Focal impulse and rotor modulation: Acute procedural observations and extended clinical follow-up

Steinberg, Jonathan S.; Shah, Yash; Bhatt, Advay G.; Sichrovsky, Tina; Arshad, Aysha; Hansinger, Emily; Musat, Dan

doi:10.1016/j.hrthm.2016.11.008

Cited by 83 publications

(78 citation statements)

References 17 publications

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“…In 2016, the observational study published by Buch et al revealed poor long-term outcomes with FIRM-guided ablation in patients with paroxysmal and persistent AF; only 37% of patients were free from AF at 18±7 months follow up (66). Steinberg et al also demonstrated low long-term efficacy with FIRMguided ablation in various AF classes in their single-center observational study (67). FIRM ablation was performed in 43 patients (72% with median of one prior PVI), followed by redo PVI in 31/43 patients.…”

Section: Focal Impulse and Rotor Modulation (Firm)mentioning

confidence: 97%

Ablation of long-standing persistent atrial fibrillation

Mody¹,

Raza²,

Jacobson³

et al. 2017

Ann. Transl. Med.

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Atrial fibrillation (AF) is the most commonly encountered arrhythmia in the clinical setting affecting nearly 6 million people in United States and the numbers are only expected to rise as the population continues to age. Broadly it is classified into paroxysmal, persistent and longstanding persistent AF.Electrical, structural and autonomic remodeling are some of the diverse pathophysiological mechanisms that contribute to the persistence of AF. Our review article emphasizes particularly on long standing persistent atrial fibrillation (LSPAF) aspect of the disease which poses a great challenge for electrophysiologists. While pulmonary vein isolation (PVI) has been established as a successful ablation strategy for paroxysmal AF, same cannot be said for LSPAF owing to its long duration, complexity of mechanisms, multiple triggers and substrate sites that are responsible for its perpetuation. The article explains different approaches currently being adopted to achieve freedom from atrial arrhythmias. These mainly include ablation techniques chiefly targeting complex fractionated atrial electrograms (CFAE), rotors, linear lesions, scars and even considering hybrid approaches in a few cases while exploring the role of delayed enhancement magnetic resonance imaging (deMRI) in the pre-procedural planning to improve the overall short and long term outcomes of catheter ablation.

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Section: Focal Impulse and Rotor Modulation (Firm)mentioning

confidence: 97%

Ablation of long-standing persistent atrial fibrillation

Mody¹,

Raza²,

Jacobson³

et al. 2017

Ann. Transl. Med.

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“…For instance, Sommer, Hindricks et al 54 and Miller et al 9,13 reported 70-80% maintenance of sinus rhythm by FIRM-ablation in populations that included challenging patients with prior failed procedures and long-standing persistent AF; as did Tomassoni, 12 Rashid 11 and others. Conversely, Buch, Shivkumar et al 42 report 21% success and Steinberg et al report 12% success 43 in patients even with paroxysmal AF despite also performing PVI. It is difficult to reconcile these results based primarily on disease severity.…”

Section: Reconciling Heterogeneity In the Success Of Source-guided Abmentioning

confidence: 98%

“…This may reflect mapping of the epicardium in these studies, where drivers are less stable on optical maps. 7,34 Third, AF-driver ablation outcomes are disappointing at some centers [41][42][43] (Table 1 summarizes PVI and driver ablation studies). Mapping differences will alter reported AF mechanisms, and Rudy et al…”

Section: Reconciling Differences Between Mapping Studies Of Af Rotatimentioning

confidence: 99%

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The continuous challenge of AF ablation: From foci to rotational activity

Narayan

Vishwanathan

Kowalewski

et al. 2017

Revista Portuguesa de Cardiologia (English Edition)

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Pulmonary vein isolation (PVI) is central to ablation approaches for atrial fibrillation (AF), yet many patients still have arrhythmia recurrence after one or more procedures despite the latest technology for PVI. Ablation of rotational or focal sources for AF, which lie outside the pulmonary veins in many patients, is a practical approach that has been shown to improve success by many groups. Localized sources lie in atrial regions shown mechanistically to sustain AF in optical mapping and clinical studies of human AF, as well as computational and animal studies. Because they arise in localized atrial regions, AF sources may explain central paradoxes in clinical practice -such as how limited ablation in patient specific sites can terminate persistent AF yet extensive anatomical ablation at stereotypical locations, which should extinguish disordered waves, does not improve success in clinical trials. Ongoing studies may help to resolve many controversies in the field of rotational sources for AF. Studies now verify rotational activation by multiple mapping approaches in the same patients, at sites where ablation terminates persistent AF. However, these studies also show that certain mapping methods are less effective for detecting AF sources than others. It is also recognized that the success of AF source ablation is technique dependent. This review article provides a mechanistic and clinical rationale to ablate localized sources (rotational and focal), and describes successful techniques for their ablation as well as pitfalls to avoid. We hope that this review will serve as a platform for future improvements in the patient-tailored ablation for complex arrhythmias.

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“…96 The initial optimism surrounding FIRM-guided ablation was blunted by the lack of reproducibility of the rotors and the results achieved at other centers, with several of them reporting worse outcomes. [97][98][99] A large, randomized trial suggested poor outcomes with FIRM-guided ablation alone but was retracted due to concerns with trial enrollment and registration. 100 However, other major centers have reported improved outcomes achieved in patients with persistent AF ablation using FIRM-guided mapping, 101,102 and there are other unfinished trials currently underway using this technology for ablation (NCT02274857, NCT02799043).…”

Section: Improvements In Mapping-seeing Is Believingmentioning

confidence: 99%