Role of high dominant frequency sites in nonparoxysmal atrial fibrillation patients: Insights from high-density frequency and fractionation mapping

Background-Ablation of complex fractionated atrial electrograms (CFAEs) has been proposed as a strategy to improve outcomes in atrial fibrillation (AF) catheter ablation, but the use of this technique remains contentious. We aimed to assess the impact of CFAE ablation in addition to pulmonary vein isolation (PVI) in patients undergoing ablation for AF. Methods and Results-We performed a random effects meta-analysis of studies comparing PVI versus PVI+CFAE ablation.The outcomes of freedom from AF/atrial tachycardia after 1 or several ablation procedures and acute procedural-related complications were assessed. Studies were searched on MEDLINE, EMBASE, COCHRANE, and clinicaltrials.gov, and sensitivity analyses were performed. Thirteen studies including a total of 1415 patients were considered eligible.

Section: Role Of Other Treatment Strategiesmentioning

confidence: 99%

Is There Still a Role for Complex Fractionated Atrial Electrogram Ablation in Addition to Pulmonary Vein Isolation in Patients With Paroxysmal and Persistent Atrial Fibrillation?

Providência

Lambiase

Srinivasan

et al. 2015

“…20 Step 3 (substrate ablation): The CFAE ablation was confined to the continuous CFAEs in the left atrium (LA) and coronary sinus (CS). 10,23 Considering and ablation were performed to terminate the organized tachycardia. The procedural AF termination was defined as AF restored to SR without electrical cardioversion.…”

Section: First Catheter Ablation Procedures For Persistent Afmentioning

confidence: 99%

Prevalence, Characteristics, Mapping, and Catheter Ablation of Potential Rotors in Nonparoxysmal Atrial Fibrillation

Lin

et al. 2013

Self Cite

Background-Identification of critical atrial substrates in patients with nonparoxysmal atrial fibrillation (AF) failing to respond to pulmonary vein isolation is important. This study investigated the signal characteristics, substrate nature, and ablation results of rotors during AF. Methods and Results-In total, 53 patients (age=55±8), 31 with persistent AF and 22 with long-lasting AF, underwent pulmonary vein isolation and substrate modification of complex fractionated atrial electrograms. Small-radius-reentrant rotors were identified from signal analyses of the dominant frequency and fractionation interval and nonlinear analyses (newly developed, beat-to-beat nonlinear measurement of the repetitiveness of the electrogram morphology >6 seconds). In 15% of the patients, activation maps demonstrated occurrences of rotor-like small-radius reentrant circuits (n=9; 1.1 per patient; cycle length=110±21 ms; diameter=11±6 mm) with fibrillation occurring outside these areas. Rotors were identified by conventional point-by-point mapping and signal analyses and were subsequently eradicated by catheter ablation in these patients. Persistent AF for <1 year, a smaller left atrial size, substrates with higher mean voltages and shorter total activation durations predicted a higher incidence of rotors (all P<0.05). In the multivariable model, areas of reentrant circuits exhibited a higher dominant frequency, kurtosis, and higher degree of a beat-to-beat electrogram similarity than areas without or outside the rotors (all P<0.05). Conclusions-Rotor-like re-entry with fibrillatory conduction was found in a limited number of patients with nonparoxysmal AF after pulmonary vein isolation. Those areas were characterized by rapid repetitive activity with a high degree of electrogram similarity. Methods Patient CharacteristicsWe enrolled 53 patients (55±8 years) with symptomatic drug-refractory nonparoxysmal AF who underwent radiofrequency ablation guided by NavX system (St Jude Medical Inc, MN). The study cohort included 31 patients (58%) with persistent AF (duration <1 year but >7 days) and 22 patients (42%) with long-lasting persistent AF (duration of ≥1 year; Table 1). All patients presented with incessant AF in the beginning of the procedure. The patients were excluded from the study if they were in sinus rhythm or had spontaneous termination of AF before the PVI. Electrophysiological StudyAn electrophysiological study and catheter ablation in the fasting state were performed in each patient after informed consent was obtained. All antiarrhythmic drugs, except amiodarone, were discontinued for ≥5 half-lives before the start of the procedure. Overall, 19 patients (36%) were treated with amiodarone before the procedure because of symptomatic AF, but no patients received that drug during the electrophysiological procedure. Electroanatomic mapping was performed in all patients. The details of the mapping have been described in other previous studies. 10,11 Signal Acquisition and Linear AnalysisDuring AF, point-by-point mapping was ...

