Ablation of rotor and focal sources reduces late recurrence of atrial fibrillation compared with trigger ablation alone: Extended follow-up of the CONFIRM trial (conventional ablation for atrial fibrillation with or without focal impulse and rotor modulation)

Sanjiv M. Narayan, Tina Baykaner, Paul Clopton, Amir Schricker, Gautam G. Lalani, David E. Krummen, Kalyanam Shivkumar, John Miller

Research output: Contribution to journalArticle

206 Citations (Scopus)

Abstract

Objectives The aim of this study was to determine if ablation that targets patient-specific atrial fibrillation (AF)-sustaining substrates (rotors or focal sources) is more durable than trigger ablation alone at preventing late AF recurrence. Background Late recurrence substantially limits the efficacy of pulmonary vein isolation for AF and is associated with pulmonary vein reconnection and the emergence of new triggers. Methods Three-year follow-up was performed of the CONFIRM (Conventional Ablation for Atrial Fibrillation With or Without Focal Impulse and Rotor Modulation) trial, in which 92 consecutive patients with AF (70.7% persistent) underwent novel computational mapping. Ablation comprised source (focal impulse and rotor modulation [FIRM]) and then conventional ablation in 27 patients (FIRM guided) and conventional ablation alone in 65 patients (FIRM blinded). Patients were followed with implanted electrocardiographic monitors when possible (85.2% of FIRM-guided patients, 23.1% of FIRM-blinded patients). Results FIRM mapping revealed a median of 2 (interquartile range: 1 to 2) rotors or focal sources in 97.7% of patients during AF. During a median follow-up period of 890 days (interquartile range: 224 to 1,563 days), compared to FIRM-blinded therapy, patients receiving FIRM-guided ablation maintained higher freedom from AF after 1.2 ± 0.4 procedures (median 1; interquartile range: 1 to 1) (77.8% vs. 38.5%, p = 0.001) and a single procedure (p < 0.001) and higher freedom from all atrial arrhythmias (p = 0.003). Freedom from AF was higher when ablation directly or coincidentally passed through sources than when it missed sources (p < 0.001). Conclusions FIRM-guided ablation is more durable than conventional trigger-based ablation in preventing 3-year AF recurrence. Future studies should investigate how ablation of patient-specific AF-sustaining rotors and focal sources alters the natural history of arrhythmia recurrence. (The Dynamics of Human Atrial Fibrillation; NCT01008722).

Original languageEnglish
Pages (from-to)1761-1768
Number of pages8
JournalJournal of the American College of Cardiology
Volume63
Issue number17
DOIs
StatePublished - May 6 2014

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Atrial Fibrillation
Recurrence
Pulmonary Veins
Cardiac Arrhythmias

Keywords

  • ablation
  • atrial fibrillation
  • clinical trial
  • electrical rotors
  • FIRM

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Ablation of rotor and focal sources reduces late recurrence of atrial fibrillation compared with trigger ablation alone : Extended follow-up of the CONFIRM trial (conventional ablation for atrial fibrillation with or without focal impulse and rotor modulation). / Narayan, Sanjiv M.; Baykaner, Tina; Clopton, Paul; Schricker, Amir; Lalani, Gautam G.; Krummen, David E.; Shivkumar, Kalyanam; Miller, John.

In: Journal of the American College of Cardiology, Vol. 63, No. 17, 06.05.2014, p. 1761-1768.

Research output: Contribution to journalArticle

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title = "Ablation of rotor and focal sources reduces late recurrence of atrial fibrillation compared with trigger ablation alone: Extended follow-up of the CONFIRM trial (conventional ablation for atrial fibrillation with or without focal impulse and rotor modulation)",
abstract = "Objectives The aim of this study was to determine if ablation that targets patient-specific atrial fibrillation (AF)-sustaining substrates (rotors or focal sources) is more durable than trigger ablation alone at preventing late AF recurrence. Background Late recurrence substantially limits the efficacy of pulmonary vein isolation for AF and is associated with pulmonary vein reconnection and the emergence of new triggers. Methods Three-year follow-up was performed of the CONFIRM (Conventional Ablation for Atrial Fibrillation With or Without Focal Impulse and Rotor Modulation) trial, in which 92 consecutive patients with AF (70.7{\%} persistent) underwent novel computational mapping. Ablation comprised source (focal impulse and rotor modulation [FIRM]) and then conventional ablation in 27 patients (FIRM guided) and conventional ablation alone in 65 patients (FIRM blinded). Patients were followed with implanted electrocardiographic monitors when possible (85.2{\%} of FIRM-guided patients, 23.1{\%} of FIRM-blinded patients). Results FIRM mapping revealed a median of 2 (interquartile range: 1 to 2) rotors or focal sources in 97.7{\%} of patients during AF. During a median follow-up period of 890 days (interquartile range: 224 to 1,563 days), compared to FIRM-blinded therapy, patients receiving FIRM-guided ablation maintained higher freedom from AF after 1.2 ± 0.4 procedures (median 1; interquartile range: 1 to 1) (77.8{\%} vs. 38.5{\%}, p = 0.001) and a single procedure (p < 0.001) and higher freedom from all atrial arrhythmias (p = 0.003). Freedom from AF was higher when ablation directly or coincidentally passed through sources than when it missed sources (p < 0.001). Conclusions FIRM-guided ablation is more durable than conventional trigger-based ablation in preventing 3-year AF recurrence. Future studies should investigate how ablation of patient-specific AF-sustaining rotors and focal sources alters the natural history of arrhythmia recurrence. (The Dynamics of Human Atrial Fibrillation; NCT01008722).",
keywords = "ablation, atrial fibrillation, clinical trial, electrical rotors, FIRM",
author = "Narayan, {Sanjiv M.} and Tina Baykaner and Paul Clopton and Amir Schricker and Lalani, {Gautam G.} and Krummen, {David E.} and Kalyanam Shivkumar and John Miller",
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T1 - Ablation of rotor and focal sources reduces late recurrence of atrial fibrillation compared with trigger ablation alone

