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Choi Y, Lim B, Yang SY, Yang SH, Kwon OS, Kim D, Kim YG, Park JW, Yu HT, Kim TH, Yang PS, Uhm JS, Shim J, Kim SH, Sung JH, Choi JI, Joung B, Lee MH, Kim YH, Oh YS, Pak HN. Clinical Usefulness of Virtual Ablation Guided Catheter Ablation of Atrial Fibrillation Targeting Restitution Parameter-Guided Catheter Ablation: CUVIA-REGAB Prospective Randomized Study. Korean Circ J 2022; 52:699-711. [PMID: 35927040 PMCID: PMC9470491 DOI: 10.4070/kcj.2022.0113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/18/2022] [Accepted: 06/08/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND AND OBJECTIVES We investigated whether extra-pulmonary vein (PV) ablation targeting a high maximal slope of the action potential duration restitution curve (Smax) improves the rhythm outcome of persistent atrial fibrillation (PeAF) ablation. METHODS In this open-label, multi-center, randomized, and controlled trial, 178 PeAF patients were randomized with 1:1 ratio to computational modeling-guided virtual Smax ablation (V-Smax) or empirical ablation (E-ABL) groups. Smax maps were generated by computational modeling based on atrial substrate maps acquired during clinical procedures in sinus rhythm. Smax maps were generated during the clinical PV isolation (PVI). The V-Smax group underwent an additional extra-PV ablation after PVI targeting the virtual high Smax sites. RESULTS After a mean follow-up period of 12.3±5.2 months, the clinical recurrence rates (25.6% vs. 23.9% in the V-Smax and the E-ABL group, p=0.880) or recurrence appearing as atrial tachycardia (11.1% vs. 5.7%, p=0.169) did not differ between the 2 groups. The post-ablation cardioversion rate was higher in the V-Smax group than E-ABL group (14.4% vs. 5.7%, p=0.027). Among antiarrhythmic drug-free patients (n=129), the AF freedom rate was 78.7% in the V-Smax group and 80.9% in the E-ABL group (p=0.776). The total procedure time was longer in the V-Smax group (p=0.008), but no significant difference was found in the major complication rates (p=0.497) between the groups. CONCLUSIONS Unlike a dominant frequency ablation, the computational modeling-guided V-Smax ablation did not improve the rhythm outcome of the PeAF ablation and had a longer procedure time. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02558699.
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Affiliation(s)
- Young Choi
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Byounghyun Lim
- Department of Cardiology, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Song-Yi Yang
- Department of Cardiology, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - So-Hyun Yang
- Department of Cardiology, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Oh-Seok Kwon
- Department of Cardiology, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Daehoon Kim
- Department of Cardiology, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Yun Gi Kim
- Department of Cardiology, Korea University Cardiovascular Center, Korea University, Seoul, Korea
| | - Je-Wook Park
- Department of Cardiology, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Hee Tae Yu
- Department of Cardiology, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Tae-Hoon Kim
- Department of Cardiology, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Pil-Sung Yang
- Department of Cardiology, Bundang CHA Hospital, CHA College of Medicine, Seoul, Korea
| | - Jae-Sun Uhm
- Department of Cardiology, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Jamin Shim
- Department of Cardiology, Korea University Cardiovascular Center, Korea University, Seoul, Korea
| | - Sung Hwan Kim
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung-Hoon Sung
- Department of Cardiology, Bundang CHA Hospital, CHA College of Medicine, Seoul, Korea
| | - Jong-Il Choi
- Department of Cardiology, Korea University Cardiovascular Center, Korea University, Seoul, Korea
| | - Boyoung Joung
- Department of Cardiology, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Moon-Hyoung Lee
- Department of Cardiology, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Young-Hoon Kim
- Department of Cardiology, Korea University Cardiovascular Center, Korea University, Seoul, Korea
| | - Yong-Seog Oh
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
| | - Hui-Nam Pak
- Department of Cardiology, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea.
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Park JW, Lim B, Hwang I, Kwon OS, Yu HT, Kim TH, Uhm JS, Joung B, Lee MH, Pak HN. Restitution Slope Affects the Outcome of Dominant Frequency Ablation in Persistent Atrial Fibrillation: CUVIA-AF2 Post-Hoc Analysis Based on Computational Modeling Study. Front Cardiovasc Med 2022; 9:838646. [PMID: 35310982 PMCID: PMC8927985 DOI: 10.3389/fcvm.2022.838646] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 01/28/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionAlthough the dominant frequency (DF) localizes the reentrant drivers and the maximal slope of the action potential duration (APD) restitution curve (Smax) reflects the tendency of the wave-break, their interaction has never been studied. We hypothesized that DF ablation has different effects on atrial fibrillation (AF) depending on Smax.MethodsWe studied the DF and Smax in 25 realistic human persistent AF model samples (68% male, 60 ± 10 years old). Virtual AF was induced by ramp pacing measuring Smax, followed by spatiotemporal DF evaluation for 34 s. We assessed the DF ablation effect depending on Smax in both computational modeling and a previous clinical trial, CUVIA-AF (170 patients with persistent AF, 70.6% male, 60 ± 11 years old).ResultsMean DF had an inverse relationship with Smax regardless of AF acquisition timing (p < 0.001). Virtual DF ablations increased the defragmentation rate compared to pulmonary vein isolation (PVI) alone (p = 0.015), especially at Smax <1 (61.5 vs. 7.7%, p = 0.011). In post-DF ablation defragmentation episodes, DF was significantly higher (p = 0.002), and Smax was lower (p = 0.003) than in episodes without defragmentation. In the post-hoc analysis of CUVIA-AF2, we replicated the inverse relationship between Smax and DF (r = −0.47, p < 0.001), and we observed better rhythm outcomes of clinical DF ablations in addition to a PVI than of empirical PVI at Smax <1 [hazard ratio 0.45, 95% CI (0.22–0.89), p = 0.022; log-rank p = 0.021] but not at ≥ 1 (log-rank p = 0.177).ConclusionWe found an inverse relationship between DF and Smax and the outcome of DF ablation after PVI was superior at the condition with Smax <1 in both in-silico and clinical trials.
