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Honarbakhsh S, Roney C, Wharmby A, Vidal Horrach C, Hunter RJ. Spatial and temporal relationship between focal and rotational activations and their relationship to structural remodeling in patients with persistent atrial fibrillation. Heart Rhythm 2024; 21:752-761. [PMID: 38286244 DOI: 10.1016/j.hrthm.2024.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 01/17/2024] [Accepted: 01/19/2024] [Indexed: 01/31/2024]
Abstract
BACKGROUND Focal and rotational activations have been demonstrated in atrial fibrillation (AF), but their relationship to each other and to structural remodeling remains unclear. OBJECTIVE The purpose of this study was to assess the relationship of focal and rotational activations to underlying low-voltage zones (LVZs) (<0.5 mV) and to determine whether there was a temporal (≤500 ms) and spatial (≤12 mm) relationship between these activations. METHODS Patients undergoing catheter ablation for persistent AF were included. All patients underwent pulmonary vein isolation. Unipolar signals were collected to identify focal and rotational activations using a wavefront propagation algorithm. RESULTS In 40 patients, 105 activations were identified (57 [54.3%] focal; 48 [45.7%] rotational). Rotational activations were co-localized to LVZs (35/48 [72.9%]) whereas focal activations were not (11/57 in LVZ [19.3%]; P <.001). The proportion of the left atrium occupied by LVZs predicted rotational activations occurrence (area under the curve 0.96; 95% confidence interval 0.90-1.00; P <.001). In patients with a relatively healthy atrium, in which the atrium consisted of ≤15% LVZs, only focal activations were identified. Thirty-two of the 35 rotational activations (91.4%) located in LVZs also showed a temporal and spatial relationship to a focal activation. The presence of a LVZ within 12 mm of the focal activation was a strong predictor for whether a paired rotational activation would also occur in that vicinity. CONCLUSION Rotational activations are largely confined to areas of structural remodeling and have a clear spatial and temporal relationship with focal activations suggesting they are dependent on them. These novel mechanistic observations outline a plausible model for patient-specific mechanisms maintaining AF.
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Affiliation(s)
- Shohreh Honarbakhsh
- Electrophysiology Department, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Queen Mary University of London, London, United Kingdom.
| | | | - Amy Wharmby
- Electrophysiology Department, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | | | - Ross J Hunter
- Electrophysiology Department, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
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2
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Roney C, Honarbakhsh S. Does spatiotemporal dispersion indicate a patient-unique fingerprint or a generic characteristic of persistent atrial fibrillation? Heart Rhythm 2024; 21:553-554. [PMID: 38307308 DOI: 10.1016/j.hrthm.2024.01.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 01/29/2024] [Indexed: 02/04/2024]
Affiliation(s)
- Caroline Roney
- Queen Mary University of London, London, United Kingdom.
| | - Shohreh Honarbakhsh
- Queen Mary University of London, London, United Kingdom; Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
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Franco E, Lozano-Granero C, Matía Francés R, Hernández-Madrid A, Sánchez I, Zamorano JL, Moreno J. Subjective identification and ablation of drivers improves rhythm control in patients with persistent atrial fibrillation. The CHAOS-AF study. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024:S1885-5857(24)00042-2. [PMID: 38336154 DOI: 10.1016/j.rec.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 01/22/2024] [Indexed: 02/12/2024]
Abstract
INTRODUCTION AND OBJECTIVES The optimal approach for persistent atrial fibrillation (AF) ablation remains unknown. In patients with persistent AF, we compared an ablation strategy based on pulmonary vein isolation (PVI) plus ablation of drivers (PVI+D), with a conventional PVI-only approach performed in a 1:1 propensity score-matched cohort. METHODS Drivers were subjectively identified using conventional high-density mapping catheters (IntellaMap ORION, PentaRay NAV or Advisor HD Grid), without dedicated software, as fractionated continuous or quasicontinuous electrograms on 1 to 2 adjacent bipoles, which were ablated first; and as sites with spatiotemporal dispersion (the entire cycle length comprised within the mapping catheter) plus noncontinuous fractionation, which were only targeted in patients without fractionated continuous electrograms, or without AF conversion after ablation of fractionated continuous electrograms. Ablation included PVI plus focal or linear ablation targeting drivers. RESULTS A total of 50 patients were included in each group (61±10 years, 25% women). Fractionated continuous electrograms were found and ablated in 21 patients from the PVI+D group (42%), leading to AF conversion in 7 patients. In the remaining 43 patients, 143 sites with spatiotemporal dispersion plus noncontinuous fractionation were targeted. Globally, AF conversion was achieved in 21 patients (42%). The PVI+D group showed lower atrial arrhythmia recurrences at 1 year of follow-up (30.6% vs 48%; P=.048) and at the last follow-up (46% vs 72%; P=.013), and less progression to permanent AF (10% vs 40%; P=.001). CONCLUSIONS Subjective identification and ablation of drivers, added to PVI, increased 1-year freedom from atrial arrhythmia and decreased long-term recurrences and progression to permanent AF.
