

Accurate estimation of entropy in very short physiological time series: the problem of atrial fibrillation detection in implanted ventricular devices

Entropy estimation is useful but difficult in short time series. For example, automated detection of atrial fibrillation (AF) in very short heart beat interval time series would be useful in patients with cardiac implantable electronic devices that record only from the ventricle. Such devices require efficient algorithms, and the clinical situation demands accuracy. Toward these ends, we optimized the sample entropy measure, which reports the probability that short templates will match with others within the series. We developed general methods for the rational selection of the template length m and the tolerance matching r. The major innovation was to allow r to vary so that sufficient matches are found for confident entropy estimation, with conversion of the final probability to a density by dividing by the matching region volume, 2r(m). The optimized sample entropy estimate and the mean heart beat interval each contributed to accurate detection of AF in as few as 12 heartbeats. The final algorithm, called the coefficient of sample entropy (COSEn), was developed using the canonical MIT-BIH database and validated in a new and much larger set of consecutive Holter monitor recordings from the University of Virginia. In patients over the age of 40 yr old, COSEn has high degrees of accuracy in distinguishing AF from normal sinus rhythm in 12-beat calculations performed hourly. The most common errors are atrial or ventricular ectopy, which increase entropy despite sinus rhythm, and atrial flutter, which can have low or high entropy states depending on dynamics of atrioventricular conduction.     

Analysis of ECG in ventricular fibrillation in man and animals based on chaos theory

The methods of the chaos theory were used to estimate the degree of irregularity of ventricular fibrillation in human and experimental animals. To verify the hypothesis that the degree of chaos depends on the species of the living organisms, the parameters characterizing the degrees of irregularity of ventricular fibrillation were estimated and compared. The comparative analysis was performed using 32 fragments of electrocardiographic records from five patients with sudden ventricular fibrillation bouts and 215 episodes of induced fibrillation in 17 animals. It was shown that fibrillation in human and animals has a different degree of regularity and different values of the chaotic component. The highest values of chaos were recorded in dogs, the lowest degree of chaos was observed in human. Rabbits and rats are intermediate, between dogs and humans. The fractuality of the structure-function organization of myocardium is discussed.     

Assessment of the dynamics of atrial signals and local atrial period series during atrial fibrillation: effects of isoproterenol administration

Background  

The autonomic nervous system (ANS) plays an important role in the genesis and maintenance of atrial fibrillation (AF), but quantification of its electrophysiologic effects is extremely complex and difficult. Aim of the study was to evaluate the capability of linear and non-linear indexes to capture the fine changing dynamics of atrial signals and local atrial period (LAP) series during adrenergic activation induced by isoproterenol (a sympathomimetic drug) infusion.     

Structural differences between atrial and ventricular myosins from normal human hearts

Comparisons were made between myosins isolated from the right and left ventricles and the atria of normal human hearts. Parameters examined included electrophoretic mobilities of native molecules, K+ and Ca2+ dependent enzymatic activities, light chain composition, peptide patterns from partial proteolytic digests of entire heavy chains or rods, and maps of complete digests of specific 21 and 25 kilodalton heavy chain fragments. Human ventricular and atrial myosins differ in all parameters except in the charge of molecules. Structural differences between cardiac myosins derived from the two sources were apparent in both the head and tail portions of the heavy chains. With respect to the above parameters no differences were found between myosins from left and right human ventricles.     

Roles of the AV junction in determining the ventricular response to atrial fibrillation.

