JACC: CLINICAL ELECTROPHYSIOLOGY VOL. 6, NO.

12, 2020

ª 2020 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

PUBLISHED BY ELSEVIER

MAPPING

The Rapid Prediction of

Focal Wavefront Origins
Integration With a 3-Dimensional Mapping System

Deepak Saluja, MD,a Tal Bar-on, BA,b Gal Hayam, BA,b John Kassotis, MD, ENGSCID,c William J. Kostis, PHD, MD,c
James Coromilas, MDc

ABSTRACT

OBJECTIVES This study assessed the accuracy of an algorithm that predicts the origin of focal arrhythmias using a
limited number of data points.

BACKGROUND Despite advances in technology, ablations can be time-consuming, and activation mapping continues
to have inherent limitations. The authors developed an algorithm that can predict the origin of a focal wavefront using
the location and activation timing information in 2 pairs of sampled points. This algorithm was incorporated into an
electroanatomic mapping (EAM) system to assess its accuracy in a 3-dimensional clinical environment.

METHODS EAM data from patients who underwent successful ablation of a focal wavefront using the CARTO3 system
were loaded onto an offline version of the software modified to contain the algorithm. Prediction curves were retro-
spectively generated. Predictive accuracy, defined as the distance between true and predicted origin wavefront origins,
was measured.

RESULTS Seventeen wavefronts in as many patients (2 with atrial tachycardia, 3 with orthodromic re-entrant tachy-
cardia, 8 with premature ventricular complex and/or ventricular tachycardia, 4 with focal pulmonary vein isolation
breakthroughs) were studied. Thirty-three origin predictions were attempted (1.9
0.4 per patient) using 132 points.
Predictions were successfully calculated in 31 of 33 (93.9%) attempts and were accurate to within 5.7
6.9 mm.
Individual prediction curves were accurate to within 3.0
4.7 mm.

CONCLUSIONS Focal wavefront origins may be accurately predicted in 3 dimensions using a novel algorithm incorporated
into an EAM system. (J Am Coll Cardiol EP 2020;6:1478–87) © 2020 by the American College of Cardiology Foundation.

C atheter ablation is commonly used to treat a

variety of arrhythmias. In modern practice, a
3-dimensional electroanatomical map (EAM) is
frequently used to characterize the arrhythmia wavefront
and the nature of the potential substrate (1).
Despite advances in EAM technology, ablations
may be associated with long procedure times and
high recurrence rates (2,3). In addition, current
activation mapping techniques require a stable
fiducial electrogram (EGM), unambiguous anno-
tation of activation timing, and an arrhythmia
that persists long enough to create a sufficiently
dense map (4), which are constraints that can be
limiting in the presence of fractionated EGMs or

From the aDepartment of Medicine, Columbia University, New York, New York, USA; bBiosense Webster, Yokneam, Israel; and the
c
Department of Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’
institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information,
visit the JACC: Clinical Electrophysiology author instructions page.

Manuscript received February 12, 2020; revised manuscript received May 20, 2020, accepted May 20, 2020.

ISSN 2405-500X/$36.00 https://doi.org/10.1016/j.jacep.2020.05.024

JACC: CLINICAL ELECTROPHYSIOLOGY VOL. 6, NO. 12, 2020 Saluja et al. 1479
NOVEMBER 2020:1478–87 Rapid Prediction of Focal Wavefront Origins

rhythms that are transient and/or not clinically timing relation between the selected points ABBREVIATIONS

