Anatomical Distribution of Ectopy-Triggering Plexuses in Patients With Atrial Fibrillation

Kim, Min-young; Sandler, Belinda; Sikkel, Markus B.; Cantwell, Chris D.; Leong, Kevin; Luther, Vishal; Malcolme-Lawes, Louisa; Koa‐Wing, Michael; Ng, Fu Siong; Qureshi, Norman; Sohaib, Afzal; Whinnett, Zachary I.; Fudge, Michael; Lim, Elaine; Todd, Michelle; Wright, Ian; Peters, Nicholas S.; Lim, Phang Boon; Linton, N; Kanagaratnam, Prapa

doi:10.1161/circep.120.008715

Cited by 8 publications

(11 citation statements)

References 5 publications

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Section: Discussionmentioning

confidence: 99%

“…We previously showed that both ET‐GP and AVD‐GP have a variable but discrete anatomical distribution in the left atrium which does not conform to all the anatomical areas that are known to contain GPs. 13 , 15 , 16 ET‐GP identified with synchronized HFS produces PV and non‐PV ectopy that are reminiscent of clinical AF. 15 However, synchronized HFS can only be performed in sinus rhythm, which may be challenging in patients who develop sustained AF during mapping, as this requires multiple DC cardioversions.…”

Section: Discussionmentioning

confidence: 99%

“…Initially, these patients were crossed over to PVI if they had already undergone three DC cardioversions for sustained AF or had incessant AF that could not be cardioverted. However, we previously showed that a proportion of ET‐GP co‐locates with AVD‐GP 16 . Therefore, a protocol amendment was instituted, and patients randomized to ET‐GP ablation with sustained AF had AVD‐GP mapping instead of crossing over to PVI.…”

Section: Methodsmentioning

confidence: 99%

“…However, we previously showed that a proportion of ET‐GP co‐locates with AVD‐GP. 16 Therefore, a protocol amendment was instituted, and patients randomized to ET‐GP ablation with sustained AF had AVD‐GP mapping instead of crossing over to PVI. Randomization was also later modified to 2:1 in favor of ET‐GP to offset these early crossovers.…”

Section: Methodsmentioning

confidence: 99%

“…This avoids direct myocardial capture and has been shown to trigger PV and non‐PV ectopy that can lead to AF 15 . We previously mapped these ectopy‐triggering GPs (ET‐GP) which were anatomically and functionally distinct from AVD‐GP 16 . ET‐GP have not been widely studied in patients even though the effects are comparable to clinical episodes of AF.…”

Section: Introductionmentioning

confidence: 99%

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Targeting the ectopy‐triggering ganglionated plexuses without pulmonary vein isolation prevents atrial fibrillation

Sandler

Kim

Sikkel

et al. 2021

Cardiovasc electrophysiol

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Background Ganglionated plexuses (GPs) are implicated in atrial fibrillation (AF). Endocardial high‐frequency stimulation (HFS) delivered within the local atrial refractory period can trigger ectopy and AF from specific GP sites (ET‐GP). The aim of this study was to understand the role of ET‐GP ablation in the treatment of AF. Methods Patients with paroxysmal AF indicated for ablation were recruited. HFS mapping was performed globally around the left atrium to identify ET‐GP. ET‐GP was defined as atrial ectopy or atrial arrhythmia triggered by HFS. All ET‐GP were ablated, and PVs were left electrically connected. Outcomes were compared with a control group receiving pulmonary vein isolation (PVI). Patients were followed‐up for 12 months with multiple 48‐h Holter ECGs. Primary endpoint was ≥30 s AF/atrial tachycardia in ECGs. Results In total, 67 patients were recruited and randomized to ET‐GP ablation (n = 39) or PVI (n = 28). In the ET‐GP ablation group, 103 ± 28 HFS sites were tested per patient, identifying 21 ± 10 (20%) GPs. ET‐GP ablation used 23.3 ± 4.1 kWs total radiofrequency (RF) energy per patient, compared with 55.7 ± 22.7 kWs in PVI (p = <.0001). Duration of procedure was 3.7 ± 1.0 and 3.3 ± 0.7 h in ET‐GP ablation group and PVI, respectively (p = .07). Follow‐up at 12 months showed that 61% and 49% were free from ≥30 s of AF/AT with PVI and ET‐GP ablation respectively (log‐rank p = .27). Conclusions It is feasible to perform detailed global functional mapping with HFS and ablate ET‐GP to prevent AF. This provides direct evidence that ET‐GPs are part of the AF mechanism. The lower RF requirement implies that ET‐GP targets the AF pathway more specifically.

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Section: Discussionmentioning

confidence: 99%