Circulation. 1999;100:211-214
(Circulation. 1999;100:211-214.)
© 1999 American Heart Association, Inc.
Spatial and Temporal Periodicity During Atrial Fibrillation
Ivan A. D'Cruz, MD, FRCP
Director, Echocardiography Labs,
VA Medical Center, Memphis and,
William F. Bowld Hospital,
Professor of Medicine,
University of Tennessee,
Memphis, Tenn
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Introduction
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To the Editor:
The article by Skanes et al1 presented interesting
evidence of spatial and temporal periodicity during atrial
fibrillation, contrary to the traditional concept of totally
disorganized random atrial activity in atrial fibrillation. Skanes et
al referred to recent work by others2 3 in accord with
their own.
With former colleagues in Chicago, Ill, I called attention 20 years ago
to the fact that some patients with ECG features of atrial fibrillation
have M-mode echocardiographic findings indicating
regular atrial contractions. Regular deflections on the mitral valve
echogram were demonstrated in Figures 14 and 15 of that
paper,4 although the ECG was typical of atrial
fibrillation. At the time, we speculated that one explanation for this
apparent discrepancy was one dominant circus-motion wave (producing
regular atrial contractions), with smaller subsidiary irregular
"eddies" of electrical activity responsible for the irregular
contour of ECG atrial activity.4 Over the last 2 decades,
we have noted that this phenomenon (regular diastolic
mitral deflections on echocardiography concomitant
with irregular atrial ECG deflections) is not very rare in clinical
M-mode recordings, yet few if any similar observations have
been published.
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References
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Skanes AC, Mandapati R, Berenfeld O, Davidenko JM,
Jalife J. Spatiotemporal periodicity during atrial fibrillation in the
isolated sheep heart. Circulation. 1998;98:1236–1248.[Abstract/Free Full Text]
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Gerstenfeld EP, Sahakian AV, Swiryn S. Evidence for
transient linking of atrial excitation during atrial fibrillation in
humans. Circulation. 1992;86:375–382.[Abstract/Free Full Text]
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Botteron GW, Smith JM. Quantitative assessment of the
spatial organization of atrial fibrillation in the intact human heart.
Circulation. 1996;93:513–518.[Abstract/Free Full Text]
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Prabhu R, D'Cruz I, Cohen H, Glick G.
Echocardiographic correlates of atrial contraction in
normal and abnormal atrial rhythm. Prog Cardiovasc Dis. 1978;20:463–478.[Medline]
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Response
Ravi Mandapati;
Allan Skanes, MD;
Omer Berenfeld, PhD;
Jorge M. Davidenko, MD;
José Jalife, MD
Departments of Pharmacology and Pediatrics,
SUNY Health Science Center at Syracuse,
Syracuse, NY
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Introduction
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We thank Dr D'Cruz for his interest in our article on spatiotemporal
periodicity
during atrial fibrillation (AF) in the isolated sheep
heart.
1 It is reassuring to note that our experimental
findings are
supported by data from patients suffering from AF. Indeed,
review
of the manuscript cited by Dr D'Cruz
2 reveals in
Figures 14
and 15 that excursions of the anterior mitral leaflet (AML)
show
some degree of regularity. However, careful examination of the
figures
shows that there is some beat-to-beat change in the frequency
of
AML excursions. In the same article, the authors do not provide
any
evidence but speculate that a major or dominant wave front
activating
the left atrium (LA) could be responsible for the
somewhat periodic
motion of the AML. This is certainly a possible
explanation for their
findings. It is, however, important to
note that such a suggestion was
initially made as early as 1925
by Sir Thomas Lewis, who coined the
term "impure flutter."
3
As such, the level of organization during AF may lie on a spectrum
depending on the number of sources and the degree of fractionation of
the periodic activity into independent wavelets, as well as their
subsequent fate. It is quite possible that AF in patients with mitral
valve disease is more organized than previously thought, as reported by
2 recent surgical studies.4 5 In our experimental model,
it was rare to find the entire LA being activated in a periodic
manner. Usually, only a small part of the LA demonstrated periodic
activity.
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References
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Skanes AC, Mandapati R, Berenfeld O, Davidenko JM,
Jalife J. Spatiotemporal periodicity during atrial fibrillation in the
isolated sheep heart. Circulation. 1998;98:1236–1248.
-
Prabhu R, D'Cruz I, Cohen H, Glick G.
Echocardiographic correlates of atrial contraction in
normal and abnormal atrial rhythm. Prog Cardiovasc Dis. 1978;20:463–478.
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Lewis T. The Mechanism and Graphic Registration
of the Heart Beat. 3rd ed. London, UK: Shaw & Sons; 1925:319–374.
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Sueda T, Nagata H, Shikata H, Orihashi K, Morita S,
Sueshiro M, Okada K, Matsuura Y. Simple left atrial procedure for
chronic atrial fibrillation associated with mitral valve disease.
Ann Thorac Surg. 1996;62:1797–1800.
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Harada A, Sasaki K, Fukushima T, Ikeshita M Asano T,
Yamauchi S, Tanaka S, Shoji T. Atrial activation during chronic atrial
fibrillation in patients with isolated mitral valve disease. Ann
Thorac Surg. 1996;61:104–112.[Abstract/Free Full Text]
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Introduction
References