tolerated. (Supplemental Figures 1 and 2). AND ACRONYMS

Some of these limitations may be overcome with A more detailed description of the algo-
CI = confidence interval
alternative mapping techniques. We previously rithm is presented in the Supplemental
CV = conduction velocity
described a novel algorithm that predicts the origin of Appendix. The selection of predictor points
EAM = electroanatomic
focal wavefronts using a limited number of points and their relationship to the resulting pre-
mapping
sampled during mapping (5). In a feasibility analysis diction curves is shown in Supplemental
EGM = electrogram
using 2-dimensional projections of 3-dimensional Figure 3.
ORT = orthodromic re-entrant
anatomy, we showed that wavefront origins could
PATIENT SELECTION AND ABLATION. Pa- tachycardia
be localized to an accuracy of <1 cm using informa-
tients presenting to Robert Wood Johnson PV = pulmonary vein
tion derived from 2 pairs of points.
University Hospital between December 2016 and June
To assess the usefulness of this method in a
2018 for electrophysiology study and ablation were
clinically relevant environment, we adapted the al-
retrospectively assessed for inclusion into the study.
gorithm for 3 dimensions and modified a commer-
The study was approved by the Rutgers Health Sci-
cially available EAM system to project origin
ence New Brunswick Institutional Review Board.
predictions onto the 3-dimensional map surface. In
Seventeen patients with available data in whom a
this study, we report the accuracy of the EAM-
focal wavefront was successfully mapped and ablated
incorporated algorithm that was retrospectively
using the CARTO 3 EAM system (Biosense Webster)
applied to a population of patients who presented
were included. Patients with re-entrant rhythms that
for ablation of arrhythmias with focal wavefront
resulted in focal chamber activation (e.g., ortho-
activation.
dromic re-entrant tachycardia [ORT]) were included.
Patients who underwent pulmonary vein (PV) isola-
METHODS
tion for atrial fibrillation, in which breakthrough of a
line of ablation was mapped, were also included
DESCRIPTION OF THE PREDICTION ALGORITHM.
when a single ablation lesion at the point of break-
The derivation of the 2-dimensional prediction algo-
through resulted in isolation. In such patients, the
rithm was previously described in detail (5).
atrium was mapped during PV pacing. Patients with
Briefly, consider bipoles A and B recording acti-
an abnormal voltage (<1.5 mV for ventricular tissue
vation of a focal wavefront with origin O and
or <0.5 mV for atrial tissue) indicative of endocardial
conduction velocity (CV) (Figure 1A). The timing
scarring between the wavefront origin and the points
relationship between bipoles A and B can be
used for prediction were excluded. Procedures were
explained by an origin at points O 1 , O 2, O 3, or, more
performed under general anesthesia or moderate
generally, at any locus of points along an arc con-
sedation by a single operator (D.S.). Mapping was
necting them.
performed with either a multispline 20-pole catheter
The relationship between CV, t, and the distances
(Pentaray, Biosense Webster) or an irrigated ablation
between points A and B and the wavefront origin (OA
catheter (SmartTouch or SmartTouch RMT, Biosense
and OB, respectively) are described in Figure 1B. The
Webster), which was also used for ablation. Arrhyth-
locus of points O that satisfy the equation defines a
mias were determined to be focal using the results of
curve that contains the wavefront origin. Repeating
EAM, overdrive pacing (6), and the outcome of focal
this process with a second pair of points generates a
ablation, which was acutely successful in all patients.
second curve, and their intersection may define a
Bipolar EGMs were recorded using a multichannel
discrete origin prediction. When 2 curves intersect in
electrophysiologic recorder (Boston Scientific LS Pro,
>1 location, a third curve can be generated. Their
Marlborough, Massachusetts) with filtering set to 25
combined intersection defines a discrete origin
to 300 Hz. EGM timing was annotated to the maximal
(Figure 2, Central Illustration).
deflection slope at the time of the procedure. Ablation
We programmed a custom module for an offline
success was defined as acute ablation-associated
EAM system (CARTO 3, Biosense Webster, Diamond
arrhythmia termination, PV isolation, or abolition of
Bar, California) that contained the algorithm adapted
accessory pathway conduction, followed by
for 3 dimensions. The module asks the user to define
arrhythmia noninducibility where applicable.
point-pairs from among those acquired during acti-
vation mapping. The system then calculates and APPLICATION OF THE PREDICTION ALGORITHM.
projects onto the previously acquired chamber ge- Data from study patients were retrospectively
ometry all candidate origins within a pre-specified retrieved from the EAM system and loaded onto a
margin of error that could produce the observed laptop running the modified EAM software. The
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Rapid Prediction of Focal Wavefront Origins NOVEMBER 2020:1478–87

F I G U R E 1 The Origin of a Focal Wavefront

The origin of a focal wavefront that results in relative timing (t) between bipoles A and B (A) lies on a locus of points defined mathematically in
(B). CV ¼ conduction velocity.

