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Demystifying rotors and their place in clinical translation of atrial fibrillation mechanisms

Nature Reviews Cardiology volume 14, pages 509–520 (2017)Cite this article

Subjects

Key Points

  • The concept of 'rotors' or 'spiral wave re-entry' is an approach to understanding cardiac re-entry that has been developed extensively over the past 15 years

  • Application of these concepts has improved our appreciation of the determinants of many forms of cardiac arrhythmia, including atrial fibrillation (AF)

  • Spiral wave re-entry is a sophisticated and generalizable paradigm that can be applied to all forms of cardiac re-entry, including multiple wave re-entry, re-entry around an anatomical obstacle, and discrete functional re-entry circuits

  • Phase analysis is a useful method to analyse spiral wave re-entry, identify spiral-wave core tips manifesting as phase singularities, and track their movement

  • Concepts associated with spiral wave re-entry help us to understand a range of important properties of AF, including mechanisms that maintain the arrhythmia and the effects of antiarrhythmic drugs

  • Properties of AF-maintaining rotors are central to improving drug therapy and ablation procedures; aspects of rotors in AF remain highly controversial, but ongoing research is designed to address these issues

Abstract

Treatment of atrial fibrillation (AF), the most common arrhythmia in clinical practice, remains challenging. Improved understanding of underlying mechanisms is needed to improve therapy. Functional re-entry is central to AF maintenance. The first detailed, quantitative theory of functional re-entry, the 'leading circle' model, was developed 40 years ago. Subsequently, an alternative paradigm based on 'spiral waves' has evolved. Spiral-wave generators, or 'rotors', have been identified using advanced mapping methods in experimental and clinical AF. A central tool in the analysis of spiral-wave rotors is the phase transformation, allowing for easier visualization of rotors and tracking of 'phase singularity' points at the rotor tip. In contrast to leading circle theory, which is expressed in terms familiar to (and easily understood by) cardiologists, the ideas needed to understand rotors are much more theoretical and harder for clinicians to apply. In this Review, we summarize the basic notions of phase mapping and spiral-wave rotors, and the ways in which rotor sources might be involved in AF maintenance. We discuss competing observations about the role of spatially confined rotors, short-lived rotors clustered at the edge of fibrotic zones, endocardial–epicardial interactive breeder properties and transmural re-entry, as well as studies underway to resolve them. We conclude with consideration of the clinical relevance of the issues discussed and their potential implications for the management of patients with AF.

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Figure 1: Main features of leading circle versus spiral wave concepts of re-entry.
Figure 2: Determination of phase values.
Figure 3: Comparison of transmembrane potential (Vm) and phase mapping for propagation during fixed-rate pacing in canine right atrium.
Figure 4: Maps of rotor activity.
Figure 5: Rotors, wavebreak, and multiple circuit re-entry.
Figure 6: Effects of ion current changes on rotor properties and stability.

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Acknowledgements

The authors are supported by a Foundation Grant from the Canadian Institutes of Health Research and an Operating Grant from the Quebec Heart and Stroke Foundation. The authors thank Jennifer Bacchi, Montreal Heart Institute, Quebec, Canada, for her excellent secretarial assistance with the manuscript.

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  1. Department of Medicine and Research Center, Montreal Heart Institute and Université de Montréal, 5000 Belanger Street East, Montreal, H1T 1C8, Quebec, Canada

    Stanley Nattel, Feng Xiong & Martin Aguilar

  2. Department of Pharmacology and Therapeutics, McGill University, 3655 Promenade Sir William Osler, Montreal, H3G 1Y6, Quebec, Canada

    Stanley Nattel

  3. Institute of Pharmacology, West German Heart and Vascular Center, University Duisburg-Essen, Hufeland Strasse 55, Essen, 45122, Germany

    Stanley Nattel

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Nattel, S., Xiong, F. & Aguilar, M. Demystifying rotors and their place in clinical translation of atrial fibrillation mechanisms. Nat Rev Cardiol 14, 509–520 (2017). https://doi.org/10.1038/nrcardio.2017.37

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