Simultaneous epicardial–endocardial mapping of the sinus node in humans with structural heart disease: Impact of overdrive suppression on sinoatrial exits

Ramanathan Parameswaran, Geoffrey Lee, Gwilym M. Morris, Alistair Royse, John Goldblatt, Marco Larobina, Troy Watts, Chrishan J. Nalliah, Geoffrey Wong, Ahmed M. Al-Kaisey, Robert D. Anderson, Aleksandr Voskoboinik, Hariharan Sugumar, David Chieng, Prashanthan Sanders, Peter M. Kistler, Jonathan M. Kalman

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11 Citations (Scopus)


Background: The 3-dimensional (3D) nature of sinoatrial node (SAN) function has not been characterized in the intact human heart. Objective: The purpose of this study was to characterize the 3D nature of SAN function in patients with structural heart disease (SHD) using simultaneous endocardial–epicardial (endo–epi) phase mapping. Methods: Simultaneous intraoperative endo–epi SAN mapping was performed during sinus rhythm at baseline (SRbaseline) and postoverdrive suppression at 600 ms (SRpost-pace600) and 400 ms (SRpost-pace400) using 2 Abbott Advisor HD Grid Mapping Catheters. Unipolar and bipolar electrograms (EGMs) were exported for phase analysis to determine (1) activation exits; (2) wavefront propagation sequence; (3) endo–epi dissociation; and (4) fractionation. Comparison of these variables was made among the 3 rhythms from an endo–epi perspective. Results: Sixteen patients with SHD were included. SRbaseline activations were unicentric and predominantly exited cranially (87.5%) with endo–epi synchrony. However, with overdrive suppression, a tendency for caudal exit shift and endo–epi asynchrony was observed: SRpost-pace600 vs SRbaseline: cranial endo 75% vs 87.5% (P = .046); cranial epi 68.8% vs 87.5% (P = 0.002); caudal endo 12.5% vs 6.2% (P = 0.215); caudal epi 25% vs 6.2% (P = .0003); and SRpost-pace400 vs SRbaseline: cranial endo 81.3% vs 87.5% (P = 0.335); cranial epi 68.7% vs 87.5% (P = 0.0034; caudal endo 12.5% vs 6.2% (P = .148); caudal epi 31.2% vs 6.2% (P = 0.0017), consistent with multicentricity. EGM fractionation was more prevalent with overdrive suppression. Conclusion: During mapping of the intact human heart, SAN demonstrated redundancy of sinoatrial exits with postoverdrive shift in sites of earliest activation and epi–endo dissociation of sinoatrial exits.

Original languageEnglish
Pages (from-to)2154-2163
Number of pages10
JournalHeart Rhythm
Issue number12
Publication statusPublished or Issued - Dec 2020
Externally publishedYes


  • Endocardial–epicardial mapping
  • Exits
  • Overdrive suppression
  • Sinoatrial
  • Sinus node

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

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