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Affiliation(s)
- Eduardo Franco
- Departamento de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
| | - Cristina Lozano-Granero
- Departamento de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | | | | | - Inmaculada Sánchez
- Departamento de Cardiología Pediátrica, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - José Luis Zamorano
- Departamento de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Javier Moreno
- Departamento de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
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Dhillon G, Honarbakhsh S, Abbas H, Waddingham P, Dennis AS, Ahluwalia N, Finlay M, Sohaib A, Welch S, Daw H, Sporton S, Chow A, Earley MJ, Lambiase PD, Hunter RJ. ECGI targeted ablation for persistent AF not responding to pulmonary vein isolation: Results of a two-staged strategy (TARGET AF2). Heart Rhythm O2 2023; 4:609-617. [PMID: 37936670 PMCID: PMC10626178 DOI: 10.1016/j.hroo.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
Background Mechanisms sustaining persistent atrial fibrillation (AF) remain unclear. Objectives The study sought to evaluate both the clinical outcomes and response to ablation of potential drivers in patients with recurrent persistent AF recurrence following pulmonary vein isolation (PVI). Methods A total of 100 patients with persistent AF of <2 years' duration underwent cryoballoon PVI (ECGI phenotyping of persistent AF based on driver burden and distribution to predict response to pulmonary vein isolation). Patients with documented recurrence of atrial arrhythmia within 12 months were recruited and underwent repeat PVI (if needed) followed by ablation of potential drivers (PDs) identified by electrocardiographic imaging (ECGI). PDs were defined as rotational activity >1.5 revolutions or focal activations. Cycle lengths were measured pre- and postablation. The primary outcome was freedom from atrial arrhythmia off antiarrhythmic drugs at 1 year as per guidelines. Results Of 37 patients recruited, 26 had recurrent AF and underwent ECGI-guided ablation of PDs. An average of 6.4 ± 2.7 PDs were targeted per patient. The mean ablation time targeting PDs was 15.5 ± 6.9 minutes. An ablation response occurred in 20 patients (AF termination in 6, cycle length prolongation ≥10% in 14). At 1 year, 14 (54%) of 26 patients were free from arrhythmia, and 12 (46%) of 26 were off antiarrhythmic drugs. Considering the 96 patients who completed follow-up out of the original cohort of 100 patients undergoing cryoablation in this staged strategy, freedom from arrhythmia at 1 year following the last procedure was 72 (75%) of 96, or 70 (73%) of 96 off antiarrhythmic drugs. Conclusions In patients with recurrent AF despite PVI, ECGI-guided ablation caused an acute response in a majority with reasonable long-term outcomes.
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Affiliation(s)
| | | | - Hakam Abbas
- Barts Heart Centre, St Bartholomew’s Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Peter Waddingham
- Barts Heart Centre, St Bartholomew’s Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Adam S. Dennis
- Barts Heart Centre, St Bartholomew’s Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Nikhil Ahluwalia
- Barts Heart Centre, St Bartholomew’s Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Malcolm Finlay
- Barts Heart Centre, St Bartholomew’s Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Afzal Sohaib
- Barts Heart Centre, St Bartholomew’s Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Sophie Welch
- Barts Heart Centre, St Bartholomew’s Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Holly Daw
- Barts Heart Centre, St Bartholomew’s Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Simon Sporton
- Barts Heart Centre, St Bartholomew’s Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Anthony Chow
- Barts Heart Centre, St Bartholomew’s Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Mark J. Earley
- Barts Heart Centre, St Bartholomew’s Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Pier D. Lambiase
- Barts Heart Centre, St Bartholomew’s Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Ross J. Hunter
- Barts Heart Centre, St Bartholomew’s Hospital, Barts Health NHS Trust, London, United Kingdom
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Hu D, Barajas-Martinez H, Zhang ZH, Duan HY, Zhao QY, Bao MW, Du YM, Burashnikov A, Monasky MM, Pappone C, Huang CX, Antzelevitch C, Jiang H. Advances in basic and translational research in atrial fibrillation. Philos Trans R Soc Lond B Biol Sci 2023; 378:20220174. [PMID: 37122214 PMCID: PMC10150218 DOI: 10.1098/rstb.2022.0174] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/08/2023] [Indexed: 05/02/2023] Open
Abstract
Atrial fibrillation (AF) is a very common cardiac arrhythmia with an estimated prevalence of 33.5 million patients globally. It is associated with an increased risk of death, stroke and peripheral embolism. Although genetic studies have identified a growing number of genes associated with AF, the definitive impact of these genetic findings is yet to be established. Several mechanisms, including electrical, structural and neural remodelling of atrial tissue, have been proposed to contribute to the development of AF. Despite over a century of exploration, the molecular and cellular mechanisms underlying AF have not been fully established. Current antiarrhythmic drugs are associated with a significant rate of adverse events and management of AF using ablation is not optimal, especially in cases of persistent AF. This review discusses recent advances in our understanding and management of AF, including new concepts of epidemiology, genetics and pathophysiological mechanisms. We review the current status of antiarrhythmic drug therapy for AF, new potential agents, as well as mechanism-based AF ablation. This article is part of the theme issue 'The heartbeat: its molecular basis and physiological mechanisms'.