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Baek YS, Kwon OS, Lim B, Yang SY, Park JW, Yu HT, Kim TH, Uhm JS, Joung B, Kim DH, Lee MH, Park J, Pak HN. Clinical Outcomes of Computational Virtual Mapping-Guided Catheter Ablation in Patients With Persistent Atrial Fibrillation: A Multicenter Prospective Randomized Clinical Trial. Front Cardiovasc Med 2021; 8:772665. [PMID: 34957255 PMCID: PMC8692944 DOI: 10.3389/fcvm.2021.772665] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 11/17/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Clinical recurrence after atrial fibrillation catheter ablation (AFCA) still remains high in patients with persistent AF (PeAF). We investigated whether an extra-pulmonary vein (PV) ablation targeting the dominant frequency (DF) extracted from electroanatomical map–integrated AF computational modeling improves the AFCA rhythm outcome in patients with PeAF. Methods: In this open-label, randomized, multi-center, controlled trial, 170 patients with PeAF were randomized at a 1:1 ratio to the computational modeling-guided virtual DF (V-DF) ablation and empirical PV isolation (E-PVI) groups. We generated a virtual dominant frequency (DF) map based on the atrial substrate map obtained during the clinical AF ablation procedure using computational modeling. This simulation was possible within the time of the PVI procedure. V-DF group underwent extra-PV V-DF ablation in addition to PVI, but DF information was not notified to the operators from the core lab in the E-PVI group. Results: After a mean follow-up period of 16.3 ± 5.3 months, the clinical recurrence rate was significantly lower in the V-DF than with E-PVI group (P = 0.018, log-rank). Recurrences appearing as atrial tachycardias (P = 0.145) and the cardioversion rates (P = 0.362) did not significantly differ between the groups. At the final follow-up, sinus rhythm was maintained without any AADs in 74.7% in the V-DF group and 48.2% in the E-PVI group (P < 0.001). No significant difference was found in the major complication rates (P = 0.489) or total procedure time (P = 0.513) between the groups. The V-DF ablation was independently associated with a reduced AF recurrence after AFCA [hazard ratio: 0.51 (95% confidence interval: 0.30–0.88); P = 0.016]. Conclusions: The computational modeling-guided V-DF ablation improved the rhythm outcome of AFCA in patients with PeAF. Clinical Trial Registration: Clinical Research Information Service, CRIS identifier: KCT0003613.
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Affiliation(s)
- Yong-Soo Baek
- Inha University College of Medicine and Inha University Hospital, Incheon, South Korea
| | - Oh-Seok Kwon
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, South Korea
| | - Byounghyun Lim
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, South Korea
| | - Song-Yi Yang
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, South Korea
| | - Je-Wook Park
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, South Korea
| | - Hee Tae Yu
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, South Korea
| | - Tae-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, South Korea
| | - Jae-Sun Uhm
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, South Korea
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, South Korea
| | - Dae-Hyeok Kim
- Inha University College of Medicine and Inha University Hospital, Incheon, South Korea
| | - Moon-Hyoung Lee
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, South Korea
| | - Junbeom Park
- Division of Cardiology, Department of Internal Medicine, Ewha Womans University, Seoul, South Korea
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, South Korea
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Kumagai K, Sato T, Kurose Y, Sumiyoshi T, Hasegawa K, Sekiguchi Y, Yambe M, Komaru T. Predictors of recurrence of atrial tachyarrhythmias after pulmonary vein isolation by functional and structural mapping of nonparoxysmal atrial fibrillation. J Arrhythm 2021; 38:86-96. [PMID: 35222754 PMCID: PMC8851591 DOI: 10.1002/joa3.12670] [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: 09/21/2021] [Revised: 12/09/2021] [Accepted: 12/12/2021] [Indexed: 11/07/2022] Open
Abstract
Background This study aimed to evaluate the predictors of recurrence of atrial tachyarrhythmias by structural and functional mapping: voltage, dominant frequency (DF), and rotor mapping after a pulmonary vein isolation (PVI) in nonparoxysmal atrial fibrillation (AF) patients. Methods A total of 66 nonparoxysmal AF patients were prospectively investigated. After the PVI, an online real‐time phase mapping system was used to detect the location of rotors with critical nonpassively activated ratios (%NPs) of ≧50% in each left atrial (LA) segment, and high‐DFs of ≧7 Hz were simultaneously mapped. After restoring sinus rhythm, low‐voltage areas (LVAs < 0.5 mV) were mapped using the Advisor HD grid catheter (HDG). Results Sixty‐four of 66 (97%) AF patients had minimum to mild LVAs regardless of an enlarged LAD and LA volume (45 ± 6.0 mm and 141 ± 29 ml). There were no significant differences in the max and mean DF values and %NPs between the patients with and without recurrent atrial tachyarrhythmias. However, there was a significant difference in the LVA/LA surface area between the patients with and without recurrent atrial tachyarrhythmias (p = .004). Atrial tachyarrhythmia freedom was significantly greater in those with LVAs of ≤3.3% than in those >3.3% after one procedure over 11.6 ± 0.8 months of follow‐up (77.1% vs. 33.3%, p < .001). In a multivariate analysis, the LVA/LA surface area after the PVI (HR 1.079; CI, 1.025–1.135, p = .003) was an independent predictor of AF recurrence. Conclusions The predictor of atrial tachyarrhythmia recurrence after the PVI was LVAs rather than DFs and rotors in nonparoxysmal AF patients.
