{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,22]],"date-time":"2026-10-22T04:03:38Z","timestamp":1792641818613,"version":"4.5.0"},"reference-count":20,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"5","content-domain":{"domain":["www.ahajournals.org"],"crossmark-restriction":true},"short-container-title":["Circ: Arrhythmia and Electrophysiology"],"published-print":{"date-parts":[[2016,5]]},"abstract":"<jats:sec>\n                    <jats:title>Background\u2014<\/jats:title>\n                    <jats:p>The presence of focal fibrillation waves during atrial fibrillation (AF) can, besides ectopic activity, also be explained by asynchronous activation of the atrial endo- and epicardial layer and transmurally propagating fibrillation waves. To provide direct proof of endo-epicardial asynchrony, we performed simultaneous high-resolution mapping of the right atrial endo- and epicardial wall during AF in humans.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Method and Results\u2014<\/jats:title>\n                    <jats:p>\n                      Intraoperative mapping of the endo- and epicardial right atrial wall was performed during (induced) AF in 10 patients with AF (paroxysmal: n=3; persistent: n=4; and longstanding persistent: n=3) and 4 patients without a history of AF. A clamp made of 2 rectangular 8\u00d716 electrode arrays (interelectrode distance 2 mm) was inserted into the incision in the right atrial appendage. Recordings of 10 seconds of AF were analyzed to determine the incidence of asynchronous endo-epicardial activation times (\u226515 ms) of opposite electrodes. Asynchronous endo-epicardial activation ranged between 0.9 and 55.9% without preference for either side. Focal waves appeared equally frequent at endocardium and epicardium (11% versus 13%;\n                      <jats:italic>P<\/jats:italic>\n                      =0.18). Using strict criteria for breakthrough (presence of an opposite wave within 4 mm and \u226414 ms before the origin of the focal wave), the majority (65%) of all focal fibrillation waves could be attributed to endo-epicardial excitation.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions\u2014<\/jats:title>\n                    <jats:p>We provided the first evidence for asynchronous activation of the endo-epicardial wall during AF in humans. Endo-epicardial asynchrony may play a major role in the pathophysiology of AF and may offer an explanation why in some patients therapy fails.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1161\/circep.115.003648","type":"journal-article","created":{"date-parts":[[2016,4,21]],"date-time":"2016-04-21T23:53:51Z","timestamp":1461282831000},"update-policy":"https:\/\/doi.org\/10.1161\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":190,"title":["Direct Proof of Endo-Epicardial Asynchrony of the Atrial Wall During Atrial Fibrillation in Humans"],"prefix":"10.1161","volume":"9","author":[{"given":"Natasja","family":"de Groot","sequence":"first","affiliation":[{"name":"From the Department of Cardiology (N.d.G., L.v.d.D., A.Y., E.L., C.T., P.K.) and Department of Cardiothoracic Surgery (P.v.d.W., J.B., C.K., A.B.), Erasmus Medical Center, Rotterdam, The Netherlands; and Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands (M.A.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lisette","family":"van der Does","sequence":"additional","affiliation":[{"name":"From the Department of Cardiology (N.d.G., L.v.d.D., A.Y., E.L., C.T., P.K.) and Department of Cardiothoracic Surgery (P.v.d.W., J.B., C.K., A.B.), Erasmus Medical Center, Rotterdam, The Netherlands; and Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands (M.A.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ameeta","family":"Yaksh","sequence":"additional","affiliation":[{"name":"From the Department of Cardiology (N.d.G., L.v.d.D., A.Y., E.L., C.T., P.K.) and Department of Cardiothoracic Surgery (P.v.d.W., J.B., C.K., A.B.), Erasmus Medical Center, Rotterdam, The Netherlands; and Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands (M.A.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eva","family":"Lanters","sequence":"additional","affiliation":[{"name":"From the Department of Cardiology (N.d.G., L.v.d.D., A.Y., E.L., C.T., P.K.) and Department of Cardiothoracic Surgery (P.v.d.W., J.B., C.K., A.B.), Erasmus Medical Center, Rotterdam, The Netherlands; and Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands (M.A.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christophe","family":"Teuwen","sequence":"additional","affiliation":[{"name":"From the Department of Cardiology (N.d.G., L.v.d.D., A.Y., E.L., C.T., P.K.) and Department of Cardiothoracic Surgery (P.v.d.W., J.B., C.K., A.B.), Erasmus Medical Center, Rotterdam, The Netherlands; and Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands (M.A.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paul","family":"Knops","sequence":"additional","affiliation":[{"name":"From the Department of Cardiology (N.d.G., L.v.d.D., A.Y., E.L., C.T., P.K.) and Department of Cardiothoracic Surgery (P.v.d.W., J.B., C.K., A.B.), Erasmus Medical Center, Rotterdam, The Netherlands; and Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands (M.A.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pieter","family":"van de Woestijne","sequence":"additional","affiliation":[{"name":"From the Department of Cardiology (N.d.G., L.v.d.D., A.Y., E.L., C.T., P.K.) and Department of Cardiothoracic Surgery (P.v.d.W., J.B., C.K., A.B.), Erasmus Medical Center, Rotterdam, The Netherlands; and Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands (M.A.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jos","family":"Bekkers","sequence":"additional","affiliation":[{"name":"From the Department of Cardiology (N.d.G., L.v.d.D., A.Y., E.L., C.T., P.K.) and Department of Cardiothoracic Surgery (P.v.d.W., J.B., C.K., A.B.), Erasmus Medical Center, Rotterdam, The Netherlands; and Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands (M.A.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Charles","family":"Kik","sequence":"additional","affiliation":[{"name":"From the Department of Cardiology (N.d.G., L.v.d.D., A.Y., E.L., C.T., P.K.) and Department of Cardiothoracic Surgery (P.v.d.W., J.B., C.K., A.B.), Erasmus Medical Center, Rotterdam, The Netherlands; and Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands (M.A.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ad","family":"Bogers","sequence":"additional","affiliation":[{"name":"From the Department of Cardiology (N.d.G., L.v.d.D., A.Y., E.L., C.T., P.K.) and Department of Cardiothoracic Surgery (P.v.d.W., J.B., C.K., A.B.), Erasmus Medical Center, Rotterdam, The Netherlands; and Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands (M.A.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maurits","family":"Allessie","sequence":"additional","affiliation":[{"name":"From the Department of Cardiology (N.d.G., L.v.d.D., A.Y., E.L., C.T., P.K.) and Department of Cardiothoracic Surgery (P.v.d.W., J.B., C.K., A.B.), Erasmus Medical Center, Rotterdam, The Netherlands; 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