Focal impulse and rotor modulation guided ablation versus pulmonary vein isolation for atrial fibrillation: A meta‐analysis of head‐to‐head comparative studies

Abstract

Introduction Empirical pulmonary vein isolation (PVI) remains the cornerstone for catheter ablation of atrial fibrillation (AF). Various ablation strategies and modalities are continually tested with the aim of improving ablation outcomes. Although focal impulse and rotor modulation (FIRM)‐guided ablation is currently used as an adjunct to PVI, evidence supporting this strategy is conflicting. We sought to examine whether the utilization of FIRM‐guided ablation with or without PVI is associated with a decrease in all‐atrial arrhythmia recurrence as compared to PVI alone. Methods A systematic review of PubMed, Cochrane, and Embase was performed for head‐to‐head study designs comparing outcomes of patients who underwent FIRM‐guided ablation with or without PVI to those who underwent PVI alone. The primary efficacy endpoint was all‐atrial arrhythmia recurrence. The secondary endpoints were complications rates and procedural characteristics. Results Overall, six studies comprising 674 patients undergoing either FIRM‐guided ablation ± PVI versus PVI were included (mean age 63.4 ± 9.2, male 74%, 9% paroxysmal AF, 91% nonparoxysmal AF). After a mean follow‐up of 18.8 months, FIRM‐guided ablation with or without PVI was not associated with improvement in all‐atrial arrhythmia recurrence rate compared to PVI alone (43.4% vs. 45.9%, risk ratio [RR]: 1.06; 95% confidence interval [CI]: 0.77–1.47; p = .70). No statistically significant difference was noted in complication rates between the two groups (RR: 1.66; 95% CI: 0.08–34.54; p = .74). Conclusion In this meta‐analysis of head‐to‐head comparison studies, FIRM‐guided ablation with or without PVI did not provide any benefit in improving all‐atrial arrhythmia recurrence at follow‐up when compared to PVI alone.

Find Me If You Can: First Clinical Experience Using the Novel CARTOFINDER Algorithm in a Routine Workflow for Atrial Fibrillation Ablation

“…Consequently, these ROIs should potentially be eliminated in addition to PVI. A comparable effect of focal sources was reported previously [10,14,15]. In contrast to focal ROIs, rotational findings from CARTOFINDER mapping were not reproducible during remapping.…”

Contemporary Ablation Techniques for Atrial Fibrillation: An Evidence-Based Analysis

“…Although the CONFIRM (Conventional Ablation for Atrial Fibrillation With or Without Focal Impulse and Rotor Modulation) study reported a high degree of freedom from AF with FIRM ( 42), other studies have demonstrated that, despite the association with a more organized fibrillatory activation within the LA, it does not correlate with an increase in freedom from AF, even after redo procedures (43)(44)(45)(46). Furthermore, a head-to-head meta-analysis of six studies including 716 patients (88.5% non-PAF) concluded that FIRM did not add any benefit in improving all-atrial arrhythmia recurrence (47). (Figure 5)…”

Atrial fibrillation: Insights from animal models, computational modeling, and clinical studies

“…25 A follow up study showed that FIRM-guided ablations prevented early and late arrhythmia recurrence for more than three years (compared to one year for PVI-only). 26 However, further studies have not been able to demonstrate the efficacy of reentrant driver ablation using FIRM, 27 , 28 which could potentially be attributed to the low resolution of the basket catheter. 29 …”