High-density atrial mapping, P-wave analysis, and computational simulations in Brugada syndrome: Enhancing the understanding of atrial fibrillation

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Background Increased risk of atrial fibrillation (AF) has been reported in patients with Brugada syndrome (BrS). The pathophysiology of AF susceptibility in BrS is largely unknown. Objectives To characterize the atrial electrical properties of BrS patients with and without AF based on P-wave and high-density atrial mapping (HDAM) analysis with a focus on conduction velocity (CV), and provide mechanistic insights on AF susceptibility via computer modelling. Methods ECG signals were processed, and P-wave parameters were analysed in a consecutive series of patients with and without BrS. HDAM was performed in BrS patients undergoing an electrophysiological procedure. CV vectors were numerically approximated at each recording point using polynomial surface fitting. AF initiation susceptibility was simulated in a 3-dimensional atrial model and compared with control simulations. Results 133 subjects (89 BrS patients, 44 controls) were included. AF history was present in 11% of BrS patients. BrS patients had longer mean P-wave duration compared with controls (135 ms vs. 124 ms, p<0.01) while no P-wave parameter was able to discriminate between BrS patients with and without AF. CVs correlated with total atrial activation time (TAATs (R2=0.706)), and TAATs mildly correlated with P-wave duration (R2=0.12). A significantly higher conduction pattern complexity quantified as the number of coexisting fibrillation waves, was observed in BrS compared to the control simulations. In all simulations, regardless of the degree of fibrosis, AF initiation rates were significantly higher in BrS compared to control simulations. Conclusion Conventional P-waves parameters do not identify BrS patients prone to AF. Increased TAAT are related to reduced local CVs, explaining the prolonged P wave duration observed in BrS patients. Simulation studies showed significantly higher AF susceptibility initiation in BrS compared to controls.

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