“…The settings included a refractory period of 40 ms, a peak-to-peak sensitivity between 0.05 mV and 0.1 mV, and a duration of 10 ms. Continuous CFAEs were defined as having a mean fractionation interval <50 ms and variable CFAEs as having a fractionation interval of 50 to 120 ms. [22][23][24] For fast-Fourier transform analysis, DF The bipolar signals obtained from the 5-second recording were analyzed, and the highest peak frequency of the resulting spectrum was identified as the DF. On the DF map produced by the NavX system, a high DF site was defined as a site with a frequency >8 Hz and colored bright purple.…”

Section: Cfae and Fast-fourier Transform Analysesmentioning

confidence: 99%

“…8 Detailed analysis of the NavX-based DF and CFAE maps showed that most CFAE activity occurred near a high DF site and that the cores of the widely distributed continuous CFAEs sites correlated with the high DF sites. 23 Therefore, overlap between the locations of EAT and the high DF sites implies that EAT is most likely to harbor high-frequency sites, producing a favorable condition for maintenance of AF.…”

Section: Presence Of Eat and Its Influence On Afmentioning

confidence: 99%

Does Location of Epicardial Adipose Tissue Correspond to Endocardial High Dominant Frequency or Complex Fractionated Atrial Electrogram Sites During Atrial Fibrillation?

Nagashima

Okumura

Watanabe

et al. 2012

Background— Although increased epicardial adipose tissue (EAT) volume is known to be associated with increased prevalence of atrial fibrillation (AF), the exact mechanisms are unclear. Therefore, we investigated whether EAT locations were associated with high dominant frequency (DF) sites or complicated fractionated atrial electrogram sites during AF. Methods and Results— Three-dimensional reconstruction computed tomography images depicting EAT volumes (obtained by 320-detector-row multislice computed tomography) were merged with NavX-based DF and complicated fractionated atrial electrogram maps obtained during AF for 16 patients with paroxysmal AF and for 18 patients with persistent AF. Agreement between locations of the EAT, especially EAT surrounding the left atrium, and of high DF or complicated fractionated atrial electrogram sites was quantified. In addition, serum biomarker levels were determined. EAT surrounding the left atrium volumes was significantly greater in patients with persistent AF than in patients with paroxysmal AF (52.9 cm 3 [95% CI, 44.2–61.5] versus 34.8 cm 3 [95% CI, 26.6–43.0]; P =0.007). Serum high-sensitivity C-reactive protein and interleukin-6 levels were significantly higher in persistent AF patients than in paroxysmal AF patients (median high-sensitivity C-reactive protein, 969 ng/mL [interquartile range, 307–1678] versus 320 ng/mL [interquartile range, 120–660]; P =0.008; median interleukin-6, 2.4 pg/mL [interquartile range, 1.7–3.2] versus 1.3 [interquartile range, 0.8–2.4] pg/mL; P =0.017). EAT locations were in excellent agreement with high DF sites (κ=0.77 [95% CI, 0.71–0.82]) but in poor agreement with complicated fractionated atrial electrogram sites (κ=0.22 [95% CI, 0.13–0.31]). Conclusions— Increased EAT volume and elevation of inflammatory biomarkers are noted in persistent AF rather than paroxysmal AF patients. High DF sites are located adjacent to EAT sites. Thus, EAT may be involved in the maintenance of AF.