Organized Sources Are Spatially Conserved in Recurrent Compared to Pre‐Ablation Atrial Fibrillation: Further Evidence for Non‐Random Electrical Substrates

Lalani, Gautam; Coysh, Thomas; Baykaner, Tina; Zaman, Junaid A.B.; Hopper, Kenneth D.; Schricker, Amir; Trikha, Rishi; Clopton, Paul; Krummen, David E.; Narayan, Sanjiv M.

doi:10.1111/jce.12964

Cited by 18 publications

(13 citation statements)

References 40 publications

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“…These were identified prospectively at each case. Reproducibility of this assignment by individual operators has recently been reported to be good with kappa = 0.89 (21). These data were collected prospectively by each investigator during each case, then collated retrospectively blinded to patient group.…”

Section: Methodsmentioning

confidence: 77%

Recurrent Post-Ablation Paroxysmal Atrial Fibrillation Shares Substrates With Persistent Atrial Fibrillation

Zaman

Baykaner

Clopton

et al. 2017

JACC: Clinical Electrophysiology

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Introduction The role of atrial fibrillation (AF) substrates is unclear in patients with paroxysmal AF (PAF) that recurs after pulmonary vein isolation (PVI). We hypothesized that patients with recurrent post-ablation (redo) PAF despite PVI have electrical substrates marked by rotors and focal sources, and structural substrates that resemble persistent AF more than patients with (de novo) PAF at first ablation. Methods In 175 patients at 11 centers, we compared AF substrates in both atria using 64 pole-basket catheters and phase mapping, and indices of anatomical remodeling between patients with de novo or redo PAF and first ablation for persistent AF. Results Sources were seen in all patients. More patients with de novo PAF (78.0%) had sources near PVs than patients with redo PAF (47.4%, p=0.005) or persistent AF (46.9%, p=0.001). The total number of sources per patient (p=0.444), and number of non-PV sources (p=0.701) were similar between groups, indicating that redo PAF patients had residual non-PV sources after elimination of PV sources by prior PVI. Structurally, left atrial size did not separate de novo from redo PAF (49.5±9.5 vs. 49.0±7.1mm, p=0.956) but was larger in patients with persistent AF (55.2±8.4mm, p=0.001). Conclusions Patients with paroxysmal AF despite prior PVI show electrical substrates that resemble persistent AF more closely than patients with paroxysmal AF at first ablation. Notably, these subgroups of paroxysmal AF are indistinguishable by structural indices. These data motivate studies of trigger versus substrate mechanisms for patients with recurrent paroxysmal AF after PVI.

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Section: Methodsmentioning

confidence: 77%

Recurrent Post-Ablation Paroxysmal Atrial Fibrillation Shares Substrates With Persistent Atrial Fibrillation

Zaman

Baykaner

Clopton

et al. 2017

JACC: Clinical Electrophysiology

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“…68 Temporospatial conservation of rotational AF sites in the inferior LA in a man with longstanding persistent AF. (A) At index procedure, anatomic roof line bisected a roof rotor; wide area PVI was also performed.…”

Section: Figurementioning

confidence: 99%

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

Narayan

Vishwanathan

Kowalewski

et al. 2017

Revista Portuguesa de Cardiologia

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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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“…Another possibility is that non-terminating sites may intrinsically differ; for instance, they may be slower or be associated with co-factors such as fibrosis, which may prevent acute termination even if eliminated. Another possibility is that ablation is incomplete at sites where AF does not acutely terminate, supported by our study of recurrent AF demonstrating at least one ‘conserved’ AF drive from prior mapping in each case 23 . Finally, it is also possible that some of these sites are false positive detections, although they were confirmed by a second mapping system.…”

Section: Discussionmentioning

confidence: 74%

Independent mapping methods reveal rotational activation near pulmonary veins where atrial fibrillation terminates before pulmonary vein isolation

Navara

Leef

Shenasa

et al. 2018

Cardiovasc electrophysiol

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OBJECTIVE To investigate mechanisms by which atrial fibrillation (AF) may terminate during ablation near the pulmonary veins before the veins are isolated (PVI). INTRODUCTION It remains unstudied how AF may terminate during ablation before PVs are isolated, or how patients with PV reconnection can be arrhythmia-free. We studied patients in whom PV antral ablation terminated AF before PVI, using 2 independent mapping methods. METHODS We studied patients with AF referred for ablation, in whom bi-atrial contact basket electrograms were studied by both an activation/phase mapping method and by a second validated mapping method reported not to create false rotational activity. RESULTS In 22 patients (age 60.1±10.4, 36% persistent AF), ablation at sites near the PVs terminated AF (77% to sinus rhythm) prior to PVI. AF propagation revealed rotational (n=20) and focal (n=2) patterns at sites of termination by mapping method 1 and method 2. Both methods showed organized sites that were spatially concordant (p<0.001) with similar stability (p<0.001). Vagal slowing was not observed at sites of AF termination. DISCUSSION PV antral regions where ablation terminated AF before PVI exhibited rotational and focal activation by two independent mapping methods. These data provide an alternative mechanism for the success of PVI, and may explain AF termination before PVI or lack of arrhythmias despite PV reconnection. Mapping such sites may enable targeted PV lesion sets and improved freedom from AF.

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Organized Sources Are Spatially Conserved in Recurrent Compared to Pre‐Ablation Atrial Fibrillation: Further Evidence for Non‐Random Electrical Substrates

Cited by 18 publications

References 40 publications

Recurrent Post-Ablation Paroxysmal Atrial Fibrillation Shares Substrates With Persistent Atrial Fibrillation

Recurrent Post-Ablation Paroxysmal Atrial Fibrillation Shares Substrates With Persistent Atrial Fibrillation

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

Independent mapping methods reveal rotational activation near pulmonary veins where atrial fibrillation terminates before pulmonary vein isolation

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