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Affiliation(s)
- Dan Hu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, People's Republic of China
- Cardiovascular Research Institute of Wuhan University, Wuhan 430060, People's Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, People's Republic of China
| | - Hector Barajas-Martinez
- Lankenau Institute for Medical Research, and Lankenau Heart Institute, Wynnwood, PA 19096, USA
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19104, USA
| | - Zhong-He Zhang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, People's Republic of China
- Cardiovascular Research Institute of Wuhan University, Wuhan 430060, People's Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, People's Republic of China
| | - Hong-Yi Duan
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, People's Republic of China
- Cardiovascular Research Institute of Wuhan University, Wuhan 430060, People's Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, People's Republic of China
| | - Qing-Yan Zhao
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, People's Republic of China
- Cardiovascular Research Institute of Wuhan University, Wuhan 430060, People's Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, People's Republic of China
| | - Ming-Wei Bao
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, People's Republic of China
- Cardiovascular Research Institute of Wuhan University, Wuhan 430060, People's Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, People's Republic of China
| | - Yi-Mei Du
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, People's Republic of China
| | - Alexander Burashnikov
- Lankenau Institute for Medical Research, and Lankenau Heart Institute, Wynnwood, PA 19096, USA
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19104, USA
| | - Michelle M. Monasky
- Arrhythmology Department, IRCCS Policlinico San Donato, San Donato Milanese, Milan 20097, Italy
| | - Carlo Pappone
- Arrhythmology Department, IRCCS Policlinico San Donato, San Donato Milanese, Milan 20097, Italy
- Vita-Salute San Raffaele University, Milan 20132, Italy
- Institute of Molecular and Translational Cardiology (IMTC), San Donato Milanese, Milan 20097, Italy
| | - Cong-Xin Huang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, People's Republic of China
- Cardiovascular Research Institute of Wuhan University, Wuhan 430060, People's Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, People's Republic of China
| | - Charles Antzelevitch
- Lankenau Institute for Medical Research, and Lankenau Heart Institute, Wynnwood, PA 19096, USA
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19104, USA
| | - Hong Jiang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, People's Republic of China
- Cardiovascular Research Institute of Wuhan University, Wuhan 430060, People's Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, People's Republic of China
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6
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Li K, Xu C, Zhu X, Wang X, Ye P, Jiang W, Wu S, Xu K, Li X, Wang Y, Zheng Q, Wang Y, Leng L, Zhang Z, Han B, Zhang Y, Qin M, Liu X. Multi-centre, prospective randomized comparison of three different substrate ablation strategies for persistent atrial fibrillation. Europace 2023; 25:euad090. [PMID: 37050858 PMCID: PMC10228617 DOI: 10.1093/europace/euad090] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 03/16/2023] [Indexed: 04/14/2023] Open
Abstract
AIMS The optimal strategy for persistent atrial fibrillation (PerAF) is poorly defined. We conducted a multicentre, randomized, prospective trial to compare the outcomes of different ablation strategies for PerAF. METHODS AND RESULTS We enrolled 450 patients and randomly assigned them in a 1:1:1 ratio to undergo pulmonary vein isolation and subsequently undergo the following three different ablation strategies: anatomical guided ablation (ANAT group, n = 150), electrogram guided ablation (EGM group, n = 150), and extensive electro-anatomical guided ablation (EXT group, n = 150). The primary endpoint was freedom from atrial fibrillation (AF) lasting longer than 30 s at 12 months after a single ablation procedure. After 12 months of follow-up, 72% (108) of patients in the EXT group were free from AF recurrence, as compared with the 64% (96) in the EGM group (P = 0.116), and 54% (81) in the ANAT group (P = 0.002). The EXT group showed less AF/atrial tachycardia recurrence than the EGM group (60% vs. 50%, P = 0.064) and the ANAT group (60% vs. 37.3%, P < 0.001). The EXT group showed the highest rate of AF termination (66.7%), followed by 56.7% in the EGM group, and 20.7% in the ANAT group. The AF termination signified less AF recurrence at 12 months compared to patients without AF termination (30.1% vs. 42.7%, P = 0.008). Safety endpoints did not differ significantly between the three groups (P = 0.924). CONCLUSIONS Electro-anatomical guided ablation achieved the most favourable outcomes among the three ablation strategies. The AF termination is a reliable ablation endpoint.
