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Pathophysiological Mechanisms of Atrial Fibrillation:
A Translational Appraisal
ULRICH SCHOTTEN, SANDER VERHEULE, PAULUS KIRCHHOF, AND ANDREAS GOETTE
Department of Physiology, University Maastricht, Maastricht, The Netherlands; Department of Cardiology and
Angiology, University Hospital of Münster, Münster; and Department of Cardiology, St. Vincenz Hospital,
Paderborn and Institute of Clinical Pharmacology, University Hospital Magdeburg, Magdeburg, Germany
I. Introduction 266
A. Clinical relevance: the “AF burden” 266
B. The natural history of AF 266
C. Clinical factors associated with AF 266
II. Atrial-Specific Aspects of Cardiac Physiology 267
A. Atrial electrophysiology 268
B. Electrophysiological basis of PV ectopy 269
C. Excitation-contraction coupling 272
III. Elementary Proarrhythmic Mechanisms During Atrial Fibrillation 273
A. Hierarchical and anarchical organization of AF 274
B. Cellular proarrhythmic mechanisms: automaticity and triggered activity 274
C. Mechanisms of reentry 276
IV. Experimental Paradigms of Atrial Fibrillation 278
A. AF and the autonomic nervous system 278
B. Chronic rapid atrial pacing 280
C. Heart failure 281
D. Animal models of chronic atrial dilatation 282
E. Models of AF combined with structural heart disease 282
F. Sterile pericarditis 283
G. Hypertension 283
H. Aging 283
I. Trangenic mouse models 284
V. Conditions and Mechanisms Contributing to the Initiation and Perpetuation of Atrial Fibrillation 284
A. Alterations in signaling pathways 284
B. Ion channel remodeling and shortening of refractoriness 289
C. Loss of atrial contractility and atrial dilatation 290
D. Alterations of atrial ca
2⫹
handling and abnormal impulse formation 292
E. Atrial structural remodeling and conduction disturbances 294
F. Assessment of the AF substrate by fibrillation electrogram analysis 300
VI. Specific Forms of Atrial Fibrillation 304
A. Postoperative AF 304
B. Inherited cardiomyopathies and genetic defects associated with AF 305
VII. Summary and Future Perspectives 305
A. Summary 305
B. Current challenges and future perspectives 306
Schotten U, Verheule S, Kirchhof P, Goette A. Pathophysiological Mechanisms of Atrial Fibrillation: A Trans-
lational Appraisal. Physiol Rev 91: 265–325, 2011; doi:10.1152/physrev.00031.2009.—Atrial fibrillation (AF) is an
arrhythmia that can occur as the result of numerous different pathophysiological processes in the atria. Some
aspects of the morphological and electrophysiological alterations promoting AF have been studied extensively
in animal models. Atrial tachycardia or AF itself shortens atrial refractoriness and causes loss of atrial contractility.
Aging, neurohumoral activation, and chronic atrial stretch due to structural heart disease activate a variety of
signaling pathways leading to histological changes in the atria including myocyte hypertrophy, fibroblast prolifera-
tion, and complex alterations of the extracellular matrix including tissue fibrosis. These changes in electrical,
contractile, and structural properties of the atria have been called “atrial remodeling.” The resulting electrophysi-
ological substrate is characterized by shortening of atrial refractoriness and reentrant wavelength or by local
conduction heterogeneities caused by disruption of electrical interconnections between muscle bundles. Under
Physiol Rev 91: 265–325, 2011;
doi:10.1152/physrev.00031.2009.
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on January 30, 2011physrev.physiology.orgDownloaded from
these conditions, ectopic activity originating from the pulmonary veins or other sites is more likely to occur and to
trigger longer episodes of AF. Many of these alterations also occur in patients with or at risk for AF, although the
direct demonstration of these mechanisms is sometimes challenging. The diversity of etiological factors and
electrophysiological mechanisms promoting AF in humans hampers the development of more effective therapy of
AF. This review aims to give a translational overview on the biological basis of atrial remodeling and the
proarrhythmic mechanisms involved in the fibrillation process. We pay attention to translation of pathophysiological
insights gained from in vitro experiments and animal models to patients. Also, suggestions for future research
objectives and therapeutical implications are discussed.
I. INTRODUCTION
A. Clinical Relevance: The “AF Burden”
Atrial fibrillation (AF) is the most common sustained
arrhythmia in humans, causing an increasing number of
complications and deaths (188, 289). Electrocardiogram
(ECG)-based surveys suggest that ⬃1% of the total popu-
lation is affected (275). The number of patients with AF is
likely to double or triple within the next two to three
decades (240). The prevalence of AF is clearly age depen-
dent. The growing prevalence of AF can be explained in
part by the increasing average age in the human popula-
tion (85).
AF patients usually seek medical attention because
of AF-related symptoms. Treatment of these symptoms
has been the main motivation for AF therapy in the past.
In epidemiological and other observational studies, AF is
associated with excess death (43, 417). The available data
suggest that presence of AF approximately doubles death
rates in affected individuals, independent of other known
cardiovascular conditions. Similarly, AF worsens progno-
sis in patients with acute myocardial infarction and in
patients hospitalized for heart failure. Successful mainte-
nance of sinus rhythm was associated with longer survival
in the AFFIRM trial (123). Taken together, the available
data clearly suggest that AF increases mortality in af-
fected patients, although death rates in controlled trials
(AFFIRM, AF-CHF, RACE) are not affected when ion
channel-blocking drugs are needed to maintain sinus
rhythm.
Overall, 20 –25% of all strokes are caused by AF (384),
and AF-related strokes are more severe than strokes of
other origin. The importance of cardio-embolic stroke in
AF patients is highlighted by the fact that adequate anti-
coagulation in patients with AF can prevent strokes and
reduce mortality in patients at increased risk of stroke
(120, 227). Left ventricular function, the best-validated
clinical parameter for cardiac prognosis, can be markedly
impaired in AF patients and in some trials improved when
sinus rhythm is maintained for a longer period of time
(254, 284). However, it is worth noting that AF-CHF, a
recent large trial of sinus rhythm maintenance in patients
with already severely depressed left ventricular (LV) func-
tion, and AFFIRM, the first large “rate versus rhythm”
trial, did not detect an effect of sinus rhythm on LV
function (3, 471).
Apart from antithrombotic therapy, we have so far
failed to develop therapeutic interventions that improve
prognosis in AF patients (3, 244), underscoring the need
for better, possibly earlier and more comprehensive, man-
agement of AF, as highlighted by a recent consensus
statement (289).
B. The Natural History of AF
Systematic ECG monitoring studies indicate that a
substantial portion of AF episodes is asymptomatic (262).
Usually, these episodes are self-terminating. Over time,
typically over decades, the episodes become longer, and
eventually sustained forms of AF develop. This progres-
sive behavior of the arrhythmia has been demonstrated in
several large observational studies (283, 542). An example
of a patient with progressively longer episodes of AF is
depicted in Figure 1A. It should be noted, however, that
other courses of AF also occur, ranging from frequent
paroxysmal AF that never becomes persistent to perma-
nent AF developing as the first episode. As will be dis-
cussed in sections IV–VII, the progressive nature of AF is
partly caused by AF itself, but also reflects progression of
underlying structural heart diseases. There is evidence
that the time course of AF stabilization in patients with
structural heart disease is more rapid than in “lone AF”
patients (276).
C. Clinical Factors Associated With AF
Numerous clinical conditions are associated with an
increased incidence of AF. Most of them (Fig. 1B) con-
tribute to a gradual and progressive process of atrial
remodeling characterized by changes in ion channel func-
tion, Ca
2⫹
homeostasis, and atrial structure such as cel-
lular hypertrophy, activation of fibroblasts, and tissue
fibrosis. These alterations may both favor the occurrence
of “triggers” for AF that initiate the arrhythmia and en-
hance the formation of a “substrate for AF” that promotes
its perpetuation. The association of clinical factors with
AF substrates and triggers will be discussed separately.
266 SCHOTTEN ET AL.
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1. Clinical conditions associated with the initiation
of AF
Little is known about the mechanisms or clinical
conditions that initiate episodes of the arrhythmia. This
can be illustrated by the fact that many patients with an
accumulation of the above-mentioned AF-causing factors,
e.g., patients with advanced heart failure, never experi-
ence AF in their lifetime. A sizeable portion of patients
with lone AF suffer from “focal AF” that is initiated by
triggers that can be localized to preferential sites, mainly
the pulmonary veins (PV) (217). Electrical isolation of
PVs can prevent recurrence of AF in 70 – 80% of these lone
AF patients during a follow-up period of several years
(83). Stretch-activated or catecholamine-dependent auto-
maticity (52), as well as abnormal calcium handling (440),
have been suggested as mechanisms causing AF in focal
AF patients, but so far these mechanisms have not been
shown to be related to specific clinical conditions other
than AF itself.
2. Clinical conditions associated with the development
of a substrate for AF
Hypertension is found in 60 – 80% of AF patients
(396). Hypertension is an independent predictor of AF
(581), and it contributes to AF progression. Vascular dis-
ease, and most notably coronary artery disease, is found
in one-fourth to one-third of AF patients in surveys (396,
416), and may be associated with AF-related complica-
tions (255). Heart failure with dyspnea on exertion (NYHA
classes II-IV) is found in 30% of AF patients (416), and AF
is found in 30 – 40% of patients with heart failure (115).
Heart failure and AF appear to promote each other, with
AF compromising LV function, and LV dysfunction caus-
ing atrial dilation and pressure overload. Valvular heart
disease, especially mitral valve disease, was the most
common clinical condition associated with AF 50 years
ago. Early antibiotic therapy of streptococcal infections
has markedly reduced severe mitral valve disease in more
recent surveys (396, 416). These conditions are associated
with atrial dilatation, which plays an important causative
role in the development of a substrate of AF (sects. IV and
V). Diabetes mellitus is one of the established risk factors
for stroke in AF patients (190) and is found in ⬃20% of all
patients with AF (396, 416). The high prevalence of dia-
betes mellitus in AF populations suggests that diabetes
may either cosegregate with AF due to similar conditions
that cause both AF and diabetes, or may imply that dia-
betes mellitus plays a causative role in the occurrence of
AF. Thyroid dysfunction, and especially hyperthyroidism,
is also associated with AF. Adequate therapy of thyroid
disease often terminates AF. Improved clinical manage-
ment of thyroid disease has rendered thyroid dysfuction
relatively rare in current AF populations (416).
It is well worth noting that all these clinical condi-
tions appear to enhance AF susceptibility in an additive
manner, as the prevalence of persistent AF increases
steadily depending on the number of such conditions
present (Fig. 1B). As we will discuss in sections IV–VI,
these conditions will increase AF propensity by many
diverse mechanisms. Understanding this diversity of the
mechanisms finally leading to AF is one of the unmet
challenges in unraveling AF pathophysiology.
II. ATRIAL-SPECIFIC ASPECTS OF
CARDIAC PHYSIOLOGY
Before proarrhythmic mechanisms in the atria will be
discussed, some atrial specific aspects of cardiac physi-
ology relevant to AF will be reviewed with a focus on
differences between atria and ventricles and regional dif-
ferences in function.
FIG.1.A: example of the “natural” course of the arrhythmia in an
atrial fibrillation (AF) patient. Typical pattern of time in AF (black) and
sinus rhythm (gray) over time (x-axis). AF progresses from undiagnosed
to first diagnosed, paroxysmal, persistent, and permanent. Flashes indi-
cate cardioversions as examples of therapeutic interventions that influ-
ence the time course of the arrhythmia. B: graph shows the type of AF
as a function of the number of “concomitant conditions” at the enroll-
ment visit into the AFNET registry that included 9,582 patients through-
out Germany from 2004 to 2006 (396). AF was classified as first episode,
paroxysmal, persistent, or permanent. Concomitant conditions were
defined as age ⬎75 years, hypertension, diabetes (treated), cardiomyop-
athy, heart failure, valvular disease, or replacement. The proportion of
patients in permanent AF increases while the percentage of patients in
paroxysmal AF decreases almost linearly with increasing number of
concomitant conditions. The proportion of patients in persistent AF
remains relatively constant, suggesting that this is a transitory state
between paroxysmal and permanent AF. First episode of AF becomes
less likely in the patient population with many conditions.
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A. Atrial Electrophysiology
The predominant shape of the atrial action potential
is triangular with a gradual repolarization phase as shown
in the top right inset in Figure 2. If a plateau is present, it
is less pronounced than in ventricular myocytes. The left
panel of Figure 2 shows a human atrial action potential
and its main underlying ionic currents. As in ventricular
myocytes, the main depolarizing currents are the rapidly
activating and inactivating Na
⫹
-current (I
Na
) and the L-
type Ca
2⫹
current (I
CaL
), which has somewhat slower
kinetics. The differences in action potential morphology
between atria and ventricles are mainly caused by differ-
ences in ion channel current density and kinetics of re-
polarizing currents. Some types of ion channels are selec-
tively expressed by atrial myocytes. Atrial-specific ion
channels represent interesting targets for cardioversion
of AF (160), given the risk for ventricular proarrhythmia
of traditional class I drugs (reduction of excitability and
conduction velocity, mainly by sodium channel blockade)
and class III drugs (prolongation of refractoriness, mainly
by potassium channel blockade) (465).
The ultrarapid delayed rectifier current (I
Kur
) acti-
vates ⬃100 times more quickly than the rapid delayed
rectifier current (I
Kr
). I
Kur
significantly contributes to
atrial repolarization in most species. Kv1.5, the
␣
-subunit
of I
Kur
, is expressed by atrial myocytes but to a much
lower extent in ventricular myocytes (373, 606). Most
compounds blocking I
Kur
also inhibit the transient out-
ward current (I
to
) and the acetylcholine-activated inward
rectifier current (I
KACh
) (488, 555). These drugs prolong
the atrial effective refractory period (AERP) and decrease
AF stability, without affecting the QT time (48, 136).
I
KACh
shortens the atrial action potential duration
(APD) during vagal activity. The pore-forming Kir3.x
␣
-subunits are expressed in the atria but not in the ven-
tricles (149). Tertiapin-Q selectively inhibits Kir3.x chan-
nels like I
KACh
without affecting Kir2.x channels (inward
rectifier current I
K1
) (265). In dogs with sustained AF,
tertiapin-Q can terminate AF episodes without changing
ventricular repolarization (94). Another agent under de-
velopment, NIP-142, inhibits both Kir3.x and Kv1.5 chan-
nels, leading to a atrial-selective prolongation of APD and
AERP (369). In dogs, NIP-142 prolonged AERP by 10% and
cardioverted vagally induced AF without an effect on
ventricular refractoriness (401).
Recently, the presence of apamin-sensitive Ca
2⫹
-ac-
tivated potassium channels (I
KCa
) in the heart was dem-
onstrated (636). In mouse hearts, the current density of
I
KCa
and its effect on APD are larger in the atria than in
the ventricles (636). Of the three genes encoding I
KCa
, SK1
(KCNN1) and SK2 (KCNN2) are expressed more in the
atria than in the ventricles, while the expression of SK3
(KCNN3) is similar (567). The degree of APD shortening
mediated by SK channels depends on the cytosolic Ca
2⫹
concentration, thus possibly contributing to an interac-
tion of Ca
2⫹
handling and repolarization. SK2 channels
colocalize with L-type calcium channels through a mutual
interaction with
␣
-actinin 2 (349). In some animal models,
a role of SK2 channels in the development of atrial re-
modeling or AF has been suggested. In rabbit PVs, inter-
mittent burst pacing leads to an increased trafficking of
SK2 channels to the membrane, resulting in increased
apamine-sensitive current and APD shortening (432). In
SK2 knockout mice, APD was prolonged and AF induc-
ibility was increased probably due to enhanced triggered
activity (333). Furthermore, pharmacological block of
I
KCa
resulted in prolongation of atrial refractoriness and
termination of AF in rats, guinea pigs, and rabbits (144).
However, another study demonstrated little contribution
of SK channels to repolarization in normal rat and dog
atrial myocytes (402), and the role of I
KCa
blockade in
large-animal models of AF remains to be determined.
Recently, genome-wide association studies demonstrated
FIG. 2. The atrial action potential. Top right inset: comparison of
action potentials recorded at 37°C in different species at a pacing cycle
length close to the normal sinus cycle length. Top left: human atrial
action potential simulated using the Courtemanche model (126). The
traces below display the time course of the main ionic currents respon-
sible for the action potential. Inward (depolarizing) currents are shaded
gray, and outward (repolarizing) currents are black. Bottom right: table
lists the currents with the channel alpha subunits and the responsible
genes.
268 SCHOTTEN ET AL.
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an association between lone AF and common gene vari-
ants of SK3 (166). It is currently unclear whether this
association is related to changes in myocyte repolariza-
tion or to effects in other cells types.
The inward rectifier current I
K1
stabilizes the resting
membrane potential and is an important determinant for
the initial depolarization and final repolarization of the
action potential (346). In atrial myocytes, inward rectifi-
cation of I
K1
at depolarized potentials is incomplete, al-
lowing I
K1
to play a role throughout the repolarization
phase (195). In addition, the density of I
K1
is 5- to 10-fold
smaller in atrial myocytes than in ventricular myocytes
(195). As a result, the membrane resistance of atrial myo-
cytes at rest is relatively high (205), and thus less depo-
larizing current is required to reach the action potential
threshold, making atrial myocytes inherently more excit-
able. This is reflected in model simulations that show that
the critical size of an ectopic focus required to drive the
surrounding myocardium is smaller in the atrium than in
the ventricle (269).
In the atria, gap junction channels are formed by
connexin (Cx) 40 and Cx43, and these two connexin
subtypes may combine to form heteromeric channels
(165). In contrast, ventricular myocytes predominantly
express Cx43 (575). Manipulation of Cx40 may offer a
way to affect atrial but not ventricular conduction, al-
though within the heart, Cx40 is also expressed in the
sinoatrial and atrioventricular nodes, the Purkinje system,
and endothelial cells (575).
1. Regional variation in atrial electrophysiology
Within the atria, considerable regional variation in
action potential morphology exists. As will be discussed
in detail in section IIB, PV myocytes differ from left atrial
myocytes, with a more depolarized resting membrane
potential, lower upstroke velocity, and shorter action po-
tential (161, 375). In isolated canine right atrial myocytes,
Feng et al. (178) reported relatively long APD with a
spike-and-dome morphology for myocytes from the crista
terminalis, while myocytes from close to the atrioventric-
ular (AV) groove had shorter action potentials (270 vs. 160
ms at 1-Hz stimulation, respectively). In this study, myo-
cytes from the pectinate muscles and atrial appendage
had intermediate durations. Differences in APD between
regions correlated to systematic differences in ion chan-
nel density. Burashnikov et al. (78) found a similar distri-
bution of action potential morphologies in perfused ca-
nine atria, in addition to a long APD in the bundle of
Bachmann, the main connection between right and left
atria. In some areas, like the crista terminalis, the epicar-
dium has shorter APDs than the endocardium (78, 178),
probably due to a relatively high I
to
current density in
epicardial myocytes (178). In older literature, myocytes
have been described with a fast action potential upstroke,
high conduction velocity, pronounced action potential
plateau, and long refractory period. These cells along the
caval border of the crista terminalis and in Bachmann’s
bundle remained excitable at higher potassium concen-
trations than normal atrial myocytes and may form spe-
cialized rapidly conducting tracts within the atrium (243,
579, 596).
B. Electrophysiological Basis of PV Ectopy
In humans, paroxysms of AF often originate in the
myocardial sleeves of the PVs. Haissaguerre et al. (217)
were the first to demonstrate that repetitive activity with
a very short cycle length may occur in the PVs, and that
radiofrequency ablation of such drivers can be used to
treat AF.
1. Morphology of PV myocytes
In theory, rapid activity in the PV area might result
from new impulse formation due to automaticity or trig-
gered activity or from (micro-)reentry due to abnormali-
ties in tissue structure. An argument favoring automatic-
ity is that during embryonic development, some markers,
in particular HNK-1 (51, 268), are expressed in areas
which will later form the conduction system and nodal
tissue as well as in the PV region. However, by all ac-
counts, the PVs in the adult heart consist mainly of myo-
cytes morphologically very similar to normal atrial myo-
cytes. Thus the PVs probably do not harbor large areas of
hidden nodal tissue. There are diverging reports about the
occurrence of abnormal myocytes scattered throughout
the myocardial sleeves. Using electron microscopy,
Masani (368) observed small, pale myocytes resembling
nodal P cells in normal rat PVs. In normal dog PVs, no
evidence for morphologically abnormal myocytes was
found in two studies (241, 585), whereas large PAS-posi-
tive cells (i.e., cells with a high glycogen content) were
found in another (110). In an electron microscopy study
on human PVs, Perez-Lugones et al. (447) have reported
the presence of nodal-like P cells, transitional cells, and
large Purkinje-like myocytes in patients with a history of
AF. These cell types were not present in PVs from pa-
tients without a history of AF (447). However, this study
has engendered criticism of the histological technique
itself and of the use of purely histological criteria to
classify electrical phenotypes of myocytes (12). Recently,
Morel et al. (391) have demonstrated the presence of
small Cajal-like cells in the interstitium of human PVs.
Similar cells are involved in pacemaking in the intestine,
but their role in PV automaticity is unclear, and their
presence has also been demonstrated in normal atrial
myocardium (235). The contribution of scattered abnor-
mal cell types with possible pacemaking properties re-
mains to be established. In general, a certain critical size
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is required for an ectopic focus to act as a driver for the
surrounding myocardium (269). Propagation from an ec-
topic focus is most likely when electrical coupling grad-
ually increases from the focus to the surrounding muscle,
because a high degree of electrical coupling would effec-
tively silence the focus (reviewed in Ref. 270). Interest-
ingly, a recent study has indicated that at the PV-left atrial
junction, large PAS-positive myocytes expressing the
pacemaker channel protein HCN4, are more separated by
fibrosis and inflammatory infiltrates in chronic AF pa-
tients than in sinus rhythm patients (415).
2. Electrophysiology of isolated PV myocytes
Conflicting evidence about possible differences in
cellular electrophysiology between normal atrial myocar-
dium and myocardial sleeves has come from both record-
ings of isolated myocytes (current and voltage clamp) and
multicellular preparations (optical mapping and micro-
electrode recordings).
Voltage-clamp recordings on isolated PV myocytes
from healthy dogs indicate that PV myocytes have a larger
density of slow delayed rectifier current (I
Ks
) and I
Kr
,a
lower density of I
to
and I
CaL
than normal atrial myocytes
while I
Na
, the Na
⫹
/Ca
2⫹
exchange current (I
NCX
) and
T-type Ca
2⫹
current (I
CaT
) densities were similar to that in
normal atrial myocytes (161, 375). These data agree with
action potential recordings in myocardial sleeve prepara-
tions showing that PV myocytes have a more depolarized
resting membrane potential and action potentials with a
slower upstroke velocity and shorter duration, without
showing spontaneous diastolic depolarizations, afterde-
polarizations, or automaticity (161). In combination, the
lower upstroke velocity and relatively short APD may
contribute to a larger propensity for reentry within the
myocardial sleeve. As in the rest of the atria (see section
IVB), rapid atrial pacing reduced I
to
and I
CaL
in PV myo-
cytes. As a result, differences in APD between the PV and
left atrium became smaller (95), arguing against a major
role for the PVs in AF maintenance in this model. In
addition, Coutu et al. (127) reported that calcium handling
and its

