A prospective, multicenter evaluation of ablating complex fractionated electrograms (CFEs) during atrial fibrillation (AF) identified by an automated mapping algorithm: Acute effects on AF and efficacy as an adjuvant strategy

Novak, Paul; Macle, Laurent; Whaley, Bonnie; Beardsall, Marianne; Wulffhart, Zaev; Khaykin, Yaariv

doi:10.1016/j.hrthm.2007.09.027

Cited by 162 publications

(162 citation statements)

References 17 publications

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“…It has been further proposed that these fractionated sites are important in sustaining AF, 53 and that targeting fractionated electrograms with ablation can terminate AF and prevent its re-induction or recurrence. 52,[54][55][56][57][58][59][60] The data supporting these conclusions are rather weak overall, with only a few small, randomised clinical trials providing guidance, and different studies have arrived at disparate conclusions regarding the importance, or lack thereof, of fractionated electrograms in the pathogenesis of AF.…”

Section: Limitations Of Targeting Rotors With Ablation For the Treatmmentioning

confidence: 99%

Mechanisms of Atrial Fibrillation – Reentry, Rotors and Reality

Waks

Josephson²

2014

Arrhythmia &Amp; Electrophysiology Review

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Atrial fibrillation (AF), the most common sustained arrhythmia, is a leading cause of stroke, and is associated with significant morbidity and mortality worldwide. Despite its frequency, clinical importance, and advances in technology and our knowledge of the molecular, ionic and physiological fundamentals of cardiac electrophysiology, our limited understanding of the mechanisms that initiate and sustain AF has prevented us from being able to truly cure this arrhythmia with antiarrhythmic drugs and/or ablation. This contrasts with other arrhythmias, such as AV nodal tachycardia or circus movement tachycardia using an accessory pathway, which have well-defined mechanisms and circuits that can be safely targeted with high rates of cure. The observations that AF may have different mechanisms in different patients, and that paroxysmal, persistent and permanent forms of AF may differ in how they are initiated and sustained, only serves to reinforce our lack of understanding of this ubiquitous arrhythmia. Historical Mechanisms of Atrial Fibrillation and the Multiple Wavelet HypothesisInterest and understanding of the mechanism of AF began to take form in the early 1900s. Given the chaotic and irregular nature of AF on the surface electrocardiogram, rapid firing of automatic atrial foci was considered a potential mechanism. However, after the seminal work of Mayer 1 , Mines 2 and Garrey 3 in laying the foundation for describing and understanding reentrant arrhythmias, atrial reentrant circuits emerged as the likely drivers of AF.4-7 Although these theories were conceptually sound, it was impossible to prove a specific mechanism with the technology of the time. Moe et al. demonstrated that it was probabilistically unlikely that a large number of simultaneous wavefronts would all die out simultaneously, and AF would therefore perpetuate. However, if the number of simultaneous wavelets were small and/or below a critical value (between 15 and 30 in Moe's computer model), 9 at some point all reentrant wavefronts would be simultaneously extinguished, and AF would therefore terminate. 8,9 Allessie et al. provided experimental evidence supporting this mechanism in a canine heart model of AF where four to six simultaneous reentrant wavelets were needed to sustain arrhythmia. 10 Further evidence supporting multiple wavelets in AF was demonstrated in a separate model, which evaluated the effect of various antiarrhythmic drugs on canine myocardium. This model demonstrated that termination of AF was associated with a reduction AbstractAtrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice, yet our understanding of the mechanisms that initiate and sustain this arrhythmia remains quite poor. Over the last 50 years, various mechanisms of AF have been proposed, yet none has been consistently observed in both experimental studies and in humans. Recently, there has been increasing interest in understanding how spiral waves or rotors -which are specific, organised forms of functional reentry -su...

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Section: Limitations Of Targeting Rotors With Ablation For the Treatmmentioning

confidence: 99%

Mechanisms of Atrial Fibrillation – Reentry, Rotors and Reality

Waks

Josephson²

2014

Arrhythmia &Amp; Electrophysiology Review

View full text Add to dashboard Cite

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“…In the study by Verma et. al (Verma et al, 2008), the overall agreement between algorithm-labeled (defined as mean cycle length < 120 ms) and investigator-labeled CFAEs sites was 86% for two independent investigators combined. In the study by Wu et.…”

Section: Discussionmentioning

confidence: 89%

“…Sites with highly fractionated A-EGMs almost fully encompass the sites with high DF but not always vice versa. For that reason, algorithms implemented in commercially available mapping systems were designed for detection of CFAEs rather than high DF (Scherr et al, 2007) and (Verma et al, 2008). These time-domain algorithms require specific input parameters being more flexible but, on the other hand, operator-dependent.…”

Section: Discussionmentioning

confidence: 99%

“…Temporal alterations of A-EGMs are certainly problematic issue during real-time fractionation mapping but the results of our validation study were not clearly affected by this phenomenon . Our algorithm is fully automatic and does not need any initial settings by the operator like voltage criteria required in CFAEs software of commercially available mapping systems (Scherr et al, 2007) and (Verma et al, 2008) which might be particularly sensitive to background noise and dispersion of voltages at different sites within mapped atrium. Parameter settings in our algorithms were manifold cross-validated using random split of experimental dataset into training and testing subsets.…”

Section: Discussionmentioning

confidence: 99%

“…Ablation of CFAEs as adjutant target sites appears to increase success rate of ablation for persistent AF and improves short-term outcome of AF patients as shown in numerous clinical studies. Feasibility of real-time automated detection of CFAEs was investigated, but only in two of studies this feature was directly used for ablation (Verma et al, 2008) and (Porter et al, 2008). So far, any information is missing on the utility of automated assessment of CFAE compared to investigator-based detection in directing the ablation procedure.…”

Section: Discussionmentioning

confidence: 99%

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