Key Points
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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
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Application of these concepts has improved our appreciation of the determinants of many forms of cardiac arrhythmia, including atrial fibrillation (AF)
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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
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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
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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
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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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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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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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DOI: https://doi.org/10.1038/nrcardio.2017.37
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