-adrenergic response in PV myocytes was very
similar to that of left atrial myocytes, both for myocytes
isolated from normal dogs and after a week of rapid atrial
pacing.
A competing body of evidence has been presented by
Chen and co-workers (101, 104). In isolated myocytes
from both canine and rabbit PVs, a large proportion of
cells showed spontaneous activity (40% resp. 76%), in
some cases with unusual action potential morphologies
(101, 104). In voltage-clamp recordings, spontaneously
active myocytes had a low density of I
K1
, a larger delayed
rectifier amplitude, and sometimes showed a current re-
sembling the hyperpolarization-activated pacemaker
(funny) current (I
f
) (104). After 6 – 8 wk of rapid atrial
pacing in dogs, the beating rates of spontaneously active
PV myocytes had doubled, and a higher incidence of early
and delayed afterdepolarizations was observed (101). In
this and further studies from the same group, the isolation
procedure, in which left atrial cavity (104) or PV lumen
(101) were perfused, may have affected the electrical
behavior of the resulting myocytes. Also, if normal PV
myocytes would have such a pronounced tendency to-
wards automaticity, it is surprising that AF paroxysms or
premature atrial beats originating in the PVs are not ob-
served more frequently in healthy animals.
3. Electrical activity of myocardial sleeves
The earliest reports of PV automaticity in atrial prep-
arations far predate the discovery of PV involvement in
paroxysmal AF (70, 557). Cheung (106) later described
activity of guinea pig PVs as a subsidiary pacemaker with
a low, regular intrinsic frequency.
In a study on superfused PVs from normal dogs, Chen
et al. (103) reported a large heterogeneity of action po-
tential morphologies in the myocardial sleeves. This was
accompanied by a high incidence of high-frequency irreg-
ular activity, which was further increased in PVs from
dogs after 6 – 8 wk of rapid atrial pacing (103). However,
this high intrinsic arrhythmic tendency of canine PVs was
not confirmed in studies by other laboratories, which
showed a homogeneous distribution of action potentials
throughout the myocardial sleeves without spontaneous
activity under baseline conditions (Fig. 3A) (95). Rat PVs
did not display spontaneous activity, but it was observed
during infusion of norepinephrine or a combination of
␣
-
and

-agonists (371). Rabbit PVs did not show spontane-
ous activity under baseline conditions, but PV pacemaker
activity with a diastolic depolarization was readily in-
duced by an acceleration in pacing rate in the presence of
low concentration of ryanodine (249). Thus most studies
on PV preparations indicate that the PVs are not sponta-
neously active under normal conditions, but that sponta-
neous and triggered activity can sometimes be induced,
particularly during sympathicomimetic treatment (see
also sect. IVA). In addition to the PVs, arrhythmic activity
may also originate from “myocardial sleeves” in other
atrial regions, such as myocardial extensions in the atrio-
ventricular valves and coronary sinus (37, 267, 621– 623).
Wit and co-workers have amassed an extensive body of
data on catecholamine-induced delayed afterdepolariza-
tions (DADs) and triggered activity elicited by fast pacing
or extrastimulation in the canine coronary sinus (232, 566,
621). DADs in coronary sinus myocytes involve Ca
2⫹
release from the sarcoplasmic reticulum (21) and activa-
tion of a transient inward current (565). The contribution
of catecholamine-induced triggered activity from the cor-
onary sinus in human AF is unclear at this point (280).
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4. Tissue structure of PVs
Apart from differences in cellular electrophysiology, the
PV area also shows salient features in gross anatomy and fiber
geometry. The area between the PVs shows a strong preferen-
tial superior-inferior fiber orientation on the epicardial side,
corresponding with the main propagation direction during si-
nus rhythm (364). In dog PVs, fiber orientation on the endocar-
dial slide of the sleeves was predominantly circumferential,
often with sharp transitions in fiber orientation to the epicardial
side at the proximal region of the veins (Fig. 3B) (585). After
3–5 mo of rapid atrial pacing, canine PVs showed a heteroge-
neous increase in extracellular matrix volume, coinciding with
rapid repetitive activity originating in the veins (107). In pa-
tients, there may be a relation between PV structure and the
presence of AF, with a marked variation in PV anatomy be-
tween individuals (228, 285). The superior PVs had longer and
thicker sleeves in AF patients (285). Guerra et al. (215) specif-
ically linked areas of PV wall thickening to high-frequency
potentials and the origin of ectopic beats. PVs in AF patients
also showed more fibrosis and discontinuities (228).
5. Conduction patterns in myocardial sleeves
Fractionated electrograms have been reported in the
PV-left atrial junction in humans and dogs (261, 528). This
FIG. 3. Electrophysiology of pulmonary veins (PVs). A: homogeneous distribution of action potential morphologies along the myocardial sleeve.
Photomicrograph shows the muscular layer tapering off from the left atrial ostium to the vein, endocardial side up. [Modified from Wang et al. (602),
with permission from Elsevier.] B: partial cross section of a canine PV sleeve, Masson’s trichrome staining. Within the sleeve, sharp transitions in
fiber orientation can be observed. Fibers on the luminal side (indicated by “L”) predominantly show a circumferential orientation. [Modified from
Verheule et al. (585), with permission from Oxford University Press.] C: lines of conduction block within a sleeve correlate with transition in fiber
orientation. Right: endocardial fiber orientation, with asterisk and circle indicating abrupt changes in fiber orientation. Lines of conduction block,
perpendicular to the length axis of the vein, were observed during slow pacing (left) and especially when paced with extrastimuli (middle). [Modified
from Hocini et al. (241), with permission from Wolters Kluwer Health.] D: repetitive firing in a human PV. Initial three beats of PV “focal” firing
pattern following a normal sinus beat. All three beats originated at the same site, with reentrant conduction into the vein during beat 2 and
conduction block at part of the ostium during beat 3. [Modified from Patterson et al. (440), with permission from John Wiley and Sons.]
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fractionation was explained by slow conduction and/or
conduction block between the myocardial sleeves of the
PVs and the adjacent atrial myocardium. Zones of con-
duction delay and fractionated electrograms in normal
canine PVs were associated with abrupt changes in fiber
orientation (Fig. 3C) (241). Using optical mapping on the
canine PV area, Arora et al. (23) demonstrated 2:1 con-
duction block from the proximal to distal part of PVs
during fast pacing. Reentry around a functional line of
block close to the PV-left atrial junction could be induced
by premature stimuli. The core of reentrant circuits were
also clustered in a zone of increased anisotropy at the
PV-left atrial junction in another study on canine PVs
(110). Using monophasic action potentials in AF patients,
Narayan et al. (405) described that the slope of the APD
restitution curve was larger than 1 in paroxysmal AF
patients, which allowed single premature beats to initiate
AF. In contrast, in persistent AF patients, the slope was
smaller than 1, due to the occurrence of local activation
delays (405). While application of acetylcholine flattened
the APD restitution curve and reduced APD alternans in
canine PVs, the inducibility of rapid reentrant activity was
increased (453). In addition, activation of inward rectifier
K
⫹
channels by adenosine increased dominant frequen-
cies at the PV-left atrial transition in paroxysmal AF pa-
tients, supporting a reentrant mechanism (25). Indeed,
unstable reentry circuits with entry and exit points at the
PV-LA junction have been mapped in human PVs, in con-
junction with relatively short effective refractory periods
and anisotropic conduction (310). Rapid reentrant PV
activity and fibrillatory conduction in the rest of the atria
may be interdependent, because PV isolation by RF abla-
tion reduced the probability both of bursts of PV tachy-
cardia and of persistent AF (429).
On the other hand, examples of focal spread of acti-
vation have also been reported. In normal canine atrial
preparation, optical mapping revealed focal activity with
a relatively long cycle length near the PV-left atrial junc-
tion during isoproterenol infusion (23). Using high-density
epicardial mapping, Zhou et al. (653) observed repetitive
focal activation patterns with a short cycle length in PVs
of dogs after 1 mo of rapid atrial pacing. Focal spread of
activation in the PVs, often with block within the myocar-
dial sleeve, was also reported in a canine heart failure
model (423) as well as in patients with AF (Fig. 3D). The
mechanism underlying these focal PV activation patterns
was compatible with triggered activity related to in-
creased Ca
2⫹
load (440, 441) (see also sections III and V).
In summary, PVs show differences from the normal
atrial myocardium in cellular electrophysiology and fiber
geometry. Also, abnormal cell types have been described
in some studies. These peculiarities may act in concert to
cause arrhythmogenic activity of PVs.
C. Excitation-Contraction Coupling
Research during the past 50 years has revealed that
Ca
2⫹
ubiquitously mediates excitation-contraction, exci-
tation-secretion, and excitation-transcription coupling.
Furthermore, numerous cellular responses are directly or
indirectly regulated by this important second messenger.
Mechanisms of excitation coupling in atria and ven-
tricles have been expertly reviewed in great detail else-
where (46, 55). Basically, excitation-contraction coupling
is initiated by depolarization of the cell membrane by an
action potential that triggers opening of voltage-depen-
dent L-type Ca
2⫹
channels. Influx of Ca
2⫹
triggers the
release of Ca
2⫹
from the sarcoplasmic reticulum through
Ca
2⫹
release channels or “ryanodine channels” (RYR) in a
process called Ca
2⫹
-induced Ca
2⫹
release. Ca
2⫹
binds to
troponin C activating the actin-myosin filaments, and the
myocyte starts to contract. Relaxation is initiated by a
decline of the cytosolic Ca
2⫹
concentration mainly by
resequestration of Ca
2⫹
into the sarcoplasmic reticulum
by the sarcoplasmic reticulum Ca
2⫹
-ATPase (SERCA),
which is tightly controlled by its inhibitory protein phos-
pholamban, and extrusion to the extracellular space by
the Na
⫹
/Ca
2⫹
exchanger (NCX). In hearts of larger mam-
mals, like dog, rabbit, and human, reuptake into the sar-
coplasmic reticulum and elimination by the NCX account
for ⬃70 and 30% of Ca
2⫹
removal, respectively (36), while
in mice and rats up to 90% of Ca
2⫹
is reuptaken into the
sarcoplasmic reticulum (see sect. IVI) (36).
Due to the specific ultrastructure of atrial myocytes,
the spatiotemporal pattern of Ca
2⫹
release and the way
Ca
2⫹
release is controlled differs from that in ventricular
myocytes (55). Most atrial myocytes lack appreciable t
tubules or possess only a rudimentary and more irregular
transverse t-tubular system (Fig. 4, Aand B) (32, 560). An
electron microscopic study in rat atrial myocytes showed
a transversely oriented tubular system along the Z-lines
which was formed from the membrane of the sarcoplas-
mic reticulum but not the sarcolemma (639). As in ven-
tricular myocytes, immunostaining of RYRs revealed that
most of these receptors are aligned along the Z-lines of
the sarcomeres (nonjunctional sarcoplasmic reticulum).
In atrial myocytes, an additional population of RYRs em-
bedded in sarcoplasmic reticular membranes is located
directly underneath the sarcolemma in close vicinity to
the L-type Ca
2⫹
channels, thereby forming the junctional
sarcoplasmic reticulum (90, 229).
These ultrastructural properties of atrial myocytes
have important functional consequences. Upon opening
of voltage-dependent L-type Ca
2⫹
channels, release of
Ca
2⫹
starts underneath the sarcolemma at the junctional
sarcoplasmic reticulum. From there, Ca
2⫹
release spreads
towards the center of the cell through Ca
2⫹
-induced Ca
2⫹
release mechanisms. This centripetal Ca
2⫹
“wave propa-
gation” has been documented in atrial myocytes from
272 SCHOTTEN ET AL.
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guinea pigs (342), rats (353), cats (258, 297), and humans
(229) (Fig. 4, Cand D). It has been suggested that the
regulation of centripetal wave propagation contributes to
positive inotropic modulation of excitation-contraction
coupling in atrial myocytes (354).
Another consequence of the atrial-specific cellular
ultrastructure is that in the junctional sarcoplasmic retic-
ulum, where RYR clusters are located in close vicinity to
L-type Ca
2⫹
channels, the frequency of elementary Ca
2⫹
release events (sparks), which can provoke proarrhyth-
mic Ca
2⫹
waves, is higher than in central cellular regions.
In addition, L-type Ca
2⫹
channel antagonists reduce the
spark frequency only in the junctional but only slightly in
the nonjunctional regions (515).
III. ELEMENTARY PROARRHYTHMIC
MECHANISMS DURING ATRIAL
FIBRILLATION
For a long time, reentry of excitation wavefronts was
considered the main mechanism of AF. The seminal discov-
ery of localized sources of paroxysmal AF originating from
the PVs by Haissaguerre et al. in 1998 (217) has renewed the
interest in “focal” sources of AF. Both cellular proarrhyth-
mic mechanisms, like automaticity or triggered activity, and
reentrant mechanisms might underlie these phenomena. In
the authors’ view, the relative contribution of these distinct
mechanisms, however, is likely to vary between individual
patients and cannot be fully determined at present.
FIG. 4. Excitation-contraction coupling in atrial myocytes. A: confocal image of a membrane staining of a rabbit atrial myocyte with
di-8-ANNEPS. The myocyte lacks a t-tubular system. B: schematic drawing of the ultrastructure of atrial myocytes. Ryanodine receptors (RYR) are
located underneath the sarcolemma in close vicinity to the L-type Ca
2⫹
channels (junctional SR) or along transverse proportions of the SR oriented
along the Z-lines (nonjuntional SR). Inositol 1,4,5-trisphosphate receptors (IP
3
R) are located in the junctional SR. Corbular portions of the SR serve
as reuptake and storage sites. [Modified from Bootman et al. (55), with permission from J Cell Sci.] C: confocal line scan of a Ca
2⫹
transient in a
cat atrial myocyte. The pseudo-color indicates Ca
2⫹
concentration (blue represents low, red a high concentration). Ca
2⫹
release is initiated
underneath the sarcolemma and spreads towards the center of the cell. [Modified from Blatter et al. (50), with permission from John Wiley and Sons.]
D: the central cellular Ca
2⫹
transient (ct) follows the subsarcolemmal (ss) transient with a delay of 10 –30 ms but reaches a comparable amplitude.
[Modified from Blatter et al. (50), with permission from John Wiley and Sons.]
PATHOPHYSIOLOGICAL MECHANISMS OF ATRIAL FIBRILLATION 273
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A. Hierarchical and Anarchical Organization of AF
In general, AF can be perpetuated by “hierarchical”
or “anarchical” mechanisms. In case of a hierarchical
organization of AF, the arrhythmia is driven by a rapid
localized source. As the atrial myocardium remote from
this site cannot follow the driver in a 1:1 fashion, irregular
conduction at a lower frequency ensues. Both focal dis-
charges and reentrant circuits can act as localized
sources. Irrespective of its nature, ablation of the source
will terminate AF. In the case of anarchical AF, multiple
nonlocalized sources act anarchically to sustain AF. As
long as a sufficient number of sources is present simulta-
neously, AF will be sustained. In such a scenario, ablation
of a localized driver is not possible, but ablation strategies
that restrict the propagation of wavelets may still be
successful.
Table 1 gives a few classic examples of hierarchical
and anarchical types of AF. Reentrant waves can drive AF
in both a hierarchical as well as in an anarchical form of
AF. Hierarchical AF can be maintained by multiple forms
of reentry. Stable reentry circuits (“mother waves”) driv-
ing AF can vary in size (430, 509) and are in some cases
determined by anatomical structures (73, 370). Even if
reentry circuits are unstable, they still might be able to
maintain sustained AF as long as they continuously re-
form and at least one reentry circuit is always present
(307). Other examples of hierarchical AF maintained by
reentry are rotors that can be either fixed or wandering
through the atria (356, 474, 525). Perpetuation of AF by
“multiple wavelets” represents an anarchical form of AF
with reentrant mechanism.
Cellular proarrhythmic mechanisms (automaticity
and triggered activity) can clearly drive AF in a hierarchi-
cal manner under certain circumstances (492). However,
whether cellular proarrhythmic mechanisms can produce
AF in an anarchical type of the arrhythmia is so far
hypothetical and technically difficult to determine. Until
today, no convincing experiments have been reported
supporting “polytopic ectopy” as a cause of AF. This does
not mean, however, that disseminated atrial focal dis-
charges cannot occur during AF. In fact, as will be dis-
cussed in section V, many experimental studies indirectly
imply the existence of disseminated atrial ectopy during
the fibrillation process as a contributor to the perpetua-
tion of AF.
B. Cellular Proarrhythmic Mechanisms:
Automaticity and Triggered Activity
1. Enhanced automaticity
Enhanced automaticity occurs when myocytes pos-
sessing pacemaker activity increase their rate of sponta-
neous discharge. Enhanced automaticity can be due to a
lowered threshold of the action potential upstroke (phase
0), a less negative maximal diastolic potential, or an in-
crease in the slope of spontaneous diastolic depolariza-
tion (phase 4). A characteristic feature of both normal as
well as enhanced automaticity is the phenomenon of over-
drive suppression, which is related to intracellular Na
⫹
accumulation (118, 374). As mentioned in section II B, the
presence of pacemaker cells in the pulmonary veins or in
other regions of the atria outside the sinus node is debat-
able (391). Over all, there is little evidence for the exis-
tence of enhanced automaticity as a proarrhythmic mech-
anism during AF.
2. Abnormal automaticity
Abnormal automaticity occurs when cells are depo-
larized by any kind of depolarizing current and the thresh-
old of inward currents is reached (179). In many cases,
the degree of depolarization does not allow for complete
recovery of Na
⫹
channels. Thus the upstroke of the action
potentials is often mediated by Ca
2⫹
inward currents.
Abnormal automaticity is less sensitive to overdrive sup-
pression (118) but might be abolished by compounds that
shift the membrane potential to more negative values
such as activators of inward rectifier currents (acetylcho-
line and adenosine) (468).
3. Triggered activity
Triggered activity arises from membrane oscillations
following normal action potentials (i.e., the trigger). If
TABLE 1. Examples for hierarchical and anarchical organization of AF
Hierarchical AF Anarchical AF
Reentrant mechanisms Stable mother wave macroreentrant (73, 370, 430) Multiple wavelets (7, 386, 388, 509)
Stable mother wave microreentrant (356, 509)
Unstable reentry circuits (307)
Leading circle (5)
Rotor (fixed, wandering) (356, 474, 525)
Cellular proarrhythmic mechanisms
(automaticity/triggered activity) Automatic foci (491, 492) Disseminated atrial focal discharges (hypothetical)
While reentrant mechanisms can underlie both hierarchical and anarchical types of atrial fibrillation (AF), automaticity and triggered activity have
so far been demonstrated only in hierarchical forms of AF. Reference numbers are given in parentheses.
274 SCHOTTEN ET AL.
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such membrane oscillations reach threshold of depolariz-
ing currents, they can provoke new action potentials.
Under certain circumstances, such triggered responses
can in turn elicit new action potentials, resulting in self-
sustaining runs of triggered activity (Fig. 5A). Depending
on when the membrane oscillation occurs, “early” and
“delayed” afterdepolarizations are distinguished.
A) DELAYED AFTERDEPOLARIZATIONS. Delayed afterdepolar-
izations (DADs) are membrane potential oscillations oc-
curring after full repolarization of the triggering action
potential. DADs are favored by conditions producing
Ca
2⫹
overload, like ischemia,

-adrenergic stimulation,
low extracellular K
⫹
concentration, and tachycardia (117,
277). Excess Ca
2⫹
is extruded to the extracellular space
by the Na
⫹
/Ca
2⫹
exchanger. Due to the 3:1 stochiometry
(3 Na
⫹
are exchanged for 1 Ca
2⫹
), the I
NCX
is electrogenic
and produces an inward current that depolarizes the cell.
This mechanism forms the basis for the characteristic rate
dependence of DADs. The faster the triggering rhythm,
the shorter the interval of the triggered response is and
the faster self-sustaining episodes of DADs are (277).
B) EARLY AFTERDEPOLARIZATIONS. Early afterdepolariza-
tions (EADs) are membrane oscillations occurring during
phase 2 or 3 of the action potential. They occur in the
presence of action potential prolongation. During the pro-
longed action potentials, “Ca
2⫹
window currents” may get
activated producing a new action potential upstroke
(382). Ca
2⫹
window currents occur when the voltage
threshold for activation and inactivation overlap, allowing
rapid transformational changes from inactivated to closed
and open states of the channel (264). Another mechanism
likely involved in EADs occurring during

