Ablation of Rotor and Focal Sources Reduces Late Recurrence of Atrial Fibrillation Compared With Trigger Ablation Alone

Narayan, Sanjiv M.; Baykaner, Tina; Clopton, Paul; Schricker, Amir; Lalani, Gautam; Krummen, David E.; Shivkumar, Kalyanam; Miller, John M.

doi:10.1016/j.jacc.2014.02.543

Cited by 327 publications

(155 citation statements)

References 37 publications

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“…[18][19][20][21] In the CONFIRM study (Conventional Ablation for Atrial Fibrillation With or Without Focal Impulse and Rotor Modulation), rotors and localized focal sources were present in almost all of their patients with AF (98%; mean, 2.3±1.1 concurrent rotors and focal sources) and that targeting these local areas with ablation can terminate the arrhythmia and lead to improved clinical outcomes. 13,22 Yet, despite such strong results, other research groups have failed to collaborate the high prevalence and stability of rotors, 16,23,24 even while using datasets analyzed using different sophisticated mapping techniques using datasets previously thought to show rotors in the CONFIRM study. 25 A rotor in mathematical terms is generally defined as a PS in which the phase activation progresses through a complete cycle from −π to +π.…”

Section: Discussionmentioning

confidence: 99%

“…29 To map phase with the FIRM technique, individual fibrillatory waves are substituted for unipolar action potential data using a previously validated library, which have a morphology more suited to the Hilbert transformation. 29 There are several similarities between our mapping and signal analysis method and the technique performed in the CONFIRM study, in that both studies used Constellation basket catheters, 22 to achieve high-density mapping and one would predict the same degree of interelectrode signal interpolation. There are several technical considerations and difficulties involved with mapping AF in this way, which has previously been reported by our group 30 and would have been similar across studies.…”

Section: Discussionmentioning

confidence: 99%

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Unraveling the Underlying Arrhythmia Mechanism in Persistent Atrial Fibrillation

Child

Clayton

Roney

et al. 2018

Circ: Arrhythmia and Electrophysiology

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Background: The mechanisms that initiate and sustain persistent atrial fibrillation are not well characterized. Ablation results remain significantly worse than in paroxysmal atrial fibrillation in which the mechanism is better understood and subsequent targeted therapy has been developed. The aim of this study was to characterize and quantify patterns of activation during atrial fibrillation using contact mapping. Methods: Patients with persistent atrial fibrillation (n=14; mean age, 61±8 years; ejection fraction, 59±10%) underwent simultaneous biatrial contact mapping with 64 electrode catheters. The atrial electrograms were transformed into phase, and subsequent spatiotemporal mapping was performed to identify phase singularities (PSs). RESULTS: PSs were located in both atria, but we observed more PSs in the left atrium compared with the right atrium (779±302, 552±235; P =0.015). Although some PSs of duration sufficient to complete >1 rotation were detected, the maximum PS duration was only 1150 ms, and the vast majority (97%) of PSs persisted for too short a period to complete a full rotation. Although in selected patients there was evidence of PS local clustering, overall, PSs were distributed globally throughout both chambers with no clear anatomic predisposition. In a subset of patients (n=7), analysis was repeated using an alternative established atrial PS mapping technique, which confirmed our initial findings. Conclusions: No sustained rotors or localized drivers were detected, and instead, the mechanism of arrhythmia maintenance was consistent with the multiple wavelet hypothesis, with passive activation of short-lived rotational activity. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01765075.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Unraveling the Underlying Arrhythmia Mechanism in Persistent Atrial Fibrillation

Child

Clayton

Roney

et al. 2018

Circ: Arrhythmia and Electrophysiology

View full text Add to dashboard Cite

show abstract

“…However this approach can be challenging in persistent AF patients. 47 In the future, the combined use of time, frequency and phase domain measures, including electrogram fractionation, 48 principal value decomposition and DF mapping, 49 should help elucidate mechanism of impulse propagation and the identification of the drivers and characterization of their dynamics to provide an efficient mean to facilitate patient-specific ablation procedures with well-defined end-points, 8,50,51 potentially leading to increased efficacy and safety. 52,53 …”