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Affiliation(s)
- Koji Kumagai
- Department of Cardiovascular Medicine Tohoku Medical and Pharmaceutical University Miyagi Japan
| | - Tsukasa Sato
- Department of Cardiovascular Medicine Tohoku Medical and Pharmaceutical University Miyagi Japan
| | - Yuki Kurose
- Department of Cardiovascular Medicine Tohoku Medical and Pharmaceutical University Miyagi Japan
| | - Takenori Sumiyoshi
- Department of Cardiovascular Medicine Tohoku Medical and Pharmaceutical University Miyagi Japan
| | - Kaoru Hasegawa
- Department of Cardiovascular Medicine Tohoku Medical and Pharmaceutical University Miyagi Japan
| | - Yuko Sekiguchi
- Department of Cardiovascular Medicine Tohoku Medical and Pharmaceutical University Miyagi Japan
| | - Minoru Yambe
- Department of Cardiovascular Medicine Tohoku Medical and Pharmaceutical University Miyagi Japan
| | - Tatsuya Komaru
- Department of Cardiovascular Medicine Tohoku Medical and Pharmaceutical University Miyagi Japan
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Kwon OS, Hwang I, Pak HN. Computational modeling of atrial fibrillation. INTERNATIONAL JOURNAL OF ARRHYTHMIA 2021. [DOI: 10.1186/s42444-021-00051-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
AbstractWith the aging society, the prevalence of atrial fibrillation (AF) continues to increase. Nevertheless, there are still limitations in antiarrhythmic drugs (AAD) or catheter interventions for AF. If it is possible to predict the outcome of AF management according to various AADs or ablation lesion sets through computational modeling, it will be of great clinical help. AF computational modeling has been utilized for in-silico arrhythmia research and enabled high-density entire chamber mapping, reproducible condition control, virtual intervention, not possible clinically or experimentally, in-depth mechanistic research. With the recent development of computer science and technology, more sophisticated and faster computational modeling has become available for clinical application. In particular, it can be applied to determine the extra-PV target of persistent AF catheter ablation or to select the AAD with the best effect. AF computational modeling combined with artificial intelligence is expected to contribute to precision medicine for more diverse uses in the future. Therefore, in this review, we will deal with the history, development, and various applications of computation modeling.
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Hwang I, Jin Z, Park JW, Kwon OS, Lim B, Lee J, Yu HT, Kim TH, Joung B, Pak HN. Spatial Changes in the Atrial Fibrillation Wave-Dynamics After Using Antiarrhythmic Drugs: A Computational Modeling Study. Front Physiol 2021; 12:733543. [PMID: 34630153 PMCID: PMC8497701 DOI: 10.3389/fphys.2021.733543] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 09/02/2021] [Indexed: 01/05/2023] Open
Abstract
Background: We previously reported that a computational modeling-guided antiarrhythmic drug (AAD) test was feasible for evaluating multiple AADs in patients with atrial fibrillation (AF). We explored the anti-AF mechanisms of AADs and spatial change in the AF wave-dynamics by a realistic computational model. Methods: We used realistic computational modeling of 25 AF patients (68% male, 59.8 ± 9.8 years old, 32.0% paroxysmal AF) reflecting the anatomy, histology, and electrophysiology of the left atrium (LA) to characterize the effects of five AADs (amiodarone, sotalol, dronedarone, flecainide, and propafenone). We evaluated the spatial change in the AF wave-dynamics by measuring the mean dominant frequency (DF) and its coefficient of variation [dominant frequency-coefficient of variation (DF-COV)] in 10 segments of the LA. The mean DF and DF-COV were compared according to the pulmonary vein (PV) vs. extra-PV, maximal slope of the restitution curves (Smax), and defragmentation of AF. Results: The mean DF decreased after the administration of AADs in the dose dependent manner (p < 0.001). Under AADs, the DF was significantly lower (p < 0.001) and COV-DF higher (p = 0.003) in the PV than extra-PV region. The mean DF was significantly lower at a high Smax (≥1.4) than a lower Smax condition under AADs. During the episodes of AF defragmentation, the mean DF was lower (p < 0.001), but the COV-DF was higher (p < 0.001) than that in those without defragmentation. Conclusions: The DF reduction with AADs is predominant in the PVs and during a high Smax condition and causes AF termination or defragmentation during a lower DF and spatially unstable (higher DF-COV) condition.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Hui-Nam Pak
- Yonsei University Health System, Seoul, South Korea
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Lim B, Kim J, Hwang M, Song JS, Lee JK, Yu HT, Kim TH, Uhm JS, Joung B, Lee MH, Pak HN. In situ procedure for high-efficiency computational modeling of atrial fibrillation reflecting personal anatomy, fiber orientation, fibrosis, and electrophysiology. Sci Rep 2020; 10:2417. [PMID: 32051487 PMCID: PMC7016008 DOI: 10.1038/s41598-020-59372-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 11/06/2019] [Indexed: 12/22/2022] Open
Abstract