-adrenergic
stimulation is spontaneous release of Ca
2⫹
from the sar-
coplasmic reticulum due to elevated cytosolic Ca
2⫹
con-
centrations (593). In most cases, EADs occur under bra-
dycardic conditions while DADs are more likely to occur
during tachycardia or rapid pacing.
More recently, another type of EADs was described
by Burashnikov and Antzelevitch (76). In dog atria ex-
posed to combined sympathetic and parasympathetic
stimulation, the first action potential occurring after a
pause can trigger an EAD during late phase 3 of the action
potential (“late phase 3 EADs,” see Fig. 5B) (76). These
EADs exclusively occurred when both a shortening of the
action potential (parasympathetic stimulation) and an in-
crease in Ca
2⫹
load of the cells (sympathetic stimulation)
were present. During the pause, Ca
2⫹
is accumulated in
the sarcoplasmic reticulum, and the triggering action po-
tential produces a strong release of Ca
2⫹
that exceeds the
action potential in duration. Because the action potential
is short, the high cytosolic Ca
2⫹
concentration and the
negative membrane potential generate a strong inwardly
directed I
NCX
that will produce the EAD. The important
conceptual difference between this type and other sorts
of triggered activity lies in the fact that late phase 3 EADs
are triggered by a strong but essentially normal Ca
2⫹
release from the sarcoplasmic reticulum, while DADs and
many forms of EADs are due to abnormal spontaneous
Ca
2⫹
release from intracellular Ca
2⫹
stores. Late phase 3
EADs have been suggested to play a role in the immediate
recurrences of AF (77). Interestingly, shortly after cardio-
version of AF, ultra-short refractory periods have been
reported that might further increase the likelihood for
these EADs to occur and to result in reinitiation of AF
(155). On the other hand, the occurrence of late phase 3
EADs is strictly limited to the simultaneous presence of
agents abbreviating the action potential and enhancing
Ca
2⫹
load (76, 77, 236, 440). The pharmacological inter-
ventions used in these studies (e.g., 1
M acetylcholine ⫹
1
M isoproterenol) produce massive shortening of the
action potential and provide strong enhancement of Ca
2⫹
load. Whether such extreme conditions can occur in pa-
tients with or prone to AF is currently unclear.
FIG. 5. Cellular proarrhythmic mechanisms in the atria. A: sche-
matic illustration of delayed (DAD) and early afterdepolarizations
(EAD). Both forms of triggered activity can elicit single or runs of action
potentials (AP). B: comparison of the mechanism of DAD and late phase
3 EAD. While a DAD is elicited by an abnormal Ca
2⫹
release from the
sarcoplasmic reticulum, late phase 3 EADs are due to a strong but
normal Ca
2⫹
release which outlasts the action potential (dotted line). In
both cases, the I
NCX
involved in Ca
2⫹
removal depolarizes the cell.
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C. Mechanisms of Reentry
1. Circus movement reentry
Circus movement reentry was first demonstrated in
rings prepared from jellyfish (372) and cardiac tissue
(381). It is characterized by an activation that can travel
along a preformed anatomical structure and reactivate
(reexcite) previously excited tissue. A prerequisite for
circus movement reentry is recovery of excitability after
the previous activation before the next activation reaches
the tissue again. As a consequence of this, a short refrac-
tory period and a low conduction velocity make circus
movement reentry more likely. The minimal pathlength
for circus movement reentry can be calculated as the
product of conduction velocity and refractory period
(wavelength) (613). If the path of the circuit is longer than
the wavelength, there is a delay between recovery of the
tissue and the moment of reexcitation which is called the
“temporal excitable gap.” The section of the path which
regained excitability before the next excitation is called
the “spatial excitable gap,” which can be calculated as the
product of conduction velocity and temporal excitable
gap (Fig. 6A).
Initiation of circus movement reentry requires unidi-
rectional conduction block often occurring in regions
with long refractory periods. Because of the presence of
an excitable gap, circus movement reentry can be en-
trained (600). External waves can invade the reentrant
circuit, causing block and termination of reentry.
2. The leading circle concept
In 1924, Garrey (192) proposed a concept of AF that
involved aspects of reentry without a clearly defined an-
atomical structure. In turtle cardiac muscle, he demon-
strated a sustained excitation wave rotating around a
stimulation electrode. While in these experiments the
stimulus site still might have represented an obstacle for
propagation, in 1973, Allessie et al. (6) provided the first
evidence that reentry does not necessarily require an
anatomical obstacle. In left atrial rabbit atria, tachycardia
induced by premature stimulation was due to excitation
by rotating waves. Transmembrane electrode recordings
demonstrated that the core was not fully activated but
instead showed electrotonic depolarizations preventing
the tissue from regaining full excitability. According to
the “leading circle concept,” the size of the reentry circuit
adapts to the smallest possible loop in which the wave
can continue to propagate (Fig. 6B) (5). Excitation
wavefronts are propagating through tissue with limited
excitability, and the excitable gap is small. Therefore,
the arrhythmia is relatively unstable so that small
changes in the properties of the tissue can significantly
affect the dynamics of the reentry process, the local-
ization of the circuit, and the activation cycle length.
Because of the small excitable gap, premature stimula-
tion is less likely (compared with circus movement
reentry) but still able to invade the reentry circuit
(600). In line with this, entrainment of AF in a limited
area around the stimulation electrode (1– 4 cm) has
been demonstrated in experimental (288) and clinical
studies (437).
3. Spiral wave reentry
The theory of spiral wave reentry originally stems
from observations of chemical reactions in excitable me-
dia (619) and has strongly been influenced by insights
obtained from imaging of intracellular Ca
2⫹
waves in
FIG. 6. Mechanisms of reentry. A: circus movement reentry. The size of the anatomical obstacle, the conduction velocity, and the refractory
period are the main determinants of this kind of reentry. The spatial excitable gap is the section of the path in which full excitability has been
regained. B: leading circle concept. As no anatomic obstacle exists, the reentry path adopts the minimal possible path length, which depends on
conduction velocity and refractory period. The spatial excitable gap is small. The central region is rendered unexcitable by electrotonic
depolarization by the circulating fibrillation wave. C: rotor theory reentry. The rotor rotates around an excitable yet unexcited core. Lengths of
arrows show conduction velocity. D: chaotic activation pattern caused by multiple wavelets. Waves are separated by multiple lines of conduction
block. Block lines may also occur within waves and form pivot points. Asterisks denote waves appearing within the mapped area presumably due
to transmural conduction breakthroughs reflecting a 3-dimensional substrate for AF. See text for further explanation.
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Xenopus oocytes (114, 316) and the results of computer
simulations (438, 571).
To understand spiral wave reentry, it is important to
realize that propagation in the heart depends on a critical
balance between the “source” and the “sink” of a depo-
larizing current. The source of a wavefront is the diffusion
current generated by excited tissue tending to depolarize
downstream cells, which act as a sink. If the sink is too
large, the source current is not sufficient to excite the
downstream cells and propagation fails. In convex wave-
fronts, cells at the leading tip have to activate more cells
in front of it, resulting in a relatively small source
current and a low conduction velocity. In a concave
wavefront, many cells contribute to the activation of a
lower number of downstream cells which accelerates
conduction (Fig. 7).
The classical protocol to induce spiral wave reentry
is to provoke a perpendicular collision of a wavefront
with the wavetail of another wave (119). Where the tissue
is still refractory, the colliding wave will block while the
wave encounters excitable tissue behind the wave tail.
The colliding wave will turn towards newly recovered
cells and in this way the reentry wave adopts the shape of
a rotor (Fig. 6C). Importantly, the curvature of the wave-
front increases towards the core. Because of increasing
source-sink mismatch, the conduction velocity declines
towards the core until block occurs (dotted line in Fig.
6C). Thus the core, though being excitable, remains un-
excited during spiral wave reentry. Also, the core will
tend to shorten the action potential duration in its vicinity
which together with the low conduction velocity explains
the short wavelength (conduction velocity times refrac-
tory period) in its proximity.
In general, spiral wave reentry provides a compre-
hensive concept for reentry during AF. The only, though
significant, shortcoming of this concept is that spiral wave
reentry has never been documented in AF in humans.
More specifically, to the best of the authors’ knowledge,
there is not a single graphical depiction of sustained spiral
waves occurring during AF in patients. A possible expla-
nation might be that in human atria electrophysiological
heterogeneity due to structural changes such as fibrosis is
much more pronounced than in many animal models, and
therefore, more complex propagation patterns occur. Inter-
estingly, structural remodeling resulting in fibrosis of the
atrial wall in dogs with heart failure has been shown to
reduce the stability of rotors and promote the existence of
“multiple unstable rotors” (556), a conduction pattern essen-
tially resembling multiple wavelets.
4. The multiple wavelet hypothesis
In the late 1950s, computer models of AF demon-
strated that, based on simple assumptions regarding re-
fractoriness and conduction velocity, reentrant wavelets
might wander through an excitable medium in a seem-
ingly chaotic pattern (387). According to Moe’s “multiple
wavelet hypothesis,” fibrillation wavefronts continuously
undergo wavefront-wavetail interactions resulting in
wavebreak and generation of new wavefronts. On the
other hand, block, collision, and fusion of wavefronts will
tend to reduce their number. As long as the number of
wavefronts does not decline below a critical level, multi-
ple wavelets will be capable to sustain the arrhythmia
(386, 388). Factors increasing the stability of the fibrilla-
tion process include shortening of the refractory period,
increased heterogeneity of refractoriness, slowing of con-
duction, and an increase of the tissue mass. In contrast,
prolongation of refractoriness, enhancement of conduc-
tion velocity, and reduction of the available substrate will
reduce the number of wavefronts until the arrhythmia
ceases.
In 1985, Allessie et al. (7) demonstrated for the first
time the existence of multiple wavefronts in canine atria
exposed to acetylcholine. Numerous experimental and
clinical observations could be reconciled with the multi-
ple wavelet hypothesis. For example, during the Maze
procedure, the atria are subdivided in multiple electrically
independent compartments that are too small to sustain
the arrhythmia (128, 129). A comparable mechanism can
be postulated for some ablation procedures (see sect. VI).
Furthermore, prolongation of refractoriness indeed has
been shown to reduce AF stability (87, 452).
It has recently been suggested that the multiple wave-
let hypothesis would actually not exclude the coexistence
of local sources of AF (578). These authors argue that in
certain substrates, stable rotors might act as a source of
multiple wavelets. As such, this might be true in specific
cases (655). Moe’s hypothesis, however, goes beyond the
simple existence of multiple wavelets. It implies that the
fibrillation process is actually driven by them and no
localized sources of AF exist (“anarchical” organization of
AF). The actual experimental demonstration of multiple
wavelets as the mechanism sustaining AF, however, is
technically challenging, since fibrillatory conduction
FIG. 7. Effect of wavefront curvature on conduction velocity. In a
convex wavefront, cells serve as current source for more than one
downstream cell. Because of the relatively strong sink, conduction
velocity is low. In contrast, current source of more than one cell adds up
in a convex wavefront. As a result, the source is relatively strong and
conduction velocity high.
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remote from a localized source cannot be distinguished
from multiple wavelets with current mapping tech-
niques. Thus the direct demonstration of Moe’s multiple
wavelet hypothesis would essentially require that all
other mechanisms potentially sustaining AF are ruled
out. This could only be achieved by recording all elec-
trical activity in the entire atrium, which is not possible
with the techniques currently available. As long as it is
not possible to identify all local sources of the arrhyth-
mia in AF patients, Moe’s multiple wavelet hypothesis
will remain an important but hypothetical model for the
perpetuation of AF.
IV. EXPERIMENTAL PARADIGMS OF
ATRIAL FIBRILLATION
In many patients, AF is associated with some form of
underlying heart disease. Congestive heart failure (CHF),
hypertension, valvular disease, and aging are all strong
clinical predictors of AF (275). To unravel the mecha-
nisms leading to AF, several of these factors have been
mimicked in animal models. However, in some patients,
AF is observed in the absence of underlying structural
heart disease or hypertension (“lone AF”). The analogous
animal model is that of rapid atrial pacing (RAP). In some
patients, AF episodes may be triggered by increased au-
tonomic activity, which also has been studied in animal
models. Postoperative AF has been mimicked in a canine
model of sterile pericarditis.
The controlled conditions in animal studies have al-
lowed analysis of separate factors contributing to AF
(e.g., rapid activation rates or dilatation). However, in
humans, these factors may be present in a mild form over
prolonged periods of time, and the final substrate of AF
may have evolved very slowly over a period of decades.
For practical purposes, stimuli in animal studies are ap-
plied in a more intense form, for example, creating acute
severe mitral regurgitation to study chronic dilatation
(587) and pronounced ventricular tachycardia causing a
progression towards decompensating heart failure within
a few weeks (326).
In addition, there are further important differences
between other animal models and human patient popula-
tions. Postoperative AF after open-heart surgery may not
be fully represented by sterile paricarditis models, in
which the most common arrhythmia is atrial flutter. Sev-
eral weeks of RAP are required for AF to become self-
sustaining, whereas lone AF patients often present with
sustained AF episodes. Finally, long-term animal studies
in models of aging and long-standing hypertension, two of
the most important clinical predictors of AF, are relatively
rare. With these caveats, we will give an overview of
various animal models and the mechanistic insights
gained from them.
A. AF and the Autonomic Nervous System
In paroxysmal AF patients, the onset of AF is fre-
quently preceded by altered autonomic activity (138). One
study has indicated that patients with lone AF tend to
show a vagal pattern of AF onset, while patients with
structural heart disease tend to show a sympathetic pat-
tern (125). However, other studies in lone AF patients
have indicated that AF onset is associated with a change
in autonomic balance rather than with an increase in
vagal or sympathetic drive alone (181, 563). Paroxysms of
AF and atrial tachycardia were observed in dog models of
both intermittent RAP and CHF induced by rapid ventric-
ular pacing (420, 554). In both models, monitoring of the
activities of the left stellate ganglion and vagal nerve in
ambulatory dogs revealed that the onset of AF or atrial
tachycardia was predominantly associated with simulta-
neous sympathovagal discharges.
It has long been recognized that cholinergic activity
can promote AF (192). Electrophysiological effects are
instantaneous upon application of acetylcholine or vagal
stimulation. Mainly through an increase in I
KACh
(and in
the presence of

-adrenergic stimulation also by a reduc-
tion in I
Ca,L
) APD and AERP are shortened, thereby de-
creasing the wavelength of reentry circuits (509). The
degree of AERP shortening depends on the acetylcholine
concentration applied or the intensity of vagal stimula-
tion. At very high concentrations of acetylcholine, AERP
may become as short as 30 ms in dogs (509). Although
cholinergic AF has been investigated for decades, the
exact mechanism is still controversial. In isolated atrial
preparations from normal animals, AF can often not be
induced. However, in the presence of acetylcholine, pro-
longed AF episodes are frequently observed after a single
premature beat. In isolated canine atrial preparations in
the presence of 0.5–2
M acetylcholine, Allessie et al. (7)
described multiple wavelets wandering through the atria
in a chaotic pattern, without any single tissue area dom-
inating the activation pattern. In contrast, Jalife and co-
workers (360, 525) reported a gradient in activation fre-
quency during AF, with the highest activation frequencies
occurring in the left atrium in the presence of acetylcho-
line. These high frequencies (up to 30 Hz) were proposed
to originate from stable microreentrant circuits or “ro-
tors” (356).
The mechanism of cholinergic AF may actually depend
on the acetylcholine concentration applied. Schuessler et
al. (509) have described conduction in a canine right
atrium preparation. Here, a premature stimulus caused
multiple wavelet reentry at acetylcholine concentrations
up to 1
M. In this small preparation, multiple wavelet
reentry did not sustain for longer than 2 s. Fibrillation was
only sustained (⬎2 min) at very high acetylcholine con-
centrations (⬎10
M), due to the formation of small and
localized reentrant circuits with a fast cycle length of
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30 –50 ms that dominated activation in the entire prepa-
ration (Fig. 8A). Using a detailed mathematical model,
Kneller et al. (296) have demonstrated that ACh can sta-
bilize spiral wave reentry. A heterogeneous distribution of
ACh, resulting in dispersion of refractoriness, led to fibril-
latory conduction away from the core of the spiral wave.
Adrenergic regulation of atrial electrophysiology is
more complex.

-Adrenergic receptor activation in-
creases I
CaL
(331), I
Kur
(330, 648), I
Ks
(479), and I
KACh
/I
KH
(641). On the other hand,
␣
-adrenergic stimulation inhib-
its I
to
(175), I
K1
(174), and I
KACh
/I
KH
(63, 641). In canine
atrial myocytes, the
␣
-adrenergic agonist phenylephrine
slightly increases APD, whereas the

