Christopher A B Kowalewski1,2, Fatemah Shenasa1, Miguel Rodrigo1, Paul Clopton1, Gabriela Meckler1, Mahmood I Alhusseini1, Mark A Swerdlow1, Vijay Joshi1, Samir Hossainy3, Junaid A B Zaman1,4, Tina Baykaner1, Albert J Rogers1, Johannes Brachmann5, John M Miller6, David E Krummen7, William H Sauer8, Nicholas S Peters4, Paul J Wang1, Sanjiv M Narayan9. 1. Department of Medicine, Stanford University, CA (C.A.B.K., F.S., M.R., P.C., G.M., M.I.A., M.A.S., V.J., J.A.B.Z., T.B., A.J.R., P.J.W., S.M.N.). 2. Department of Cardiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany (C.A.B.K.). 3. Department of Engineering, University of California, Berkeley (S.H.). 4. ElectroCardioMaths Programme, Imperial College, London, United Kingdom (J.A.B.Z., N.S.P.). 5. Klinikum Coburg, Germany (J.B.). 6. Department of Medicine, Indiana University, Indianapolis (J.M.M.). 7. Department of Medicine, University of California San Diego (D.E.K.). 8. Department of Medicine, University of Colorado, Denver (W.H.S.). 9. Department of Medicine, Stanford University, CA (C.A.B.K., F.S., M.R., P.C., G.M., M.I.A., M.A.S., V.J., J.A.B.Z., T.B., A.J.R., P.J.W., S.M.N.). sanjiv1@stanford.edu.
Abstract
BACKGROUND: Mechanisms for persistent atrial fibrillation (AF) are unclear. We hypothesized that putative AF drivers and disorganized zones may interact dynamically over short time scales. We studied this interaction over prolonged durations, focusing on regions where ablation terminates persistent AF using 2 mapping methods. METHODS: We recruited 55 patients with persistent AF in whom ablation terminated AF prior to pulmonary vein isolation from a multicenter registry. AF was mapped globally using electrograms for 360±45 cycles using (1) a published phase method and (2) a commercial activation/phase method. RESULTS: Patients were 62.2±9.7 years, 76% male. Sites of AF termination showed rotational/focal patterns by methods 1 and 2 (51/55 vs 55/55; P=0.13) in spatially conserved regions, yet fluctuated over time. Time points with no AF driver showed competing drivers elsewhere or disordered waves. Organized regions were detected for 61.6±23.9% and 70.6±20.6% of 1 minute per method (P=nonsignificant), confirmed by automatic phase tracking (P<0.05). To detect AF drivers with >90% sensitivity, 8 to 32 s of AF recordings were required depending on driver definition. CONCLUSIONS: Sites at which persistent AF terminated by ablation show organized activation that fluctuate over time, because of collision from concurrent organized zones or fibrillatory waves, yet recur in conserved spatial regions. Results were similar by 2 mapping methods. This network of competing mechanisms should be reconciled with existing disorganized or driver mechanisms for AF, to improve clinical mapping and ablation of persistent AF. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02997254.
BACKGROUND: Mechanisms for persistent atrial fibrillation (AF) are unclear. We hypothesized that putative AF drivers and disorganized zones may interact dynamically over short time scales. We studied this interaction over prolonged durations, focusing on regions where ablation terminates persistent AF using 2 mapping methods. METHODS: We recruited 55 patients with persistent AF in whom ablation terminated AF prior to pulmonary vein isolation from a multicenter registry. AF was mapped globally using electrograms for 360±45 cycles using (1) a published phase method and (2) a commercial activation/phase method. RESULTS:Patients were 62.2±9.7 years, 76% male. Sites of AF termination showed rotational/focal patterns by methods 1 and 2 (51/55 vs 55/55; P=0.13) in spatially conserved regions, yet fluctuated over time. Time points with no AF driver showed competing drivers elsewhere or disordered waves. Organized regions were detected for 61.6±23.9% and 70.6±20.6% of 1 minute per method (P=nonsignificant), confirmed by automatic phase tracking (P<0.05). To detect AF drivers with >90% sensitivity, 8 to 32 s of AF recordings were required depending on driver definition. CONCLUSIONS: Sites at which persistent AF terminated by ablation show organized activation that fluctuate over time, because of collision from concurrent organized zones or fibrillatory waves, yet recur in conserved spatial regions. Results were similar by 2 mapping methods. This network of competing mechanisms should be reconciled with existing disorganized or driver mechanisms for AF, to improve clinical mapping and ablation of persistent AF. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02997254.