We previously reported the feasibility and efficacy of a simulation-guided clinical catheter ablation of atrial fibrillation (AF) in an in-silico AF model. We developed a highly efficient realistic AF model reflecting the patient endocardial voltage and local conduction and tested its clinical feasibility. We acquired > 500 endocardial bipolar electrograms during right atrial pacing at the beginning of the AF ablation procedures. Based on the clinical bipolar electrograms, we generated simulated voltage maps by applying fibrosis and local activation maps adjusted for the fiber orientation. The software's accuracy (CUVIA2.5) was retrospectively tested in 17 patients and feasibility prospectively in 10 during clinical AF ablation. Results: We found excellent correlations between the clinical and simulated voltage maps (R = 0.933, p < 0.001) and clinical and virtual local conduction (R = 0.958, p < 0.001). The proportion of virtual local fibrosis was 15.4, 22.2, and 36.9% in the paroxysmal AF, persistent AF, and post-pulmonary vein isolation (PVI) states, respectively. The reconstructed virtual bipolar electrogram exhibited a relatively good similarities of morphology to the local clinical bipolar electrogram (R = 0.60 ± 0.08, p < 0.001). Feasibility testing revealed an in situ procedural computing time from the clinical data acquisition to wave-dynamics analyses of 48.2 ± 4.9 min. All virtual analyses were successfully achieved during clinical PVI procedures. We developed a highly efficient, realistic, in situ procedural simulation model reflective of individual anatomy, fiber orientation, fibrosis, and electrophysiology that can be applied during AF ablation.
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Affiliation(s)
- Byounghyun Lim
- Yonsei University Health System, Seoul, Republic of Korea
| | - Jaehyeok Kim
- Yonsei University Health System, Seoul, Republic of Korea
| | - Minki Hwang
- Yonsei University Health System, Seoul, Republic of Korea
| | - Jun-Seop Song
- Yonsei University Health System, Seoul, Republic of Korea
| | - Jung Ki Lee
- Yonsei University Health System, Seoul, Republic of Korea
| | - Hee-Tae Yu
- Yonsei University Health System, Seoul, Republic of Korea
| | - Tae-Hoon Kim
- Yonsei University Health System, Seoul, Republic of Korea
| | - Jae-Sun Uhm
- Yonsei University Health System, Seoul, Republic of Korea
| | - Boyoung Joung
- Yonsei University Health System, Seoul, Republic of Korea
| | - Moon-Hyung Lee
- Yonsei University Health System, Seoul, Republic of Korea
| | - Hui-Nam Pak
- Yonsei University Health System, Seoul, Republic of Korea.
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Abstract
The treatment of individual patients in cardiology practice increasingly relies on advanced imaging, genetic screening and devices. As the amount of imaging and other diagnostic data increases, paralleled by the greater capacity to personalize treatment, the difficulty of using the full array of measurements of a patient to determine an optimal treatment seems also to be paradoxically increasing. Computational models are progressively addressing this issue by providing a common framework for integrating multiple data sets from individual patients. These models, which are based on physiology and physics rather than on population statistics, enable computational simulations to reveal diagnostic information that would have otherwise remained concealed and to predict treatment outcomes for individual patients. The inherent need for patient-specific models in cardiology is clear and is driving the rapid development of tools and techniques for creating personalized methods to guide pharmaceutical therapy, deployment of devices and surgical interventions.
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Kumagai K, Minami K, Sugai Y, Sumiyoshi T, Komaru T. Effect of ablation at high-dominant frequency sites overlapping with low-voltage areas after pulmonary vein isolation of nonparoxysmal atrial fibrillation. J Cardiovasc Electrophysiol 2019; 30:1850-1859. [PMID: 31361055 DOI: 10.1111/jce.14090] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 07/14/2019] [Accepted: 07/17/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND The relationship between high-dominant frequency (DF) sites and low-voltage areas (LVAs) in nonparoxysmal atrial fibrillation (AF) patients still remains unknown. OBJECTIVE This study aimed to evaluate the effect of ablation at high-DF sites overlapping with LVAs after pulmonary vein ablation (PVI) of nonparoxysmal AF. METHODS A total of 128 consecutive nonparoxysmal patients with atrial fibrillation (53 persistent AF) were retrospectively investigated. The patients with AF were divided into two groups: patients with circumferential PVI alone (PVI group, n = 57) and those with PVI followed by a DF-based ablation (DF group, n = 71). RESULTS The patient characteristics did not significantly differ between the two groups. However, the LVA ( < 0.5 mV)/left atrial (LA) surface was significantly greater in the DF than the PVI group (22% vs 16%, P = .02). The total max-DF sites overlapping with LVAs in the LA were significantly greater in the DF than the PVI group (91% vs 10%, P = .001). The atrial arrhythmia freedom on antiarrhythmic drugs in the DF group was significantly greater than that in the PVI group during 10.0 ± 3.2 months of follow-up (83.1% vs 64.9%, log-rank test P = .021). The event-free survival in the PVI group decreased according to the LVA extent while it was > 80% in the DF group. The event-free survival in patients with AF especially with extensive LVAs ( ≥ 30%) in the DF group was significantly greater than that in the PVI group (81.0% vs 45.5%, log-rank test P = .035). CONCLUSIONS High-DF sites overlapping with LVAs after the PVI may be potential selective targets for modification of atrial substrates in nonparoxysmal AF patients.
