Clinical Benefit of Ablating Localized Sources for Human Atrial Fibrillation: The Indiana University FIRM Registry

John Miller, Vikas Kalra, Mithilesh Das, Rahul Jain, Jason B. Garlie, Jordan A. Brewster, Gopi Dandamudi

Research output: Contribution to journalArticle

55 Citations (Scopus)

Abstract

Background Mounting evidence shows that localized sources maintain atrial fibrillation (AF). However, it is unclear in unselected “real-world” patients if sources drive persistent atrial fibrillation (PeAF), long-standing persistent atrial fibrillation (LPeAF), or paroxysmal atrial fibrillation (PAF); if right atrial sites are important; and what the long-term success of source ablation is. Objectives The aim of this study was to analyze the role of rotors and focal sources in a large academic registry of consecutive patients undergoing source mapping for AF. Methods One hundred seventy consecutive patients (mean age 59 ± 12 years, 79% men) with PAF (37%), PeAF (31%), or LPeAF (32%). Of these, 73 (43%) had undergone at least 1 prior ablation attempt (mean 1.9 ± 0.8; range: 1 to 4). Focal impulse and rotor modulation (FIRM) with an endocardial basket catheter was used in all cases. Results FIRM analysis revealed sources in the right atrium in 85% of patients (1.8 ± 1.3) and in the left atrium in 90% of patients (2.0 ± 1.3). FIRM ablation terminated AF to sinus rhythm or atrial flutter or tachycardia in 59% (PAF), 37% (PeAF), and 19% (LPeAF) of patients, with 15 of 67 terminations due to right atrial ablation. On follow-up, freedom from AF after a single FIRM procedure for the entire series was 95% (PAF), 83% (PeAF), and 82% (LPeAF) at 1 year and freedom from all atrial arrhythmias was 77% (PAF), 75% (PeAF), and 57% (LPeAF). Conclusions In the Indiana University FIRM registry, FIRM-guided ablation produced high single-procedure success, mostly in patients with nonparoxysmal AF. Data from mapping, acute terminations, and outcomes strongly support the mechanistic role of biatrial rotors and focal sources in maintaining AF in diverse populations. Randomized trials of FIRM-guided ablation and mechanistic studies to determine how rotors form, progress, and regress are needed.

Original languageEnglish (US)
Pages (from-to)1247-1256
Number of pages10
JournalJournal of the American College of Cardiology
Volume69
Issue number10
DOIs
StatePublished - Mar 14 2017

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Atrial Fibrillation
Registries
Heart Atria
Atrial Flutter
Tachycardia

Keywords

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

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Clinical Benefit of Ablating Localized Sources for Human Atrial Fibrillation : The Indiana University FIRM Registry. / Miller, John; Kalra, Vikas; Das, Mithilesh; Jain, Rahul; Garlie, Jason B.; Brewster, Jordan A.; Dandamudi, Gopi.

In: Journal of the American College of Cardiology, Vol. 69, No. 10, 14.03.2017, p. 1247-1256.

Research output: Contribution to journalArticle

Miller, John ; Kalra, Vikas ; Das, Mithilesh ; Jain, Rahul ; Garlie, Jason B. ; Brewster, Jordan A. ; Dandamudi, Gopi. / Clinical Benefit of Ablating Localized Sources for Human Atrial Fibrillation : The Indiana University FIRM Registry. In: Journal of the American College of Cardiology. 2017 ; Vol. 69, No. 10. pp. 1247-1256.
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abstract = "Background Mounting evidence shows that localized sources maintain atrial fibrillation (AF). However, it is unclear in unselected “real-world” patients if sources drive persistent atrial fibrillation (PeAF), long-standing persistent atrial fibrillation (LPeAF), or paroxysmal atrial fibrillation (PAF); if right atrial sites are important; and what the long-term success of source ablation is. Objectives The aim of this study was to analyze the role of rotors and focal sources in a large academic registry of consecutive patients undergoing source mapping for AF. Methods One hundred seventy consecutive patients (mean age 59 ± 12 years, 79{\%} men) with PAF (37{\%}), PeAF (31{\%}), or LPeAF (32{\%}). Of these, 73 (43{\%}) had undergone at least 1 prior ablation attempt (mean 1.9 ± 0.8; range: 1 to 4). Focal impulse and rotor modulation (FIRM) with an endocardial basket catheter was used in all cases. Results FIRM analysis revealed sources in the right atrium in 85{\%} of patients (1.8 ± 1.3) and in the left atrium in 90{\%} of patients (2.0 ± 1.3). FIRM ablation terminated AF to sinus rhythm or atrial flutter or tachycardia in 59{\%} (PAF), 37{\%} (PeAF), and 19{\%} (LPeAF) of patients, with 15 of 67 terminations due to right atrial ablation. On follow-up, freedom from AF after a single FIRM procedure for the entire series was 95{\%} (PAF), 83{\%} (PeAF), and 82{\%} (LPeAF) at 1 year and freedom from all atrial arrhythmias was 77{\%} (PAF), 75{\%} (PeAF), and 57{\%} (LPeAF). Conclusions In the Indiana University FIRM registry, FIRM-guided ablation produced high single-procedure success, mostly in patients with nonparoxysmal AF. Data from mapping, acute terminations, and outcomes strongly support the mechanistic role of biatrial rotors and focal sources in maintaining AF in diverse populations. Randomized trials of FIRM-guided ablation and mechanistic studies to determine how rotors form, progress, and regress are needed.",
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AU - Garlie, Jason B.

AU - Brewster, Jordan A.

AU - Dandamudi, Gopi

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N2 - Background Mounting evidence shows that localized sources maintain atrial fibrillation (AF). However, it is unclear in unselected “real-world” patients if sources drive persistent atrial fibrillation (PeAF), long-standing persistent atrial fibrillation (LPeAF), or paroxysmal atrial fibrillation (PAF); if right atrial sites are important; and what the long-term success of source ablation is. Objectives The aim of this study was to analyze the role of rotors and focal sources in a large academic registry of consecutive patients undergoing source mapping for AF. Methods One hundred seventy consecutive patients (mean age 59 ± 12 years, 79% men) with PAF (37%), PeAF (31%), or LPeAF (32%). Of these, 73 (43%) had undergone at least 1 prior ablation attempt (mean 1.9 ± 0.8; range: 1 to 4). Focal impulse and rotor modulation (FIRM) with an endocardial basket catheter was used in all cases. Results FIRM analysis revealed sources in the right atrium in 85% of patients (1.8 ± 1.3) and in the left atrium in 90% of patients (2.0 ± 1.3). FIRM ablation terminated AF to sinus rhythm or atrial flutter or tachycardia in 59% (PAF), 37% (PeAF), and 19% (LPeAF) of patients, with 15 of 67 terminations due to right atrial ablation. On follow-up, freedom from AF after a single FIRM procedure for the entire series was 95% (PAF), 83% (PeAF), and 82% (LPeAF) at 1 year and freedom from all atrial arrhythmias was 77% (PAF), 75% (PeAF), and 57% (LPeAF). Conclusions In the Indiana University FIRM registry, FIRM-guided ablation produced high single-procedure success, mostly in patients with nonparoxysmal AF. Data from mapping, acute terminations, and outcomes strongly support the mechanistic role of biatrial rotors and focal sources in maintaining AF in diverse populations. Randomized trials of FIRM-guided ablation and mechanistic studies to determine how rotors form, progress, and regress are needed.

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KW - ablation

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KW - electrical rotors

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