{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,8]],"date-time":"2026-10-08T16:04:13Z","timestamp":1791475453794,"version":"4.3.4"},"reference-count":27,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"17","content-domain":{"domain":["www.ahajournals.org"],"crossmark-restriction":true},"short-container-title":["Circulation"],"published-print":{"date-parts":[[2010,10,26]]},"abstract":"<jats:sec>\n            <jats:title>Background\u2014<\/jats:title>\n            <jats:p>During persistent atrial fibrillation (AF), waves with a focal spread of activation are frequently observed. The origin of these waves and their relevance for the persistence of AF are unknown.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Methods and Results\u2014<\/jats:title>\n            <jats:p>\n              In 24 patients with longstanding persistent AF and structural heart disease, high-density mapping of the right and left atria was performed during cardiac surgery. In a reference group of 25 patients, AF was induced by rapid pacing. For data analysis, a mapping algorithm was developed that separated the fibrillatory process into its individual wavelets and identified waves with a focal origin. During persistent AF, the incidence of focal fibrillation waves in the right atrium was almost 4-fold higher than during acute AF (median, 0.46 versus 0.12 per cycle per 1 cm\n              <jats:sup>2<\/jats:sup>\n              (25th to 75th percentile, 0.40 to 0.77 and 0.01 to 0.27;\n              <jats:italic>P<\/jats:italic>\n              &lt;0.0001). They were widely distributed over both atria and were recorded at 46\u00b118 of all electrodes. A large majority (90.5) occurred as single events. Repetitive focal activity (&gt;3) happened in only 0.8. The coupling interval was not more than 11 ms shorter than the average AF cycle length (\n              <jats:italic>P<\/jats:italic>\n              =0.04), and they were not preceded by a long interval. Unipolar electrograms at the site of origin showed small but clear R waves. These data favor epicardial breakthrough rather than a cellular focal mechanism as the underlying mechanism. Often, conduction from a site of epicardial breakthrough was blocked in 1 or more directions. This generated separate multiple wave fronts propagating in different directions over the epicardium.\n            <\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Conclusions\u2014<\/jats:title>\n            <jats:p>Focal fibrillation waves are due to epicardial breakthrough of waves propagating in deeper layers of the atrial wall. In patients with longstanding AF, the frequency of epicardial breakthroughs was 4 times higher than during acute AF. Because they provide a constant source of independent fibrillation waves originating over the entire epicardial surface, they offer an adequate explanation for the high persistence of AF in patients with structural heart disease.<\/jats:p>\n          <\/jats:sec>","DOI":"10.1161\/circulationaha.109.910901","type":"journal-article","created":{"date-parts":[[2010,10,12]],"date-time":"2010-10-12T04:22:19Z","timestamp":1286857339000},"page":"1674-1682","update-policy":"https:\/\/doi.org\/10.1161\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":310,"title":["Electropathological Substrate of Longstanding Persistent Atrial Fibrillation in Patients With Structural Heart Disease"],"prefix":"10.1161","volume":"122","author":[{"given":"Natasja M.S.","family":"de Groot","sequence":"first","affiliation":[{"name":"From the Department of Physiology, Cardiovascular Research Institute Maastricht (N.M.S.d.G., U.S., M.A.A.); Medtronic Bakken Research Center Maastricht, Maastricht (R.P.M.H.); Department of Cardiology, Erasmus Medical Center, Rotterdam (E.B.); Department of Cardiology, Leiden University Medical Center, Leiden (N.M.S.d.G., M.J.S.); and Department of Cardiology, Maastricht University Medical Center, Maastricht (J.L.S., H.C.), the Netherlands."