Basic Science for the Clinical Electrophysiologist Phase Mapping of Cardiac Fibrillation

Phase is a descriptor that tracks the progression of a defined region of myocardium through the action potential and has been demonstrated to be an effective parameter in analyzing spatiotemporal changes during fibrillation. In this review, the basic principles behind phase mapping are presented mainly in the context of ventricular fibrillation (VF), atrial fibrillation (AF), and fibrillation from experimental monolayer data. During fibrillation, the phase distribution changes over time, depending on activation patterns. Analyzing these phase patterns provides us insight into the fibrillatory dynamics and helps clarify the mechanisms of cardiac fibrillation and modulation by interventions. Winfree1 introduced the phase analysis to study cardiac fibrillation in the late eighties. This time-encoding technique deals with a scenario where the activation periods are the same over the surface being mapped. To deal with the scenario of varying activation period over the mapped surface (common in animal and human fibrillation models), Gray et al2,3 introduced the state-space encoding concept from nonlinear dynamics. In analyzing spatiotemporal phase maps constructed from electric or optical mapping of the surface of heart during VF, points around which the phase progresses through a complete cycle from to are of great interest. At these points, the phase becomes indeterminate and the activation wave fronts hinge to these points and rotate around them in an organized fashion. These points in the phase map are called phase singularity (PS) points. Bray et al4 developed a procedure to locate PS points in a phase map. Nash et al5 used phase mapping to study the entire ventricular epicardium of human hearts with a sock containing 256 unipolar contact electrodes. The development of this phase mapping tool has led to better understanding of fibrillation dynamics as evidenced by the use of phase mapping in detecting PS and their role in demonstrating organization during VF. Some of these works and their findings are (1) PS colocalize with anatomic heterogeneities, and their spatial meandering is modulated by these heterogeneities,6 (2) PS correlates with the locations of wave breaks,7 (3) in myopathic human hearts, phase maps were used to show that the organization of electric activity were characterized by wave fronts emanating from a few rotors,8 and (4) phase mapping technique has also been applied to investigate the mechanism of fibrillation.7–9 Clinical electrophysiologists innovating therapies for both AF and VF are commonly not aware of phase mapping. This review addresses this shortcoming with the hope that by introducing the basic concepts of phase mapping to a greater audience, there will be an opportunity to devise therapies for these arrhythmias on a mechanistic basis.