Ablation of Driver Domains During Persistent Atrial Fibrillation

Kalifa, Jérôme; Avula, Uma Mahesh R.

doi:10.1161/circulationaha.114.011635

Cited by 5 publications

(2 citation statements)

References 37 publications

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“…Second, AF electrograms from some forms of the inverse solution may not accurately depict contact recordings in AF . Third, a recent study on electrograms computed from the body surface by the inverse solution validated the CONFIRM trial, by showing a small number of AF driver regions that were temporally stable for days (between mapping and ablation) in spatially limited atrial regions targeted for ablation. In addition, projecting electrograms from the heart to the body surface may appear to magnify precession .…”

Section: Discussionmentioning

confidence: 99%

Stability of Rotors and Focal Sources for Human Atrial Fibrillation: Focal Impulse and Rotor Mapping (FIRM) of AF Sources and Fibrillatory Conduction

Swarup

Baykaner

Rostamian

et al. 2014

Cardiovasc electrophysiol

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Rotors and focal sources for human AF mapped by FIRM over prolonged time periods precess ("wobble") but remain within stable regions for thousands of cycles. Conversely, emanating activity such as spiral waves disorganize and collide with the fibrillatory milieu, explaining difficulties in using activation mapping or signal processing analyses at fixed electrodes to detect AF rotors. These results provide a rationale for targeted ablation at AF sources rather than fibrillatory spiral waves.

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Section: Discussionmentioning

confidence: 99%

Stability of Rotors and Focal Sources for Human Atrial Fibrillation: Focal Impulse and Rotor Mapping (FIRM) of AF Sources and Fibrillatory Conduction

Swarup

Baykaner

Rostamian

et al. 2014

Cardiovasc electrophysiol

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“…39 Third, notwithstanding these differences, a recent study using the inverse solution 37 showed a small number of AF drivers regions that were temporally stable (for days between mapping and ablation) in limited atrial regions targeted for ablation as in the CONFIRM trial. 40 Finally, studying only short ECG segments between QRS complexes from the inverse solution 37 may diminish stability evident when AF is mapped for longer periods. 41 Re-mapping after rotor elimination may help to validate rotors that are physiological and eliminated by ablation, a central element of FIRM-guided ablation.…”

Section: Conventional Ablation For Atrial Fibrillation With or Withoumentioning

confidence: 99%

Role of Rotors in the Ablative Therapy of Persistent Atrial Fibrillation

Schricker¹,

Zaman²,

Narayan³

2015

Arrhythmia &Amp; Electrophysiology Review

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Catheter ablation is more effective than pharmacological therapy for the secondary prevention of patients with paroxysmal 1,2 and persistent 3,4 atrial fibrillation (AF) and has an emerging role in the primary prevention of paroxysmal AF. 5,6 Nevertheless, in randomised clinical trials (RCTs) its success in treating patients with paroxysmal AF is 40-60 % for a single procedure and 70 % for multiple procedures at one year, 1,2 and results for persistent AF are lower. 7,8 Thus, there is an urgent unmet need to improve our understanding of mechanistic targets for AF in each patient, to match recent advances in ablation energy delivery and catheter positioning.This report reviews mechanistic data on human AF, mapping technologies that provide the opportunity to reconcile fundamental mechanisms in individual patients and their therapeutic application. Atrial Fibrillation MechanismsAF is initiated by triggers predominantly near the pulmonary veins (PV), 9 with increasingly recognised sites outside the PVs. [10][11][12] To improve success, ablation to eliminate AF triggers should thus also target non-PV triggers, although they are transient and difficult to locate. Another potential ablative target is the mechanistic cascade by which triggers initiate AF, yet this is relatively unstudied. We recently showed -using wide-area mapping during spont aneous and induced AF -that the first cycles of AF after a trigger exhibit a single organised re-entrant spiral wave or focal driver (see Figure 1) that subsequently disorganises. 13 Remarkably, these AF-initiating mechanisms may be relatively spatially fixed for each patient -even for different triggers from both atria -separated by 2.1 ± 1.7 cm from trigger sites (see Figure 1). 13 Thus, AF initiation is likely to be a two-step mechanistic process, in which 1) a trigger initiates an organised spiral wave or focal source at patient-specific anatomical sites that 2) lead rapidly to disorganisation to produce the classical AF phenotype. This begs the question of whether AF maintenance is driven by self-sustaining disorganisation, or whether disorganisation is actually sustained by localised AF drivers (rotors or focal drivers).Self-sustaining disorganisation was traditionally considered the mechanism of AF maintenance. This mechanism is supported by computational models in which multiple wavelets sustain AF if there is enough room in the atrium ('critical mass'), 14 proposals that dissociation between the epicardium and endocardium may be contributory 15 and plaque recordings from the atria of patients in the operating room showing re-entry without apparent organisation. Limitations to these studies are that fibrillatory maps are based upon recordings that poorly represent local activation;16 only small areas of the atria were mapped (<10-20 %) and while these studies show that disorganisation exists they did not test if it self-sustains. The success of widespread ablation or Maze surgery supports the concept of self-sustaining disorganisation, but are also consistent with coinci...

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Rotor mapping and ablation to treat atrial fibrillation

Zaman

Peters²,

Narayan³

2015

Current Opinion in Cardiology

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Purpose of review Rotors have long been postulated to drive atrial fibrillation, but evidence has been limited to animal models. This changed recently with the demonstration using focal impulse and rotor modulation (FIRM) mapping that rotors act as human atrial fibrillation sources. This mechanistic approach to diagnosing the causes of atrial fibrillation in individual patients has been supported by substantially improved outcomes from FIRM-guided ablation, resulting in increased attention to rotors as therapeutic targets. Recent findings In this review, we outline the pathophysiology of rotors in animal and in-silico studies of fibrillation, and how this motivated FIRM mapping in humans. We highlight the characteristics of rotors in human atrial fibrillation, now validated by several techniques, with discussion on similar and discrepant findings between techniques. The interventional approaches to eliminate atrial fibrillation rotors are explained and the ablation results in latest studies using FIRM are discussed. Summary We propose that mapping localized sources for human atrial fibrillation, specifically rotors, is moving the field towards a unifying hypothesis that explains several otherwise contradictory observations in atrial fibrillation management. We conclude by suggesting areas of potential research that may reveal more about these critical sites and how these may lead to better and novel treatments for atrial fibrillation.

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Ablation of Driver Domains During Persistent Atrial Fibrillation

Cited by 5 publications

References 37 publications

Stability of Rotors and Focal Sources for Human Atrial Fibrillation: Focal Impulse and Rotor Mapping (FIRM) of AF Sources and Fibrillatory Conduction

Stability of Rotors and Focal Sources for Human Atrial Fibrillation: Focal Impulse and Rotor Mapping (FIRM) of AF Sources and Fibrillatory Conduction

Role of Rotors in the Ablative Therapy of Persistent Atrial Fibrillation

Rotor mapping and ablation to treat atrial fibrillation

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