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Affiliation(s)
- Kaige Li
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No.241 West Huaihai Road, Shanghai 200030, China
| | - Changhao Xu
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No.241 West Huaihai Road, Shanghai 200030, China
| | - Xiyao Zhu
- Department of Clinical Integration of Traditional Chinese and Western medicine, First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Xinhua Wang
- Department of Cardiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ping Ye
- Department of Cardiology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Weifeng Jiang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No.241 West Huaihai Road, Shanghai 200030, China
| | - Shaohui Wu
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No.241 West Huaihai Road, Shanghai 200030, China
| | - Kai Xu
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No.241 West Huaihai Road, Shanghai 200030, China
| | - Xiangting Li
- Department of Cardiology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Ying Wang
- Department of Cardiology, Second Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Qidong Zheng
- Department of Cardiology, Yuhuan Second People's Hospital, Yuhuan, China
| | - Yanzhe Wang
- Department of Cardiology, Changshu Hospital of Traditional Chinese Medicine, Changshu, China
| | - Lihua Leng
- Department of Cardiology, The PLA Navy Anqing Hospital, Anqing, China
| | - Zengtang Zhang
- Department of Cardiology, Jinan City People’s Hospital, Jinan, China
| | - Bing Han
- Department of Cardiology, Xuzhou Central Hospital, Xuzhou, China
| | - Yu Zhang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No.241 West Huaihai Road, Shanghai 200030, China
| | - Mu Qin
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No.241 West Huaihai Road, Shanghai 200030, China
| | - Xu Liu
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No.241 West Huaihai Road, Shanghai 200030, China
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7
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Xu CH, Xiong F, Jiang WF, Liu X, Liu T, Qin M. Rotor mechanism and its mapping in atrial fibrillation. Europace 2023; 25:783-792. [PMID: 36734272 PMCID: PMC10062333 DOI: 10.1093/europace/euad002] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 12/28/2022] [Indexed: 02/04/2023] Open
Abstract
Treatment of atrial fibrillation (AF) remains challenging despite significant progress in understanding its underlying mechanisms. The first detailed, quantitative theory of functional re-entry, the 'leading circle' model, was developed more than 40 years ago. Subsequently, in decades of study, an alternative paradigm based on spiral waves has long been postulated to drive AF. The rotor as a 'spiral wave generator' is a curved 'vortex' formed by spin motion in the two-dimensional plane, identified using advanced mapping methods in experimental and clinical AF. However, it is challenging to achieve complementary results between experimental results and clinical studies due to the limitation in research methods and the complexity of the rotor mechanism. Here, we review knowledge garnered over decades on generation, electrophysiological properties, and three-dimensional (3D) structure diversity of the rotor mechanism and make a comparison among recent clinical approaches to identify rotors. Although initial studies of rotor ablation at many independent centres have achieved promising results, some inconclusive outcomes exist in others. We propose that the clinical rotor identification might be substantially influenced by (i) non-identical surface activation patterns, which resulted from a diverse 3D form of scroll wave, and (ii) inadequate resolution of mapping techniques. With rapidly advancing theoretical and technological developments, future work is required to resolve clinically relevant limitations in current basic and clinical research methodology, translate from one to the other, and resolve available mapping techniques.
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Affiliation(s)
- Chang-Hao Xu
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine,
Shanghai Jiao Tong University, 241 Huaihai West Road, Xuhui
District, Shanghai 200030, China
| | - Feng Xiong
- Montreal Heart Institute, Department of Medicine, University of
Montreal, 5000, Bélanger street, Montréal, Québec H1T
1C8, Canada
| | - Wei-Feng Jiang
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine,
Shanghai Jiao Tong University, 241 Huaihai West Road, Xuhui
District, Shanghai 200030, China
| | - Xu Liu
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine,
Shanghai Jiao Tong University, 241 Huaihai West Road, Xuhui
District, Shanghai 200030, China
| | - Tao Liu
- Corresponding authors. Tao Liu, 238 Jiefang Road, Wuchang
District, Wuhan, Hubei 430060, China. Tel: +86 (027) 8804 1911, Fax:+86-(027)-8804-2292.
E-mail address:; Mu Qin, 241 Huaihai
West Road, Xuhui District, Shanghai, 200030, China. Tel: +8621628219902603, Fax:
+862162821105. E-mail address:
| | - Mu Qin
- Corresponding authors. Tao Liu, 238 Jiefang Road, Wuchang
District, Wuhan, Hubei 430060, China. Tel: +86 (027) 8804 1911, Fax:+86-(027)-8804-2292.