F I G U R E 2 Bipoles Used to Generate Curves

(A) Bipoles A and B are used to generate a prediction curve. (B) Bipoles C and D are used to generate a second curve. (C) When superimposed,
their intersection predicts the origin (red dot). (D) When the curves intersect at more locations, a third curve (generated using bipoles B and C)
can define a unique origin.
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NOVEMBER 2020:1478–87 Rapid Prediction of Focal Wavefront Origins

C ENTR AL I LL U STRA T I O N The Generation of Wavefront Origin Predictions

A B O
O1
OA OB
A O2 B

A B
t = (OA/CV)-(OB/CV)
O3 or
CV * t = OA - OB

t t

A A
B B
100mm/sec 100mm/sec

A B C D
C C C

D D D

A B A B A B

A A A A
B B B B
C C C C
D D D D
100mm/sec 100mm/sec 100mm/sec 100mm/sec

Saluja, D. et al. J Am Coll Cardiol EP. 2020;6(12):1478–87.

Top left : (A) The recorded timing between 2 bipoles can be explained by a focal wavefront originating in any one of a series of points along a curve, which can be
defined mathematically as in B. Bottom left (A to C): Using 2 pairs of points, in intersection between 2 curves can define a unique origin. (D) When >2 intersections exist,
a third curve (produced using the same points in a different combination) can be added to define the unique origin. CV ¼ conduction velocity.

module requires the user to specify the point-pairs to
be analyzed and to define values for CV and the
margin of error, which was administratively set at
1 mm for all prediction attempts.
CV was calculated in a manner adapted from
previously reported studies (7–9). Isochronal maps
were constructed at 5-ms intervals. Pairs of adjacent
points whose activation was parallel to the local
vector were chosen from among the available
points. The points used for CV measurement were
distinct from those used for prediction curve gen-
eration. The number of CV measurements taken per
patient was dependent on the number of point-pairs
available with a suitable activation vector. For each
pair of points, a CV was calculated as the difference
in activation time divided by the linear distance
between them as measured by a digital measuring
tool native to the EAM. Individual CV measure-
ments were averaged to define a single CV value
per patient, which was used for all curve calcula-
tions in that patient.
For each prediction attempt, 2 point-pairs (pre-
dictor points) were chosen at random from among the
points mapped during the clinical ablation. The dif-
ference in activation time (t) and geodesic distance
between the points were automatically calculated. A
prediction curve calculation was attempted for each
pair of predictor points, and the output graphically
displayed on the EAM. When a single intersection of
the 2 curves was present, the mid-point of the inter-
section was considered the predicted origin. When >1
intersection was present, a third curve was generated
using the same points in a different pair combination,
and the mid-point of their smallest intersectional area
was considered to be the origin prediction (see
Figure 2 and the Supplemental Appendix for addi-
tional information). Secondary intersections falling in
electrically inert regions of anatomy (e.g., in the
middle of the mitral valve plane) were considered
invalid and discarded.
An example of the algorithm output is shown in
Figure 3. Two prediction attempts per patient were
1482 Saluja et al. JACC: CLINICAL ELECTROPHYSIOLOGY VOL. 6, NO. 12, 2020

Rapid Prediction of Focal Wavefront Origins NOVEMBER 2020:1478–87

F I G U R E 3 Origin Prediction for a LV PVC

Prediction curves (blue, green, and red lines) were calculated. Their intersection (oval) predicts the wavefront origin. Wavefront propagation is
graphically represented by the progression of colors from red (earliest) to violet (latest). The site of successful ablation (blue dot) is considered
the true wavefront origin. LV ¼ left ventricular; PVC ¼ premature ventricular complex.

targeted, although greater or fewer prediction at-
tempts were allowed depending on the availability of
adequate points.
OUTCOME MEASURES. For each wavefront, the true
origin was defined as the center of the successful
ablation lesion. The primary accuracy outcome was
the distance between the predicted and true origins.
The secondary accuracy outcome was the minimum
distance between an individual prediction curve and
the true origin.
STATISTICAL ANALYSIS. Statistical
performed using Prism 7.0b (GraphPad Software, San
Diego, California) and SPSS 23.0 (IBM Corp., Armonk,
New York). Continuous data are presented as mean

