Yenn-Jiang Lin1, Men-Tzung Lo2, Shih-Lin Chang1, Li-Wei Lo1, Yu-Feng Hu1, Tze-Fan Chao1, Fa-Po Chung1, Jo-Nan Liao1, Chin-Yu Lin1, Huan-Yu Kuo2, Yi-Chung Chang3, Chen Lin2, Ta-Chuan Tuan1, Hsu-Wen Vincent Young4, Kazuyoshi Suenari5, Van Buu Dan Do5, Suunu Budhi Raharjo5, Norden E Huang4, Shih-Ann Chen6. 1. Faculty of Medicine and Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan. 2. Department of Biomedical Sciences and Engineering, National Central University, Jhong-Li, Taoyuan, Taiwan; Center for Dynamical Biomarkers and Translational Medicine, National Central University, Jhong-Li, Taoyuan, Taiwan. 3. Institute of Communication Engineering, National Taiwan University, Taipei, Taiwan. 4. Center for Dynamical Biomarkers and Translational Medicine, National Central University, Jhong-Li, Taoyuan, Taiwan. 5. Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan. 6. Faculty of Medicine and Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan; Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan. Electronic address: epsachen@ms41.hinet.net.
Abstract
OBJECTIVES: This prospective study compared the efficacy of atrial substrate modification guided by a nonlinear phase mapping technique with that of conventional substrate ablation. BACKGROUND: The optimal ablation strategy for persistent atrial fibrillation (AF) was unknown. METHODS: In phase 1 study, we applied a cellular automation technique to simulate the electrical wave propagation to improve the phase mapping algorithm, involving analysis of high-similarity electrogram regions. In addition, we defined rotors and focal AF sources, using the physical parameters of the divergence and curvature forces. In phase 2 study, we enrolled 68 patients with persistent AF undergoing substrate modification into 2 groups, group-1 (n = 34) underwent similarity index (SI) and phase mapping techniques; group-2 (n = 34) received complex fractionated atrial electrogram ablation with commercially available software. Group-1 received real-time waveform similarity measurements in which a phase mapping algorithm was applied to localize the sources. We evaluated the single-procedure freedom from AF. RESULTS: In group-1, we identified an average of 2.6 ± 0.89 SI regions per chamber. These regions involved rotors and focal sources in 65% and 77% of patients in group-1, respectively. Group-1 patients had shorter ablation procedure times, higher termination rates, and significant reduction in AF recurrence compared to group-2 and a trend toward benefit for all atrial arrhythmias. Multivariate analysis showed that substrate mapping using nonlinear similarity and phase mapping was the independent predictor of freedom from AF recurrence (hazard ratio: 0.26; 95% confidence interval: 0.09 to 0.74; p = 0.01). CONCLUSIONS: Our study showed that for persistent AF ablation, a specified substrate modification guided by nonlinear phase mapping could eliminate localized re-entry and non-pulmonary focal sources after pulmonary vein isolation.
OBJECTIVES: This prospective study compared the efficacy of atrial substrate modification guided by a nonlinear phase mapping technique with that of conventional substrate ablation. BACKGROUND: The optimal ablation strategy for persistent atrial fibrillation (AF) was unknown. METHODS: In phase 1 study, we applied a cellular automation technique to simulate the electrical wave propagation to improve the phase mapping algorithm, involving analysis of high-similarity electrogram regions. In addition, we defined rotors and focal AF sources, using the physical parameters of the divergence and curvature forces. In phase 2 study, we enrolled 68 patients with persistent AF undergoing substrate modification into 2 groups, group-1 (n = 34) underwent similarity index (SI) and phase mapping techniques; group-2 (n = 34) received complex fractionated atrial electrogram ablation with commercially available software. Group-1 received real-time waveform similarity measurements in which a phase mapping algorithm was applied to localize the sources. We evaluated the single-procedure freedom from AF. RESULTS: In group-1, we identified an average of 2.6 ± 0.89 SI regions per chamber. These regions involved rotors and focal sources in 65% and 77% of patients in group-1, respectively. Group-1 patients had shorter ablation procedure times, higher termination rates, and significant reduction in AF recurrence compared to group-2 and a trend toward benefit for all atrial arrhythmias. Multivariate analysis showed that substrate mapping using nonlinear similarity and phase mapping was the independent predictor of freedom from AF recurrence (hazard ratio: 0.26; 95% confidence interval: 0.09 to 0.74; p = 0.01). CONCLUSIONS: Our study showed that for persistent AF ablation, a specified substrate modification guided by nonlinear phase mapping could eliminate localized re-entry and non-pulmonary focal sources after pulmonary vein isolation.
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