-agonist isoprotero-
nol decreases APD (334). As a net result of sympathetic
stimulation, the plateau potential of the action potential is
increased (527), while the total APD is unaffected or even
decreased (654). The resulting increase in sarcoplasmic
Ca
2⫹
load may enhance triggered activity (620).
The macroscopic innervation of the heart has been
described in detail by Kawashima et al. (282). Within the
atria, the autonomic nervous system forms an intricate
system of ganglionated plexi, especially concentrated in a
number of interconnected fat pads (434). Targetted abla-
tion of these fat pads may (490, 493) or may not (131, 421)
be a useful adjunct in treating AF in patients. The effect of
vagal stimulation on atrial refractoriness is heteroge-
neous because of heterogeneity in the distribution of
parasympathetic nerve endings and/or M
2
-cholinoceptors
(4, 343). In contrast, the effect of sympathetic stimulation
on refractoriness is more homogeneous (343). Enhanced
heterogeneity in vagal innervation (by ablation of the right
PV fat pad) (237) and in sympathetic innervation (by
application of phenol) (424) can both increase AF stabil-
ity.
The PV region, and the PV-left atrial junction in par-
ticular, is rich in both parasympathetic and sympathetic
FIG. 8. Mechanism of AF in animal models. A: during infusion of acetylcholine (ACh), the mechanism of AF can depend on the applied dose.
At 10
⫺6
M ACh, multiple wavelet reentry with functional lines of conduction block was observed in a canine right atrial preparation. At a
concentration of 10
⫺4.5
M, a single micro-reentrant circuit became dominant in the same preparation. [Adapted from Schuessler et al. (509), with
permission from Wolters Kluwer Health.] B: AF begets AF: in control goats, a high-frequency burst evokes only5sofAF.After 24 h of artificially
maintained AF with a “fibrillation pacemaker,” episode length has increased to 20 s. After 2 wk of AF, episodes last for more than 24 h. [Modified
from Wijffels et al. (614).] C: AF with and without underlying structural heart disease. Fibrillation maps recorded after 48 h of rapid atrial pacing
(RAP) from the left atrial free wall of a control goat (left) and a goat after 4 wk of atrioventricular block (right). In dilated atria, fibrillation waves
were less uniform, and local crowding of isochrones occurred more frequently. Local conduction delays of 8 ms between neighboring electrodes
are displayed in the lower panels. A higher degree of dissociation of fibrillation waves was observed in dilated atria. [Adapted from Neuberger et
al. (410), with permission from Elsevier.]
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nerve endings (22, 553). In addition, APD shortening dur-
ing acetylcholine infusion is relatively large in the poste-
rior left atrium (335), probably due to a relatively high
expression of I
KACh
(487). The normal physiological rele-
vance of the high degree of autonomic innervation and
responsiveness of the PV myocardium is unclear. As de-
tailed in section IIB, PV myocardial sleeves in healthy
animals or preparations probably do not show rapid spon-
taneous activity, but it can be elicited by both parasym-
pathetic and sympathetic stimulation. As explained in
section III, the combination of vagal and sympathetic
activity may provoke triggered activity (mainly late phase
3 EADs) or promote AF triggered by PV firing (441, 494).
This combination can create a state with short APD and
increased Ca
2⫹
load in atrial myocytes and may explain
observations that simultaneous sympathovagal discharge
is associated with the onset of AF paroxysms in both
patients and animal models (described above).
The autonomic ganglia in the PV area can be acti-
vated directly by high-frequency electrical stimulation. In
dogs, this led to episodes of AF and atrial tachycardia that
could be inhibited by both sympathetic and vagal phar-
macological blockade (489). In isolated canine PV prepa-
rations, autonomic nerve stimulation decreased APD and
increased rapid firing associated with EADs (442). Vagal
blockade by atropine prevented APD shortening in these
preparations and abolished rapid firing. Sympathetic
blockade by atenolol or a high dose of ryanodine (prob-
ably reducing sarcoplasmic Ca
2⫹
load) also prevented the
spontaneous PV activity.
In summary, the local electrophysiological properties
of the PV myocardium may play an important role in AF
paroxysms triggered by autonomic imbalance. However,
as shown recently by Lemola et al. (321), AF due to strong
vagal activation is still observed after selective PV isola-
tion, but it disappeared after selective ablation of the
autonomic ganglia overlying the PV ostia. Therefore, the
current clinical ablation strategies may be effective be-
cause they affect both the PV myocardium and the adja-
cent autonomic ganglia.
B. Chronic Rapid Atrial Pacing
A major advance in the understanding of AF was the
observation that AF itself induces atrial changes that
promote AF (393, 614). In a goat model, only seconds of
AF could be induced by burst pacing in control animals,
whereas AF episodes lasting hours were induced after 2
days of pacing. Sustained AF (⬎24 h) was observed after
a week of artificially maintained AF (Fig. 8B) (614). In a
canine model, continuous RAP (400 beats/min) for 6 wk
increased the AF duration from seconds to minutes (194,
393, 647). The increased AF stability was associated with
a decrease in AERP to ⬃55% of baseline values in both
goats and dogs (614, 647). In the dog, the spatial hetero-
geneity of the AERP was increased by RAP, and this
seemed to be an independent determinant of enhanced
AF vulnerability (172). RAP causes a progressive decrease
in the densities of I
CaL
and I
to
and an increase in I
K1
(96,
647). This process of “electrical remodeling” results in a
shift towards the repolarizing currents, leading to APD
and AERP shortening (see also section VBand Fig. 10). As
in atria infused with acetylcholine, AERP shortening can
contribute to AF stability.
Interestingly, the time courses of AERP shortening
and AF stabilization diverge. In the goat, the AERP was
already maximally reduced after 24 h of AF, whereas AF
stability continued to increase over the ensuing weeks
(614). Moreover, in goats subjected to sequential 4-wk
periods of AF separated by 1 wk of sinus rhythm to allow
full recovery of the AERP, an acceleration of AF stabili-
zation was observed, independent of alterations in AERP
(562). These findings indicate that besides electrical re-
modeling, at least one other factor contributes to the
progression of AF.
Structural remodeling has been proposed as a candi-
date for this “second factor,” since it takes place in a
slower time domain of weeks to months. RAP induces
structural alterations that develop progressively, includ-
ing atrial dilatation (517), myocyte hypertrophy, loss of
sarcomeres, accumulation of glycogen, and mitochondrial
abnormalities (30, 393). In contrast to the rapid recovery
of the AERP after restoration of sinus rhythm, recovery of
morphological abnormalities is slow and incomplete (29).
The contribution of these structural changes to AF stabil-
ity is unknown at this moment. Overall, fibrosis is not
increased in the atria of AF goats and dogs (30, 326).
However, the volume of extracellular matrix (ECM) per
myocyte in goats increases during months of AF (29). This
pattern is similar to interstitial fibrosis or “microfibrosis”
observed during aging, which can lead to slow, discontin-
uous conduction during transverse propagation (529). In-
deed, a recent study compared goats with 6 mo of AF to
goats with 3 mo of AF, demonstrating a higher degree of
dissociation at the later time point, leading to a larger
number of smaller fibrillation waves (587a). This increase
in complexity of fibrillatory conduction was accompanied
by myocyte hypertrophy and increased interstitial fibro-
sis. In cell cultures, rapid pacing can cause myocytes to
release factors that alter the behavior of cultured fibro-
blasts (81). In vivo, such paracrine factors released by
myocytes at high activation rates may modulate fibro-
blasts function, possibly contributing to ECM remodeling.
Another factor that can directly affect myocardial
conduction is electrical coupling between myocytes me-
diated by gap junctions. In the goat model, no quantitative
changes in the total expression of the gap junction pro-
teins Cx40 and Cx43 levels were found, but the distribu-
tion of Cx40 became more heterogeneous during persis-
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tent AF (572). The significance of Cx40 heterogeneity for
AF is unclear; conduction during slow pacing was not
affected (572), but the effects during fibrillatory conduc-
tion may be more pronounced.
For the interpretation of RAP models, the possible
contribution of high and irregular ventricular rates to
atrial structural remodeling should be considered. In
the dog, most early studies were performed with a
single atrial burst pacemaker, leading to a high ventric-
ular rate. Most researchers now combine RAP with
complete AV block and a separate low-rate ventricular
pacemaker (80 –100 beats/min). This distinction among
RAP models may explain some of the discrepancies in
the literature. For example, dogs with a single atrial
pacemaker show a progressive reduction in atrial con-
duction velocity (194) and an underlying decrease in
I
Na
(193), whereas the double pacemaker/AV block
model does not (326, 586). One study in goats has
investigated the role of high ventricular rates. Atrial
structural abnormalities were observed in a model of
RAP alone, but were virtually absent in a model of RAP
with a controlled ventricular rate (500). In dogs, 3 mo
of RAP increased atrial fibrosis even after AV node
ablation, but to a smaller degree than in a group with-
out controlled ventricular rate (31). In sheep, 15 wk of
RAP with and without controlled ventricular rate were
compared (13). With a controlled ventricular rate, many
animals did not develop persistent AF, and no signifi-
cant increase in fibrosis was observed. In contrast, in
the group without AV block, persistent AF developed
more rapidly, along with conduction heterogeneity and
extensive atrial fibrosis. Thus RAP without a controlled
ventricular rate appears to provoke structural changes
that increase AF stability. These changes might be
caused by a mild form of a ventricular tachycardiomy-
opathy. RAP models with and without controlled ven-
tricular rate are both relevant to human AF, corre-
sponding to AF without and with effective rate control,
respectively.
Taken together, the increased stability of AF in mod-
els of RAP involves electrical remodeling by shortening of
AERP and contribution of a “second factor,” which is
likely to involve structural alterations.
C. Heart Failure
To investigate how CHF promotes AF, an experimen-
tal model of CHF has been used by Nattel and co-workers
(326). Overt heart failure was induced by pacing dogs
with a ventricular pacemaker at a high rate (⬎200 beats/
min) for 5 wk. The duration of induced AF episodes was
increased from a few seconds in control dogs to several
minutes in CHF dogs. Although in this model some ionic
currents were altered (see sect. Vand Fig. 10), CHF did
not reduce APD and AERP or increase AERP heteroge-
neity. In fact, AERP was significantly increased in intact
dogs (97, 539). In addition, CHF did not alter the overall
conduction velocity during slow pacing (326). Therefore,
the mechanisms leading to increased AF stability due to
CHF and RAP show important differences.
In contrast to RAP models, atrial fibrosis is dramati-
cally increased in CHF dogs (326), with large areas of
connective tissue. These structural abnormalities were
accompanied by regional conduction heterogeneity (Fig.
12C). Further studies have supported the key role of atrial
fibrosis in the promotion of AF in this model (97, 522).
When rapid ventricular pacing was followed by a 1-mo
period of slow ventricular pacing, ventricular function
and atrial dimensions recovered completely (97). At this
point, atrial electrophysiology had also normalized, but
atrial fibrosis, conduction heterogeneities, and AF stabil-
ity remained present, indicating that AF stability was
determined by structural rather than electrical remodel-
ing (97, 522).
Atrial damage in the CHF model occurs rapidly,
with a peak in inflammation, apoptosis, and necrosis
within 24 h after activation of the ventricular pace-
maker (220). These indicators of tissue injury gradually
disappeared in the following 5 wk. In the ventricle,
fibrosis developed only slowly over the entire period of
ventricular pacing, leading to a modest increase in
fibrosis over a 5-wk period. In fact, changes in gene
expression were far more extensive in the left atrium
than in the left ventricle (89).
The renin-angiotensin system is an important media-
tor in the development of an AF substrate in CHF. In the
atria of CHF dogs, tissue angiotensin II levels were rapidly
increased by rapid ventricular pacing and remained ele-
vated thereafter (220). Inhibition of ANG II production by
the angiotensin-converting enzyme (ACE) blocker enala-
pril not only attenuated CHF-induced atrial fibrosis but
also reduced conduction heterogeneity and AF stability
(328, 518). Atrial fibrosis and increased AF stability in the
canine CHF model can also be inhibited by simvastatin
(523), pirfenidone (318), polyunsaturated
3 fatty acids
(478), and sprionolactone (640). The PPAR
␣
activator
fenofibrate was not effective in this model (523), but in
rabbits with tachycardiomyopathy-induced CHF, the
PPAR
␥
acitvator pioglitazone did reduce atrial structural
remodeling and AF stability (519).
The differences in atrial pathology between CHF and
RAP models are reflected in gene expression profiles as
assessed by microarrays (88). In the canine RAP model,
changes entailed mainly downregulation of gene expres-
sion. In the CHF model, changes are quantitatively larger
and include a strong upregulation of extracellular matrix-
related genes.
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D. Animal Models of Chronic Atrial Dilatation
Atrial dilatation can be both cause and consequence
of AF. In patients, atrial enlargement correlates with the
incidence of AF (183, 233), and left atrial size is a strong
independent predictor for the development of AF (42). On
the other hand, several studies imply that AF also causes
atrial enlargement (485), and cardioversion to SR leads to
a decrease in atrial dimensions (607).
Chronic atrial dilatation occurs in several animal
models with an increased AF vulnerability. In a dog model
of RAP with a controlled ventricular rate, the diastolic left
atrial surface area increased by 24% (estimated by con-
sidering the atrium as a sphere with an area of 4
r
2
)
(517). In a sheep model of chronic hypertension, left atrial
surface area increased by 22% (292), and by an estimated
80% in a canine CHF model (517). However, in these
models, the role of atrial dilatation itself in the develop-
ment of a substrate of AF cannot be established. For this
purpose, several models of chronic atrial dilatation with-
out heart failure have been developed. Although most of
these models display an increased AF vulnerability, they
differ considerably in the structural changes associated
with atrial dilatation. Apart from any structural changes,
the increase in substrate size inherent to atrial dilatation
will also contribute to AF stability, as shown by Zou et al.
in a mathematical model (655).
Partial occlusion of the pulmonary artery and partial
avulsion of the tricuspid valve in dogs resulted in enlarged
right atria with cellular hypertrophy and increased inter-
stitial fibrosis (59). The increased AF stability in this
model was not due to electrical remodeling since action
potentials were not significantly different from control
dogs. In dogs with mitral regurgitation (MR) due to partial
mitral valve avulsion, the left atrium dilated within min-
utes, followed by a gradual increase to 167% of the base-
line left atrial area after 3 wk (587). Histological analysis
demonstrated areas of inflammatory infiltrates and
slightly increased fibrosis, without myocyte hypertrophy
(214, 587). Cx40 and Cx43 expression in the atrial free
walls did not show marked changes (214). The increased
duration of induced AF episodes could not be explained
by a decrease in wavelength, because the AERP was
homogeneously increased and the overall conduction ve-
locity was unchanged. High-resolution optical mapping
revealed heterogeneous left atrial conduction heterogene-
ity during pacing with short cycle lengths and extrastimu-
lation (see Fig. 12A), indicating that the increased AF
vulnerability was caused by increased conduction heter-
ogeneity associated with structural changes (586), remi-
niscent of the canine CHF model. By analyzing activation
sequences during AF in a canine MR model, Cox et al.
(129) showed that AF was maintained by the presence of
multiple unstable reentrant circuits.
In another model of chronic atrial dilatation, the time
course of atrial dilatation and AF stabilization was studied
(411). Chronic complete AV block in goats resulted in a
slow idioventricular rhythm, and volume overload of the
ventricles caused a progressive atrial enlargement and
myocyte hypertrophy. In a time period of 4 wk of AV
block, the right atrial area gradually increased by 29%.
Atrial dilatation was paralleled by a gradual increase in
AF stability while AERP and dispersion of refractoriness
remained constant. During sinus rhythm and slow pacing,
atrial conduction velocity was slightly increased. How-
ever, atrial mapping showed a higher incidence of areas
with slow conduction during fast pacing in dilated atria
(see Fig. 12B). Interestingly, atrial fibrosis was not in-
creased in this model, suggesting that atrial fibrosis does
not form a necessary condition for increased AF vulner-
ability in dilated atria. Also, the expression of Cx40 and
Cx43 did not show marked alterations. The difference in
atrial fibrosis between models may be related to the time
course of atrial dilatation. In the goat AV block model, the
slower time course may allow atrial myocytes to adapt
and undergo cellular hypertrophy. In the canine models,
partial valvular avulsion causes a sudden onset of dilata-
tion, which may lead to acute damage and subsequent
replacement fibrosis.
In a rabbit model, an arteriovenous shunt led to
chronic overload with an estimated increase in left atrial
surface area of 112% (238). Atrial conduction velocity was
significantly decreased by ⬃30%. The inducibility of AF
was increased, and in the majority of cases, the arrhyth-
mias arose from the posterior left atrium, with either a
focal pattern of origin or a single reentrant circuit. In this
model, the expression levels of both Cx40 and Cx43 pro-
tein were significantly reduced (230).
In summary, animal models have demonstrated that
chronic atrial dilatation increases AF stability without
shortening of refractoriness. The contribution of in-
creased tissue mass is also probably limited. Fibrosis and
cellular hypertrophy occur in most but not all models of
atrial dilatation. The relationship between these factors
and alterations in conduction will be discussed further in
section VE.
E. Models of AF Combined With Structural
Heart Disease
Some 70 – 80% of AF patients have some preexisting
form of structural heart disease (325). There is evidence
that the time course of AF stabilization in patients with
structural heart disease is more rapid than in lone AF
patients (276, 283). Thus the most common scenario of AF
stabilization is that electrical remodeling takes place in
atria that are already structurally remodeled. From animal
studies, little is known about the process of remodeling
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due to AF, AF stabilization, and the efficacy of antiar-
rhythmic drugs in this setting.
Everett et al. (170) studied a dog model in which
atrial dilatation due to mitral avulsion was combined with
RAP for 6 wk, leading to sustained AF. After cardiover-
sion, spontaneous AF episodes and a high incidence of
atrial premature beats were observed, but these phenom-
ena disappeared within a week. However, atrial structural
changes and the vulnerability to induced AF remained.
Neuberger et al. (410) created AV block in a goat model,
leading to atrial dilatation. After 4 wk, RAP was applied
for 48 h. In dilated atria, RAP still led to AERP shortening,
but the AF cycle length did not decrease, indicating a
longer excitable gap during AF. The duration of AF epi-
sodes after 48 h of RAP was significantly prolonged in
dilated atria compared with nondilated atria, with an
increased incidence of conduction block (Fig. 8C).
In dogs, RAP with a preexisting substrate of CHF
caused less AERP shortening than RAP alone (521). How-
ever, the conduction velocity was decreased by RAP in
the presence of CHF but not by either CHF or RAP alone.
Atrial fibrosis and AF stability due to CHF was not exac-
erbated by 1 wk of RAP, but the incidence of sustained AF
was increased. Also, RAP in the presence of CHF failed to
alter the density of I
to
,I
NCX
, and I
Ks
and had a smaller
effect on I
CaL
and I
K1
than RAP alone (96). Thus the
effects of AF in atria with preexisting structural heart
disease, a common clinical scenario, may differ from
those of lone AF.
F. Sterile Pericarditis
A clinically highly relevant form of AF occurs in up to
50% of patients in the first days after cardiac surgery
(157). This postoperative form of AF has been mimicked
in a canine model of sterile pericarditis, in which the atria
are dusted with talcum powder and covered with a layer
of gauze at the end of open heart surgery (435). The
predominant arrhythmia in this model is atrial flutter.
However, as in patients (467, 598), the initiation of flutter
requires a previous period of AF (520). During this tran-
sitional phase of AF, a line of functional block can de-
velop, most often along the crista terminalis between the
superior and inferior vena cava (73, 370, 569). If this line
of block becomes long enough, a stable reentry circuit
can develop and AF converts to flutter. Conversely, if the
line of block at the core of the flutter circuit becomes too
short, flutter can convert to AF (430, 601). During AF in
the sterile pericarditis model, unstable reentrant circuits
with a very short cycle length have been observed (307).
These unstable circuits often disappear and reform
around anatomic obstacles or functional lines of block.
Even if only one circuit is present, fibrillatory conduction
can be maintained when the circuit is too fast for 1:1
conduction to the rest of the atrium.
Altered connexin expression may be an important
contributor to atrial conduction disturbances in sterile
pericarditis. Cx40, Cx43, and
␣
-actinin disappeared in the
epicardial layer and were reduced in the midmyocardial
layer, while the endocardial distribution was normal
(472). These changes may lead to transmural heterogene-
ity in electrical coupling and a disruption of epicardial
conduction. The importance of the inflammatory compo-
nent in arrhythmia vulnerability is underscored by studies
showing that anti-inflammatory agents such as atorvasta-
tin (308) and prednisone (202) can prevent AF and atrial
flutter in this model.
G. Hypertension
Long-term animal studies in models of hypertension,
an important clinical predictor of AF, are relatively rare.
In 11-mo-old spontaneously hypertensive rats, the induc-
ibility of atrial tachycardia was increased, accompanied
by a decrease in I
CaL
and an increase in fibrosis (108). In
a sheep model of long-standing elevated blood pressure
induced by prenatal corticosteroid exposure (mean arte-
rial pressure 94 vs. 71 mmHg in control sheep), 4- to
5-yr-old animals had increased AF stability, reduced con-
duction velocities, no change in refractoriness, and in-
creased fibrosis with myocyte hypertrophy and myolysis
(292). Thus models of elevated blood pressure seem to
share some important features of the AF substrate with
the more extensively studied models of structural heart
disease of CHF and dilatation. Unfortunately, no data are
available on the signaling pathways involved in the struc-
tural remodeling process induced by hypertension.
H. Aging
Although the clinical prevalence of AF strongly in-
creases with age (176), the intrinsic contribution of aging
to AF promotion is difficult to study in humans due to the
long time span of senescence and the presence of numer-
ous confounding factors. AF is also quite common in
some species of domestic animals during aging, but its
pathogenesis has not been studied systematically (71).
Several animal models have been used to investigate ag-
ing-related AF. Spach et al. (536) studied conduction pat-
terns in canine atria and found an age-dependent slowing
of transverse propagation that correlated with the devel-
opment of extensive collagenous septa that separated
small groups of fibers. Similarly, in a comparative study of
young and old rats, AF could only be induced in old rats,
while the AERP was not different between age groups
(231). Instead, conduction slowing and enhanced AF vul-
nerability were associated with an age-dependent in-
crease in heterogeneous interstitial fibrosis.
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In dogs, Koura et al. (304) demonstrated that with
age, the amount of interstitial fibrosis and fatty infiltrates
increased and that Cx43 became increasingly concen-
trated at end-to-end connections between myocytes.
High-resolution optical mapping of a small tissue area
revealed enhanced anisotropy of conduction in old dogs,
while the APD was not altered (304). Most notably, ex-
tremely slow transverse conduction, sometimes causing a
“zig-zag” conduction pattern, was only observed in old
atria. Such dissociated conduction between adjacent fi-
bers may become widespread throughout the atria at
advanced age.
At the cellular level, a study performed in adult (1–5
yr) and old (⬎8 yr) dogs showed an age-induced shift in
membrane currents that gave rise to a slight (⬃15%)
increase in APD and ERP (Fig. 10) (17). In addition,
increased APD heterogeneity and slower conduction of
premature beats was observed in aged atrial tissue (16,
17). Despite these changes in atrial electrophysiology, the
inducibility of AF was not significantly increased in this
study (16). In rabbits, aging increased the tendency to-
ward formation of DADs in the PVs (624, 625).
Taken together, these studies show that even in the
absence of any underlying pathology, the senescent heart
possesses structural characteristics that predispose to
AF. However, in these animal models, the extent of elec-
trical and structural alterations is often not sufficient to
lead to the increased AF vulnerability that is associated
with aging in humans.
I. Trangenic Mouse Models
It was originally thought that fibrillation required a
substrate of a certain size (192, 390, 618). According to
this “critical mass” hypothesis, the mouse heart (at 0.0005
times the weight of the adult human heart) would be too
small to be able to fibrillate. However, more recent ob-
servations of fibrillation in very small hearts represent a
challenge to the critical mass hypothesis (570). In a study
on mice with selective atrial fibrosis due to overexpres-
sion of TGF-

1, the atrial wavelength was ⬃15 mm (582).
With its length of ⬃5 mm, these atria could probably not
accommodate more than one reentrant wavelet, assuming
a homogeneous substrate. However, increased atrial fi-
brosis in this model made the atria a structurally hetero-
geneous substrate with an increased AF inducibility (Fig.
12E).
APD shortening in response to administration of cho-
linergic agonists can also be sufficient to increase AF
vulnerability in normal mice (305, 597), and in one study,
AF could be induced in normal mice without pharmaco-
logical intervention (508). Thus, at least as a “proof of
principle,” the mouse heart can be a useful model for AF,
even when the underlying mechanism is likely to be re-
entrant. However, the question remains open to which
extent arrhythmias in very small mouse atria with the
complete absence or marked overexpression of a single
gene can be translated to human pathology.
In recent years, increased AF vulnerability in a num-
ber of transgenic mouse models with altered expression
of ion channels has been reported. Deletion of the gap
junction protein Cx40 leads to decreased atrial conduc-
tion velocity and increased AF stability (216, 583). In mice
overexpressing Kir2.1, the increase in I
K1
current was
associated with spontaneous AF episodes (332), perhaps
through the stabilization of rotors (141). Deletion of
KNCE1, an auxiliary subunit for I
Ks
that normally stabi-
lizes the open state, unexpectedly shortened APD and led
to spontaneous AF episodes (558). Deletion of Ca
2⫹
-acti-
vated SK2 potassium channels also increased APD and AF
inducibility (333).
A growing number of transgenic mice display pro-
nounced atrial enlargement and an associated increase in
spontaneous or inducible AF: mice overexpressing junc-
tin (247), mice with cardiac-specific overexpression of
angiotensin converting enzyme (634), cAMP-response el-
ement modulator (395), TNF-
␣
(473), junctate-1 (248), and
overexpression of the G
␣
q protein (239). In these mice, it
is difficult to assess to what extent AF vulnerability re-
sults directly from the genetic defect or from atrial dila-
tation and the concomitant alterations in tissue structure.
While mouse models might be useful to study the
mechanisms of specific proarrhythmic phenomena as
such, translation of these findings to pathophysiology of
AF in humans is inherently problematic. The action po-
tential is much shorter so that the currents contributing to
atrial repolarization differ between mice and men (Fig. 2).
Also, Ca
2⫹
handling in mice is characterized by a very
rapid Ca
2⫹
reuptake and a very pronounced contribution
of Ca
2⫹
reuptake to diastolic Ca
2⫹
elimination (418).
Proarrhythmic mechanisms occurring in mice that are
related to altered Ca
2⫹
handling or ion channel function
therefore not necessarily, and in some cases are not likely
to, reflect the electrophysiological phenomena that would
occur in humans with similar defects in cell function.
V. CONDITIONS AND MECHANISMS
CONTRIBUTING TO THE INITIATION AND
PERPETUATION OF ATRIAL FIBRILLATION
A. Alterations in Signaling Pathways
The structural and functional adaptations of the atria
to underlying heart disease or AF are the result of the
regulation by multiple signaling pathways that can occur
either as a consequence of AF or before the onset of AF,
usually triggered by underlying structural heart disease.
Figure 9 summarizes the AF-related changes in atrial sig-
naling.
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1. Changes in atrial signaling preceding AF
A) ATRIAL PRESSURE AND VOLUME OVERLOAD. Chronic atrial
stretch appears to be one of the most prominent trigger
mechanisms for signaling changes involved in the patho-
genesis of AF. Interestingly, atria appear to react much
faster and more strongly to increased wall stress due to
dilatation than ventricular myocardium (221). The induc-
tion of heart failure by rapid ventricular pacing induces
the development of apoptosis and increased collagen syn-
thesis in the atria within a couple of days, whereas the
degree of such changes is substantially smaller and the time
course much slower in the ventricles (326). At the molecular
level, the development of atrial fibrosis due to pressure
and/or volume overload is mediated by both angiotensin
II-dependent and angiotensin II-independent mechanism
(328, 523). Left ventricular failure increases atrial synthesis
of angiotensin II, and thereby atrial fibrosis is induced via
activation of mitogen-activated protein kinases (201). Sig-
naling pathways mediated by angiotensin II type 1 recep-
tors (AT1 receptors) are linked to G proteins. Binding of
angiotensin II to AT1 receptors leads to tyrosine phos-
phorylation of receptor tyrosine kinases (656). The acti-
vated monomeric G protein Ras interacts with Raf-1 and
activated Raf-1 then phosphorylates the kinases MEK-1
and MEK-2. In the final step of this signaling cascade,
extracellular signal regulated kinases (ERK-1 and ERK-2)
are activated by phosphorylation. ERKs lead to activation
of transcription factors, such as Elk-1 and c-fos, which are
responsible for the effects on gene transcription (545).
Studies have shown a linear correlation between angio-
FIG. 9. Atrial signal transduction pathways regulating gene expression in atrial tissue. Signal transduction is induced by several autocrine and
paracrine factors. After binding of various ligands (angiotensin II, TGF-

1, PDGF) to cell-surface receptors, numerous intracellular signaling
cascades are activated, which regulate essential programs of gene expression responsible for hypertrophy, proliferation, cell survival, and cell death.
A central role for redox-signaling is played by NF
B, which is activated after reactive oxygen species (ROS) are generated. One source for ROS is
the activated NADPH oxidase. Under baseline conditions, NF
B is retained in the cytosol as an inactive complex with inhibitory I
B proteins.
Activation occurs via rapid degradation of the complex and phosphorylation by I
B kinases. Angiotensin signaling encompasses several phosphor-
ylation steps. As a final step, phosphorylated MAP-kinases (ERK, p38, and JNK) induce the cellular response by activation of transcription factors.
Cytokines bind to corresponding cytokine receptors, leading to the activation of Janus kinases (JAKs). STAT proteins are the common targets of
JAKs. Upon phosphorylation, STATs dimerize and translocate to the nucleus where they bind to interferon response elements or
␥
-interferon-
activated sequences and thereby initiate target gene transcription. AF induces activation of several signal transduction pathways and intracellular
signaling molecules. Therefore, structural changes (hypertrophy, fibroblast activation and proliferation, apoptosis) are induced at the cellular and
tissue level. These alterations contribute to electrophysiological and morphological alterations of fibrillating atria. After binding of various ligands
(angiotensin II, TGF-

1, CTGF, PDGF) to cell-surface receptors or via increased calcium influx, intracellular signaling cascades are activated during
AF to induce the development of atrial hypertrophy, proliferation of fibroblast, increased collagen synthesis, increased expression of adhesion
molecules (VCAM-1, PAI-1), induction of apoptosis, and increased expression of autocrine and paracrine factors like angiotensin II, TGF, CTGF, and
matrix metalloproteases (MMP). AT-1, angiotensin II type 1 receptors; TGF-