E-mail address:; Mu Qin, 241 Huaihai
West Road, Xuhui District, Shanghai, 200030, China. Tel: +8621628219902603, Fax:
+862162821105. E-mail address:
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8
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Delgado-López M, Heeger CH, Tilz RR. [New mapping tools for catheter ablation of atrial fibrillation]. Herzschrittmacherther Elektrophysiol 2022; 33:380-385. [PMID: 36239817 DOI: 10.1007/s00399-022-00902-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 09/12/2022] [Indexed: 06/16/2023]
Abstract
The pulmonary veins have been recognized as the primary source of atrial triggers, and their isolation has become the cornerstone for ablation of atrial fibrillation. However, long-term success rates after pulmonary vein isolation (PVI) are limited. Several promising new mapping techniques are described in this article, aiming to better understand the mechanisms underlying the induction and maintenance of atrial fibrillation and to develop more effective ablation strategies.
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Affiliation(s)
- Maryuri Delgado-López
- Klinik für Rhythmologie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein (UKSH), Ratzeburger Allee 160, 23538, Lübeck, Deutschland.
| | - Christian-Hendrik Heeger
- Klinik für Rhythmologie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein (UKSH), Ratzeburger Allee 160, 23538, Lübeck, Deutschland
- Partner Site Lübeck, Deutsches Zentrum für Herzkreislaufforschung e. V. (DZHK), Lübeck, Deutschland
| | - Roland Richard Tilz
- Klinik für Rhythmologie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein (UKSH), Ratzeburger Allee 160, 23538, Lübeck, Deutschland
- Partner Site Lübeck, Deutsches Zentrum für Herzkreislaufforschung e. V. (DZHK), Lübeck, Deutschland
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9
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Honarbakhsh S, Schilling RJ, Keating E, Finlay M, Hunter RJ. Coronary sinus electrogram characteristics predict termination of AF with ablation and long-term clinical outcome. J Cardiovasc Electrophysiol 2022; 33:2139-2151. [PMID: 35775822 PMCID: PMC9796101 DOI: 10.1111/jce.15618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 05/10/2022] [Accepted: 06/29/2022] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Markers predicting atrial fibrillation (AF) termination and freedom from AF/atrial tachycardia (AT) has been proposed. This study aimed to evaluate the role of novel coronary sinus (CS) electrogram characteristics in predicting the acute ablation response and freedom from AF/AT during follow-up. METHODS Patients undergoing ablation for persistent AF as part of the Stochastic Trajectory Analysis of Ranked signals mapping study were included. Novel CS electrogram characteristics including CS cycle length variability (CLV) and CS activation pattern stability (APS) and proportion of low voltage zones (LVZs) were reviewed as potential predictors for AF termination on ablation and freedom from AF/AT during follow-up. The relationship between localized driver characteristics and CS electrogram characteristics was also assessed. RESULTS Sixty-five patients were included. AF termination was achieved in 51 patients and 80% of patients were free from AF/AT during a follow-up of 29.5 ± 3.7 months. CS CLV of <30 ms, CS APS of ≥30% and proportion of LVZ < 30% showed high diagnostic accuracy in predicting AF termination on ablation and freedom from AF/AT during follow-up (CS CLV odds ratio [OR] 25.6, area under the curve [AUC] 0.91; CS APS OR 15.9, AUC 0.94; proportion of LVZs OR 21.4, AUC 0.88). These markers were independent predictors of AF termination on ablation and AF/AT recurrence during follow-up. Ablation of a smaller number of drivers that demonstrate greater dominance strongly correlate with greater CS organization. CONCLUSION Novel CS electrogram characteristics were independent predictors of AF termination and AF/AT recurrence during follow-up. These markers can potentially aid in predicting outcomes and guide ablation and follow-up strategies.
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Affiliation(s)
- Shohreh Honarbakhsh
- The Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS TrustLondonUK
| | - Richard J. Schilling
- The Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS TrustLondonUK
| | - Emily Keating
- The Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS TrustLondonUK
| | - Malcolm Finlay
- The Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS TrustLondonUK
| | - Ross J. Hunter
- The Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS TrustLondonUK
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10
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Gagyi RB, Szegedi N, Simon J, Wijchers S, Bhagwandien R, Kong MH, Ruppersberg P, Szili-Torok T. Left atrial anatomical variations correlate with atrial fibrillation sources near the left atrial ridge. Front Cardiovasc Med 2022; 9:928384. [PMID: 36247472 PMCID: PMC9554407 DOI: 10.3389/fcvm.2022.928384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 08/31/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction Anatomical variations and characteristics of the left atrium (LA) may have a previously undescribed effect on source locations in atrial fibrillation (AF). This is the first study aiming to investigate the relationship between anatomical characteristics of the LA and non-PV sources detected by electrographic flow (EGF) mapping in patients with persistent AF. Materials and methods We analyzed cardiac computed tomography (CT) and EGF mapping data in patients who underwent radiofrequency catheter ablation (CA). EGF mapping is a novel method based on Horn–Schunk flow estimation algorithm, used to estimate cardiac action potential flow in the atria that can detect AF sources in patients with persistent AF. By analyzing EGF maps obtained during CA procedures, we localized non-PV sources in the LA. Results Thirty patients were included in this study (mean age 62.4 ± 6.8 years). Ten patients had AF sources near the LA ridge, while twenty patients had no leading source (source activity > 26%) near the LA ridge. LA anatomical characteristics, left atrial appendage (LAA) length, and ostial diameter showed no correlation with the presence of a leading source. We documented 19 patients with abutting LAA and left superior pulmonary vein (LSPV) (distance < 2 mm), and 11 patients with non-abutting LAA–LSPV (distance > 2 mm). Three out of 19 patients presented with a leading source near ridge in the abutting LAA–LSPV group, while 7 out of 11 patients presented with a leading source near the ridge in the non-abutting LAA-LSPV group (p = 0.01). Conclusion Our data suggests that non-abutting LAA-LSPV is associated with the presence of AF sources near the LA ridge.
