Quantification of the transmural dynamics of atrial fibrillation by simultaneous endocardial and epicardial optical mapping in an acute sheep model

BACKGROUND: Therapy strategies for atrial fibrillation based on electrical characterization are becoming viable personalized medicine approaches to treat a notoriously difficult disease. In light of these approaches that rely on high-density surface mapping, this study aims to evaluate the presence of three-dimensional electrical substrate variations within the transmural wall during acute episodes of atrial fibrillation. METHODS AND RESULTS: Optical signals were simultaneously acquired from the epicardial and endocardial tissue during acute fibrillation in ovine isolated left atria. Dominant frequency, regularity index, propagation angles and phase dynamics were assessed and correlated across imaging planes to gauge the synchrony of the activation patterns compared to paced rhythms. Static frequency parameters were well correlated spatially between the endocardium and the epicardium (dominant frequency, 0.79+/-0.06 and regularity index, 0.93+/-0.009). However, dynamic tracking of propagation vectors and phase singularity trajectories revealed discordant activity across the transmural wall. The absolute value of the difference in the number, spatial stability, and temporal stability of phase singularities between the epicardial and endocardial planes was significantly greater than 0 with a median difference of 1.0, 9.27%, and 19.75%, respectively. The number of wavefronts with respect to time was significantly less correlated and the difference in propagation angle was significantly larger in fibrillation compared to paced rhythms. CONCLUSIONS: Atrial fibrillation substrates are dynamic three-dimensional structures with a range of discordance between the epicardial and endocardial tissue. The results of this study suggest that transmural propagation may play a role in AF maintenance mechanisms.