Authors: Gautam G Lalani; Amir Schricker; Michael Gibson; Armand Rostamian; David E Krummen; Sanjiv M Narayan Journal: J Am Coll Cardiol Date: 2012-02-07 Impact factor: 24.094
Authors: Sanjiv M Narayan; Michael R Franz; Paul Clopton; Etienne J Pruvot; David E Krummen Journal: Circulation Date: 2011-06-06 Impact factor: 29.690
Authors: Brian J Hansen; Jichao Zhao; Thomas A Csepe; Brandon T Moore; Ning Li; Laura A Jayne; Anuradha Kalyanasundaram; Praise Lim; Anna Bratasz; Kimerly A Powell; Orlando P Simonetti; Robert S D Higgins; Ahmet Kilic; Peter J Mohler; Paul M L Janssen; Raul Weiss; John D Hummel; Vadim V Fedorov Journal: Eur Heart J Date: 2015-06-08 Impact factor: 29.983
Authors: Nassir F Marrouche; David Wilber; Gerhard Hindricks; Pierre Jais; Nazem Akoum; Francis Marchlinski; Eugene Kholmovski; Nathan Burgon; Nan Hu; Lluis Mont; Thomas Deneke; Mattias Duytschaever; Thomas Neumann; Moussa Mansour; Christian Mahnkopf; Bengt Herweg; Emile Daoud; Erik Wissner; Paul Bansmann; Johannes Brachmann Journal: JAMA Date: 2014-02-05 Impact factor: 56.272
Authors: John M Miller; Robert C Kowal; Vijay Swarup; James P Daubert; Emile G Daoud; John D Day; Kenneth A Ellenbogen; John D Hummel; Tina Baykaner; David E Krummen; Sanjiv M Narayan; Vivek Y Reddy; Kalyanam Shivkumar; Jonathan S Steinberg; Kevin R Wheelan Journal: J Cardiovasc Electrophysiol Date: 2014-07-23
Authors: Mahmood Alhusseini; David Vidmar; Gabriela L Meckler; Christopher A Kowalewski; Fatemah Shenasa; Paul J Wang; Sanjiv M Narayan; Wouter-Jan Rappel Journal: J Cardiovasc Electrophysiol Date: 2017-03-20
Authors: Miguel Rodrigo; Andreu M Climent; Ismael Hernández-Romero; Alejandro Liberos; Tina Baykaner; Albert J Rogers; Mahmood Alhusseini; Paul J Wang; Francisco Fernández-Avilés; Maria S Guillem; Sanjiv M Narayan; Felipe Atienza Journal: Circ Arrhythm Electrophysiol Date: 2020-02-13
Authors: M Swerdlow; M Tamboli; M I Alhusseini; N Moosvi; A J Rogers; G Leef; P J Wang; A Rillig; J Brachmann; W H Sauer; P Ruppersberg; S M Narayan; T Baykaner Journal: Pacing Clin Electrophysiol Date: 2019-03-24 Impact factor: 1.976
Authors: Mahmood I Alhusseini; Firas Abuzaid; Albert J Rogers; Junaid A B Zaman; Tina Baykaner; Paul Clopton; Peter Bailis; Matei Zaharia; Paul J Wang; Wouter-Jan Rappel; Sanjiv M Narayan Journal: Circ Arrhythm Electrophysiol Date: 2020-07-06
Authors: George Leef; Fatemah Shenasa; Neal K Bhatia; Albert J Rogers; William Sauer; John M Miller; Mark Swerdlow; Mallika Tamboli; Mahmood I Alhusseini; Erin Armenia; Tina Baykaner; Johannes Brachmann; Mintu P Turakhia; Felipe Atienza; Wouter-Jan Rappel; Paul J Wang; Sanjiv M Narayan Journal: Circ Arrhythm Electrophysiol Date: 2019-07-29
Authors: Vasanth Ravikumar; Elizabeth Annoni; Preethy Parthiban; Sharon Zlochiver; Henri Roukoz; Siva K Mulpuru; Elena G Tolkacheva Journal: J Cardiovasc Electrophysiol Date: 2021-02-22
Authors: Michael Tb Pope; Pawel Kuklik; Andre Briosa E Gala; Milena Leo; Michael Mahmoudi; John Paisey; Timothy R Betts Journal: J Cardiovasc Electrophysiol Date: 2021-07-28 Impact factor: 2.942