SD. Categorical data are presented as percentages.
Normality was assessed with the Shapiro-Wilk test.
Comparisons of continuous data were performed with
analysis of variance or the Kruskal-Wallis test, as
appropriate. Univariate linear regression analysis was
used to assess the effects of measured variables on
the accuracy of the primary and secondary outcomes.
Variables that were significant in univariate analysis
were retained for multivariate analysis. All reported p
analysis was values were 2-tailed. Values of p # 0.05 were deemed
statistically significant.
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T A B L E 1 Characteristics of the Patients and Wavefronts Studied

ventricle in 8 patients. Three patients had ORTs
using accessory pathways that were mapped at their
Patient # Sex Age (yrs) Chamber Ablation Type Origin Location
atrial insertion (2 during ORT and 1 during ventric-
1 F 62 LA PVI Right posterior carina
ular pacing). Twelve patients were women (70.6%),
2 F 74 RV PVC Posterior RVOT
and the mean age was 58.2
10.9 years. There were
3 M 42 LA AP Left lateral
4 F 80 RV PVC Septal RVOT 43.9
28.5 activation points available for analysis
5 M 54 LV VT Inferior basal per patient.
6 F 55 LA AP Left lateral
CV MEASUREMENT. There were 64 measurements of
7 F 48 RV PVC Septal RVOT
CV (3.8
1.6 per patient; range: 2 to 8). The overall
8 F 54 LA AT Lateral
average CV was 0.74
0.36 m/s. The measured CV
9 F 61 RA AT Lateral
10 M 64 RV PVC Basal septal and the cycle lengths at which they were measured
11 F 72 LA PVI Right septal are presented for individual rhythms and for the
12 M 51 LA AP Left lateral group as a whole in Figure 4. To assess the effect of CV
13 F 38 LV PVC Septal LVOT measurement variability on predictive accuracy, the
14 F 53 RV PVC Septal RVOT CV SD was recorded for each patient. The mean CV SD
15 F 57 LA PVI Right inferoseptal
was 0.25
0.17 m/s.
16 F 61 RV PVC Septal RVOT
17 M 63 LA PVI Right posterior carina PREDICTION GENERATION. A total of 132 point-pairs
were selected for prediction curve generation. Char-
AP ¼ accessory pathway; AT ¼ atrial tachycardia; LA ¼ left atrium; LV ¼ left
ventricle; LVOT ¼ left ventricular outflow tract; PVC ¼ premature ventricular acteristics of the predictor points are described in
complex; PVI ¼ pulmonary vein insolation; RA ¼ right atrium; RV ¼ right ventricle;
Supplemental Table 1 and Figure 5. The distance from
RVOT ¼ right ventricular outflow tract; VT ¼ ventricular tachycardia.
a predictor point to the wavefront origin (p < 0.001)
and the distance between point-pairs (p ¼ 0.009)
differed among the arrhythmias studied, but the
RESULTS value of t did not.
A total of 33 origin prediction attempts were made
One wavefront was studied in each of 17 patients. among 17 patients (1.9
0.4 per patient). In 16 of 33
The demographic and rhythm characteristics of the (48.5%) attempts, a unique prediction was defined by a
study patients are given in Table 1. Wavefront acti- single intersection between 2 prediction curves. In 17
vation initiated in the atrium in 9 patients and in the of 33 (51.5%) attempts, 2 intersections were

F I G U R E 4 Mean CV and Cycle Length/Coupling Interval of the Wavefront Studied

Mean CV and cycle length/coupling interval of the wavefront studied. AT ¼ atrial tachycardia; ORT ¼ orthodromic re-entrant tachycardia;
PVC/VT ¼ premature ventricular complex; PVI ¼ pulmonary vein isolation.
1484 Saluja et al.
Rapid Prediction of Focal Wavefront Origins
F I G U R E 5 Characteristics of the Predictor Points
Characteristics of the predictor points used to construct prediction curves overall and for individual wavefront types. Abbreviations as in Figure 4.
encountered; 2 of the attempts were considered
anatomically invalid and discarded. Among the
remaining 15 of the 33 (45.5%) attempts, a third curve
was generated to define an unambiguous prediction.
In these cases, the 2 intersections occurred 37.7