, transforming growth factor

; PDGF, platelet-derived growth factor;
JNK, c-jun terminal kinase; ERK, extracellular signal regulated kinases; STAT, signal tranducer and activators of transcription; CaMK II, Ca
2⫹
/
calmodulin-dependent protein kinase II; PAI, plasminogen activator inhibitor; VCAM, vascular cell adhesion molecule.
PATHOPHYSIOLOGICAL MECHANISMS OF ATRIAL FIBRILLATION 285
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tensin II, ERK1/2 activation, and the degree of atrial fi-
brosis (328). Another tyrosine kinase that is activated by
angiotensin II is janus kinase 2 (JAK2) (367). JAK2 ini-
tiates activation of transcription factors STAT-1 and
STAT-3. A recent study demonstrated that the angiotensin
II/Rac1/STAT3 pathway is an important signaling pathway
involved in atrial structural remodeling (564). In addition
to angiotensin II, pacing-induced ventricular failure also
increased atrial TGF-

and PDGF levels. TGF-

operates
predominantly by autocrine and paracrine mechanisms.
Binding of a TGF-

homodimer to two TGF-

type II
receptors causes phosphorylation of signaling molecules
belonging to the family known as SMADs. When phos-
phorylated, SMADs aggregate and enter the nucleus to
induce myocardial fibrosis (61). In addition, TGF-

can
redirect protein synthesis to favor expression of fetal
genes as described in fibrillating atria (439). A mouse
model that overexpresses TGF-

1 develops profound
atrial fibrosis and AF, whereas the ventricles are normal
(582). Interestingly, atrial fibroblasts are activated signif-
icantly faster than ventricular fibroblasts in CHF models,
explaining the rapid and more severe degree of interstitial
fibrosis in the atria (79). Burstein et al. (79) demonstrated
that atrial fibroblasts react more strongly to angiotensin II
than ventricular fibroblasts. Importantly, proliferation of
atrial fibroblasts was consistently more pronounced than
that of ventricular fibroblasts when stimulated with a
range of growth factors including angiotensin II and
TGF-

1 (79). Connective tissue growth factor (CTGF) is
implicated in various fibrotic disorders and is produced
by fibroblasts after activation by TGF-

1. Moreover, atrial
CTGF was identified as a candidate factor in CHF-induced
atrial fibrosis by analysis of gene networks (79).
Several studies clearly suggest that oxidative stress
contributes to atrial remodeling in CHF models (98). The
peroxisome proliferator-activated receptor-
␥
(PPAR-
␥
)
activator pioglitazone antagonizes angiotensin II actions
and possesses anti-inflammatory and antioxidant proper-
ties. Pioglitazone attenuated CHF-induced atrial struc-
tural remodeling and AF vulnerability (519). In the same
study, both pioglitazone and candesartan reduced TGF-

,
TNF-
␣
, and mitogen-activated protein kinase, but neither
affected p38-kinase or c-Jun NH
2
-terminal kinase activa-
tion. In contrast,
-3 polyunsaturated fatty acids attenuate
CHF-related phosphorylation of the mitogen-activated
protein kinases ERK and p38 (478).
In failing human myocardium, NADPH oxidase-re-
lated ROS production increases, which in turn enhances
expression and activity of Rac1. Application of 3-hydroxy-
3-methylglutaryl coenzyme A reductase inhibitors (st-
atins) like simvastatin downregulate Rac1-GTPase activ-
ity by reducing isoprenylation and translocation of Rac1
to the cell membrane (2). Inhibition of Rac1 by statins
decreases NADPH oxidase-related reactive oxygen spe-
cies production in cardiac myocytes and reduces myocar-
dial hypertrophy. Furthermore, simvastatin reduces hu-
man atrial myofibroblast proliferation via a RhoA path-
way (455). In addition, simvastatin, but not fenofibrate
(PPAR-
␣
agonist), inhibits canine atrial fibroblast prolif-
eration, which paralleled collagen-synthetic fibroblast
function (449). Thus statins and PPAR-
␣
agonists have
very different efficacy in preventing CHF-related atrial
structural remodeling.
Chronic atrial stretch is also associated with an al-
tered expression of matrix metalloproteinases (MMP).
MMPs are a large group of enzymes that function to break
down the extracellular matrix. Patients with persistent AF
show decreased atrial expression/activity of MMP-1 and
increased tissue inhibitor of metalloproteinase (TIMP)-1
levels (200, 363). In AF patients with congestive heart
failure, an increased collagen I fraction appears to be
associated with upregulation of MMP-2 and downregula-
tion of TIMP-1 (121, 635). These apparent discrepancies
could be explained by temporal changes in MMPs func-
tion and the presence of concomitant cardiac diseases
(valvular regurgitation, heart failure, etc.), which have a
substantial effect on atrial MMP expression (14). In addi-
tion to MMPs, ADAMs (a disintegrin and metalloprotein-
ase) also influence interstitial matrix composition and
cell-cell and cell-matrix interactions. ADAMs form a large
family of membrane-bound glycoproteins that function in
proteolysis, signaling, cell adhesion, and cleavage-secre-
tion of membrane-bound proteins (498). Arndt et al. (20)
described the effect of AF in patients with concomitant
heart diseases on regulation of ADAMs. Atrial tissue of
patients with permanent AF shows increased levels of
ADAM10 and ADAM15. Membrane expression of ADAM15
is significantly upregulated during AF, whereas most
ADAM15 is largely confined to the cytoplasm during sinus
rhythm. The ADAM15/

1-integrin ratio is significantly in-
creased in fibrillating tissue and correlates with the left
atrial diameter and the duration of fibrillation. Thus reg-
ulation of MMPs and ADAMs may influence the composi-
tion of interstitial matrix and, furthermore, contributes to
geometrical changes and dilatation of the atria and ven-
tricles (257).
B) AGING. Another important factor that influences
atrial pathology is aging (199). Both replacement and
reactive fibrosis, possibly induced by increased levels of
TGF-

are postulated to contribute to structural changes
in the elderly. Other profibrotic molecular mechanisms
(e.g., angiotensin II, bradykinin, endothelin-1) influencing
this process still need to be clarified. In very old myocar-
dium, higher levels of active p38
MAPK
in atrial trabeculae
after ischemia point towards an increased cellular stress,
which is even more pronounced after postischemic reper-
fusion. A recent study showed that aging significantly
influences PV anatomy, which may contribute to generate
triggers for AF. CT analysis revealed that left atrial ap-
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pendages and the four PV trunks become dilated in pa-
tients older than 50 years (436).
In addition to morphological changes, the aging pro-
cess is also accompanied by modified cellular Ca
2⫹
han-
dling (624). Aging is accompanied by upregulation of
InsP
3
Rs and transient receptor potential C (TRPC) chan-
nels but decreased SERCA activity. Whether these factors
contribute to PV arrhythmogenesis is currently unknown.
Another structural change commonly observed with
increasing age is isolated atrial amyloidosis (IAA). The
incidence of IAA increases with age (466). The formation
of amyloid fibrils takes place by a nucleated growth mech-
anism. As IAA is formed locally at the site where atrial
natriuretic peptide (ANP) is synthesized, a high local
concentration of the precursor protein and enhanced syn-
thesis of ANP contribute to the formation of amyloid
deposits. Apart from an association with AF, the presence
of atrial amyloid correlated with age, gender, surface
P-wave duration, and valvular diseases. The highest prev-
alence of atrial amyloid were found in patients undergo-
ing mitral valve replacement (466). Of note, the amount of
amyloid is inversely related to the amount of interstitial
fibrosis, supporting the concept that amyloid itself pro-
duces an arrhythmogenic substrate (466, 644).
2. Changes in atrial singaling as a consequence of AF
A) IMPACT OF AF ON OXIDATIVE STRESS. Several lines of
evidence suggest an association between oxidative stress
and AF (92, 300, 379). Rapid atrial pacing models showed
that AF decreases tissue ascorbate levels and increases
protein nitration, a biomarker of oxidative and nitrosative
stress (92). Biochemical evidence for oxidation by per-
oxynitrite and hydroxyl (
●
OH) radicals, both downstream
products of O
2
·⫺
generation, has also been demonstrated
in experimental models. Thus AF itself induces substan-
tial oxidative stress in fibrillating atrial tissue. Recently, it
was shown that AF caused left atrial endocardial dysfunc-
tion manifested as a 73% decrease in NO
·
production and
a 1.8-fold upregulation of plasminogen activator inhibi-
tor-1 (PAI-1) (82). One possible explanation for the reduc-
tion in NO
·
is increased oxidative degradation by O
2
·⫺
.
Recent studies suggest that increased O
2
·⫺
production is
at least partly the result of increased NAD(P)H oxidase
and xanthine oxidase (XO) activities. Interestingly, the
data indicate that the increase in O
2
·⫺
production is
greater in the left than in the right atrium. Increased
NAD(P)H oxidase activity could be explained by an in-
crease in active Rac1 (151). The mechanism of increased
NAD(P)H oxidase activity appeared to be increased en-
zyme activation (486). A membrane-bound gp91
phox
con-
taining NAD(P)H oxidase in atrial myocytes was the main
source of atrial superoxide production in human atrial
tissue (82). In contrast to findings in sinus rhythm pa-
tients, NO synthases (NOSs) contributed significantly to
atrial superoxide production in fibrillating atria, suggest-
ing that increased oxidative stress in AF may lead to NOS
“uncoupling” (287). In addition, downregulation of eNOS
has also been described in rapid pacing models (75).
These findings indicate that a myocardial NAD(P)H oxi-
dase and, to a lesser extent, dysfunctional NOS contribute
significantly to superoxide production in the fibrillating
human atrial myocardium (287). Rapid pacing of atrial
tissue slices in vitro demonstrated that atrial tachycardia
is associated with mitochondrial dysfunction and oxida-
tive stress-activated signal transduction (75, 496). Thereby,
oxidative stress could contribute to metabolic and structural
atrial changes in AF. It has been shown that AF activates the
redox-sensitive NF-
B signaling pathway, which causes an
elevated expression of target genes, LOX-1 and ICAM-1.
Increased expression of these adhesion molecules may con-
tribute to an increased risk for platelet and leukocyte adhe-
sion to the atrial endocardium, which may initiate atrial
thrombogenesis (75). However, the true clinical impact of
these molecular changes on thrombogenesis remains to be
defined.
B) IMPACT OF AF ON CALCIUM-DEPENDENT PROTEASES AND
PHOSPHATASES.Ca
2⫹
-dependent proteases like calpain and
phosphatases are activated during AF (66, 164, 198). Cal-
cineurin (Cn) is a calcium-activated serine-threonine
phosphatase composed of a catalytic A-subunit (59 – 63
kDa) and a regulatory B-subunit (19 kDa) (389). Three
catalytic genes (A-subunit) have been identified, of which
CnA
␣
and CnA

are present in the heart (549). The in-
duction of cardiac hypertrophy has been associated with
an increase in CnA

(but not in CnA
␣
) expression (72).
An elevation in the intracellular Ca
2⫹
concentration leads
to calmodulin saturation and the subsequent activation of
calcineurin (130). Activated calcineurin dephosphorylates
nuclear factor of activated T cells (NFAT), allowing trans-
location of NFAT into the nucleus. NFATc3 plays a pivotal
role in regulating the hypertrophic pathways. Of note,
FK506, a Cn inhibitor, abolishes the hypertrophic re-
sponse induced by electrical pacing of atrial tissue slices
(74). Rapid pacing causes an upregulation of CnA activity,
leading to increased dephosphorylation of the transcrip-
tion factor NFATc3. This in turn increases the transcrip-
tion of genes responsible for the atrial hypertrophic cel-
lular response, characterized by an increased expression
of troponin I, ANP, and

-myosin heavy chain (74). The
presence of hypertrophied atrial myocytes during AF is a
consistent finding of several studies (30, 186). Increased
calcineurin enzyme activity was also shown in pigs with
AF (337). In this in vivo model, NFAT-c3 and NFAT-c4
were increased in the nuclei in AF tissue (337). In another
in vitro study, CnA activity increased during8hofrapid
pacing, but returned to baseline at 24 h (459). Interest-
ingly, CnA activity was associated with transcriptional
downregulation of calcium channel protein.
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The histopathology of fibrillating atria is thought to
be similar to chronically ischemic ventricular myocar-
dium (30, 186). Ischemia/reperfusion injury is mediated
by increased levels of cytosolic Ca
2⫹
, which causes acti-
vation of the Ca
2⫹
-dependent proteases calpain I and
calpain II (197). It had been proposed that AF-induced
atrial contractile dysfunction is at least partially due to
calpain I-dependent degradation of contractile proteins.
However, as will be explained in section VC, force gener-
ation and Ca
2⫹
affinity of myofilaments are only modestly
altered in patients with AF. An in vitro study on HL-1
atrial myocytes showed that 24-h electrical field stimula-
tion at 5 Hz reduced plasmalemmal levels of L-type Ca
2⫹
channel
␣
1C
-subunit by 72% compared with controls,
whereas there was no change in amount of the potassium
channel subunits Kv4.3 and Kv1.5 (67). In that model,
rapid pacing induced marked changes in cellular struc-
ture; myolysis and nuclear condensation, paralleled by a
14-fold increase in calpain activity. Interestingly, inhibi-
tion of calpain, but not the calcium antagonist verapamil,
prevented these ultrastructural changes.
B. Ion Channel Remodeling and Shortening
of Refractoriness
In patients, paroxysms of AF often tend to become
longer with time, ultimately leading to persistent AF. An-
imal models of rapid atrial pacing have helped to under-
stand this progressive nature of the arrhythmia. AF itself
leads to changes which increase the stability of AF (614).
It is widely believed that “electrical remodeling” plays an
important role in this process. The rapid rates of AF cause
a shortening and a loss of rate adaptation of the AERP
(194, 614), as discussed in section IVB. In patients, the
existence of electrical remodeling is well established. Sev-
eral clinical studies have shown that atrial APD in AF
patients is shorter than in patients in sinus rhythm (26, 58,
132, 182, 646). In addition to AERP shortening, AF pa-
tients show a loss of rate adaptation of the AERP (26, 58,
182). Some studies have also reported an increased AERP
dispersion (378, 383).
The molecular mechanisms underlying APD shorten-
ing in human AF have been extensively investigated in
atrial myocytes isolated from the right atrial appendage of
patients undergoing open chest surgery. The properties of
these myocytes thus reflect not only adaptations to the
rhythm of the patients but also to underlying structural
heart disease, medication, and age (189). This shortcom-
ing can partly be overcome by matching respective con-
trol populations but remains a potential confounding fac-
tor in most of these experimental investigations.
The available data show that the molecular mecha-
nisms of electrical remodeling occur at the level of ex-
pression and/or phosphorylation of ion channels (Fig. 10,
expertly reviewed in Refs. 408, 626). Of the depolarizing
currents, I
Na
was unaltered (57) while I
CaL
density was
⬃70% lower compared with patients in sinus rhythm (57,
68, 526, 576). The mRNA for the L-type channel
␣
-subunit,
Cav1.2, shows a corresponding decrease both in RAP
animal models and AF patients (56, 68, 69, 573, 649).
However, some studies have reported a decrease of L-
type Ca
2⫹
channel subunit protein expression (68, 69,
649), whereas others have found that protein levels were
unchanged (111, 506). Differences in patient populations
(underlying heart disease, antiarrhythmic drugs) may be
responsible for these discrepancies. Increased activity of
protein phosphatase 2A (PP2A) resulting in hypophos-
phorylation of the Ca
2⫹
channel was found to cause I
CaL
downregulation in one study (111), although in another
study, L-type channel open probability was increased,
rather pointing towards decreased PP2A activity (294).
Finally, increased calpain activity may contribute to in-
creased proteolysis of L-type channel protein (66, 198).
Of the repolarizing potassium currents, I
to
(57, 209,
577) is strongly reduced in chronic AF. The resulting
slowing of phase 1 repolarization of the atrial action
potential has been found in human atrial action potentials
of patients with AF (112) but was not consistently found
in animal models. The inward rectifier potassium current
I
K1
(57, 146, 148, 577) and the corresponding subunits
Kir2.1 (mRNA and protein) were found to be increased in
AF patients (189). The reported increase in I
K1
probably
has a significant contribution in APD shortening (652).
AF decreases the mRNA and protein for the I
KACh
subunit Kir 3.1 and 3.4 (68, 69). In myocytes from AF
patients, the I
KACh
-mediated response to acetylcholine is
blunted (146), but I
KACh
is constitutively active due to
abnormal channel phosphorylation by protein kinase C
(PKC) (94, 145, 592), making this current an interesting
target for APD prolongation.
For I
Kur
, no change (57, 209, 628) or a decrease (62,
577) was reported. Christ et al. (112) recently reported
that amplitudes of both rapidly and slowly inactivating
components of I
Kur
were lower in AF patients. No
FIG. 10. Atrial action potentials in models of AF. Top panel: superposition of control action potentials with action potentials measured in atrial
myocytes from canine models of rapid atrial pacing (RAP), congestive heart failure (CHF), and aging and in myocytes from patients with chronic
AF and structural heart disease. The dotted line represents 0 mV. Action potentials are modified from the following references: RAP (647), CHF
(327), aging (16), human AF (57), and human SHD (302). Stimulation frequency was 1 Hz in all cases. The table provides an overview of alterations
in ionic currents in various animal models of AF and in myocytes from human patients with AF and structural heart disease. Changed are expressed
as “fold change.” Na, no data available. Note that the reported current changes due to RAP are derived from models of RAP with AV block.
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changes in the Na
⫹
/K
⫹
pump current were found in AF
patients (627). Apart from electrical remodeling caused
by AF, underlying heart disease in itself can also lead to
changes in ionic current that may also increase the like-
lihood for AF (see Fig. 10 for quantitative details) (626,
629).
Does the process of electrical remodeling explain the
progressive nature of AF in patients? Often, AF can be
cardioverted by agents that prolong the atrial APD. This
indicates that a prolongation of the AERP is antiarrhyth-
mic but does not show to which extent the AERP short-
ening contributes to AF stability. Importantly, the success
rate of chemical cardioversion is relatively high in recent-
onset AF, but its efficacy decreases with longer AF dura-
tion (15). The exact time course of electrical remodeling
during AF in humans is unknown, but in animal models it
is complete within at most a few days. The limited effi-
cacy of ion channel blockers in the treatment of chronic
AF indicates that other processes occurring more slowly
than electrical remodeling contribute to the stability of AF
in many patients.
Several studies reported that a short right atrial APD
directly after cardioversion was correlated to a higher AF
recurrence (124, 426). The question is how long this effect
persists. In most patients with recent onset of paroxysmal
AF, the time spent in sinus rhythm between two AF
episodes may be long enough to completely reverse elec-
trical remodeling. In animal models, complete reversal of
electrical remodeling takes place within 2–3 days of sinus
rhythm with a gradual prolongation of the AERP and
recovery of the rate adaptation response (504, 562, 615). A
number of clinical studies have demonstrated that after
cardioversion of persistent AF in patients, the AERP also
gradually increases and normal refractoriness is restored
within several days (357, 460, 646). Interestingly, several
other studies showed that increased vulnerability to AF
after cardioversion still exists 2– 4 wk after reversal of
electrical remodeling (561, 568). This discrepancy in time
course also indicates that the effect of other processes
than just electrical remodeling remain present after car-
dioversion of AF.
Expression and/or activity of the calmodulin-depen-
dent kinase II (CaMKII) has been shown to be enhanced
in fibrillating and dilated atria in animal models and pa-
tients with AF (409, 559). The most relevant target pro-
teins of CaMKII are ryanodine receptors, phospholamban,
L-type Ca
2⫹
channels, and proteins involved in the epige-
netic regulation of atrial myocytes (e.g., histone-acety-
lases). In normal atrial myocytes, CaMKII activation plays
an important role in frequency adaptation of cell function.
In AF, CaMKII activation might contribute to generation
of abnormal impulse formation as will be described in
section VD.
C. Loss of Atrial Contractility and
Atrial Dilatation
Loss of atrial contractile function after cardioversion of
AF was first documented by Logan et al. in 1965 (Fig. 11A)
(344). Echocardiographic studies showed that this atrial
contractile dysfunction correlated with the duration of AF
and that it could take months before the atrial transport
function was fully recovered (358, 359). While after 2 wk
of AF, recovery of atrial contractile function was com-
plete within 24 h of sinus rhythm, it took more than 1 mo
to recover from AF lasting more than 6 wk (358). The
degree of atrial contractile function appears not to de-
pend on whether AF was cardioverted pharmacologically
or by direct-current shock (226). In cases with spontane-
ous termination of AF, a similar degree of atrial contrac-
tile dysfunction was demonstrated (171, 212).
The most important clinical consequence of loss of
atrial contractile dysfunction due to AF is the low blood
flow velocity in the atria following cardioversion, which
significantly contributes to the thromboembolic risk as-
sociated with AF (45). Most thromboembolic events oc-
cur shortly after cardioversion (⬎90% within 10 days),
which suggests that preformed atrial thrombi are being
dislodged from the atrial wall due to restoration of vigor-
ous atrial contractions (49). However, transesophageal
echocardiography has shown that new atrial thrombi can
be formed after cardioversion (173), stressing a role of
prolonged depression of contractility as a factor promot-
ing thrombus formation after cardioversion (49). The loss
of atrial contractility also increases the compliance of the
fibrillating atria, which may enhance progressive dilata-
tion during AF and may contribute to further stabilization
of the arrhythmia (502). In contrast, restoration of sinus
rhythm has been shown to reduce atrial size (206, 574).
Finally, delayed recovery of atrial contraction after car-
dioversion might contribute to the delayed recovery of
exercise capacity (341).
The mechanisms responsible for atrial contractile
dysfunction following cardioversion are not completely
understood. In experimental and clinical studies, vera-
pamil was able to largely prevent the atrial dysfunction
after short periods of AF, indicating that atrial stunning is
mediated by Ca
2⫹
overload (133, 319). While the altered
atrial function after short paroxysms of AF is likely to be
the result of changes in cellular metabolism, long-lasting
atrial tachyarrhythmias may induce additional changes
causing a more persistent atrial contractile dysfunction.
Some studies point towards an important role of I
CaL
downregulation as a cause of atrial contractile dysfunc-
tion. In dogs with sustained atrial tachycardia (6 wk), the
degree of shortening of isolated atrial myocytes was
shown to be reduced and associated with a pronounced
reduction of the Ca
2⫹
transient (295, 547). In this model,
I
CaL
has been reported to be downregulated by 70% (647).
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In goats, the time course of electrical remodeling (pre-
sumably related to I
CaL
downregulation) followed a time
course comparable to the progressive loss of atrial con-
tractility during the first days of AF, suggesting that both
phenomena are due to the same underlying mechanism
(504). Downregulation of I
CaL
directly reduces Ca
2⫹
influx
into the cell but also shortens the atrial action potential
(211, 647), which further reduces Ca
2⫹
entry into the cell.
Vice versa, compounds which prolong the atrial action
potential but do not directly interfere with I
CaL
have been
shown to enhance Ca
2⫹
influx and atrial contractility
(136, 503, 608).
There are reasons to assume that in patients with
prolonged AF, other mechanisms beyond downregulation
of I
CaL
also contribute to loss of atrial contractility after
cardioversion. In such patients, recovery from electrical
remodeling occurs within a couple of days after cardio-
version, whereas restoration of atrial contraction takes
weeks to months. This indicates that I
CaL
downregulation
alone cannot explain the more persistent depression of
atrial contractile function after prolonged AF. Additional
mechanisms have been studied in right atrial trabeculae
prepared from the right atrial appendage of patients un-
dergoing mitral valve repair with and without long-stand-
ing AF (Fig. 11B) (501, 505). In patients with persistent
AF, the contractile force was reduced by ⬃75%. Interest-
ingly, contractile reserve of these preparations and the
sarcomere content were hardly reduced (⫺18%), indicat-
ing that the contribution of myolysis to the loss of atrial
contractile function is very limited. Also, the post-rest
potentiation was fully maintained, and diastolic proper-
ties were preserved, illustrating that the function of the
FIG. 11. Mechanisms of atrial contractile dysfunction due to AF. A: loss of the a-wave after electrical cardioversion of AF. [Modified from Logan
et al. (344), with permission from Elsevier.] B: depressed contractility in trabeculae isolated from right atrial appendage of patients undergoing mitral
valve surgery. [Modified from Schotten et al. (501).] C: confocal line scan of Ca
2⫹
release in atrial myocytes isolated from rabbits after rapid atrial
pacing for 5 days (RAP) or sham. In RAP cells, central cellular Ca
2⫹
release is blunted, indicating failure of intracellular Ca
2⫹
wave propagation in
tachycardia-induced atrial remodeling. [Modified from Greiser et al. (210).] D: schematic illustration of Ca
2⫹
handling alterations in AF. Down-
regulation of I
CaL
, upregulation of I
NCX
, and defective release of Ca
2⫹
from the sarcoplasmic reticulum are the main mechanisms of atrial contractile
dysfunction (dark red labels) while alterations of SR Ca
2⫹
load or myofilament function play a minor role (dark green labels).
PATHOPHYSIOLOGICAL MECHANISMS OF ATRIAL FIBRILLATION 291
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sarcoplasmic reticulum was not largely altered. In con-
trast, the positive inotropic effect of isoproterenol was
markedly impaired, although the density of the