Section: Discussionmentioning

confidence: 99%

Mechanisms of Atrial Fibrillation

Berenfeld¹,

Jalife²

2014

Cardiology Clinics

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Summary Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in humans. However its mechanisms are poorly understood and AF therapy is often sub-optimal. This article reviews recent experimental, numerical and clinical data on dynamics of wave propagation during AF and its mechanistic link to ionic and structural properties of the atria. At the outset, we review numerical and optical mapping data suggesting that the sustained activity of periodic drivers (rotors) with exceedingly high dominant frequencies (DF) of excitation underlies the spatial dispersion and irregularity of activation rates that characterize AF. We show how optical mapping of the fibrillating atria in isolated normal sheep hearts has revealed that the rotors tend to localize in the left atrium (LA). We then discuss exciting new data in the sheep model of tachypacing induced AF demonstrating that the DF of paroxysmal AF episodes increases progressively over days or weeks during the transition to persistent AF (PeAF) and that the rate of the DF increase predicts the onset of PeAF. The data show that the DF increase during the transition may be explained by rotor acceleration secondary to upregulation of IK1 and downregulation of ICaL. The article concludes with a discussion on how translation of experimentally derived knowledge on the behavior and frequency of rotors may find its way into the clinic. We focus on studies in which the analysis of the spatial patterns of DF distribution in the atria of patients with paroxysmal vs persistent has increased our understanding of human AF and how that knowledge might contribute to improve the outcome of AF ablation procedures.

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“…74,75 FIRM-guided ablation of persistent AF has shown higher 3-year freedom from AF compared with conventional ablation (single-procedure freedom from AF at 890 days, 75% versus 30%). 76 However, none of these studies on rotors and focal sources were randomized.…”

Section: 53-55mentioning

confidence: 99%

Ablation of Atrial Fibrillation

2016

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Atrial fibrillation (AF) is the most common arrhythmia encountered by cardiologists and is a major cause of morbidity and mortality. Risk factors for AF include age, male sex, genetic predisposition, hypertension, diabetes mellitus, sleep apnea, obesity, excessive alcohol, smoking, hyperthyroidism, pulmonary disease, air pollution, heart failure, and possibly excessive exercise. The management of AF involves decisions about rate versus rhythm control. Asymptomatic patients are generally managed with rate control and anticoagulation. Symptomatic patients will desire rhythm control. Rhythm control options are either antiarrhythmic agents or ablation, with each having its own risks and benefits. Ablation of AF has evolved from a rare and complex procedure to a common electrophysiological technique. Selection of patients to undergo ablation is an important aspect of AF care. Patients with the highest success rates of ablation are those with normal structural hearts and paroxysmal AF, although those with congestive heart failure have the greatest potential benefit of the procedure. Although pulmonary vein isolation of any means/energy source is the approach generally agreed on for those with paroxysmal AF, optimal techniques for the ablation of nonparoxysmal AF are not yet clear. Anticoagulation reduces thromboembolic complications; the newer anticoagulants have eased management for both the patient and the cardiologist. Aggressive management of modifiable risk factors (hypertension, diabetes mellitus, sleep apnea, obesity, excessive alcohol, smoking, hyperthyroidism, pulmonary disease, air pollution, and possibly excessive exercise) after ablation reduces the odds of recurrent AF and is an important element of care.

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Ablation of Rotor and Focal Sources Reduces Late Recurrence of Atrial Fibrillation Compared With Trigger Ablation Alone

Cited by 327 publications

References 37 publications

Unraveling the Underlying Arrhythmia Mechanism in Persistent Atrial Fibrillation

Unraveling the Underlying Arrhythmia Mechanism in Persistent Atrial Fibrillation

Mechanisms of Atrial Fibrillation

Ablation of Atrial Fibrillation

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