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Affiliation(s)
- Koji Kumagai
- Department of Cardiovascular Medicine, Tohoku Medical and Pharmaceutical University, Miyagi, Japan.,Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Kentaro Minami
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Yoshinao Sugai
- Department of Cardiovascular Medicine, Tohoku Medical and Pharmaceutical University, Miyagi, Japan.,Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Takenori Sumiyoshi
- Department of Cardiovascular Medicine, Tohoku Medical and Pharmaceutical University, Miyagi, Japan
| | - Tatsuya Komaru
- Department of Cardiovascular Medicine, Tohoku Medical and Pharmaceutical University, Miyagi, Japan
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Filos D, Tachmatzidis D, Maglaveras N, Vassilikos V, Chouvarda I. Understanding the Beat-to-Beat Variations of P-Waves Morphologies in AF Patients During Sinus Rhythm: A Scoping Review of the Atrial Simulation Studies. Front Physiol 2019; 10:742. [PMID: 31275161 PMCID: PMC6591370 DOI: 10.3389/fphys.2019.00742] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 05/28/2019] [Indexed: 11/13/2022] Open
Abstract
The remarkable advances in high-performance computing and the resulting increase of the computational power have the potential to leverage computational cardiology toward improving our understanding of the pathophysiological mechanisms of arrhythmias, such as Atrial Fibrillation (AF). In AF, a complex interaction between various triggers and the atrial substrate is considered to be the leading cause of AF initiation and perpetuation. In electrocardiography (ECG), P-wave is supposed to reflect atrial depolarization. It has been found that even during sinus rhythm (SR), multiple P-wave morphologies are present in AF patients with a history of AF, suggesting a higher dispersion of the conduction route in this population. In this scoping review, we focused on the mechanisms which modify the electrical substrate of the atria in AF patients, while investigating the existence of computational models that simulate the propagation of the electrical signal through different routes. The adopted review methodology is based on a structured analytical framework which includes the extraction of the keywords based on an initial limited bibliographic search, the extensive literature search and finally the identification of relevant articles based on the reference list of the studies. The leading mechanisms identified were classified according to their scale, spanning from mechanisms in the cell, tissue or organ level, and the produced outputs. The computational modeling approaches for each of the factors that influence the initiation and the perpetuation of AF are presented here to provide a clear overview of the existing literature. Several levels of categorization were adopted while the studies which aim to translate their findings to ECG phenotyping are highlighted. The results denote the availability of multiple models, which are appropriate under specific conditions. However, the consideration of complex scenarios taking into account multiple spatiotemporal scales, personalization of electrophysiological and anatomical models and the reproducibility in terms of ECG phenotyping has only partially been tackled so far.
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Affiliation(s)
- Dimitrios Filos
- Lab of Computing, Medical Informatics and Biomedical Imaging Technologies, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Nicos Maglaveras
- Lab of Computing, Medical Informatics and Biomedical Imaging Technologies, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Department of Industrial Engineering and Management Sciences, Northwestern University, Evanston, IL, United States
| | - Vassilios Vassilikos
- 3rd Cardiology Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioanna Chouvarda
- Lab of Computing, Medical Informatics and Biomedical Imaging Technologies, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Yu HT, Jeong DS, Pak HN, Park HS, Kim JY, Kim J, Lee JM, Kim KH, Yoon NS, Roh SY, Oh YS, Cho YJ, Shim J. 2018 Korean Guidelines for Catheter Ablation of Atrial Fibrillation: Part II. INTERNATIONAL JOURNAL OF ARRHYTHMIA 2018. [DOI: 10.18501/arrhythmia.2018.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Dharmaprani D, McGavigan AD, Chapman D, Kutlieh R, Thanigaimani S, Dykes L, Kalman J, Sanders P, Pope K, Kuklik P, Ganesan AN. Temporal stability and specificity of high bipolar electrogram entropy regions in sustained atrial fibrillation: Implications for mapping. J Electrocardiol 2018; 53:18-27. [PMID: 30580097 DOI: 10.1016/j.jelectrocard.2018.11.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 11/02/2018] [Accepted: 11/17/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND The potential utility of entropy (En) for atrial fibrillation (AF) mapping has been demonstrated in previous studies by multiple groups, where an association between high bipolar electrogram (EGM) entropy and the pivot of rotors has been shown. Though En is potentially attractive new approach to ablation, no studies have examined its temporal stability and specificity, which are critical to the application of entropy to clinical ablation. In the current study, we sought to objectively measure the temporal stability and specificity of bipolar EGM entropy in medium to long term recordings using three studies: i) a human basket catheter AF study, ii) a tachypaced sheep AF study and iii) a computer simulation study. OBJECTIVE To characterize the temporal dynamics and specificity of Approximate, Sample and Shannon entropy (ApEn/SampEn/ShEn) in human (H), sheep (S), and computer simulated AF. METHODS 64-electrode basket bi-atria sustained AF recordings (H:15 min; S:40 min) were separated into 5 s segments. ShEn/ApEn/SampEn were computed, and co-registered with NavX 3D maps. Temporal stability was determined in terms of: (i) global pattern stability of En and (ii) the relative stability the top 10% of En regions. To provide mechanistic insights