-adreno-
ceptors and the expression of the inhibitory and stimula-
tory G proteins were unaltered (501). The catecholamine-
stimulated adenylyl cyclase activity was not reduced, in-
dicating that the

-adrenergic signal transduction was not
desensitized (505). Thus, in contrast to ventricular tachy-
cardiomyopathy, which is due to a dysfunction of the
sarcoplasmic reticulum and

-adrenergic desensitization,
atrial contractile dysfunction after prolonged AF must be
due to other mechanisms.
Oxidative injury (379) as well as reduced phosphor-
ylation of myofibrillar proteins (164) have been suggested
to reduce the performance of the contractile apparatus in
patients with AF. Also, myosin binding protein C was
found to be dephosphorylated in patients with AF (164),
which would also be in line with reduced contractile
performance of the atrial myofibrils. Some studies on
skinned fibers showed that both the maximal force gen-
eration and also the Ca
2⫹
sensitivity of the myofilaments
were unaltered (163, 406). A more recent report demon-
strated a reduction in maximum tension and the rate of
tension development, and an increase in myofilament
Ca
2⫹
sensitivity in patients with AF (40). The extent to
which these changes contribute to loss of atrial contrac-
tility due to AF is difficult to assess but might be limited
in the light of preserved contractile reserve of intact
muscle preparations.
Recently, confocal imaging of Ca
2⫹
release from the
sarcoplasmic reticulum showed that the centripetal Ca
2⫹
wave propagation was significantly impaired in atrial
myocytes isolated from dogs (596a) and rabbits (210)
undergoing rapid atrial pacing for 5 days (Fig. 11C). These
studies indicate that impaired release of Ca
2⫹
from the
sarcoplasmic reticulum might contribute to loss of atrial
contractility. The mechanism underlying impaired Ca
2⫹
release from the sarcoplasmic reticulum is currently un-
known but not related to downregulation of I
CaL
(210).
Instead, impaired coupling between Ca
2⫹
channels and
RYRs was recently reported in sheep with persistent AF
(322). In patients with AF, an upregulation of the Na
⫹
/
Ca
2⫹
exchanger was reported that potentially reduces
Ca
2⫹
load of atrial myocytes contributing to contractile
dysfunction in AF (505). The main mechanisms causing
atrial contractile dysfunction due to AF are summarized
in Figure 11D.
Atrial dilatation without concomitant AF can also
cause an atrial contractile dysfunction. In animal models
of heart failure, atrial emptying function is reduced (517),
and in patients, loss of atrioventricular synchrony due to
single chamber ventricular demand (VVI) pacing in-
creases left atrial diameter while markers of atrial con-
tractility decrease (537). In goats with atrial dilatation due
to AV block, atrial dysfunction was related to reduced
sarcoplasmic Ca
2⫹
load due to phospholamban dephos-
phorylation and ryanodine receptor hyperphosphoryla-
tion (211). Reduced atrial contractile function was asso-
ciated with disruption of a t-tubular system in atrial myo-
cytes of sheep with heart failure (142). In dogs with
congestive heart failure, reduced atrial contractility is
associated with prolonged action potential duration, ele-
vated diastolic Ca
2⫹
concentrations, and increased ampli-
tude of Ca
2⫹
transients (643). These findings point to-
wards reduced force generation or Ca
2⫹
sensitivity of the
contractile apparatus. Myosin binding protein C phos-
phorylation was reduced in both goats with atrial dilata-
tion due to AV block and in dogs with CHF. Whether this
also contributes to reduced contractile performance in
dilated atria is currently unclear.
AF may not only cause contractile dysfunction in the
atria but also in the ventricles. Persistent elevation of
ventricular rate above 130 beats/min can produce a tachy-
cardiomyopathy of the ventricles (286, 433). Reduction of
the heart rate might reverse normal pump function, em-
phasizing that ventricular rate control might not only
prevent deterioration of LV function but also restore
pump function that is already compromised (188).
D. Alterations of Atrial Ca
2ⴙ
Handling and
Abnormal Impulse Formation
During the past years, alterations of intracellular
Ca
2⫹
handling in dilated and fibrillating atria have at-
tracted the attention of many research groups. Many of
these studies indirectly suggest a role of triggered activity
in the generation of fibrillation wavefronts in patients
with AF. Vest et al. (589) demonstrated an enhanced open
probability of the RYRs in atrial myocardium of dogs
undergoing RAP as well as of patients with sustained AF,
which in both cases was due to hyperphosphorylation of
the RYR channel at the PKA site. The authors conclude
that these alterations might facilitate spontaneous Ca
2⫹
release events from the sarcoplasmic reticulum, which in
turn might induce DADs and possibly trigger action po-
tentials. In agreement with this, Hove-Madson et al. (253)
reported an increase of the frequency of Ca
2⫹
sparks
(elementary Ca
2⫹
release events) in atrial myocytes iso-
lated from the right atria of patients with sustained AF.
The Ca
2⫹
load of the sarcoplasmic reticulum was unal-
tered, which supports the hypothesis that the increase in
spontaneous Ca
2⫹
release was due to a change of the
intrinsic properties of the RYRs. Recently, increased leak
of Ca
2⫹
from the sarcoplasmic reticulum and elevated
diastolic Ca
2⫹
concentrations have indeed been described
in right human atrial myocytes (409). In this study, hyper-
phosphorylation of RYRs was shown to be due to en-
hanced activity of CaMKII, as mentioned in section VA.
This interesting hypothesis, however, raises some impor-
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tant questions. For instance, it is unclear why despite the
fact that in atrial myocytes isolated from the right atrial
appendages of patients with AF the Ca
2⫹
spark frequency
is enhanced, ectopic activity originating in this region is a
rare phenomenon. Similarly, dogs after 2 mo of RAP do
not develop atrial ectopy, although the open probability of
the atrial ryanodine channels has been reported to be
increased (589). Also, increased open probability alone
only transiently enhances spontaneous Ca
2⫹
release from
the sarcoplasmic reticulum, since increased release
would reduce the sarcoplasmic Ca
2⫹
load and in turn
spontaneous Ca
2⫹
release (580). However, in ventricular
myocytes of dogs with heart failure, enhanced diastolic
Ca
2⫹
release has been observed even in the presence of
reduced Ca
2⫹
load of the sarcoplasmic reticulum (306). In
this model, reduced Ca
2⫹
release during the steady-state
Ca
2⫹
transients might have prevented progressive empty-
ing of the Ca
2⫹
stores. Another possibility is that stimu-
lation of the Ca
2⫹
reuptake rate maintains Ca
2⫹
load and
produces a sustained enhancement of Ca
2⫹
release
events. Of note, phosphorylation levels of phospholam-
ban, an inhibitory protein controlling the reuptake of
Ca
2⫹
into the sarcoplasmic reticulum by the sarcoplasmic
reticulum Ca
2⫹
-ATPase (SERCA), is increased in atrial
myocardium of patients with AF (164). Enhanced phos-
phorylation of phospholamban dissociates the molecule
from SERCA and stimulates reuptake of Ca
2⫹
into the
sarcoplasmic reticulum, possibly increasing Ca
2⫹
load
and spontaneous Ca
2⫹
release from the intracellular Ca
2⫹
stores. So far, however, there is no evidence for enhanced
reuptake of Ca
2⫹
into the sarcoplasmic reticulum in fib-
rillating atrial myocardium. Rather, experiments with iso-
lated right atrial trabeculae show that at any level of Ca
2⫹
load, the diastolic properties of atrial myocardium of
patients with AF are unaltered (505). Recently, in mice
with a genetic gain-of-function defect in the RYRs, spon-
taneous AF was absent at rest but could be induced by
rapid pacing, which also resulted in increased hyperphos-
phorylation of RYRs at the CaMKII phosphorylation site
(100). Importantly, pharmacological and genetic inhibi-
tion of CaMKII prevented AF inducibility. Taken together,
these data suggest that enhanced Ca
2⫹
leak through hy-
perphosphorylated or defective RYRs alone might not be
sufficient to produce relevant atrial ectopy. It is unknown
whether in patients, enhanced sympathetic stimulation or
simply the high rate during AF can sufficiently enhance
Ca
2⫹
load of atrial myocytes to provoke proarrhythmic
Ca
2⫹
spontaneous leak through hyperphosphorylated
RYRs.
The question of whether atrial pathology might en-
hance spontaneous electrical activity has been addressed
by several authors. In cats with atrial dilatation due to
spontaneously occurring cardiomyopathy, resting mem-
brane potentials have been reported to be more positive,
and action potentials showed lower amplitudes and up-
stroke velocities (60). In the presence of catecholamines,
automaticity and triggered activity were frequently found
in atrial preparations from dilated atria but only occasion-
ally occurred in normal atria. In dogs with heart failure
induced by rapid ventricular pacing, action potential du-
ration was prolonged, and frequently DADs occurred
(539). Left atrial myocytes showed increased diastolic
Ca
2⫹
concentrations and sarcoplasmic Ca
2⫹
loading.
Spontaneous action potentials occurred more frequently
in heart failure dogs compared with controls and were
suppressed by inhibition of SR Ca
2⫹
release and the Na
⫹
/
Ca
2⫹
exchanger (643). Of note, in none of the aforemen-
tioned studies (60, 539, 643) has ectopic activity or spon-
taneous onset of atrial tachyarrhythmias been reported.
The response to pacing can provide valuable infor-
mation about trigger mechanisms of AF. After treatment
with ryanodine, rabbit PVs showed pacemaker activity
that was enhanced when the preparations were tran-
siently paced at a higher rate (249). In canine PVs exposed
to pituitary adenylyl-cyclase activating polypeptide
(PACAP), which mimics neurohumoral dysbalance,
rapid atrial pacing caused ectopic beats that were cou-
pled with a shorter cycle length when the triggered
cycle length was also short (236). In dogs with CHF,
rapid pacing induced an atrial tachycardia with repetitive
radial spread of activation. The postpacing interval as
well as the cycle length of the tachycardia itself were
positively correlated with the pacing cycle lengths trigger-
ing the tachycardia (539). All these findings are consistent
with enhanced Ca
2⫹
loading of atrial myocytes causing
spontaneous release of Ca
2⫹
from the sarcoplasmic retic-
ulum and repetitive DADs. Reentrant mechanisms appear
less likely because here a high rate of the triggering
impulses results in a longer postpacing interval. It should
be noted, however, that DADs do not invariably react on
pacing protocols (267) and the specificity of such tests to
identify a specific proarrhythmic mechanism might be
limited (620).
Mapping of the activation pattern during or at the
onset of AF has also been used to support a role of
ectopic discharges in initiation and perpetuation of AF. Of
note, demonstration of radial spread of activation from a
localized area does not allow direct determination of the
mechanism of an arrhythmia, but to some degree sup-
ports the existence of a localized source of AF. For ex-
ample, activation mapping has revealed the onset of AF
triggered by a spontaneous beat originating from the PVs
in dogs during autonomic imbalance (236) or with con-
gestive heart failure (109, 423) and in rats during glyco-
lytic inhibition (427). In patients with paroxysmal AF,
endocardial mapping of the PVs demonstrated radial
spread of activation of spontaneous beats in the PVs
initiating runs of AF (440). It is important to note, how-
ever, that radial spread of activation can also be due to
“breakthrough” of wavefronts originating from deeper
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layers of the atrial wall (159). Therefore, these studies do
not prove that in the studies mentioned localized sources
have induced episodes of AF.
A higher level of evidence for the presence of a
localized driver for AF comes from observations of radial
spread of activation occurring repetitively at the same
site. This conduction pattern has been described in dogs
with CHF and AF-induced by RAP (177, 653). In the study
by Fenelon et al. (177), repetitive radial spread of activa-
tion was documented in the endocardium and the epicar-
dium primarily at sites along the crista terminalis. Zhou et
al. (653) reported repetitive focal spread of activation in
the PVs of dogs with AF. Based on these activation pat-
terns, the authors of both studies cannot rule out micro-
reentry as a mechanism of repetitive radial spread of
activation. However, they did provide additional argu-
ments in favor of a cellular proarrhythmic mechanism
(see below).
Other studies interpreted an increased incidence of
radial spread of activation in structurally altered atria as
an argument for cellular proarrhythmic mechanisms in-
ducing AF. In dogs with pacing-induced heart failure,
acetylcholine increased the rate of “focal discharges”
from the PVs by factor 3 (109). Nitta el al. (419) observed
multiple “focal activations” with fibrillatory conduction in
patients with AF undergoing open chest surgery. The
mechanism of these events, however, remains unclear.
They might be due to cellular proarrhythmic activity, but
they might also be due to an increased incidence of
“breakthroughs” due to transmural conduction, which
more likely occurs in a complex substrate for AF as
explained in section VE(159).
Finally, the response of electrical activity to pharma-
cological compounds has been used as an argument in
favor of the presence of focal discharges during atrial
tachyarrhythmias. Spontaneously occurring arrhythmias
in PVs of dogs undergoing 6 – 8 wk of rapid atrial pacing
were suppressed by sodium channel blockers or magne-
sium (103). In canine PV, left atrial preparations exposed
to acetylcholine, thapsigargin, and ryanodine eliminated
focal discharges from the PVs (109). The atrial tachycar-
dia with repetitive radial spread of activation in dogs with
CHF was terminated by compounds reducing Ca
2⫹
load-
ing like verapamil, flunarizine, and ryanodine (539). The
experiments with verapamil and ryanodine suggest that
Ca
2⫹
loading might be critical for some forms of sponta-
neous electrical activity occurring in AF-related atrial
pathologies and support the role of DADs as a trigger
mechanism for spontaneous activity in the atrium. In
contrast, flunarizine has also been shown to terminate
reentrant rhythms like atrial flutter in the canine sterile
pericarditis model, illustrating that the response to fluna-
rizine cannot be taken as an argument for the existence of
Ca
2⫹
-related cellular proarrhythmic mechanisms (591). In
sheep atria exposed to acute stretch and adrenocholin-
ergic stimulation (perfusion with high concentrations of
isoproterenol and acetylcholine), both caffeine and ryan-
odine inhibited breakthroughs showing radial spread of
activation during AF. The sensitivity of these break-
throughs to compounds which empty the sarcoplasmic
reticular Ca
2⫹
stores might be taken as an argument in
favor of focal discharges as the underlying mechanism
under these specific conditions (639a).
In summary, the role of altered Ca
2⫹
homeostasis for
initiation and perpetuation of AF is still obscure, mainly
due to technical limitations of existing experimental ap-
proaches. As confirmation of Ca
2⫹
-dependent AF mecha-
nisms might have consequences for our understanding of
the working mechanisms of antiarrhythmic drugs (147), it
requires further clarification.
E. Atrial Structural Remodeling and
Conduction Disturbances
As explained in sections IV and VB, apart from elec-
trical remodeling, other factors must also contribute to
the high susceptibility to the arrhythmia in patients with
AF. This “second factor” may entail alterations in atrial
tissue structure. The relation between structural alter-
ations and AF has been studied in many different clinical
entities. Clearly, structural alterations of atria are not
exclusively related to AF but at least to the same degree
as the existence of structural heart disease present in an
individual patient. The kind of structural alterations also
shows a high diversity. For example, Frustaci and co-
workers (185, 187) have described evidence of occult
atrial pathology, such as myocyte necrosis, myocarditis,
and fibrosis, in patients with lone AF. However, the ma-
jority of chronic AF patients is of advanced age or suffers
from structural heart disease. Of the various aspects of
atrial structural remodeling in these patients, the conse-
quences of fibrosis, myocyte hypertrophy, and altered
connexin distribution have been studied most exten-
sively, as discussed below.
1. Atrial fibrosis
Atrial fibrosis is thought to be one of the most im-
portant factors in the formation of a substrate for AF (407,
529). Atrial fibrosis has been observed in biopsies from
patients with AF (301) as well as in patients with specific
risk factors for AF, such as valvular disease (14), rheu-
matic heart disease (352, 450), dilated and hypertrophic
cardiomyopathy (422), and advanced age (336).
Myocytes are organized in bundles, separated by per-
imysial fibrous tissue. Within these bundles, strands of
myocytes can be separated from each other by endomy-
sial fibrous tissue. Structural remodeling due to heart
disease is often associated with fibrosis and an increased
transverse fiber separation. In the atria, collagenous septa
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between myofibers increase in volume during normal ag-
ing (304, 530). Similarly, the extracellular matrix volume
per myocyte increased in the goat of 4 mo of RAP (29).
Also in atria of animal models of atrial dilatation (59, 587)
and CHF (326), the amount of fibrosis is increased. How-
ever, in these models and in particular in the CHF model,
larger areas of fibrosis are observed, which are more
similar to “replacement fibrosis” secondary to tissue dam-
age and cell death. Various degrees and forms of atrial
fibrosis and the resulting conduction disturbances are
shown on Figure 12. Atrial fibrosis may in itself be suffi-
cient to increase AF vulnerability, as shown in mice with
selective atrial fibrosis due to overexpression of TGF-

1
(582).
Spach and Boineau (529) have demonstrated that the
nonuniform anisotropic arrangement in cell-to-cell con-
nections leads to discontinuous conduction at a micro-
scopic scale. While longitudinal propagation may still be
fast, transverse propagation may show “discontinuous
conduction,” i.e., discrete time delays in activation of
adjoining myocytes or myocyte bundles (529). During
such delays due to poor electrical coupling, propagation
FIG. 12. Relation between structural alterations and changes in conduction in animal models of AF. Fibrosis is stained in blue (Trichrome), red
(Sirius red), or light blue (Toluidine Bbue). Myocytes are stained red (Trichrome), green (Sirius red), or dark blue (Toluidine blue). A: in a canine
model of chronic atrial dilatation due to mitral insufficiency, inflammatory infiltrates and fibrosis were increased. During slow pacing, activation
wavefronts spread rapidly and homogeneously, but during extrastimulation, areas of slow conduction were observed. [Adapted from Verheule and
co-workers (586, 587).] B: cellular hypertrophy without an increase in fibrosis was reported in a goat model of chronic biatrial dilatation due to AV
block. Fast pacing (BCL 200 ms) revealed areas of slow conduction. [Adapted from Neuberger et al. (411).] C: pronounced increase in fibrosis in
a canine model of CHF due to rapid ventricular pacing was associated with areas of conduction heterogeneity in the left atrium. [Adapted from Li
et al. (326).] D: 6 mo of RAP led to increased interstitial fibrosis in the goat. During slow pacing, the conduction velocity in the left atrium was
decreased by 30%. E: mouse model of selective atrial fibrosis due to overexpression of TGF-

