Characterization of drivers maintaining atrial fibrillation: Correlation with markers of rapidity and organization on spectral analysis

Honarbakhsh, Shohreh; Schilling, Richard J.; Providência, Rui; Keating, Emily; Chow, Anthony; Sporton, Simon; Earley, Mark J.; Lambiase, Pier D.; Hunter, Ross J.

doi:10.1016/j.hrthm.2018.04.020

Cited by 38 publications

(99 citation statements)

References 30 publications

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“…The definition used for localized drivers in AF continues to be debated with alternative definitions used in different studies . There are data emerging from centers using different mapping technologies suggesting that AF may be sustained by focal and rotational sources that are spatially stable but with temporal periodicity . However, it remains unclear how best to map and ablate these potential drivers.…”

Section: Discussionmentioning

confidence: 99%

“…Ablation was stopped if: (a) 5 minutes of ablation had been performed, (b) no signal remained at the ablation site, or (c) a study‐defined ablation response had been achieved. Ablation responses were defined as the termination of AF (into AT or sinus rhythm), or CL slowing of ≥30 ms. Our group has previously applied this definition . AF CL was measured over 30 beats from the PentaRay catheter positioned in the LA appendage.…”

Section: Methodsmentioning

confidence: 99%

“…Global atrial mapping to identify localized drivers in persistent atrial fibrillation (AF) has formed the foundation for several mapping systems, which utilize either basket catheters or noninvasive surface electrocardiogram recordings. When dealing with the constantly changing cycle length (CL) of AF there is a clear advantage in achieving simultaneous atrial mapping.…”

Section: Introductionmentioning

confidence: 99%

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STAR mapping method to identify driving sites in persistent atrial fibrillation: Application through sequential mapping

Honarbakhsh

Schilling

Finlay

et al. 2019

Cardiovasc electrophysiol

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Introduction The optimal way to map localized drivers in persistent atrial fibrillation (AF) remains unclear. The objective of the study was to apply a novel vector mapping approach called Stochastic Trajectory Analysis of Ranked signals (STAR) in AF. Methods and Results Patients having persistent AF ablation were included. Early sites of activation (ESA) identified on global STAR maps created with basket catheters were used to guide AF ablation post‐pulmonary vein isolation (PVI). All patients also had sequential STAR maps created with ≥10 PentaRay recordings of 30 seconds. These were validated offline in their ability to identify the ESA targeted with a study‐defined ablation response (AF termination or cycle length [CL] slowing of ≥30 ms). Thirty‐two patients were included in whom 92 ESA were identified on the global STAR maps, with 73 of 83 targeted sites demonstrating an ablation response (24 AF termination and 49 CL slowing). Sixty‐one out of 73 (83.6%) ESA were also identified on the sequential STAR maps. These showed greater consistency (P < .001), were seen pre‐ and post‐PVI (P < .001) and were more likely to be associated with AF termination on ablation (P = .007). The sensitivity and specificity of sequential mapping for the detection of ESA with an ablation response was 84.9% (95% confidence interval [CI] = 74.6‐92.2) and 90.0% (95% CI = 55.5‐99.8), respectively. During a follow‐up of 19.4 ± 3.7 months, 28 (80%) patients were free from AF/atrial tachycardia. Conclusions STAR mapping consistently identified ESA in all patients and the ablation response was compatible with ESA being driver sites. Mechanistically important ESA were successfully identified using sequential recordings.

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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STAR mapping method to identify driving sites in persistent atrial fibrillation: Application through sequential mapping

Honarbakhsh

Schilling

Finlay

et al. 2019

Cardiovasc electrophysiol

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“…CARTO has recently produced CARTOFINDER (Biosense Webster) which times electrograms relative to each other in a 250 ms window which then moves through a continuous recording to show wavefront movement over time. This has enjoyed some success demonstrating focal and rotational activations in AF and an automated approach to their detection has been developed . The Topera and ECGi mapping systems rely on phase mapping to identify drivers.…”

Section: Discussionmentioning

confidence: 99%

“…The maximum GEPD was varied between 1 and 9 cm for all STAR maps. For each GEPD the number of paired electrodes was manually determined from all the maps for each anatomical LA surface using a previously described LA model . In brief, the LA was segmented into five anatomical surfaces (anterior, roof, septum, lateral, and posterior‐inferior).…”