into underlying mechanisms, stability characteristics were compared to models depicting various propagation patterns. To verify these results, cross-validation was performed across multiple En algorithms, across species, and compared with dominant frequency (DF) temporal characteristics. The specificity of En was also determined by looking at the association of En to rotors and areas of wave cross propagation. RESULTS Episodes of AF were analysed (H:26 epochs, 6040 s; S:15 epochs, 14,160 s). The global pattern of En was temporally unstable (CV- H:13.42% ± 4.58%; S:14.13% ± 8.13%; Friedman- H: p > 0.001; S: p > 0.001). However, within this dynamic flux, the top 10% of ApEn/SampEn/ShEn regions were relatively temporally stable (Kappa >0.6) whilst the top 10% of DF regions were unstable (Kappa <0.06). In simulated AF scenarios, the experimental data were optimally reproduced in the context of an AF pattern with stable rotating waves surrounded by wavelet breakup (Kappa: 0.610; p < 0.0001). CONCLUSION En shows global temporal instability, however within this dynamic flux, the top 10% regions exhibited relative temporal stability. This suggests that high En regions may be an appealing ablation target. Despite this, high En was associated with not just the pivot of rotors but also with areas of cross propagation, which suggests the need for future work before clinical application is possible.
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Affiliation(s)
- Dhani Dharmaprani
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, SA, Australia
| | - Andrew D McGavigan
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, SA, Australia; Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia
| | | | | | - Shivshankar Thanigaimani
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, SA, Australia
| | - Lukah Dykes
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, SA, Australia
| | | | - Prashanthan Sanders
- University of Adelaide, Adelaide, SA, Australia; South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Kenneth Pope
- College of Science and Engineering, Flinders University of South Australia, Adelaide, SA, Australia
| | - Pawel Kuklik
- Department of Cardiology, University Medical Centre, Hamburg, Germany
| | - Anand N Ganesan
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, SA, Australia; Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia.
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Trayanova NA, Boyle PM, Nikolov PP. Personalized Imaging and Modeling Strategies for Arrhythmia Prevention and Therapy. CURRENT OPINION IN BIOMEDICAL ENGINEERING 2018; 5:21-28. [PMID: 29546250 PMCID: PMC5847279 DOI: 10.1016/j.cobme.2017.11.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The goal of this article is to review advances in computational modeling of the heart, with a focus on recent non-invasive clinical imaging- and simulation-based strategies aimed at improving the diagnosis and treatment of patients with arrhythmias and structural heart disease. Following a brief overview of the field of computational cardiology, we present recent applications of the personalized virtual-heart approach in predicting the optimal targets for infarct-related ventricular tachycardia and atrial fibrillation ablation, and in determining risk of sudden cardiac death in myocardial infarction patients. The hope is that with such models at the patient bedside, therapies could be improved, invasiveness of diagnostic procedures minimized, and health-care costs reduced.
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Affiliation(s)
- Natalia A Trayanova
- Institute for Computational Medicine and Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD
| | - Patrick M Boyle
- Institute for Computational Medicine and Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD
| | - Plamen P Nikolov
- Institute for Computational Medicine and Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD
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Lim B, Hwang M, Song JS, Ryu AJ, Joung B, Shim EB, Ryu H, Pak HN. Effectiveness of atrial fibrillation rotor ablation is dependent on conduction velocity: An in-silico 3-dimensional modeling study. PLoS One 2017; 12:e0190398. [PMID: 29287119 PMCID: PMC5747478 DOI: 10.1371/journal.pone.0190398] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 12/14/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND We previously reported that stable rotors are observed in in-silico human atrial fibrillation (AF) models, and are well represented by a dominant frequency (DF). In the current study, we hypothesized that the outcome of DF ablation is affected by conduction velocity (CV) conditions and examined this hypothesis using in-silico 3D-AF modeling. METHODS We integrated 3D CT images of left atrium obtained from 10 patients with persistent AF (80% male, 61.8±13.5 years old) into in-silico AF model. We compared AF maintenance durations (max 300s), spatiotemporal stabilities of DF, phase singularity (PS) number, life-span of PS, and AF termination or defragmentation rates after virtual DF ablation with 5 different CV conditions (0.2, 0.3, 0.4, 0.5, and 0.6m/s). RESULTS 1. AF maintenance duration (p<0.001), spatiotemporal mean variance of DF (p<0.001), and the number of PS (p = 0.023) showed CV dependent bimodal patterns (highest at CV0.4m/s and lowest at CV0.6m/s) consistently. 2. After 10% highest DF ablation, AF defragmentation rates were the lowest at CV0.4m/s (37.8%), but highest at CV0.5 and 0.6m/s (all 100%, p<0.001). 3. In the episodes with AF termination or defragmentation followed by 10% highest DF ablation, baseline AF maintenance duration was shorter (p<0.001), spatiotemporal mean variance of DF was lower (p = 0.014), and the number of PS was lower (p = 0.004) than those with failed AF defragmentation after DF ablation. CONCLUSION Virtual ablation of DF, which may indicate AF driver, was more likely to terminate or defragment AF with spatiotemporally stable DF, but not likely to do so in long-lasting and sustained AF conditions, depending on CV.
