Sanjiv M Narayan1, David E Krummen2, Paul Clopton3, Kalyanam Shivkumar4, John M Miller5. 1. Department of Medicine, University of California, San Diego, California; Veterans Affairs Medical Center, San Diego, California; University of California, Los Angeles, California. Electronic address: snarayan@ucsd.edu. 2. Department of Medicine, University of California, San Diego, California; Veterans Affairs Medical Center, San Diego, California. 3. Veterans Affairs Medical Center, San Diego, California. 4. University of California, Los Angeles, California. 5. The Krannert Institute of Cardiology, Indiana University, Indianapolis, Indiana.
Abstract
OBJECTIVES: This study sought to determine whether ablation of recently described stable atrial fibrillation (AF) sources, either directly by Focal Impulse and Rotor Modulation (FIRM) or coincidentally when anatomic ablation passes through AF sources, may explain long-term freedom from AF. BACKGROUND: It is unclear why conventional anatomic AF ablation can be effective in some patients yet ineffective in others with similar profiles. METHODS: The CONFIRM (Conventional Ablation for AF With or Without Focal Impulse and Rotor Modulation) trial prospectively revealed stable AF rotors or focal sources in 98 of 101 subjects with AF at 107 consecutive ablation cases. In 1:2 fashion, subjects received targeted source ablation (FIRM) followed by conventional ablation, or conventional ablation alone. We determined whether ablation lesions on electroanatomic maps passed through AF sources on FIRM maps. RESULTS: Subjects who completed follow-up (n = 94; 71.2% with persistent AF) showed 2.3 ± 1.1 concurrent AF rotors or focal sources that lay near pulmonary veins (22.8%), left atrial roof (16.0%), and elsewhere in the left (28.2%) and right (33.0%) atria. AF sources were ablated directly in 100% of FIRM cases and coincidentally (e.g., left atrial roof) in 45% of conventional cases (p < 0.05). During a median (interquartile range) of 273 days (138 to 636 days) after one procedure, AF was absent in 80.3% of patients if sources were ablated but in only 18.2% of patients if sources were missed (p < 0.001). Freedom from AF was highest if all sources were ablated, intermediate if some sources were ablated, and lowest if no sources were ablated (p < 0.001). CONCLUSIONS: Elimination of stable AF rotors and focal sources may explain freedom from AF after diverse approaches to ablation. Patient-specific AF source distributions are consistent with the reported success of specific anatomic lesion sets and of widespread ablation. These results support targeting AF sources to reduce unnecessary ablation, and motivate studies on FIRM-only ablation.
OBJECTIVES: This study sought to determine whether ablation of recently described stable atrial fibrillation (AF) sources, either directly by Focal Impulse and Rotor Modulation (FIRM) or coincidentally when anatomic ablation passes through AF sources, may explain long-term freedom from AF. BACKGROUND: It is unclear why conventional anatomic AF ablation can be effective in some patients yet ineffective in others with similar profiles. METHODS: The CONFIRM (Conventional Ablation for AF With or Without Focal Impulse and Rotor Modulation) trial prospectively revealed stable AF rotors or focal sources in 98 of 101 subjects with AF at 107 consecutive ablation cases. In 1:2 fashion, subjects received targeted source ablation (FIRM) followed by conventional ablation, or conventional ablation alone. We determined whether ablation lesions on electroanatomic maps passed through AF sources on FIRM maps. RESULTS: Subjects who completed follow-up (n = 94; 71.2% with persistent AF) showed 2.3 ± 1.1 concurrent AF rotors or focal sources that lay near pulmonary veins (22.8%), left atrial roof (16.0%), and elsewhere in the left (28.2%) and right (33.0%) atria. AF sources were ablated directly in 100% of FIRM cases and coincidentally (e.g., left atrial roof) in 45% of conventional cases (p < 0.05). During a median (interquartile range) of 273 days (138 to 636 days) after one procedure, AF was absent in 80.3% of patients if sources were ablated but in only 18.2% of patients if sources were missed (p < 0.001). Freedom from AF was highest if all sources were ablated, intermediate if some sources were ablated, and lowest if no sources were ablated (p < 0.001). CONCLUSIONS: Elimination of stable AF rotors and focal sources may explain freedom from AF after diverse approaches to ablation. Patient-specific AF source distributions are consistent with the reported success of specific anatomic lesion sets and of widespread ablation. These results support targeting AF sources to reduce unnecessary ablation, and motivate studies on FIRM-only ablation.