18.6 mm apart.
Among these 15 prediction attempts, the 3 curves
resulted in a precise triple intersection in 11 (77.3%),
and in the remaining 3 of 15 (20.0%) attempts, bound
a region with an area of 0.17
0.12 cm 2 (Supplemental
Figure 4). In 11 of 15 (77.3%) attempts, the 3 curves
generated secondary intersections, and the smaller
intersectional area was considered to be the origin
prediction. The mean area of these secondary pre-
dictions was 17.2
51 cm 2. In 1 case, the third curve
did not intersect the initial 2 curves at any point, and
the prediction failed.
Eighty-six calculations were required to generate
81 prediction curves (94.2% success rate). On 5 occa-
sions, no locations were found on the EAM map sur-
face that satisfied the observed t and the calculated
CV within the pre-specified margin of error, and the
curve was unresolved. In each of these attempts, a
curve was successfully drawn using a different com-
bination of the previously sampled points. In 2 cases,
prediction curves were successfully drawn but did
not intersect at any location. Therefore, successful
origin predictions were made in 31 of 33 (93.9%) at-
tempts (Supplemental Table 1).
PREDICTIVE ACCURACY. Overall, origin predictions
were accurate to within 5.7
6.9 mm (the primary
outcome; n ¼ 31). Among individual wavefront types,
JACC: CLINICAL ELECTROPHYSIOLOGY VOL. 6, NO. 12, 2020
NOVEMBER 2020:1478–87
accuracy was best for ORTs and least for premature
ventricular complexes (Figure 6). Sorted by chamber of
origin, predictions were accurate to within 0.0

0.0 mm (n ¼ 2) in the left ventricle, 3.9
4.4 mm in the
left atrium (n ¼ 16), 5.8
0.9 mm in the right atrium
(n ¼ 2), and 9.3
9.4 mm in the right ventricle (n ¼ 11).
We calculated an overlap index to determine to
what extent a lesion placed at the predicted origin
would overlap the clinically successful lesion (see the
Supplemental Figure 5). With lesion radii of 3 mm, the
percentage overlap was calculated as 35.5
43.2%.
With 4-mm lesions, the overlap was 41.9
41.0%.
Individual prediction curves were accurate to
within 3.0
4.7 mm (the secondary outcome; n ¼ 81).
For the individual arrhythmias, the order of accuracy
followed the same pattern as the primary outcome
(Figure 6). Sorted by chamber of origin, individual
prediction curves were accurate to within 1.6
2.9 mm
(n ¼ 7) in the left ventricle, 0.8
1.5 mm in the left
atrium (n ¼ 37), 0.9
1.5 mm in the right atrium (n ¼ 6),
and 6.4
5.8 mm in the right ventricle (n ¼ 31).
In univariate analysis, the primary accuracy
outcome was associated with CV SD (p ¼ 0.02;
ß ¼ 0.39; 95% confidence interval: [CI]: 0.06 to 0.73).
The secondary accuracy outcome was associated
with the chamber of origin (p # 0.001; ß ¼ 0.46;
95% CI: 0.66 to 0.23), CV (p ¼ 0.001; ß ¼ 0.35;
95% CI: 0.14 to 0.56), CV SD (p ¼ 0.004; ß ¼ 0.32;
95% CI: 0.11 to 0.53), rhythm (p ¼ 0.001; ß ¼ 0.36;
95% CI: 0.57 to 0.15), and the distance between
predictor point-pairs (p ¼ 0.03; ß ¼ 0.25; 95% CI: 0.03
to 0.47). However, in multivariate analysis, none of
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F I G U R E 6 Primary and Secondary Accuracy Results
(Left) Primary and (Right) secondary accuracy results overall and for individual wavefront types. Abbreviations as in Figure 4.
the variables retained significant independent asso-
ciation (Table 2).
COMPARISON OF RESOLVED PREDICTION CURVES
VERSUS UNRESOLVED PREDICTION CURVES. Five
of 86 total attempted prediction curve calculations
(5.8%) yielded an undefined solution. Although un-
derpowered for such comparisons, measured vari-
ables were not different between predictor pairs from
successful and unsuccessful calculations (Table 3).
DISCUSSION
We previously demonstrated that wavefront origin
predictions using a novel algorithm were accurate to
within >1 cm in a 2-dimensional representation of
3-dimensional space. In the present study, we retro-
spectively assessed its accuracy in a clinically rele-
vant environment by modifying the algorithm for 3
dimensions and incorporating it into a commercially
available EAM. Overall, 31 of 33 (93.4%) of the
attempted predictions were successful. Predicted or-
igins were accurate to within 5.7
6.9 mm and indi-
vidual prediction curves to within 3.0
4.7 mm.
The evolution of EAM techniques, including the
development of high-density mapping with multipole
catheters, has improved the ability to understand
wavefront propagation and substrates (10,11). How-
ever, conventional mapping methods still have
certain limitations. Activation annotation requires a
stable fiducial point and cycle length, as well as un-
ambiguous determination of local activation. In pa-
tients with unstable, short-lived, and/or rapidly
Saluja et al. 1485
Rapid Prediction of Focal Wavefront Origins
transforming arrhythmias, detailed activation map-
ping may not be feasible. In certain such cases, abla-
tion of arrhythmogenic substrate may be considered
(12), but this strategy is not possible in patients with
idiopathic arrhythmias.
Alternative mapping methods have been devel-
oped to address some of these issues, including
noncontact array (13) and body surface potential
mapping (14,15), but these require additional hard-
ware. Our method allows for rapid origin pre-
dictions using conventionally obtained information.
Theoretically, using multipolar catheters, pre-
dictions could be generated with a minimum of 3
simultaneously acquired points used in different
pair combinations during a single beat of recorded
arrhythmia.
The concept used in this algorithm is analogous to
trilateration, in which a signal from a fixed position is
used to calculate the distance to a location. When
signals from multiple positions are used, a unique
location can be calculated. Similar methodology has
been applied previously both in basic science (16) and
in clinical medicine (17).
DETERMINANTS OF PREDICTIVE ACCURACY. Curve
predictions in this method assume a uniform value
for CV between the predictor points and the wave-
front origin. Therefore, accuracy is vulnerable to the
effects of anisotropy and errors in the measurement
of CV.
In univariate analysis, predictive accuracy was
associated with factors that either inform the vari-
ability in CV measurement or may be associated with
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error values would minimize unresolved calculations

