Impact of three dimensional atrial fibrosis on development and stability of rotational and focal sources in atrial fibrillation — A 3D simulation and clinical high-density mapping study in persistent atrial fibrillation

The arrhythmogenic mechanisms of atrial fibrillation (AF) are still not well understood. Increased atrial fibrosis is a structural hallmark in patients with persistent AF. We assessed the electrogram signature rotational activity and their spatial relationship to low voltage areas in patients with persistent AF. Computer simulations implicating 3-dimensional atrial tissue with different amount of atrial fibrosis were used to assess development and stability of rotational activities during AF. Rotor anchoring occurred at the borderzone between fibrosis and healthy atrial tissue with 12 consecutive rotations prior to rotor extinction. Rotational activity in fibrotic tissue resulted in fractionated signals and were overlapped with large negative electrograms in unipolar recording mode from neighboring healthy tissue — impressing as a focal source. Necessary conditions for development and stability of rotational activities around fibrosis were on the one hand a minimum size of atrial fibrosis area equal or larger than 10mm × 10mm and on the other hand the degree of atrial fibrosis of 40%. Clinical data showed that AF termination sites were located within low voltage areas (displaying <0,5mV in AF on the multielectrode mapping catheter) in 80% and at their borderzones in 20% of cases.