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Affiliation(s)
- Byounghyun Lim
- Yonsei University Health System, Seoul, Republic of Korea
| | - Minki Hwang
- Yonsei University Health System, Seoul, Republic of Korea
| | - Jun-Seop Song
- Yonsei University Health System, Seoul, Republic of Korea
| | - Ah-Jin Ryu
- Department of Mechanical and Biomedical Engineering, Kangwon National University, Chuncheon, Ganwon-do, Republic of Korea
| | - Boyoung Joung
- Yonsei University Health System, Seoul, Republic of Korea
| | - Eun Bo Shim
- Department of Mechanical and Biomedical Engineering, Kangwon National University, Chuncheon, Ganwon-do, Republic of Korea
| | - Hyungon Ryu
- NVIDIA, Yonsei University, Department of Mathematics, Seoul, Republic of Korea
| | - Hui-Nam Pak
- Yonsei University Health System, Seoul, Republic of Korea
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Calvo D, Rubín J, Pérez D, Morís C. Ablation of Rotor Domains Effectively Modulates Dynamics of Human: Long-Standing Persistent Atrial Fibrillation. Circ Arrhythm Electrophysiol 2017; 10:CIRCEP.117.005740. [PMID: 29254947 DOI: 10.1161/circep.117.005740] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 11/03/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND In human long-standing persistent atrial fibrillation, rotors potentially explain atrial fibrillation maintenance, but their ablation remains controversial. We aimed to explore original phase/frequency mapping methods to locate rotors and track changes induced by their ablation. METHODS AND RESULTS Thirteen patients with long-standing persistent atrial fibrillation (duration, 12-72 months) underwent phase/frequency mapping (Hilbert/Fourier transforms; CARTO-Finder) of the left and right atria (PentaRay catheter). A rotor domain was defined as an area displaying at least 3 consecutive rotations. Ablation was performed by circumferential pulmonary vein isolation plus linear ablation of extrapulmonary rotor domains. We identified 19 rotor domains in 10 patients (1.8±1.1 per patient; 7 in the right atrium versus 12 in the left atrium; 15 extrapulmonary). Overall, rotor domains (9.2±2.2 rotations) displayed higher frequency of activation (6.41 Hz; 95% confidence interval, 6.24-6.57) than nonrotor domains (6.17 Hz; 95% confidence interval, 6.1-6.23; P=0.021), with interatrial frequency gradients established by the spatial location of the rotor domain (P=0.016). Fibrillatory conduction was suggested as a decrease in the frequency of the slower atria after ablation close to main interatrial conduction fascicles (P=0.035). Ablation of rotor domains (ablation line, 3.5±0.9 cm) effectively decreased the frequency of activation in both ipsilateral and contralateral atria (P<0.05 for both), whereas ablation of nonrotor domains did not. Acute conversion to sinus rhythm was observed in 2 patients after ablation of rotor domains. At 1-year follow-up, 70% remained in sinus rhythm (85% out-of-antiarrhythmic drugs). CONCLUSIONS Rotor domains appropriately explain long-standing persistent atrial fibrillation physiology at its frequency content. Their ablation effectively modifies dynamics on restricted ablation.
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Affiliation(s)
- David Calvo
- From the Department of Cardiology, Arrhythmia Unit, Hospital Universitario Central de Asturias, Oviedo, Spain; and Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain.