T A B L E 2 Univariate and Multivariate Analyses of the
Determinants of the Primary and Secondary Endpoints
but compromise accuracy. Conversely, more restric-
tive error would improve accuracy while increasing
Univariate Multivariate
unresolved calculations. Because prediction curve
Primary endpoint
width increases with both the margin of error and
Rhythm 0.48 —
increasing distance between the curve and the pre-
Chamber 0.051 —
Cycle length 0.76 — diction points, origins at greater distances from their
CV 0.07 — predictor points will be biased toward decreased ac-
CV SD 0.02 — curacy at larger values of error.
Secondary endpoint MULTIPLE INTERSECTIONS. In 15 of 33 cases, a pair
Rhythm 0.001 0.70 of prediction curves generated 2 intersections that
Chamber <0.001 0.11
were 37.7
18.6 mm apart. Although a third curve
Cycle length 0.93 —
was generated in each of these cases, it is possible
CV 0.001 0.12
CV SD 0.004 0.44
that when a region of interest can be broadly defined
Point-to-wavefront distance 0.052 — before detailed mapping (e.g., when electrocardiog-
Distance between points 0.03 0.41 raphy analysis is used to plan premature ventricular
Activation D between points 0.21 — complex mapping), secondary intersections could
occur far enough outside of the area of interest that
CV ¼ conduction velocity; SD ¼ standard deviation.
they could be practically discarded.
STUDY LIMITATIONS. In this report, we studied
the degree of anisotropy, which is known to vary both rhythms with focal chamber activation. Rhythms with
within and between chambers (18,19). Similarly, the continuous macro-re-entrant activation (e.g., typical
negative effects of CV heterogeneity on predictive atrial flutter) cannot be described as having a discreet
accuracy would be expected to increase with dis- wavefront origin, and therefore, could not be char-
tance. Consistent with this, in univariate analysis, acterized with this method.
accuracy decreased with increasing distance between We studied patients with normal endocardial
predictor points. voltage. The presence of myocardial scarring is known
Inaccuracies in CV measurement may be mitigated to cause CV variability (20). A focal wavefront propa-
by using predictor points with similar relative timing. gating through an abnormal substrate would therefore
In this case, the term t*CV, and therefore, the effects be expected to have significant CV heterogeneity,
of errors in its measurement, is minimized (see which would compromise predictive accuracy. Thus,
Figure 1). However, this approach will not correct for predictions through tissue that was expected to
regional anisotropy, which, when present, would be contain region scar, especially when done at a distance
expected to compromise predictive accuracy, espe- (e.g., using cardiac resynchronization therapy bipole
cially when applied over a distance (see the timing to characterize ventricular tachycardia in a
following). It is possible that adapting the algorithm myopathic ventricle) would have limited accuracy.
to correct for regional CV variability will improve its Conversely, CV heterogeneity outside of the region
accuracy in certain circumstances. between the wavefront origin and the predictor points
We defined a margin of error term into the algo- would not affect accuracy. In this way, sampling re-
rithm, which was administratively set at 1 mm. Higher gions of normal myocardium could predict the point at
which a wavefront emerged from an area of scarring.
This might be relevant in patients with micro-re-
T A B L E 3 Univariate Analysis of the Determinants of the
Unresolved Curve entrant arrhythmias or in macro-re-entrant arrhyth-
mias with a focal exit point from a protected circuit.
p Value
For these reasons, initial voltage mapping might be
Rhythm 0.89
required to characterize where this algorithm might
Chamber of origin 0.76
Cycle length 0.40 best be applied, especially in cases when regions of
CV 0.35 scar are suspected. Therefore, this method might be
CV SD 0.44 most efficient when multiple or transient arrhythmias
Point-to-wavefront distance 0.94 are encountered in the same chamber, because a
Distance between points 0.34 single anatomic shell and CV could be used for mul-
Activation D between points 0.15
tiple predictions.
Abbreviation as in Table 2.
This was a single-center retrospective study per-
formed on a modest number of patients. A
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NOVEMBER 2020:1478–87 Rapid Prediction of Focal Wavefront Origins