The statistical properties of RR interval sequences during cholinergic atrial fibrillation were studied in anesthetized dogs both in control conditions and after the selective injection of dromotropic agents into the atrioventricular (AV) node artery. It was observed that RR interval histogram configurations depended mainly on the mean heart rate, regardless of whether it was a control or a post-injection sequence. The sequences were found to vary from almost regular at fast rates to highly irregular at slow rates, covering all intermediate possibilities. Since the injections of dromotropic agents into the AV node artery were carried out during sinus rhythm between the episodes of fibrillation, their influences on the AV junction, as reflected both on the length of the PR interval during sinus rhythm and on the RR interval dispersion during fibrillation, could be compared. The dispersion of RR intervals was found to increase as the PR interval duration became longer. In addition, it was observed that the generally random character of the RR interval sequences during fibrillation was not affected by the injection of dromotropic agents into the AV node artery. These results were interpreted as an indication that, for a well-established atrial fibrillation, the degree of ventricular irregularity (dispersion of RR intervals) is related to the conductivity within the AV junction and that the random character of RR interval sequences is related to the atrial fibrillatory activity itself.     

Paced QRS morphology predicts incident left ventricular systolic dysfunction and atrial fibrillation

Background

The prognostic significance of paced QRS complex morphology on surface ECG remains unclear. This study aimed to assess long-term outcomes associated with variations in the paced QRS complex.

Acceleration of ventricular rate by amiodarone in atrial fibrillation associated with the Wolff-Parkinson-White syndrome

Amiodarone has proved to be a valuable drug in atrial fibrillation associated with the Wolff-Parkinson-White syndrome. When it was administered to a patient with this syndrome in atrial fibrillation, who had previously suffered an inferior myocardial infarction, the ventricular rate accelerated from 170 to 230 beats/minute.This unusual case emphasises the need for full electrophysiological assessment of patients with the Wolff-Parkinson-White syndrome for whom amiodarone treatment is being considered.     

心房颤动患者血清脑钠肽水平变化的临床研究

目的：探讨患者心房颤动（房颤,AF）发作时对血清脑钠肽水平的影响。方法：选择阵发性房颤组、持续性房颤组、对照组（窦性心律）患者各30例,观察各组血清脑钠肽水平;并对阵发性房颤组中心室率≤100 beats/min与心室率〉100 beats/min的患者进行亚组分析;观察阵发性房颤组复律后24 h和30 d血清脑钠肽水平。结果：阵发性房颤组和持续性房颤组血清脑钠肽水平明显高于对照组（P〈0.01）,房颤复律后血清脑钠肽水平很快下降。结论：血清脑钠肽水平在房颤发作时明显升高,血清脑钠肽水平的升高与房颤的发作有关。     

The investigation of the synchronization between rhythms in the human cardiovascular system from time series of R-R-intervals

We demonstrated that, from the sequence of R-R intervals, it is possible to calculate the instantaneous phases and instantaneous frequencies of the main rhythmic processes governing the cardiovascular dynamics in humans, namely, the main heart rhythm, respiration, and the process of slow regulation of blood pressure with basic frequency close to 0.1 Hz. For the cases of spontaneous respiration and paced respiration with a fixed frequency, the synchronization between the rhythms of the cardiovascular system was investigated based on the analysis of only the time series of R-R intervals. It is shown that the main heart rhythm and the rhythm of low-frequency regulation of blood pressure can be synchronized with respiration.     

Also the very elderly benefit from warfarin in atrial fibrillation

Warfarin therapy is the cornerstone in the prevention of thromboembolism in patients with atrial fibrillation. It reduces the risk of stroke by two thirds in comparison with no anticoagulation. 1 A weak alternative to warfarin is aspirin, which is also effective over placebo in the prevention of stroke in atrial fibrillation. 1 Aspirin is safer than warfarin in general use. The incidence of atrial fibrillation sharply increases with age, but also the risk of bleeding from warfarin shows the same pattern.     

Hypothermia resulting in characteristic ECG changes mimicking an acute myocardial infarction: Osborn waves and atrial fibrillation

Hypothermia can cause several ECG changes which can be mistaken for other cardiac diseases, most importantly acute transmural ischaemia. These ECG changes correlate strongly with the degree of hypothermia and the prognosis of the patient. This brief report presents a 32-year-old male who was seen after a drowning accident. After resuscitation a 12-lead electrocardiogram showed changes typical for hypothermia: atrial fibrillation and Osborn waves. The ECG of the patient normalised after rewarming.     