Authors: Hakan Oral; Carlo Pappone; Aman Chugh; Eric Good; Frank Bogun; Frank Pelosi; Eric R Bates; Michael H Lehmann; Gabriele Vicedomini; Giuseppe Augello; Eustachio Agricola; Simone Sala; Vincenzo Santinelli; Fred Morady Journal: N Engl J Med Date: 2006-03-02 Impact factor: 91.245
Authors: Michel Haïssaguerre; Prashanthan Sanders; Mélèze Hocini; Yoshihide Takahashi; Martin Rotter; Frederic Sacher; Thomas Rostock; Li-Fern Hsu; Pierre Bordachar; Sylvain Reuter; Raymond Roudaut; Jacques Clémenty; Pierre Jaïs Journal: J Cardiovasc Electrophysiol Date: 2005-11
Authors: Hakan Oral; Aman Chugh; Eric Good; Petar Igic; Darryl Elmouchi; David R Tschopp; S Scott Reich; Frank Bogun; Frank Pelosi; Fred Morady Journal: Heart Rhythm Date: 2005-11 Impact factor: 6.343
Authors: Jayakumar Sahadevan; Kyungmoo Ryu; Leora Peltz; Celeen M Khrestian; Robert W Stewart; Alan H Markowitz; Albert L Waldo Journal: Circulation Date: 2004-11-01 Impact factor: 29.690
Authors: W M Jackman; K J Beckman; J H McClelland; X Wang; K J Friday; C A Roman; K P Moulton; N Twidale; H A Hazlitt; M I Prior Journal: N Engl J Med Date: 1992-07-30 Impact factor: 91.245
Authors: Sorin Lazar; Sanjay Dixit; Francis E Marchlinski; David J Callans; Edward P Gerstenfeld Journal: Circulation Date: 2004-11-08 Impact factor: 29.690
Authors: Hildegard Tanner; Gerhard Hindricks; Richard Kobza; Anja Dorszewski; Petra Schirdewahn; Christopher Piorkowski; Jin-Hong Gerds-Li; Hans Kottkamp Journal: J Am Coll Cardiol Date: 2005-07-19 Impact factor: 24.094
Authors: Tsu-Juey Wu; Rahul N Doshi; Hsun-Lun A Huang; Carlos Blanche; Robert M Kass; Alfredo Trento; Wen Cheng; Hrayr S Karagueuzian; C Thomas Peter; Peng-Sheng Chen Journal: J Cardiovasc Electrophysiol Date: 2002-06
Authors: Michel Haïssaguerre; Mélèze Hocini; Prashanthan Sanders; Yoshihide Takahashi; Martin Rotter; Frederic Sacher; Thomas Rostock; Li-Fern Hsu; Anders Jonsson; Mark D O'Neill; Pierre Bordachar; Sylvain Reuter; Raymond Roudaut; Jacques Clémenty; Pierre Jaïs Journal: Circulation Date: 2006-02-07 Impact factor: 29.690
Authors: Matthew J Gonzales; Kevin P Vincent; Wouter-Jan Rappel; Sanjiv M Narayan; Andrew D McCulloch Journal: Europace Date: 2014-11 Impact factor: 5.214
Authors: Tina Baykaner; Paul Clopton; Gautam G Lalani; Amir A Schricker; David E Krummen; Sanjiv M Narayan Journal: Can J Cardiol Date: 2013-08-30 Impact factor: 5.223
Authors: Miguel Rodrigo; Andreu M Climent; Alejandro Liberos; Francisco Fernández-Avilés; Omer Berenfeld; Felipe Atienza; Maria S Guillem Journal: Heart Rhythm Date: 2017-04-10 Impact factor: 6.343
Authors: Seungyup Lee; Jayakumar Sahadevan; Celeen M Khrestian; Ivan Cakulev; Alan Markowitz; Albert L Waldo Journal: Circulation Date: 2015-10-23 Impact factor: 29.690
Authors: Hugo Enrique Coutiño; Carlo de Asmundis; Giacomo Mugnai; Darragh Moran; Valentina De Regibus; Erwin Ströker; Ken Takarada; Diego Ruggiero; Rajin Choudhury; Stefan Beckers; Carla Van Gompel; Jan Poelaert; Saverio Iacopino; Pasquale Filannino; Pedro Brugada; Gian-Battista Chierchia Journal: J Interv Card Electrophysiol Date: 2016-08-25 Impact factor: 1.900
Authors: Tina Baykaner; Albert J Rogers; Gabriela L Meckler; Junaid Zaman; Rachita Navara; Miguel Rodrigo; Mahmood Alhusseini; Christopher A B Kowalewski; Mohan N Viswanathan; Sanjiv M Narayan; Paul Clopton; Paul J Wang; Paul A Heidenreich Journal: Circ Arrhythm Electrophysiol Date: 2018-05