Driver Domains in Persistent Atrial Fibrillation

BACKGROUND—Specific noninvasive signal processing was applied to identify drivers in distinct categories of persistent atrial fibrillation (AF). METHODS AND RESULTS—In 103 consecutive patients with persistent AF, accurate biatrial geometry relative to an array of 252 body surface electrodes was obta...

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Published in:Circulation (New York, N.Y.) N.Y.), 2014-08, Vol.130 (7), p.530-538
Main Authors: Haissaguerre, Michel, Hocini, Meleze, Denis, Arnaud, Shah, Ashok J, Komatsu, Yuki, Yamashita, Seigo, Daly, Matthew, Amraoui, Sana, Zellerhoff, Stephan, Picat, Marie-Quitterie, Quotb, Adam, Jesel, Laurence, Lim, Han, Ploux, Sylvain, Bordachar, Pierre, Attuel, Guillaume, Meillet, Valentin, Ritter, Philippe, Derval, Nicolas, Sacher, Frederic, Bernus, Olivier, Cochet, Hubert, Jais, Pierre, Dubois, Remi
Format: Article
Language:English
Subjects:
Aged
Atrial Fibrillation - diagnosis
Atrial Fibrillation - physiopathology
Atrial Fibrillation - surgery
Biological and medical sciences
Blood and lymphatic vessels
Body Surface Potential Mapping - methods
Cardiac dysrhythmias
Cardiology. Vascular system
Catheter Ablation - methods
Diseases of the peripheral vessels. Diseases of the vena cava. Miscellaneous
Electronics
Electrophysiologic Techniques, Cardiac - methods
Engineering Sciences
Female
Follow-Up Studies
Heart
Humans
Male
Medical sciences
Middle Aged
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Summary:BACKGROUND—Specific noninvasive signal processing was applied to identify drivers in distinct categories of persistent atrial fibrillation (AF). METHODS AND RESULTS—In 103 consecutive patients with persistent AF, accurate biatrial geometry relative to an array of 252 body surface electrodes was obtained from a noncontrast computed tomography scan. The reconstructed unipolar AF electrograms acquired at bedside from multiple windows (duration, 9±1 s) were signal processed to identify the drivers (focal or reentrant activity) and their cumulative density map. The driver domains were catheter ablated by using AF termination as the procedural end point in comparison with the stepwise-ablation control group. The maps showed incessantly changing beat-to-beat wave fronts and varying spatiotemporal behavior of driver activities. Reentries were not sustained (median, 2.6 rotations lasting 449±89 ms), meandered substantially but recurred repetitively in the same region. In total, 4720 drivers were identified in 103 patients3802 (80.5%) reentries and 918 (19.5%) focal breakthroughs; most of them colocalized. Of these, 69% reentries and 71% foci were in the left atrium. Driver ablation alone terminated 75% and 15% of persistent and long-lasting AF, respectively. The number of targeted driver regions increased with the duration of continuous AF2 in patients presenting in sinus rhythm, 3 in AF lasting 1 to 3 months, 4 in AF lasting 4 to 6 months, and 6 in AF lasting longer. The termination rate sharply declined after 6 months. The mean radiofrequency delivery to AF termination was 28±17 minutes versus 65±33 minutes in the control group (P
ISSN:0009-7322
1524-4539
DOI:10.1161/CIRCULATIONAHA.113.005421