Section: Methodsmentioning

confidence: 99%

Development, in vitro validation and human application of a novel method to identify arrhythmia mechanisms: The stochastic trajectory analysis of ranked signals mapping method

Honarbakhsh

Hunter

Finlay

et al. 2019

Cardiovasc electrophysiol

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Introduction Stochastic trajectory analysis of ranked signals (STAR) is a novel method for mapping arrhythmia. The aim was to describe its development and validation as a mapping tool. Methods and Results The method ranks electrodes in terms of the proportion of the time they lead relative to neighboring electrodes and ascribes a predominant direction of activation between electrodes. This was conceived with the aim of mapping atrial fibrillation (AF) drivers. Validation of this approach was performed in stages. First, in vitro simultaneous multi‐electrode array and optical mapping were performed on spontaneously fibrillating HL1 cell cultures, to determine if such a method would be able to determine early sites of activation (ESA). A clinical study acquiring unipolar electrograms using a 64‐pole basket for the purposes of STAR mapping in patients undergoing atrial tachycardia (AT) ablation. STAR maps were analyzed by physicians to see if arrhythmia mechanisms could be correctly determined. Mapping was then repeated during atrial pacing. STAR mapping of in vitro activation sequences accurately correlated to the optical maps of planar and rotational activation. Thirty‐two ATs were mapped in 25 patients. The ESA accurately identified focal/micro‐reentrant ATs and the mechanism of macro‐reentrant ATs was effectively demonstrated. STAR method accurately identified four pacing sites in all patients. Conclusions This novel STAR method correlated well with the gold standard of optical mapping in vitro and was able to accurately identify AT mechanisms. Further analysis is needed to determine whether the method might be of use mapping AF.

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The spatiotemporal electrogram dispersion ablation targeting rotors is more effective for elderly patients than non‐elderly population

Sakata

Tanaka

Yamashita

et al. 2023

Journal of Arrhythmia

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Background Modulating atrial fibrillation (AF) drivers has been proposed as one of the effective ablation strategies for non‐paroxysmal AF (non‐PAF). However, the optimal non‐PAF ablation strategy is still under debate because the exact mechanisms of AF persistence including focal activity and/or rotational activity, are not well‐understood. Recently, spatiotemporal electrogram dispersion (STED) assumed to indicate rotors in the form of rotational activity is proposed as an effective target for non‐PAF ablation. We aimed to clarify the effectiveness of STED ablation for modulating AF drivers. Methods STED ablation plus pulmonary vein isolation was applied in 161 consecutive non‐PAF patients not undergoing previous ablation. STED areas within the entire left and right atria were identified and ablated during AF. After the procedures, the STED ablation's acute and long‐term outcomes were investigated. Results (1) Despite a more effective acute outcome of the STED ablation for both AF termination and non‐inducibility of atrial tachyarrhythmias (ATAs), Kaplan–Meier curves showed that the 24‐month freedom ratio from ATAs was 49%, which resulted from the higher recurrence ratio of atrial tachycardia (AT) rather than AF. (2) A multivariate analysis showed that the determinant of ATA recurrences was only a non‐elderly age, not long‐standing persistent AF, and an enlarged left atrium, which were conventionally considered as key factors. Conclusions STED ablation targeting rotors was effective in elderly non‐PAF patients. Therefore, the main mechanism of AF persistency and the component of the fibrillatory conduction might vary between elders and non‐elders. However, we should be careful about post‐ablation ATs following substrate modification.

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Characterization of drivers maintaining atrial fibrillation: Correlation with markers of rapidity and organization on spectral analysis

Abstract: Intermittent focal or rotational drivers were identified in all patients. Drivers consistently correlated to organization markers. Greater temporal stability and organization predicted AF termination with driver ablation.

Cited by 38 publications

References 30 publications

STAR mapping method to identify driving sites in persistent atrial fibrillation: Application through sequential mapping

STAR mapping method to identify driving sites in persistent atrial fibrillation: Application through sequential mapping

Development, in vitro validation and human application of a novel method to identify arrhythmia mechanisms: The stochastic trajectory analysis of ranked signals mapping method

The spatiotemporal electrogram dispersion ablation targeting rotors is more effective for elderly patients than non‐elderly population

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