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Affiliation(s)
- Rita B. Gagyi
- Department of Cardiology, Electrophysiology, Erasmus MC, Rotterdam, Netherlands
| | - Nándor Szegedi
- Heart and Vascular Center, The Semmelweis University Hospital, Budapest, Hungary
| | - Judit Simon
- Heart and Vascular Center, The Semmelweis University Hospital, Budapest, Hungary
| | - Sip Wijchers
- Department of Cardiology, Electrophysiology, Erasmus MC, Rotterdam, Netherlands
| | - Rohit Bhagwandien
- Department of Cardiology, Electrophysiology, Erasmus MC, Rotterdam, Netherlands
| | | | | | - Tamas Szili-Torok
- Department of Cardiology, Electrophysiology, Erasmus MC, Rotterdam, Netherlands
- *Correspondence: Tamas Szili-Torok,
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11
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Franco E, Lozano Granero C, Matía R, Hernández-Madrid A, Sánchez Pérez I, Zamorano JL, Moreno J. Stabilization of unstable reentrant atrial tachycardias via fractionated continuous electrical activity ablation (CHAOS study). Cardiol J 2022; 30:799-809. [PMID: 35578756 PMCID: PMC10635713 DOI: 10.5603/cj.a2022.0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 11/11/2021] [Accepted: 11/19/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Unstable reentrant atrial tachycardias (ATs) (i.e., those with frequent circuit modification or conversion to atrial fibrillation) are challenging to ablate. We tested a strategy to achieve arrhythmia stabilization into mappable stable ATs based on the detection and ablation of rotors. METHODS All consecutive patients from May 2017 to December 2019 were included. Mapping was performed using conventional high-density mapping catheters (IntellaMap ORION, PentaRay NAV, or Advisor HD Grid). Rotors were subjectively identified as fractionated continuous (or quasi-continuous) electrograms on 1-2 adjacent bipoles, without dedicated software. In patients without detectable rotors, sites with spatiotemporal dispersion (i.e., all the cycle length comprised within the mapping catheter) plus non-continuous fractionation on single bipoles were targeted. Ablation success was defined as conversion to a stable AT or sinus rhythm. RESULTS Ninety-seven patients with reentrant ATs were ablated. Of these, 18 (18.6%) presented unstable circuits. Thirteen (72%) patients had detectable rotors (median 2 [1-3] rotors per patient); focal ablation was successful in 12 (92%). In the other 5 patients, 17 sites with spatiotemporal dispersion were identified and targeted. Globally, and excluding 1 patient with spontaneous AT stabilization, ablation success was achieved in 16/17 patients (94.1%). One-year freedom from atrial arrhythmias was similar between patients with unstable and stable ATs (66.7% vs. 65.8%, p = 0.946). CONCLUSIONS Most unstable reentrant ATs show detectable rotors, identified as sites with single-bipole fractionated quasi-continuous signals, or spatiotemporal dispersion plus non-continuous fractionation. Ablation of these sites is highly effective to stabilize the AT or convert it into sinus rhythm.
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Affiliation(s)
- Eduardo Franco
- Arrhythmia Unit, Cardiology Department, University Hospital Ramón y Cajal, Madrid, Spain.
