Simultaneous Endo‐Epicardial Mapping of the Human Right Atrium: Unraveling Atrial Excitation

BACKGROUND: The significance of endo‐epicardial asynchrony (EEA) and atrial conduction block (CB), which play an important role in the pathophysiology of atrial fibrillation (AF) during sinus rhythm is poorly understood. The aim of our study was therefore to examine 3‐dimensional activation of the human right atrium (RA). METHODS AND RESULTS: Eighty patients (79% men, 39% history of AF) underwent simultaneous endo‐epicardial sinus rhythm mapping of the inferior, middle and superior RA. Areas of CB were defined as conduction delays of ≥12 ms, EEA as activation time differences of opposite electrodes of ≥15 ms and transmural CB as CB at similar endo‐epicardial sites. CB was more pronounced at the endocardium (all locations P<0.025). Amount, extensiveness and severity of CB was higher at the superior RA. Transmural CB at the inferior RA was associated with a higher incidence of post‐operative AF (P=0.03). EEA occurred up to 84 ms and was more pronounced at the superior RA (superior: 27 ms [interquartile range, 18.3–39.3], versus mid‐RA: 20.3 ms [interquartile range, 0–29.9], and inferior RA: 0 ms [interquartile range, 0–21], P<0.001). Hypertension (P=0.009), diabetes mellitus (P=0.018), and hypercholesterolemia (P=0.015) were associated with a higher degree of EEA. CB (P=0.007) and EEA (P=0.037) were more pronounced in patients with a history of persistent AF compared with patients without AF history. CONCLUSIONS: This study provides important insights into complex atrial endo‐epicardial excitation. Significant differences in conduction disorders between the endo‐ and epicardium and a significant degree of EEA are already present during sinus rhythm and are more pronounced in patients with cardiovascular risk factors or a history of persistent AF.