prospective trial would be necessary to fully assess

the accuracy of this method, its effect on procedure ADDRESS FOR CORRESPONDENCE: Dr. Deepak Saluja,

time, and its overall clinical usefulness. Other topics
for future study include the feasibility of including
terms that account for CV anisotropy and a formal
assessment of the impact of chamber curvature and
geometry on predictive accuracy.
Columbia University, Vagelos College of Physicians
and Surgeons, 622 West 168th Street, New York, New
York, New York 10032. E-mail: a.saluja@columbia.edu.

PERSPECTIVES
CONCLUSIONS

COMPETENCY IN MEDICAL KNOWLEDGE: Current activa-

The location of wavefronts of focal origin can be
tion mapping methods have certain limitations, especially in
accurately predicted in a subset of patients using a
cases when arrhythmias are not tolerated or are transient. This
novel algorithm that requires a limited number of
study assessed a mathematical algorithm designed to predict the
points. This may be of clinical utility in cases with
origin of focal wavefronts using a limited number of data points.
multiple, transient, or untolerated arrhythmias.
The algorithm was incorporated into a commercial EAM system.
Additional study is necessary to assess the algo-
The results indicated that wavefront origins could be accurately
rithm’s effect on procedural efficiency.
localized with this approach.
AUTHOR RELATIONSHIP WITH INDUSTRY
TRANSLATIONAL OUTLOOK: This approach has the poten-
This work was supported by research funding from Biosense Webster. Dr.
tial to allow for rapid mapping of arrhythmias using limited data
Saluja is a patent holder (through Rutgers University) of the background
in certain circumstances. Further assessment of this algorithm’s
technology used in this research. Mr. Bar-on and Mr. Hayam are employees
of Biosense Webster. Dr. Coromilas has been a consultant for DRF and ability to improve the efficiency or efficacy of ablation proced-
Abbott; and has been a member of the Clinic Events Committee for Abbott. ures is warranted.
All other authors have reported that they have no relationships relevant to
the contents of this paper to disclose.

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KEY WORDS arrhythmia, conduction
velocity, electroanatomic mapping,
mapping algorithms, wavefronts
A PP END IX For an expanded Methods section
and supplemental figures and a table, please
see the online version of this paper.