1. Left atrial activation maps show increased
heterogeneity of conduction during pacing at a cycle length of 150 ms (582).
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may become increasingly dependent on I
CaL
rather than
I
Na
(514, 546). Discontinuities in conduction can become
more apparent at short cycle lengths or during extra-
stimulation with short coupling intervals due to incom-
plete recovery of Na
⫹
and Ca
2⫹
channels (534, 546). This
may allow reentry to occur in very small circuits (529, 534,
535). Discontinuous conduction between poorly coupled
myocytes forms the basis of “electrical dissociation” dur-
ing AF that is reflected by fractionated electrograms.
Although there are strong indications from animal
models that atrial fibrosis can be proarrhythmic (80, 169),
some questions regarding the role of atrial fibrosis in the
development of a substrate of AF are so far unresolved.
First, the association between atrial fibrosis and AF
is quantitatively not very strong. Some, but not all, human
studies have found that atrial fibrosis is more pronounced
in chronic AF patients than in patients with sinus rhythm
(53, 301, 475). The degree of atrial fibrosis and fibrogenic
activity correlates with the persistence of AF (208, 635).
However, from these studies it is unclear whether in-
creased fibrosis is caused by underlying structural disease
or by AF itself. In some of these studies, the degree of the
underlying heart disease is not well documented. From a
careful comparison of structural heart disease patients
with and without AF, Anné et al. (14) have concluded that
AF itself is not associated with atrial fibrosis but is instead
related to the underlying structural heart disease.
Second, it is unclear what the quantitative relation
between atrial fibrosis and conduction disturbances is. As
discussed in section IVD, some animal models of atrial
dilation show both atrial fibrosis and conduction distur-
bances (586). However, other models show similar con-
duction disturbances in the absence of atrial fibrosis
(411).
Another question is how different types of fibrosis,
for example, large areas of replacement fibrosis (as in the
canine CHF model) or thin strands of interstitial fibrosis
(as in models of aging), affect atrial conduction. In ven-
tricular cardiomyopathy, Kawara et al. (281) have demon-
strated that conduction abnormalities strongly depend on
the pattern of fibrosis. In this study, diffuse fibrosis with
short fibrotic strands only marginally affected conduc-
tion. However, long fibrotic strands could cause pro-
nounced conduction slowing during extrastimulation, es-
pecially during transverse propagation.
Finally, the question remains how important atrial
fibrosis is as a causative factor for AF in humans. In
patients undergoing open heart surgery, the degree of
fibrosis does correlate with the occurrence of postop-
erative AF (199) and with the recurrence of AF (475).
However, both the degree of atrial fibrosis and the
occurrence of AF may reflect the severity of underlying
heart disease, without a strong, direct causal link be-
tween fibrosis and AF. Indeed, a significant degree of
atrial fibrosis can be present in patients without a
history of AF (199).
Despite the fact that the association between atrial
fibrosis and AF is surprisingly weak, experimental and
clinical studies show that prevention of atrial fibrosis
can delay the development of a substrate of AF. Several
compounds (statins, ACE inhibitors, AT
1
-receptor
blocker, fish oil, and glucocorticoids) have been proven
to effectively delay the structural remodeling process
and reduce AF stability in a variety of experimental
models (309, 318, 328, 380, 477, 478, 523). In patients,
several post hoc analyses of clinical trials and small-
scale proof-of-principle studies suggest that therapy
with ACE inhibitors, AT
1
-receptor blocker, statins, and
polyunsaturated fatty acids (PUFAs) are useful to pre-
vent the occurrence of AF. The details of these studies
are summarized in Tables 2–5. It is tempting to specu-
late that the beneficial effect reported in these studies
is due to an antifibrotic effect in the atria. However,
improvement of the patients’ hemodynamics with nor-
malization of atrial pressures might also have contrib-
uted to the beneficial effects of these compounds. The
current ESC guidelines for the management of AF con-
tain recommendations for the use of ACE inhibitors,
AT1-receptor blockers, and statins for primary and sec-
ondary prevention of AF (see section on upstream ther-
apy) (168a).
Unfortunately, compared with fibrosis, amyloidosis
(323, 466, 541) and fatty infiltrates (39), which can occur
widely in elderly patients and can potentially have a sim-
ilar impact on conduction, have received comparatively
little attention. Mechanistic studies on the role of these
structural changes in AF are so far lacking.
2. Altered connexin expression
Another relevant factor for atrial conduction may be
altered connexin expression. In the working myocardium,
conduction velocity is higher in the longitudinal than in
the transverse direction. In the transverse direction, a
propagating wavefront has to cross more cell-to-cell
boundaries within a given distance. In addition, the
smaller and sparser gap junctional plaques at side-to-side
connections represent a higher resistance than the larger
intercalated discs at end-to-end connections (531). With
age, gap junctions also become increasingly localized at
end-to-end connections between myocytes, thus further
increasing anisotropy (207, 304, 448).
Several studies have reported alterations in Cx40
and/or Cx43 in patients with AF, but the observations are
not consistent (152). In patients with chronic AF, both
higher (454) and lower (404, 617) levels of Cx40 were
reported. Another study reported lateralization of connex-
ins, with an increased heterogeneity in Cx40 distribution
and a reduction of Cx43 (301).
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TABLE 2. Clinical trials of renin-angiotensin system inhibition to prevent new-onset AF in patients with CHF or AMI (primary prevention) and
patients with hypertension (primary prevention)
References Study Design Patients Intervention Primary Outcome
Pedersen et al. (445) TRACE study (post hoc analysis) 1,577 Patients with AMI and reduced
LVEF
Trandolapril versus placebo Reduced incidence of new-onset AF
Follow-up: 2–4 yr
Pizetti et al. (451) GISSI-3 study (post hoc analysis) 17,749 Patients with AMI Lisinopril versus nolisinopril No difference in new-onset AF
Follow-up: 4 yr
Vermes et al. (588) SOLVD study (post hoc analysis) 347 Patients with LV dysfunction Enalapril versus placebo Reduced incidence of new-onset AF
Follow-up: 2.9 yr
Alsheikh-Ali et al. (9) SOLVD study (post hoc analysis) 6,797 Patients with LV dysfunction Enalapril versus placebo Reduced incidence of hospitalisation
with AF
Follow-up: 34 mo
Maggioni et al. (355) Val-HeFT study (post hoc analysis) 4,395 Patients with chronic
symptomatic HF
Valsartan versus placebo Reduced incidence of new-onset AF
Follow-up: 23 mo
Ducharme et al. (150) CHARM study (prespezified secondary
end point)
6,379 Patients with symptomatic
CHF
Candesartan versus placebo Reduced incidence of new-onset AF
Follow-up: 37.7 mo
Hansson et al. (224) CAPPP study randomized, open label
(analysis on adverse event reports)
10,985 Patients with hypertension Captopril versus
diuretics ⫾beta-blocker
No difference in new-onset AF
Follow-up: 6.1 yr
Hansson et al. (223) STOP-2 study (randomized, open label) 6,628 Patients with hypertension Enalapril/lisinopril versus
CCB versus
diuretics ⫾beta-blocker
No difference in new-onset AF
Study duration: 4 yr
Lh’Allier et al. (312) Retrospective longitudinal cohort study
(from an administrative database of
8 million people in the USA)
10,926 Patients with hypertension ACEI versus CCB Reduced incidence of new-onset AF
Average follow-up: 4.5 yr
Wachtell et al. (594) LIFE study (randomized, double-blind) 8,851 Patients with
hypertension⫹ECG LVH
Losartan versus atenolol Reduced incidence of new-onset AF
Follow-up: 4.8 yr
Salehian et al. (480) HOPE study (post hoc analysis) 8,835 Patients at high cardiovascular
risk without known heart failure
or LV systolic dysfunction
Ramipril versus placebo No difference in new-onset AF
Follow-up: 4.5 yr
Schmieder et al. (499) VALUE study (randomized,
double-blind)
13,760 Patients with hypertension at
high cardiovascular risk
Valsartan versus amlodipine Reduced incidence of new-onset AF
Follow-up: 聿5yr
ACEI, angiotensin-converting enzyme inhibitor; AF, atrial fibrillation; AMI, acute myocardial infarction; ARB, angiotensin receptor blockers; CCB, calcium channel blockers; CHF,
congestive heart failure; CI, confidence interval; HR, hazard ratio; LV, left ventricular; LVEF, left ventricular ejection fraction; LVH, left ventricular hypertrophy.
PATHOPHYSIOLOGICAL MECHANISMS OF ATRIAL FIBRILLATION 297
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In patients undergoing open-chest surgery, high Cx40
levels correlated with low conduction velocities (274) and
an increased incidence of postoperative AF (154). These
findings agree with measurements on strands of cultured
atrial myocytes from transgenic mice, where a reduction
in Cx40 led to an increased conduction velocity (38).
However, Kanagaratnam et al. (272) reported that in
chronic AF patients, lower relative Cx40 levels detected
by immunohistochemistry were associated with an in-
creased complexity of AF conduction patterns.
TABLE 3. Clinical trials of statins to prevent new-onset and progression of AF (primary and
secondary prevention)
References Study Design Patients Intervention Primary Outcome
Young-Xu et al.
(645)
Prospective observational
cohort
449 Patients with chronic stable
angina, without CHF
Statins versus no statins Reduced incidence of new-
onset AF
Average follow-up: 5 yr
Merckx et al. (377) Retrospective 218 Patients on statins and 449
matched controls in SR
without LV dysfunction
Statins versus no statins Reduced incidence of new-
onset AF
Mean follow-up: 6.5 yr
Dernellis et al. (140) Randomized, single-blind 80 Patients with proven
paroxysmal AF and
C-reactive protein levels
between 0.8 and 13 mg/l
Atorvastatin versus
placebo
Paroxysmal AF resolved in
65% of statin-treated
patients versus 10% with
placebo
Follow-up: 4–6 mo of
therapy
Amit et al. (11) Retrospective 264 Patients with permanent
pace makers
Statins versus no statins Reduced incidence of new-
onset AF
Median follow-up: 359 days
Hanna et al. (219) Retrospective 25,268 Patients with CHF Lipid-lowering drug use
versus no use
Reduced incidence of new-
onset AF
Adabag et al. (1) Retrospective 13,783 Patients with CHD Statins versus no statins No difference in new-onset
AF
Average follow-up: 4.8 yr
Ramani et al. (463) Retrospective 1,526 Patients with acute
coronary syndrome
Statins versus no statins at
time of admission
Reduced incidence of new-
onset AF
CHD, coronary heart diseases; CHF, congestive heart failure.
TABLE 4. Clinical Trials of statins to prevent recurrence of AF after thoracic surgery
References Study Design Patients Intervention Primary Outcome
Auer et al. (28) SPPAF study (prospective
cohort)
253 Patients with no CHF
or LV dysfunction
undergoing cardiac
surgery
Statin use before surgery
versus no statin use
Reduced incidence of
postoperative AF
Amar et al. (10) Prospective cohort 131 Patients undergoing
major lung or
esophageal surgery
Statin use before surgery
versus no statin use
Reduced incidence of
postoperative AF
Marin et al. (362) Prospective cohort 234 Patients undergoing
CABG
Statin use for median duration
of 31 days before surgery
versus no statin use
Reduced incidence of
postoperative AF
Patti et al. (443) ARMYDA-3 (randomized,
double–blind)
200 Patients undergoing
cardiac surgery
Atorvastatin versus placebo
starting 7 days before
surgery and continued until
hospital discharge
Reduced incidence of
postoperative AF
Chello et al. (99) Randomized, double-blind 40 Patients undergoing
CABG
Atorvastatin versus placebo
started 3 wk before surgery
Reduced incidence of
postoperative AF
Ozaydin et al. (431) Prospective cohort 362 Patients undergoing
first elective CABG
Statin use for a mean duration
of 2.7 mo before surgery
versus no statin use
Reduced incidence of
postoperative AF
Lertsburapa et al. (324) Prospective cohort from
the AFIST I, II, and III
studies
555 Patients undergoing
cardiothoracic surgery
Statin use before surgery
versus no statin use
Reduced incidence of
postoperative AF
Virani et al. (590) Retrospective study 4,044 Patients undergoing
cardiac surgery
Statin use before surgery
versus no statin use
No difference in incidence of
postoperative AF
CABG, coronary artery bypass graft; CHF, congestive heart failure; CI, confidence interval; LV, left ventricular.
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Although altered connexin distribution patterns may play
a role in forming a substrate for (micro)-reentry in AF, their
exact contribution requires further investigation. Normal atrial
myocytes have a high degree of electrical coupling. The extent
to which electrical coupling has to decrease to affect wavefront
propagation is still a matter of discussion. Some information on
the relation between connexin expression and conduction ve-
locity has been obtained in transgenic mouse models. In Cx40
heterozygous mice, atrial conduction velocity was not affected,
but in Cx40 knockout mice, atrial conduction velocity was
reduced by 30% (583). The effect of reduced electrical coupling
on propagation has been investigated in detail in mathematical
models. “Coupling clamp” experiments, in which two individ-
ual atrial myocytes were coupled via a computer, have demon-
strated that a coupling conductance of 0.65 nS is sufficient for
action potential transfer between two cells (corresponding to
3– 6 gap junction channels) (605). In reality, the average cou-
pling conductance between atrial myocytes is 170 nS or larger
(584). Shaw and Rudy (514) have shown that a reduction in gap
junctional coupling can cause slow propagation with a high
safety factor (i.e., unlikely to block). Spach and Heidlage (531)
have presented a model of a two-dimensional sheet of myo-
cytes that incorporated a detailed topology of longitudinal and
transverse gap junctions between myocytes. In this model,
activation time delays were observed during transverse propa-
gation even with normal coupling conductances. The studies
on transgenic mice and mathematical models discussed above
have investigated propagation during slow pacing. It is conceiv-
able that reduced connexin expression has a more pronounced
effect during the high and irregular activation rates of AF.
In humans, Takeuchi et al. (552) have reported that
the levels of Cx40 and Cx43 were not altered in patients
with atrial dilatation or AF. However, confocal micros-
copy showed a redistribution of Cx43, with a shift toward
the periphery of intercalated discs in the hypertrophied
myocytes of dilated atria. In a modeling study, Wilders
and Jongsma (616) showed that the electrostatic interac-
tions between neighboring gap junction channels pro-
duces a decrease in the effective junctional conductance
in a gap junctional plaque. Thus the conductance of large
gap junctional plaques is lower than would be expected
based on the number of gap junction channels present.
3. Myocyte hypertrophy
Myocyte hypertrophy has been observed in animal
models of RAP (30), atrial dilatation (59, 411), and CHF
(326). In these settings, the contribution of cellular hyper-
trophy to alterations in atrial conduction is difficult to
assess. From cable theory, it might be expected that an
increase in myocyte width would lead to an increase in
conduction velocity. Indeed, in a mathematical model of
ventricular hypertrophy, an increase in macroscopic con-
duction velocity was observed (612). However, using a
more detailed model that took the nonuniform distribu-
tion of gap junction around myocytes into account, Spach
et al. (532, 533) calculated that an increase in cell size
would lead to more pronounced propagation delays be-
tween myocytes during transverse propagation. In fact,
cell size had a larger effect on the anisotropy of conduc-
tion in this model than the distribution pattern of gap
junctional plaques around the myocyte. This finding may
explain how myocyte hypertrophy in the absence of in-
creased fibrosis can also cause conduction disturbances,
as in the goat model of chronic AV block (411).
4. Atrial architecture
Some aspects of the atrial architecture itself, apart
from pathological structural changes, may play a role in
creating a substrate for AF. Based on anatomical and
TABLE 5. Clinical trials of n-3 (omega-3) polyunsaturated fatty acids to prevent AF
References Study Design Patients Intervention Primary Outcome
Mozaffarian et al. (394) Cardiovascular Health Study
(population-based,
prospective cohort)
4,815 Patients Dietary intake
assessment
Reduced incidence
of AF
Follow-up: 12 yr
Calo et al. (84) Randomized open-label 160 Patients undergoing
elective CABG
PUFAs for at least 5 days
before surgery and up
to discharge versus
control
Reduced incidence of
postoperative AF
Frost et al. (184) Danish Diet, Cancer,
and Health study
(population-based,
prospective cohort)
47,949 Patients Dietary intake
assessment
No difference in
incidence of AF
Mean follow-up: 5.4 yr
Brouwer et al. (64) Rotterdam study:
(population-based,
prospective cohort)
5,184 Patients Dietary intake
assessment
No difference in
incidence of AF
Follow-up: 6.4 yr
CABG, coronary artery bypass graft; PUFA, polyunsaturated fatty acid.
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histological studies of the atria, areas with strong prefer-
ential fiber orientation include the crista terminalis, the
bundle of Bachmann, and the area in between the PVs
(Fig. 13A). With the intrinsic anisotropy of these regions,
structural remodeling may readily lead to dissociated con-
duction patterns. Indeed, a high incidence of fractionated
electrograms has been reported in these areas (see sect.
VF). The bundle of Bachmann forms the major conduct-
ing pathway between the right and the left atrium and
consists of parallel muscle bundles (Fig. 13B). In goats
after 1 mo of AF, this structure showed a high incidence
of complex fractionated electrograms (513).
Another salient feature of atrial anatomy is the ex-
tensive trabecular network underlying a thin epicardial
layer in a major part of right and left atria (Fig. 13C).
Scheussler et al. (510) showed by endo- and epicardial
mapping in canine hearts that epicardial and endocardial
activation patterns can be markedly different and that the
epicardial layer plays a leading role in atrial wave propa-
gation during sinus rhythm. In a study on isolated sheep
right atria, Berenfeld et al. (44) have shown how the
endocardial network of trabeculae increases the com-
plexity of activation patterns during AF. Recently,
Houben et al. (252) have suggested that with a loss of
continuity in the thin epicardial layer of the atrial wall, the
trabeculated endocardial structure may become domi-
nant, resulting in a more disorganized and stable type of
AF (252). Indeed, using simulateneous endo-epicardial
high-density mapping, Eckstein et al. (159a) could show
that significant electrical dissociation occurs between the
thin epicardial layer and the endocardial bundle network,
resulting in a complex three-dimensional medium for
wavefront propagation. In this study, the degree of endo-
epicardial electrical dissociation increased with the com-
plexity of the AF substrate (159a). Also, the majority of
“breakthroughs” could be traced back to fibrillation
waves propagating on the contralateral side of the atrial
wall and therefore are likely to be due to transmural
conduction.
One of the challenges ahead is to link the various
conduction patterns during AF to the underlying tissue
architecture and pathological changes to elucidate the
electropathological substrate for perpetuation of AF.
F. Assessment of the AF Substrate by Fibrillation
Electrogram Analysis
As described earlier, alterations in myocyte electro-
physiology and tissue structure can create a substrate for
AF. From animal models and patient studies, it has become
clear that different pathological mechanisms with different
resulting substrates can cause AF. Thus more specific treat-
ment strategies require diagnostic tools that allow assess-
ment of the nature and severity of the AF substrate in
patients. A simple electrocardiographic measure, “coarse”
versus “fine” AF, does not correlate well with atrial size (54,
595), heart disease etiology (392), or average AF cycle length
(446), but may be indicative of thromboembolic risk (638).
However, the dominant atrial cycle length determined from
surface lead v1 by Fast Fourier Transform does reflect a
spatial average of the AF cycle length in the right atrium
(246, 260, 446). In patients with new-onset AF, the dominant
atrial cycle length was higher with increasing age, increased
FIG. 13. Aspects of atrial anatomy. A: the posterior left atrium,
showing the myocardial sleeves of the pulmonary veins in a human
heart. In the area between the pulmonary veins, fibers show a preferen-
tial inferior-superior orientation. [Photo modified from Saito et al. (476),
with permission from John Wiley and Sons.] B: epicardial aspect of the
bundle of Bachmann (BB) in a goat heart, the main connection between
the right and left atrium, consisting of a large number of parallel bun-
dles. Ao, aorta. (Photo by Sander Verheule.) C: endocardial aspect
anterior part of the left and right atrium in a goat heart, showing the
extensive network of endocardial trabeculae underlying the thin epicar-
dial layer. SVC, superior caval vein. (Photo by Sander Verheule.)
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with AF duration, and was lower in patients who cardio-
verted spontaneously within the subsequent 24 h (259). A
new development is the use of tissue Doppler echocardiog-
raphy to determine the AF cycle length (156) and total atrial
conduction time (376). The latter parameter was predictive
of new-onset AF (139). At this point, the most extensive
information on the AF substrate in humans has come from
studies that have investigated atrial electrograms recorded
in patients with AF. The distribution of dominant frequen-
cies, fractionation of electrograms, and direct mapping of
conduction patterns are the main analysis techniques used,
as discussed below.
1. Distribution of dominant frequencies
Dominant frequency analysis is a relatively simple and
time-efficient method for determining the AF cycle length.
Recorded electrogram signals are broken down by Fast
Fourier Transformation into a number of constituent sinu-
soidal functions. Next, the magnitude of these sine waves is
plotted against the frequency in a “power spectrum.” The
dominant frequency is the highest peak in this power spec-
trum (412). In principle, a relatively high dominant fre-
quency may be caused by a rapid ectopic focus, disso-
ciated conduction, a rotor, or another form of reentrant
circuit or even an artifact. Dominant frequency analysis
often correlates well with the AF cycle length, but it is
sensitive to the signal quality, recording method (unipo-
lar vs. bipolar), and electrogram fractionation (414). In
fact, a recent study indicates that the overall correla-
tion between AF cycle length and dominant frequency
can be surprisingly poor, both for unipolar and bipolar
electrograms (168). A simulation study has shown that
spurious high dominant frequencies can be found when
the frequency and amplitude of deflections is variable
(413), as often occurs in fibrillation electrograms.
Newer forms of signal processing may improve robust-
ness of AF cycle length determination (113, 251).
Lazar et al. (314) reported that in paroxysmal AF
patients, dominant frequencies in the PV-left atrial junc-
tion were higher than in the coronary sinus and posterior
right atrium. Persistent AF patients did not show a con-
sistent dominant frequency gradients between these sites
FIG. 14. Substrate of AF in patients. A: schematic representation of high dominant frequency sites in patients with paroxysmal AF (left) and
permanent AF (right). Clustering of these sites at PV and PV-left atrial ostial sites was observed in patients with paroxysmal AF. In permanent AF
patients, high dominant frequency sites occurred throughout the atria. B: unipolar electrograms and underlying activation patterns during acute AF
in humans, recorded with a high-density array of electrodes from the right atrial free wall. Top left: four wavefronts (arrows) collide at the dashed
lines. Fractionated electrograms with short double potentials were recorded at sites of collision. Bottom left: long double potentials were recorded
along a functional line of block (thick black line). Complex fractionated potentials were recorded at pivot points (curved arrows, bottom right) and
in regions of slow conduction (crowded isochrones, top right). [Adapted from Konings et al. (299).]
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(314). PV isolation reduced the left-to-right dominant fre-
quency gradients in paroxysmal AF (313). Similarly, Sand-
ers et al. (482) found in a more detailed analysis that high
dominant frequency sites in paroxysmal AF were prefer-
entially clustered around the PVs, whereas persistent AF
patients displayed a wider distribution of high dominant
frequency sites (Fig. 14A). Correspondingly, PV isolation
led to a significant decrease in the average atrial dominant
frequency in paroxysmal AF patients, but not in persistent
AF patients (484). Within another group of paroxysmal AF
patients, a higher degree of dominant frequency organi-
zation predicted the success of PV isolation (551). Lin et
al. (340) reported that a gradient in dominant frequency
was present from an arrhythmogenic PV or superior caval
vein site to the rest of the atrium in paroxysmal AF. Other
studies have indicated that a left to right gradient may
also be present in persistent AF patients (143, 474, 633).
Lazar et al. (313) have found that PV isolation was more
successful in persistent AF patients if a left to right dom-
inant frequency gradient was present. On the other
hand, a study by Schuessler et al. (511) has indicated
that the location of the area of highest dominant fre-
quency may be unstable, especially in persistent AF,
but also in paroxysmal AF. Nevertheless, an ablation
strategy specifically targeting high dominant frequency
sites was effective in 88% of paroxysmal and 56% of
persistent AF patients (24).
2. Relation between electrogram fractionation and
activation pattern
Structural alterations can disrupt electrical connec-
tions between muscle bundles. As a result of this, the
muscle bundles become activated out of phase during AF.
This dissociation of electrical activity is reflected by frac-
tionated electrograms. An electrogram is fractionated
when it shows more than one deflection per activation
cycle length. Fractionated electrograms may be relatively
simple with two deflections per cycle (short or long dou-
ble potentials) or more complex, in some cases displaying
“continuous electrical activity” throughout the whole cy-
cle. In all cases, fractionation reflects differences in acti-
vation time within the area sensed by the electrode. How-
ever, the degree of fractionation is not necessarily diag-
nostic for the severity of the AF substrate: long double
potentials can signify the presence of an arrhythmogenic
line of block that can cause reentrant conduction,
whereas complex fractionation may in many cases only
reflect local dyssynchroneities within broad fibrillation
waves, without effect on the overall activation pattern.
In recordings of acute AF from right atria in Wolff-
Parkinson-White patients, 23% of the fibrillation electro-
grams were fractionated, compared with 7% during sinus
rhythm (299). Of these fractionated electrograms, ⬃0.2%
displayed complex fractionation (⬎2 deflections) during
sinus rhythm, compared with 6% during AF. Fractionation
of unipolar fibrillation electrograms was observed in ar-
eas of slow conduction, at lines of conduction block,
around pivot points and in regions where wavefronts
collided (Fig. 14B) (299). The observation that during AF,
collision and slow conduction were associated with frac-
tionated electrograms indicates that these activation pat-
terns were associated with dyssynchronous activation in
the atrial wall. Lines of block can be either anatomical
(i.e., also present during slow pacing) or functional (i.e.,
absent at long cycle lengths, but present during fast pac-
ing). During slow pacing with propagation perpendicular
to an anatomical line of block formed by an incision,
electrograms displayed double deflections corresponding
to the activation time points at either side of the line of
block (135). However, fractionated electrograms ob-
served around functional lines of block were often com-
plex, showing numerous deflections. Slow, discontinuous
transverse conduction between fibers partially separated
by fibrotic tissue may explain why the recorded fraction-
ated electrograms were more complex than in the case of
a complete anatomical lesion.
In simulations with an atrial model, Jacquemet et al.
(263) showed that fractionated electrograms did not oc-
cur in homogeneous tissue, even with a high degree of
anisotropy. However, when abrupt changes in conductiv-
ity were introduced, fractionated electrograms were ob-
served. Similar to the correlation between activation pat-
tern and electrogram fractionation in patients (299), the
morphology and distribution of fractionated electrograms
in this model varied from beat to beat, depending on
variations in propagation direction. However, fraction-
ation may preferentially occur at certain anatomical loca-
tions. In recent clinical studies, the regional distribution
of sites with a high degree of electrogram fractionation
appeared to be stable over time (398, 470, 495).
3. Fractionated electrograms as indicators of the
AF substrate
In chronic AF or atria of hearts with underlying heart
disease, the slow process of structural remodeling may
increase transverse fiber separation and may reduce the
number of side-to-side connections throughout the free
walls. As a result, fractionated electrograms would be-
come more frequent and more widespread. Several stud-
ies indicate that the degree of electrogram fractionation
does indeed correlate with AF maintenance. During ex-
trastimulation, electrogram fractionation has a longer du-
ration in paroxysmal AF patients than in healthy control
subjects (548), and the prevalence of fractionated electro-
grams (mainly double potentials) in the coronary sinus
musculature (279) and PVs (234) is higher than in patients
without AF. In paroxysmal AF patients, a more extensive
distribution of fractionated electrograms is predictive for
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a transition to persistent AF (403), and fractionation is
more localized to the PV region. In contrast, their occur-
rence is more widespread in persistent AF (339, 632).
Some known risk factors for AF are also associated with
increased electrogram fractionation. Compared with age-
matched controls, CHF patients showed both a higher
incidence of double potentials along the crista terminalis
and an increased AF vulnerability and stability (483). In
addition, the incidence of electrogram fractionation in-
creases with age (93, 293).
A high degree of fractionation may also be a direct
result of a high activation rate. Rostock et al. (469) dem-
onstrated that local AF cycle length shortening preceded
the development of electrogram fractionation. In parox-
ysmal AF, fractionated electrograms tend to be clustered
at the PVs, which often act as high-frequency drivers of
AF in those patients, whereas fractionated electrograms
show a wider distribution in chronic AF patients (339,
543, 632). In addition, electrogram fractionation is ob-
served in close proximity to sites with a high dominant
frequency (543).
Several studies indicate that fractionation is linked to
parasympathetic activity. In paroxysmal AF patients, elec-
trogram fractionation was associated with vagal activity,
an effect that could be mimicked by adenosine adminis-
tration (320). In addition, fractionation preferentially oc-
curred near ganglionated plexi (278). In dogs, acetylcho-
line injection into ganglionated plexi led to local high
activation frequencies with irregular fractionated electro-
grams (350). As noted above, the occurrence of fraction-
ation may be correlated with the activation frequency.
Therefore, the association between vagal activity and
electrogram fractionation may be caused by a (local)
acceleration of the fibrillatory rate.
4. Ablation of fractionated electrograms
Because of its association with complex activation
patterns mapping of electrogram fractionation during AF
may allow identification of regions with structural con-
duction disturbances that are involved in perpetuation of
AF. Nademanee and co-workers (398, 399) have studied
fractionated electrograms in patients with paroxysmal
and chronic AF and frequently localized “complex frac-
tionated atrial electrograms” (CFAE) in the interatrial
septum, PVs and the left atrial roof (398, 399). Ablation of
areas with these CFAEs resulted in restoration of sinus
rhythm in 91% of the patients after a follow-up of 1 yr.
Other groups have used similar electrogram character-
istics to search for underlying local left atrial parasym-
pathetic innervation (“ganlionated plexus”), and asso-
ciated the perceived benefit of CFAE ablation with
parasympathetic denervation (250, 338). More recent
controlled trials have not been able to reproduce the
findings of Nademanee, and even suggest that CFAE
ablation does not alter the natural time course of AF
(428). Also, the benefit of ablation of CFAEs alone or as
an adjunct to PV isolation appears to be limited (428).
However, more specific electrogram-guided strategies,
such as ablation of electrograms with continuous activity
or a high gradient in activation rate, may improve efficacy
(550). Recent advances of the field of ablation of fraction-
ated electrograms have been expertly reviewed elsewhere
(397, 630) and are beyond the focus of this article.
5. Mapping of AF conduction patterns
Although the distribution of dominant frequencies
and fractionated electrograms can provide valuable infor-
mation on the AF substrate, direct mapping of activation
patterns using contact electrograms provides the most
direct electrophysiological information on the AF sub-
strate. Bipolar electrograms represent a convenient way
to reduce noise and far-field (ventricular) potentials, but
the morphology of a bipolar electrogram is sensitive to
the propagation direction and is more difficult to interpret
in case of dissociated or fractionated signals. Unipolar
electrograms allow a more accurate determination of lo-
cal activation times and are therefore preferable for a
detailed reconstruction of activation patterns. One of the
first studies to describe AF conduction patterns investi-
gated the right atrium during electrically induced AF in
patients undergoing surgery for WPW syndrome (298).
During sinus rhythm and atrial pacing, right atrial conduc-
tion in WPW patients is mostly homogeneous and isotro-
pic (222). During electrically induced AF, right atrial con-
duction showed varying degrees of complexity (298).
With increasing complexity, the number of wavefronts
simultaneously present underneath the mapping elec-
trode frequency and irregularity of the AF cycle length
increased. Clearly, complex AF was driven by more and
narrower waves. Cox et al. (129) studied WPW patients
with paroxysmal AF and described conduction of multi-
ple wavefronts around areas of conduction block in both
atria, in some cases with a single reentrant circuit be-
tween the caval veins in the RA. In chronic AF patients
undergoing mitral valve surgery, several studies reported
rapid repetitive left atrial activation with more complex
fibrillatory conduction in the right atrium, consistent with
left atrial driver regions (225, 419, 544). Similar rapid
repetitive activation was recorded in the left atrial poste-
rior wall of a varied group of chronic AF patients with
structural heart disease, but with more uniform and
broader wavefronts in the right atrium (633). Kanagarat-
nam and co-workers (272, 273) did not detect differences
in the complexity (again quantified by the number of
wavefronts simultaneously present) of right atrial con-
duction during acute and chronic AF. However, in an-
other study in patients with persistent AF, a high degree
of variability in AF wavefront propagation was observed
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throughout the right atrium (464). Recently, Allessie et al.
(7a) have described a new, more quantitative, method for
analyzing fibrillation waves, showing an increase in lon-
gitudinal dissociation between waves in chronic AF com-
pared with acute AF. The PV region showed a higher
degree of dissociation than the RA free wall. Longitudinal
dissociation resulted in narrower wavefronts and a higher
number of simultaneous fibrillation waves. A variety of
right atrial activation patterns in chronic AF were re-
ported by Holm et al. (245), with multiple coexisting
fibrillation waves in some patients and repetitive focal spread
of activation in others, most likely reflecting transmural con-
duction of fibrillation waves (breakthroughs). De Groot et al.
(135a) have recently demonstrated that the incidence of “epi-
cardial breakthroughs” is higher in chronic than in acute AF.
The origin of these waves was nonrepetitive in time and wide-
spread throughout the atria. Based on these and other charac-
teristics, the authors have argued that most breakthroughs are
caused by transmural conduction.
Several studies have investigated conduction pat-
terns in arrhythmogenic thoracic veins of paroxysmal AF
patients. In atrial tachycardia originating in the superior
caval vein, Shah et al. (512) observed slow and anisotro-
pic conduction within the myocardial sleeve, compatible
with a tendency for local reentry. Similarly, mapping with
a 64-electrode basket catheter in the PVs found relatively
fast, narrow activation waves along the length axis of the
vein and slow conduction perpendicular to it (481). The
presence of this dissociated conduction patterns was pre-
dictive for the efficacy of ablation at that vein. In contrast,
using similar recording methods, Arentz et al. (19) ob-
served predominantly radial spread of activation without
indications for local reentrant circuits in the PV myocar-
dial sleeves. However, breakthrough patterns at the PV-
left atrial junction, leading to focal spread of activation
were also observed during sinus rhythm and atrial pacing
(137). In the latter study, mapping during ectopic activity
often showed a “multifocal” pattern of activation within
the PV area mapped with a basket catheter.
Overall, detailed studies on atrial conduction pat-
terns at various stages of the development of an AF
substrate are disappointingly rare, probably due to the
limited opportunity for mapping studies in patients and
the complexity of the time-consuming techniques in-
volved. Automated and rapid analysis of fibrillation
electrograms might enable objective and prompt anal-
ysis of activation patterns during AF in the future (251).
Another interesting new possibility is the recording of
atrial activation patterns by ECG imaging (ECGI). This
approach addresses the inverse problem by integrating
body surface mapping with detailed anatomical data
from magnetic resonance imaging (461). ECGI can de-
lineate atrial activation patterns during sinus rhythm
(462), atrial pacing (385), atrial flutter (604), and focal
atrial tachycardia (603). Recently, the first study char-
acterizing epicardial activation patterns during AF us-
ing ECGI was published (130a). The results show a
large variability in the complexity of AF increasing with
longer duration of the arrhythmia. It will be important
to validate the ability of this technique to image the
fibrillation process up to a level of complexity which
enables a clinically meaningful classification of AF.
VI. SPECIFIC FORMS OF ATRIAL
FIBRILLATION
A. Postoperative AF
In up to 30% of patients who undergo open heart
surgery, usually associated with the use of cardiopulmo-
nary bypass, AF occurs during the first days after the
operation (538, 609). The most important factor that de-
termines the incidence of postoperative AF is the type of
surgery (8, 27). The highest incidence of postoperative AF
occurs with mitral valve repair in single cardiac surgery
and with coronary artery bypass graft surgery plus mitral
valve repair in combined cardiac surgery.
Postoperative AF differs in some respects from other clin-
ical forms of the arrhythmia. The insertion of a cannula in the
right atrium and, depending on the type of operation, other cuts
in the atrial walls, and compromised hemodynamics are poten-
tial external stressors that may promote postoperative AF.
Importantly, the use of anti-inflammatory agents may prevent
postoperative AF (34, 218, 611), suggesting an important role of
systemic or local inflammatory processes. It is known that
cardiac surgery causes a biphasic complement activation that
is associated with a higher incidence of the arrhythmia (65).
Furthermore, during cardiopulmonary bypass, free radicals are
produced (116) and atrial ischemia due to inadequate atrial
protection during cardiac arrest occurs. However, several stud-
ies failed to show a lower incidence of the arrhythmia with
off-pump versus on-pump surgery (1, 513, 547, 636), question-
ing the importance of cardiopulmonary bypass. Finally, sympa-
thetic activation appears to promote postoperative AF. In af-
flicted patients, norepinephrine levels are elevated, and preop-
erative and postoperative use of