| | - José Rubín
- From the Department of Cardiology, Arrhythmia Unit, Hospital Universitario Central de Asturias, Oviedo, Spain; and Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | - Diego Pérez
- From the Department of Cardiology, Arrhythmia Unit, Hospital Universitario Central de Asturias, Oviedo, Spain; and Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | - César Morís
- From the Department of Cardiology, Arrhythmia Unit, Hospital Universitario Central de Asturias, Oviedo, Spain; and Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
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Shim J, Hwang M, Song JS, Lim B, Kim TH, Joung B, Kim SH, Oh YS, Nam GB, On YK, Oh S, Kim YH, Pak HN. Virtual In-Silico Modeling Guided Catheter Ablation Predicts Effective Linear Ablation Lesion Set for Longstanding Persistent Atrial Fibrillation: Multicenter Prospective Randomized Study. Front Physiol 2017; 8:792. [PMID: 29075201 PMCID: PMC5641589 DOI: 10.3389/fphys.2017.00792] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 09/27/2017] [Indexed: 11/13/2022] Open
Abstract
Objective: Radiofrequency catheter ablation for persistent atrial fibrillation (PeAF) still has a substantial recurrence rate. This study aims to investigate whether an AF ablation lesion set chosen using in-silico ablation (V-ABL) is clinically feasible and more effective than an empirically chosen ablation lesion set (Em-ABL) in patients with PeAF. Methods: We prospectively included 108 patients with antiarrhythmic drug-resistant PeAF (77.8% men, age 60.8 ± 9.9 years), and randomly assigned them to the V-ABL (n = 53) and Em-ABL (n = 55) groups. Five different in-silico ablation lesion sets [1 pulmonary vein isolation (PVI), 3 linear ablations, and 1 electrogram-guided ablation] were compared using heart-CT integrated AF modeling. We evaluated the feasibility, safety, and efficacy of V-ABL compared with that of Em-ABL. Results: The pre-procedural computing time for five different ablation strategies was 166 ± 11 min. In the Em-ABL group, the earliest terminating blinded in-silico lesion set matched with the Em-ABL lesion set in 21.8%. V-ABL was not inferior to Em-ABL in terms of procedure time (p = 0.403), ablation time (p = 0.510), and major complication rate (p = 0.900). During 12.6 ± 3.8 months of follow-up, the clinical recurrence rate was 14.0% in the V-ABL group and 18.9% in the Em-ABL group (p = 0.538). In Em-ABL group, clinical recurrence rate was significantly lower after PVI+posterior box+anterior linear ablation, which showed the most frequent termination during in-silico ablation (log-rank p = 0.027). Conclusions: V-ABL was feasible in clinical practice, not inferior to Em-ABL, and predicts the most effective ablation lesion set in patients who underwent PeAF ablation.
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Affiliation(s)
- Jaemin Shim
- Cardiovascular Center, Korea University, Seoul, South Korea
| | - Minki Hwang
- Division of Cardiology, Yonsei University Health System, Seoul, South Korea
| | - Jun-Seop Song
- Division of Cardiology, Yonsei University Health System, Seoul, South Korea
| | - Byounghyun Lim
- Division of Cardiology, Yonsei University Health System, Seoul, South Korea
| | - Tae-Hoon Kim
- Division of Cardiology, Yonsei University Health System, Seoul, South Korea
| | - Boyoung Joung
- Division of Cardiology, Yonsei University Health System, Seoul, South Korea
| | - Sung-Hwan Kim
- Division of Cardiology, Catholic University of Korea, Seoul, South Korea
| | - Yong-Seog Oh
- Division of Cardiology, Catholic University of Korea, Seoul, South Korea
| | - Gi-Byung Nam
- Asan Medical Center, University of Ulsan, Seoul, South Korea
| | - Young Keun On
- Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea
| | - Seil Oh
- Division of Cardiology, Seoul National University, Seoul, South Korea
| | - Young-Hoon Kim
- Cardiovascular Center, Korea University, Seoul, South Korea
| | - Hui-Nam Pak
- Division of Cardiology, Yonsei University Health System, Seoul, South Korea
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Kim TH, Uhm JS, Kim JY, Joung B, Lee MH, Pak HN. Does Additional Electrogram-Guided Ablation After Linear Ablation Reduce Recurrence After Catheter Ablation for Longstanding Persistent Atrial Fibrillation? A Prospective Randomized Study. J Am Heart Assoc 2017; 6:JAHA.116.004811. [PMID: 28174170 PMCID: PMC5523774 DOI: 10.1161/jaha.116.004811] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Although circumferential pulmonary vein isolation (CPVI) catheter ablation may not be sufficient for long‐standing persistent atrial fibrillation (L‐PeAF), it is not clear which ablation strategy is beneficial in addition to CPVI. We sought to investigate whether additional complex fractionated atrial electrogram (CFAE)‐guided ablation improves clinical outcomes in L‐PeAF patients who exhibit continuous atrial fibrillation (AF) after CPVI and linear ablation (Line). Methods and Results This study enrolled 137 L‐PeAF patients (71.4% male, 61.6±10.9 years old) who underwent radiofrequency catheter ablation. We conducted CPVI+Line based on the Dallas lesion set (posterior box+anterior line) after baseline CFAE mapping in all patients. If AF was defragmented (terminated or changed to atrial tachycardia), the procedure was stopped (AF‐Defrag group, n=29). If AF was maintained after CPVI+Line, we mapped the CFAE again and randomly assigned the patient to the CPVI+Line group (n=54) or the additional CFAE ablation group (CPVI+Line+CFAE group, n=54). L‐PeAF was defragmented during CPVI+Line in 21.2% of patients (29/137, AF‐Defrag group). The mean CFAE cycle length was prolonged (P<0.001), and CFAE area (CFAE cycle length <120 milliseconds) was reduced (P<0.001) after CPVI+Line in the remaining patients. Procedure time was longer in the CPVI+Line+CFAE group than the CPVI+Line group (P=0.023), but procedure‐related complication rates did not vary. During 22.3±13.2 months of follow‐up, the clinical recurrence rates were 17.2% in the AF‐Defrag group, 18.5% in the CPVI+Line group, and 32.1% in the CPVI+Line+CFAE group (log rank, P=0.166). Conclusions Although CPVI+Line reduces and localizes CFAE area, additional CFAE ablation after CPVI+Line does not improve the clinical outcomes of catheter ablation in patients with L‐PeAF.
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Affiliation(s)
| | - Jae-Sun Uhm
- Yonsei University Health System, Seoul, Korea
| | | | | | | | - Hui-Nam Pak
- Yonsei University Health System, Seoul, Korea
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