Adaptive frequency tracking of the baseline ECG identifies the site of atrial fibrillation termination by catheter ablation

Multiple organization indices have been used to predict the outcome of stepwise catheter ablation in long-standing persistent atrial fibrillation (AF), however with limited success. Our study aims at developing innovative organization indices from baseline ECG (i.e. during the procedure, before ablation) in order to identify the site of AF termination by catheter ablation. Seventeen consecutive male patients (age 60 ± 5 years, AF duration 7 ± 5 years) underwent a stepwise catheter ablation. Chest lead V6 was placed in the back (V6b). QRST cancelation was performed from chest leads V1 to V6b. Using an innovative adaptive harmonic frequency tracking, two measures of AF organization were computed to quantify the harmonics components of ECG activity: (1) the adaptive phase difference variance (APD) between the AF harmonic components as a measure of AF regularity, and (2) and adaptive organization index (AOI) evaluating the cyclicity of the AF oscillations. Both adaptive indices were compared to indices computed using a time-invariant approach: (1) ECG AF cycle length (AFCL), (2) the spectrum based organization index (OI), and (3) the time-invariant phase difference TIPD. Long-standing persistent AF was terminated into sinus rhythm or atrial tachycardia in 13/17 patients during stepwise ablation, 11 during left atrium ablation (left terminated patients – LT), 2 during the right atrium ablation (right terminated patients – RT), and 4 were non terminated (NT) and required electrical cardioversion. Our findings showed that LT patients were best separated from RT/NT before ablation by the duration of sustained AF and by AOI on chest lead V1 and APD from the dorsal lead V6b as compared to ECG AFCL, OI and TIPD, respectively. Our results suggest that adaptive measures of AF organization computed before ablation perform better than time-invariant based indices for identifying patients whose AF will terminate during ablation within the left atrium. These findings are indicative of a higher baseline organization in these patients that could be used to select candidates for the termination of AF by stepwise catheter ablation.     

Detection of focal source and arrhythmogenic substrate from body surface potentials to guide atrial fibrillation ablation

Focal sources (FS) are believed to be important triggers and a perpetuation mechanism for paroxysmal atrial fibrillation (AF). Detecting FS and determining AF sustainability in atrial tissue can help guide ablation targeting. We hypothesized that sustained rotors during FS-driven episodes indicate an arrhythmogenic substrate for sustained AF, and that non-invasive electrical recordings, like electrocardiograms (ECGs) or body surface potential maps (BSPMs), could be used to detect FS and AF sustainability. Computer simulations were performed on five bi-atrial geometries. FS were induced by pacing at cycle lengths of 120–270 ms from 32 atrial sites and four pulmonary veins. Self-sustained reentrant activities were also initiated around the same 32 atrial sites with inexcitable cores of radii of 0, 0.5 and 1 cm. FS fired for two seconds and then AF inducibility was tested by whether activation was sustained for another second. ECGs and BSPMs were simulated. Equivalent atrial sources were extracted using second-order blind source separation, and their cycle length, periodicity and contribution, were used as features for random forest classifiers. Longer rotor duration during FS-driven episodes indicates higher AF inducibility (area under ROC curve = 0.83). Our method had accuracy of 90.6±1.0% and 90.6±0.6% in detecting FS presence, and 93.1±0.6% and 94.2±1.2% in identifying AF sustainability, and 80.0±6.6% and 61.0±5.2% in determining the atrium of the focal site, from BSPMs and ECGs of five atria. The detection of FS presence and AF sustainability were insensitive to vest placement (±9.6%). On pre-operative BSPMs of 52 paroxysmal AF patients, patients classified with initiator-type FS on a single atrium resulted in improved two-to-three-year AF-free likelihoods (p-value < 0.01, logrank tests). Detection of FS and arrhythmogenic substrate can be performed from ECGs and BSPMs, enabling non-invasive mapping towards mechanism-targeted AF treatment, and malignant ectopic beat detection with likely AF progression.