Electrographic flow mapping of persistent atrial fibrillation: intra- and inter-procedure reproducibility in the absence of ‘ground truth’

Purpose of review A low ceiling of efficacy exists for the treatment of persistent atrial fibrillation via pulmonary vein isolation without adjunctive ablations, which is likely because they do not target an individual patient's specific underlying disease mechanisms. Electrographic flow (EGF) mapping is the first system that reliably displays wavefront propagation through the atria. It is a promising tool for localizing sources of atrial fibrillation, guiding targeted ablation, and visualizing conduction through the atrial substrate. Recent findings We describe EGF mapping with emphasis on contemporary studies examining map reproducibility and use cases in the preclinical and clinical environment. Animal experiments demonstrated that maps were interpretable across increasingly complex rhythms with pacing during spontaneously persistent atrial fibrillation reliably simulating EGF sources. The FLOW-AF randomized controlled trial showed that source ablation improved outcomes and that EGF map properties may be used to phenotype patients based on their atrial fibrillation mechanisms and recurrence likelihoods. Summary Targeted ablation strategies balance the risks of insufficiently ablating atrial fibrillation triggers with exacerbating disease through additional scar formation. EGF mapping leverages spatiotemporal relationships in voltage to localize sources and quantify substrate health. Further research is needed to optimize phenotyping and treatment efforts.

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Analysis of the Time-Dependent Behaviors of Atrial Fibrillation with Electrographic Flow Mapping

Haines,

Kong,

Ruppersberg

et al. 2024

Preprint

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Background Electrographic flow (EGF) mapping algorithms employing Horn-Schunck flow estimations can create temporospatial visualizations of atrial electrical wavefront propagations during atrial fibrillation (AF). Reproducible patterns of centrifugal EGF activation from discrete sites may represent sites of AF origin or sources. Our objectives were to assess the patterns and prevalence of AF sources using EGF mapping. Methods Unipolar electrograms were recorded for 1-minute with 64-pole basket catheters. Flow estimates were constructed by passing consecutive frames through an algorithm to learn and then compare typical wave direction patterns to describe flow-field evolution. During each 2-second segment, sites initiating centrifugal activation patterns were defined as AF sources. Maps of source location/activity duration were generated. Results The EGF method was applied to 405 prospective and retrospective patients with persistent or long-standing persistent AF. Mean age 62.5 years; mean LA size 54 mm; mean AF duration 4.6 years. EGF mapping found 6.6 ± 2.4 AF sources/patient (range 1 to 17). Distribution was 55% LA and 45% RA. Dominant sources (prevalence >20%) were demonstrated in 185 (45.7%) patients, but only 10.7% of all sources were dominant. While AF cycle length (CL) was not affected by source prevalence, CL variance significantly decreased as source prevalence increased. Conclusions Complex AF conduction patterns make ablation challenging, but EGF mapping enables detection and organization of time-dependent AF behaviors. Although many low prevalence sources are detected, they may not be clinically relevant, while higher prevalence sources seem to modulate AF. Recording durations of 1 minute facilitate source discrimination.

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Electrographic flow mapping of persistent atrial fibrillation: intra- and inter-procedure reproducibility in the absence of ‘ground truth’

Cited by 3 publications

References 36 publications

PVI-only is not enough for all patients with persistent AF: A FLOW-AF subgroup analysis

PVI-only is not enough for all patients with persistent AF: A FLOW-AF subgroup analysis

Electrographic flow mapping of atrial fibrillation

Analysis of the Time-Dependent Behaviors of Atrial Fibrillation with Electrographic Flow Mapping

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