-adrenoceptor blockers
decreases the incidence of postoperative AF (271, 610).
On the other hand, postoperative AF appears to share
some pathophysiological mechanisms with other forms of
AF. For example, the duration of the preoperative P-wave
on the surface ECG does predict the occurrence of post-
operative AF (540). Interestingly, the P-wave duration
correlates with the amount of interstitial fibrosis, which
predicts the occurrence of postoperative AF supporting
the concept that fibrosis is also involved in the pathogen-
esis of this type of AF (199). Advanced age is also a
known risk factor for the development of postoperative
AF, which can be explained by age-related structural
changes like fibrosis and atrial dilatation. Like in other
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forms of AF, there is also emerging evidence that oxida-
tive stress contributes to the vulnerability to postopera-
tive AF (91, 248). Also, complex changes in ionic channels
and gap junctions might enhance the propensity for post-
operative AF (154, 273, 348, 576).
B. Inherited Cardiomyopathies and Genetic
Defects Associated With AF
Numerous inherited syndromes associated with AF have
been identified during the past years (Table 6). The mechanistic
link to AF is not always obvious and sometimes surprising. For
example, patients with an inherited prolongation of the atrial
action potential carry a risk for AF (41, 266, 351, 651). Most
patients show short episodes of paroxysmal AF, and some data
may suggest that these arrhythmias can be initiated by EADs
(290, 291). Both short and long QT syndromes are associated
with AF, indicating that channelopathies can predispose to the
arrhythmia by multiple mechanisms. Also the Brugada syn-
drome is associated with supraventricular arrhythmias, often
including AF (158, 311, 497). Whether Na
⫹
channel mutations,
usually loss-of-function mutations, provoke AF in these pa-
tients is not known. Because of the large genetic heterogene-
ity of Brugada syndrome, a clear cause and effect anal-
ysis is challenging. Finally, in some, but not all, patients
with catecholaminergic polymorphic ventricular tachy-
cardia caused by genetic defects of RYR2, sinus node
and AV-nodal dysfunction and AF occur (47).
In addition to these channelopathies, several other
inherited cardiomyopathies are strongly associated with
AF of early onset (Table 6). Hypertrophic cardiomyopathy
is a well-known example for this association. A familial
form of ventricular preexcitation and abnormal LV hypertrophy
associated with mutations in the PRKAG gene is also often
associated with AF. These associations may suggest that ab-
normal ventricular hypertrophy can promote AF, possibly
through cardiomyocyte dysarray, diastolic dysfunction, or met-
abolic deficiency (345). Other genetic defects associated with
AF comprise mutations in the atrial natriuretic peptide and
changes in transcription factors (AF in Holt-Oram syndrome
and the association of PITX2 and AF) (213, 456). The patho-
physiological role of these common genetic variants for the
initiation and perpetuation of AF certainly warrants further
investigation.
VII. SUMMARY AND FUTURE PERSPECTIVES
A. Summary
Figure 15 provides an overview of the main mecha-
nisms involved in initiation and perpetuation of AF as
described in sections IV–VI. Figure 15 emphasizes the
TABLE 6. Genetic abnormalities associated with AF identified in patients with inherited cardiomyopathies
carrying a high risk for AF and genetic defects found in association with AF
Cardiac Abnormality/Type of AF Genetic Defect
AF Prevalence (Estimate)/Associated
With AF In
Inherited cardiomyopathies (366) associated with AF
Brugada syndrome Loss-of-function SCN5A mutations (10–15% of
patients)
10–20% (158)
Long QT syndrome Late gain-of-function SCN5A and loss-of-function
K channel mutations, among others
5–10% (266, 290, 291, 651)
Short QT syndrome Gain-of-function K channel mutations 70% (191, 196)
Catecholaminergic VT Loss-of-function ryanodine receptor mutation Rare families (47)
Hypertrophic cardiomyopathy Sarcomeric proteins 5–15% (317, 347, 365)
Wolff-Parkinson-White syndrome
and abnormal LVH
PRKAG mutations Rare familial forms (18, 204)
Holt-Oram syndrome with AF TBX5 mutations (regulatory gene) Family clusters (456)
Gene defects associated with AF
“Lone” AF Loss-of-function SCN5A mutations 5% of “lone” AF patients (134, 167)
AF and heart failure SCN5A mutation Rare forms of AF (425)
“Lone” AF Gain-of-function K channel mutations Rare families with AF and short QT
interval (102)
“Lone” AF Loss-of-function K channel polymorphisms Rare families, associated with long QT
syndrome (524)
“Lone” AF Loss-of-function KV1.5 mutation (I
Kur
)Rare patients (524)
“Lone” AF Somatic connexin40 mutations “Lone AF” patients (203) (requires
atrial tissue for testing)
“Lone” AF Frameshift (loss-of-function) ANP mutation Large families (242)
All types of AF PITX2 polymorphism (involved in pulmonary
and cardiac development)
Populations in Iceland (213)
Reference numbers are given in parentheses. [From Kirchhoff et al. (289).]
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dynamic character of the process and the diversity of the
contributors to the atrial remodeling process. The dia-
gram mainly consists of four positive-feedback loops. The
central element in all loops is the arrhythmia itself, which at the
same time represents both trigger and effect of the four circular
processes. The circular positive-feedback enhancement of
these pathophysiological changes explains the general ten-
dency of AF to become more stable with time. Also, many of
the mechanisms synergistically interact once AF has become
manifest in a patient. Since the contribution of these different
factors to AF varies from patient to patient, the progression of
AF shows a high inter-individual variability. Initially, pathophys-
iological factors like structural heart diseases, arrhythmias, ag-
ing, or inherited diseases are required to drive the positive
feedback loops, but once the pathophysiological alterations in
the atria have reached a certain threshold, the process will
sustain itself and AF will become more stable over time.
B. Current Challenges and Future Perspectives
The increase in life expectancy and recent improve-
ments in treatment of acute heart disease have resulted in
FIG. 15 . Overview of mechanisms of AF. Four different positive-feedback loops are proposed as the main driving forces for the atrial remodeling process.
Enhanced Ca
2⫹
loading during AF is believed to underlie most of the cellular proarrhythmic mechanisms (trigger loop). The main process in the electrical loop
is an altered contribution of ion channels to the action potential configuration that protects atrial myocytes against excessive Ca
2⫹
loading. Abbreviation of the
action potential facilitates reentry and thereby promotes AF. In the structural loop, chronic atrial stretch activates numerous signaling cascades that produce
alterations of the extracellular matrix and conduction disturbances, also facilitating reentrant mechanisms. The main changes of the contractile properties of the
heart are loss of atrial contractility which increases atrial compliance and the development of a ventricular tachycardiomyopathy, both of which increase stretch
in the atrial wall. The circular positive-feedback enhancement of these pathophysiological changes explains the general tendency of AF to become more stable
with time. It should be noted that the different loops are interconnected by mechanisms that are part of more than one loop. For example, increased Ca
2⫹
loading
enhances trigger activity (trigger loop) and also results in a change in the ion channel population and activity (electrical loop). Reentrant mechanisms are
promoted by both shortening of refractoriness (electrical loop) as well as by conduction disturbances resulting from tissue fibrosis (structural loop). Like in a
system of meshing gear wheels, one loop will drive the other, leading to progression of the arrhythmia. However, the proposed system of gear wheels does not
start to move spontaneously. Structural heart diseases, arrhythmias, aging, or inherited diseases are required to initiate movement of one or more of these wheels.
When the pathophysiological alterations eventually reach a certain threshold, AF will ensue.
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a major increase in number of patients living with heart
failure and/or AF. Although the socioeconomic burden of
AF is growing steadily and significant progress has been
made in understanding the pathophysiology of this ar-
rhythmia, treatment of AF patients is still far from satis-
factory. The success rate of pharmacological cardiover-
sion is still limited, and antiarrhythmic drugs are unable
to prevent recurrences of AF (86, 122, 488). Prevention of
thromboembolic events still requires potentially harmful
anticoagulation therapy (256, 599). Radiofrequency abla-
tion, originally developed for treatment of paroxysmal
AF, varies in its efficacy to cure persistent AF and is
afflicted with a number of potentially serious side effects
(180, 400, 457, 458, 650).
In the authors’ view, addressing the following re-
search objectives might help to improve therapeutic ap-
proaches for AF.
Mechanisms contributing to the initiation and perpet-
uation of AF show a high diversity and interindividual
variability. Functional and structural changes in the atria
can promote AF by a variety of processes that may in-
volve ion channel remodeling, atrial fibrosis, inflamma-
tion, apoptosis, loss of cell-cell contacts, altered auto-
nomic tone, cellular hypertrophy, and deposition of amy-
loid. Better understanding of the factors that initiate and
maintain AF in specific patients or patient groups will not
only allow to chose appropriate therapeutic approaches,
but also help to limit therapy duration to periods when
these therapies are really beneficial.
To develop individualized therapy for AF, a classifi-
cation of the arrhythmia based on the pathophysiological
changes in the atria needs to be developed. Current ther-
apeutic regimes are most often chosen based on clinical
symptoms and the duration of AF (paroxysmal or persis-
tent AF). These categories, though helpful, do not neces-
sarily reflect the nature and degree of electrophysiologi-
cal changes resulting in AF. New diagnostic tools for AF
classification might include invasive and noninvasive
electrophysiological measurements, biochemical mark-
ers, and imaging techniques.
The structural alterations that progressively increase AF
susceptibility occur relatively early during atrial remodeling, in
most cases before the first onset of AF, and certainly before the
arrhythmia becomes persistent. Identification of patients in
early stages of this remodeling process might enable timely and
effective preventive therapy.
The development of new upstream therapy targets
requires the identification of relevant microstructural de-
terminants of conduction disturbances. Most importantly,
the exact qualitative and quantitative relation between
atrial fibrosis and conduction disturbances needs to be
determined.
The role of ectopic focal discharges in the perpetuation of
persistent AF is largely unknown. Clarification of mechanisms
and contribution of abnormal impulse formation to the perpet-
uation of persistent AF might offer the opportunity to identify
new pharmacological targets for AF therapy.
Given the complexity of the mechanisms causing AF
and the significant contribution of nonmodifiable factors
such as aging and genetic predispositions, we believe that
even an early, aggressive, and individualized therapy will
not prevent or “cure” AF in the foreseeable future. How-
ever, addressing the above-mentioned research objectives
might allow the postponing of the time point to accept AF
in an individual patient. In other cases, we might, based
on pathophysiological insights, prefer to refrain from po-
tentially harmful interventions.
ACKNOWLEDGMENTS
U. Schotten and S. Verheule contributed equally to this work.
Address for reprint requests and other correspondence:
U. Schotten, Dept of Physiology, Univ. of Maastricht, PO Box
616, 6200 MD Maastricht, The Netherlands (e-mail: Schotten
@maastrichtuniversity.nl).
GRANTS
This work was supported by the Dutch Research Organi-
zation (NWO, VIDI-Grant 016.086.379), the Foundation Leducq
(07 CVD 03), and the German Federal Ministry of Education and
Research through the Atrial Fibrillation Competence Network
(01Gi0204), and the European Union (European Network for
Translational Network in Atrial Fibrillation).
DISCLOSURES
No conflicts of interest, financial or otherwise, are declared
by the author(s).
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