| | | | - Roberto Matía
- Arrhythmia Unit, Cardiology Department, University Hospital Ramón y Cajal, Madrid, Spain
| | | | | | - José Luis Zamorano
- Arrhythmia Unit, Cardiology Department, University Hospital Ramón y Cajal, Madrid, Spain
| | - Javier Moreno
- Arrhythmia Unit, Cardiology Department, University Hospital Ramón y Cajal, Madrid, Spain
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12
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Atrial Fibrillation: A Look at the Rhythm You Can't See. JACC Clin Electrophysiol 2022; 8:578-581. [PMID: 35589169 DOI: 10.1016/j.jacep.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 04/11/2022] [Indexed: 11/21/2022]
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13
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Honarbakhsh S, Dhillon G, Abbas H, Waddingham PH, Dennis A, Ahluwalia N, Welch S, Daw H, Sporton S, Chow A A, Earley MJ, Lambiase PD, Hunter RJ. Non-invasive Electrocardiographic Imaging guided targeting of drivers of persistent atrial fibrillation: the TARGET-AF1 trial. Heart Rhythm 2022; 19:875-884. [DOI: 10.1016/j.hrthm.2022.01.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/25/2022] [Accepted: 01/30/2022] [Indexed: 12/12/2022]
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14
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Salinet J, Molero R, Schlindwein FS, Karel J, Rodrigo M, Rojo-Álvarez JL, Berenfeld O, Climent AM, Zenger B, Vanheusden F, Paredes JGS, MacLeod R, Atienza F, Guillem MS, Cluitmans M, Bonizzi P. Electrocardiographic Imaging for Atrial Fibrillation: A Perspective From Computer Models and Animal Experiments to Clinical Value. Front Physiol 2021; 12:653013. [PMID: 33995122 PMCID: PMC8120164 DOI: 10.3389/fphys.2021.653013] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/22/2021] [Indexed: 01/16/2023] Open
Abstract
Electrocardiographic imaging (ECGI) is a technique to reconstruct non-invasively the electrical activity on the heart surface from body-surface potential recordings and geometric information of the torso and the heart. ECGI has shown scientific and clinical value when used to characterize and treat both atrial and ventricular arrhythmias. Regarding atrial fibrillation (AF), the characterization of the electrical propagation and the underlying substrate favoring AF is inherently more challenging than for ventricular arrhythmias, due to the progressive and heterogeneous nature of the disease and its manifestation, the small volume and wall thickness of the atria, and the relatively large role of microstructural abnormalities in AF. At the same time, ECGI has the advantage over other mapping technologies of allowing a global characterization of atrial electrical activity at every atrial beat and non-invasively. However, since ECGI is time-consuming and costly and the use of electrical mapping to guide AF ablation is still not fully established, the clinical value of ECGI for AF is still under assessment. Nonetheless, AF is known to be the manifestation of a complex interaction between electrical and structural abnormalities and therefore, true electro-anatomical-structural imaging may elucidate important key factors of AF development, progression, and treatment. Therefore, it is paramount to identify which clinical questions could be successfully addressed by ECGI when it comes to AF characterization and treatment, and which questions may be beyond its technical limitations. In this manuscript we review the questions that researchers have tried to address on the use of ECGI for AF characterization and treatment guidance (for example, localization of AF triggers and sustaining mechanisms), and we discuss the technological requirements and validation. We address experimental and clinical results, limitations, and future challenges for fruitful application of ECGI for AF understanding and management. We pay attention to existing techniques and clinical application, to computer models and (animal or human) experiments, to challenges of methodological and clinical validation. The overall objective of the study is to provide a consensus on valuable directions that ECGI research may take to provide future improvements in AF characterization and treatment guidance.
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Affiliation(s)
- João Salinet
- Biomedical Engineering, Centre for Engineering, Modelling and Applied Social Sciences (CECS), Federal University of ABC, São Bernardo do Campo, Brazil
| | - Rubén Molero
- ITACA Institute, Universitat Politècnica de València, València, Spain
| | - Fernando S. Schlindwein
- School of Engineering, University of Leicester, United Kingdom and National Institute for Health Research, Leicester Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - Joël Karel
- Department of Data Science and Knowledge Engineering, Maastricht University, Maastricht, Netherlands
| | - Miguel Rodrigo
- Electronic Engineering Department, Universitat de València, València, Spain
| | - José Luis Rojo-Álvarez
- Department of Signal Theory and Communications and Telematic Systems and Computation, University Rey Juan Carlos, Madrid, Spain
| | - Omer Berenfeld
- Center for Arrhythmia Research, University of Michigan, Ann Arbor, MI, United States
| | - Andreu M. Climent
- ITACA Institute, Universitat Politècnica de València, València, Spain
| | - Brian Zenger
- Biomedical Engineering Department, Scientific Computing and Imaging Institute (SCI), and Cardiovascular Research and Training Institute (CVRTI), The University of Utah, Salt Lake City, UT, United States
| | - Frederique Vanheusden
- Department of Engineering, School of Science and Technology, Nottingham Trent University, Nottingham, United Kingdom
| | - Jimena Gabriela Siles Paredes
- Biomedical Engineering, Centre for Engineering, Modelling and Applied Social Sciences (CECS), Federal University of ABC, São Bernardo do Campo, Brazil
| | - Rob MacLeod
- Biomedical Engineering Department, Scientific Computing and Imaging Institute (SCI), and Cardiovascular Research and Training Institute (CVRTI), The University of Utah, Salt Lake City, UT, United States
| | - Felipe Atienza