T2 - Extended follow-up of the CONFIRM trial (conventional ablation for atrial fibrillation with or without focal impulse and rotor modulation)

AU - Narayan, Sanjiv M.

AU - Baykaner, Tina

AU - Clopton, Paul

AU - Schricker, Amir

AU - Lalani, Gautam G.

AU - Krummen, David E.

AU - Shivkumar, Kalyanam

AU - Miller, John

PY - 2014/5/6

Y1 - 2014/5/6

N2 - Objectives The aim of this study was to determine if ablation that targets patient-specific atrial fibrillation (AF)-sustaining substrates (rotors or focal sources) is more durable than trigger ablation alone at preventing late AF recurrence. Background Late recurrence substantially limits the efficacy of pulmonary vein isolation for AF and is associated with pulmonary vein reconnection and the emergence of new triggers. Methods Three-year follow-up was performed of the CONFIRM (Conventional Ablation for Atrial Fibrillation With or Without Focal Impulse and Rotor Modulation) trial, in which 92 consecutive patients with AF (70.7% persistent) underwent novel computational mapping. Ablation comprised source (focal impulse and rotor modulation [FIRM]) and then conventional ablation in 27 patients (FIRM guided) and conventional ablation alone in 65 patients (FIRM blinded). Patients were followed with implanted electrocardiographic monitors when possible (85.2% of FIRM-guided patients, 23.1% of FIRM-blinded patients). Results FIRM mapping revealed a median of 2 (interquartile range: 1 to 2) rotors or focal sources in 97.7% of patients during AF. During a median follow-up period of 890 days (interquartile range: 224 to 1,563 days), compared to FIRM-blinded therapy, patients receiving FIRM-guided ablation maintained higher freedom from AF after 1.2 ± 0.4 procedures (median 1; interquartile range: 1 to 1) (77.8% vs. 38.5%, p = 0.001) and a single procedure (p < 0.001) and higher freedom from all atrial arrhythmias (p = 0.003). Freedom from AF was higher when ablation directly or coincidentally passed through sources than when it missed sources (p < 0.001). Conclusions FIRM-guided ablation is more durable than conventional trigger-based ablation in preventing 3-year AF recurrence. Future studies should investigate how ablation of patient-specific AF-sustaining rotors and focal sources alters the natural history of arrhythmia recurrence. (The Dynamics of Human Atrial Fibrillation; NCT01008722).

AB - Objectives The aim of this study was to determine if ablation that targets patient-specific atrial fibrillation (AF)-sustaining substrates (rotors or focal sources) is more durable than trigger ablation alone at preventing late AF recurrence. Background Late recurrence substantially limits the efficacy of pulmonary vein isolation for AF and is associated with pulmonary vein reconnection and the emergence of new triggers. Methods Three-year follow-up was performed of the CONFIRM (Conventional Ablation for Atrial Fibrillation With or Without Focal Impulse and Rotor Modulation) trial, in which 92 consecutive patients with AF (70.7% persistent) underwent novel computational mapping. Ablation comprised source (focal impulse and rotor modulation [FIRM]) and then conventional ablation in 27 patients (FIRM guided) and conventional ablation alone in 65 patients (FIRM blinded). Patients were followed with implanted electrocardiographic monitors when possible (85.2% of FIRM-guided patients, 23.1% of FIRM-blinded patients). Results FIRM mapping revealed a median of 2 (interquartile range: 1 to 2) rotors or focal sources in 97.7% of patients during AF. During a median follow-up period of 890 days (interquartile range: 224 to 1,563 days), compared to FIRM-blinded therapy, patients receiving FIRM-guided ablation maintained higher freedom from AF after 1.2 ± 0.4 procedures (median 1; interquartile range: 1 to 1) (77.8% vs. 38.5%, p = 0.001) and a single procedure (p < 0.001) and higher freedom from all atrial arrhythmias (p = 0.003). Freedom from AF was higher when ablation directly or coincidentally passed through sources than when it missed sources (p < 0.001). Conclusions FIRM-guided ablation is more durable than conventional trigger-based ablation in preventing 3-year AF recurrence. Future studies should investigate how ablation of patient-specific AF-sustaining rotors and focal sources alters the natural history of arrhythmia recurrence. (The Dynamics of Human Atrial Fibrillation; NCT01008722).

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KW - atrial fibrillation

KW - clinical trial

KW - electrical rotors

KW - FIRM

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