Atrial fibrillation (AF) is regarded as a complex arrhythmia, with one or more co-existing mechanisms, resulting in an intricate structure of atrial activations. Fractionated atrial electrograms (AEGs) were thought to represent arrhythmogenic tissue and hence have been suggested as targets for radiofrequency ablation. However, current methods for ablation target identification have resulted in suboptimal outcomes for persistent AF (persAF) treatment, possibly due to the complex spatiotemporal dynamics of these mechanisms. In the present work, we sought to characterize the dynamics of atrial tissue activations from AEGs collected during persAF using recurrence plots (RPs) and recurrence quantification analysis (RQA). 797 bipolar AEGs were collected from 18 persAF patients undergoing pulmonary vein isolation (PVI). Automated AEG classification (normal vs. fractionated) was performed using the CARTO criteria (Biosense Webster). For each AEG, RPs were evaluated in a phase space estimated following Takens' theorem. Seven RQA variables were obtained from the RPs: recurrence rate; determinism; average diagonal line length; Shannon entropy of diagonal length distribution; laminarity; trapping time; and Shannon entropy of vertical length distribution. The results show that the RQA variables were significantly affected by PVI, and that the variables were effective in discriminating normal vs. fractionated AEGs. Additionally, diagonal structures associated with deterministic behavior were still present in the RPs from fractionated AEGs, leading to a high residual determinism, which could be related to unstable periodic orbits and suggesting a possible chaotic behavior. Therefore, these results contribute to a nonlinear perspective of the spatiotemporal dynamics of persAF.
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