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, and Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - María S. Guillem
- ITACA Institute, Universitat Politècnica de València, València, Spain
| | - Matthijs Cluitmans
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Pietro Bonizzi
- Department of Data Science and Knowledge Engineering, Maastricht University, Maastricht, Netherlands
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15
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Quintanilla JG, Shpun S, Jalife J, Filgueiras-Rama D. Novel approaches to mechanism-based atrial fibrillation ablation. Cardiovasc Res 2021; 117:1662-1681. [PMID: 33744913 PMCID: PMC8208747 DOI: 10.1093/cvr/cvab108] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 02/12/2021] [Accepted: 03/18/2021] [Indexed: 01/23/2023] Open
Abstract
Modern cardiac electrophysiology has reported significant advances in the understanding of mechanisms underlying complex wave propagation patterns during atrial fibrillation (AF), although disagreements remain. One school of thought adheres to the long-held postulate that AF is the result of randomly propagating wavelets that wonder throughout the atria. Another school supports the notion that AF is deterministic in that it depends on a small number of high-frequency rotors generating three-dimensional scroll waves that propagate throughout the atria. The spiralling waves are thought to interact with anatomic and functional obstacles, leading to fragmentation and new wavelet formation associated with the irregular activation patterns documented on AF tracings. The deterministic hypothesis is consistent with demonstrable hierarchical gradients of activation frequency and AF termination on ablation at specific (non-random) atrial regions. During the last decade, data from realistic animal models and pilot clinical series have triggered a new era of novel methodologies to identify and ablate AF drivers outside the pulmonary veins. New generation electroanatomical mapping systems and multielectrode mapping catheters, complimented by powerful mathematical analyses, have generated the necessary platforms and tools for moving these approaches into clinical procedures. Recent clinical data using such platforms have provided encouraging evidence supporting the feasibility of targeting and effectively ablating driver regions in addition to pulmonary vein isolation in persistent AF. Here, we review state-of-the-art technologies and provide a comprehensive historical perspective, characterization, classification, and expected outcomes of current mechanism-based methods for AF ablation. We discuss also the challenges and expected future directions that scientists and clinicians will face in their efforts to understand AF dynamics and successfully implement any novel method into regular clinical practice.
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Affiliation(s)
- Jorge G Quintanilla
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Myocardial Pathophysiology Area, Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | | | - José Jalife
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Myocardial Pathophysiology Area, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Department of Internal Medicine, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI 48109, USA
| | - David Filgueiras-Rama
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Myocardial Pathophysiology Area, Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
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16
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Honarbakhsh S, Schilling RJ, Providencia R, Dhillon G, Bajomo O, Keating E, Finlay M, Hunter RJ. Ablation guided by STAR-mapping in addition to pulmonary vein isolation is superior to pulmonary vein isolation alone or in combination with CFAE/linear ablation for persistent AF. J Cardiovasc Electrophysiol 2021; 32:200-209. [PMID: 33368766 PMCID: PMC8607469 DOI: 10.1111/jce.14856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/19/2020] [Accepted: 11/27/2020] [Indexed: 11/18/2022]
Abstract
Introduction The optimal ablation approach for persistent atrial fibrillation (AF) remains unclear. Methods and Results Objective was to compare the long‐term rates of freedom from AF/AT in patients that underwent STAR mapping guided ablation against outcomes of patients undergoing conventional ablation procedures. Patients undergoing ablation for persistent AF as part of the Stochastic Trajectory Analysis of Ranked signals (STAR) mapping study were included. Outcomes following 'pulmonary vein isolation (PVI) plus STAR mapping guided ablation (STAR mapping cohort) were compared to patients undergoing PVI alone ablation during the same time period and also a propensity‐matched cohort undergoing PVI plus the addition of complex fractionated electrogram (CFAE) and/or linear ablation (“conventional ablation”). Rates of procedural AF termination and freedom from AF/AT during follow‐up were compared. Sixty‐five patients were included in both the STAR cohort and propensity matched conventional ablation cohort. AF termination rates were significantly higher in the STAR cohort (51/65, 78.5%) than conventional ablation cohort (10/65, 15.4%) and PVI alone ablation cohort (13/50, 26.0%; STAR cohort vs. other 2 cohorts both p < .001). There was no significant difference in procedure time between the three cohorts. During ≥20 months follow‐up a lower proportion of patients had AF/AT recurrence in the STAR cohort (20.0%) compared with the conventional ablation cohort (50.8%) or the PVI alone ablation cohort (50.0%; both p < .05 compared to STAR cohort). Conclusions Outcomes of PVI plus STAR mapping guided ablation was superior to PVI alone or in combination with linear/CFAE ablation. A multicenter randomized controlled trial is planned to confirm these findings.
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Affiliation(s)
| | | | | | | | | | - Emily Keating
- Barts Heart Centre, Barts Health NHS Trust, London, UK
| | | | - Ross J Hunter
- Barts Heart Centre, Barts Health NHS Trust, London, UK.,Queen Mary University of London
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