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Richard P.M.","family":"Houben","sequence":"additional","affiliation":[{"name":"From the Department of Physiology, Cardiovascular Research Institute Maastricht (N.M.S.d.G., U.S., M.A.A.); Medtronic Bakken Research Center Maastricht, Maastricht (R.P.M.H.); Department of Cardiology, Erasmus Medical Center, Rotterdam (E.B.); Department of Cardiology, Leiden University Medical Center, Leiden (N.M.S.d.G., M.J.S.); and Department of Cardiology, Maastricht University Medical Center, Maastricht (J.L.S., H.C.), the Netherlands."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joep L.","family":"Smeets","sequence":"additional","affiliation":[{"name":"From the Department of Physiology, Cardiovascular Research Institute Maastricht (N.M.S.d.G., U.S., M.A.A.); Medtronic Bakken Research Center Maastricht, Maastricht (R.P.M.H.); Department of Cardiology, Erasmus Medical Center, Rotterdam (E.B.); Department of Cardiology, Leiden University Medical Center, Leiden (N.M.S.d.G., M.J.S.); and Department of Cardiology, Maastricht University Medical Center, Maastricht (J.L.S., H.C.), the Netherlands."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eric","family":"Boersma","sequence":"additional","affiliation":[{"name":"From the Department of Physiology, Cardiovascular Research Institute Maastricht (N.M.S.d.G., U.S., M.A.A.); Medtronic Bakken Research Center Maastricht, Maastricht (R.P.M.H.); Department of Cardiology, Erasmus Medical Center, Rotterdam (E.B.); Department of Cardiology, Leiden University Medical Center, Leiden (N.M.S.d.G., M.J.S.); and Department of Cardiology, Maastricht University Medical Center, Maastricht (J.L.S., H.C.), the Netherlands."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ulrich","family":"Schotten","sequence":"additional","affiliation":[{"name":"From the Department of Physiology, Cardiovascular Research Institute Maastricht (N.M.S.d.G., U.S., M.A.A.); Medtronic Bakken Research Center Maastricht, Maastricht (R.P.M.H.); Department of Cardiology, Erasmus Medical Center, Rotterdam (E.B.); Department of Cardiology, Leiden University Medical Center, Leiden (N.M.S.d.G., M.J.S.); and Department of Cardiology, Maastricht University Medical Center, Maastricht (J.L.S., H.C.), the Netherlands."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Martin J.","family":"Schalij","sequence":"additional","affiliation":[{"name":"From the Department of Physiology, Cardiovascular Research Institute Maastricht (N.M.S.d.G., U.S., M.A.A.); Medtronic Bakken Research Center Maastricht, Maastricht (R.P.M.H.); Department of Cardiology, Erasmus Medical Center, Rotterdam (E.B.); Department of Cardiology, Leiden University Medical Center, Leiden (N.M.S.d.G., M.J.S.); and Department of Cardiology, Maastricht University Medical Center, Maastricht (J.L.S., H.C.), the Netherlands."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Harry","family":"Crijns","sequence":"additional","affiliation":[{"name":"From the Department of Physiology, Cardiovascular Research Institute Maastricht (N.M.S.d.G., U.S., M.A.A.); Medtronic Bakken Research Center Maastricht, Maastricht (R.P.M.H.); Department of Cardiology, Erasmus Medical Center, Rotterdam (E.B.); Department of Cardiology, Leiden University Medical Center, Leiden (N.M.S.d.G., M.J.S.); and Department of Cardiology, Maastricht University Medical Center, Maastricht (J.L.S., H.C.), the Netherlands."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maurits A.","family":"Allessie","sequence":"additional","affiliation":[{"name":"From the Department of Physiology, Cardiovascular Research Institute Maastricht (N.M.S.d.G., U.S., M.A.A.); Medtronic Bakken Research Center Maastricht, Maastricht (R.P.M.H.); Department of Cardiology, Erasmus Medical Center, Rotterdam (E.B.); Department of Cardiology, Leiden University Medical Center, Leiden (N.M.S.d.G., M.J.S.); and Department of Cardiology, Maastricht University Medical Center, Maastricht (J.L.S., H.C.), the Netherlands."}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","reference":[{"key":"e_1_3_4_2_2","doi-asserted-by":"publisher","unstructured":"Allessie M de Groot NM Houben R Schotten U Smeets J Crijns H. 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