Direct or coincidental elimination of stable rotors or focal sources may explain successful atrial fibrillation ablation

On-treatment analysis of the CONFIRM trial (Conventional Ablation for AF with or Without Focal Impulse and Rotor Modulation)

Sanjiv M. Narayan, David E. Krummen, Paul Clopton, Kalyanam Shivkumar, John Miller

Research output: Contribution to journalArticle

129 Citations (Scopus)

Abstract

Objectives: This study sought to determine whether ablation of recently described stable atrial fibrillation (AF) sources, either directly by Focal Impulse and Rotor Modulation (FIRM) or coincidentally when anatomic ablation passes through AF sources, may explain long-term freedom from AF. Background: It is unclear why conventional anatomic AF ablation can be effective in some patients yet ineffective in others with similar profiles. Methods: The CONFIRM (Conventional Ablation for AF With or Without Focal Impulse and Rotor Modulation) trial prospectively revealed stable AF rotors or focal sources in 98 of 101 subjects with AF at 107 consecutive ablation cases. In 1:2 fashion, subjects received targeted source ablation (FIRM) followed by conventional ablation, or conventional ablation alone. We determined whether ablation lesions on electroanatomic maps passed through AF sources on FIRM maps. Results: Subjects who completed follow-up (n = 94; 71.2% with persistent AF) showed 2.3 ± 1.1 concurrent AF rotors or focal sources that lay near pulmonary veins (22.8%), left atrial roof (16.0%), and elsewhere in the left (28.2%) and right (33.0%) atria. AF sources were ablated directly in 100% of FIRM cases and coincidentally (e.g., left atrial roof) in 45% of conventional cases (p < 0.05). During a median (interquartile range) of 273 days (138 to 636 days) after one procedure, AF was absent in 80.3% of patients if sources were ablated but in only 18.2% of patients if sources were missed (p < 0.001). Freedom from AF was highest if all sources were ablated, intermediate if some sources were ablated, and lowest if no sources were ablated (p < 0.001). Conclusions: Elimination of stable AF rotors and focal sources may explain freedom from AF after diverse approaches to ablation. Patient-specific AF source distributions are consistent with the reported success of specific anatomic lesion sets and of widespread ablation. These results support targeting AF sources to reduce unnecessary ablation, and motivate studies on FIRM-only ablation. (The Dynamics of Human Atrial Fibrillation; NCT01008722)

Original languageEnglish
Pages (from-to)138-147
Number of pages10
JournalJournal of the American College of Cardiology
Volume62
Issue number2
DOIs
StatePublished - Jul 9 2013

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Atrial Fibrillation
Therapeutics
Pulmonary Veins
Heart Atria

Keywords

  • ablation
  • atrial fibrillation
  • FIRM
  • focal source
  • rotor
  • treatment

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

@article{2590054d137849bea06625a9f0ce0abb,
title = "Direct or coincidental elimination of stable rotors or focal sources may explain successful atrial fibrillation ablation: On-treatment analysis of the CONFIRM trial (Conventional Ablation for AF with or Without Focal Impulse and Rotor Modulation)",
abstract = "Objectives: This study sought to determine whether ablation of recently described stable atrial fibrillation (AF) sources, either directly by Focal Impulse and Rotor Modulation (FIRM) or coincidentally when anatomic ablation passes through AF sources, may explain long-term freedom from AF. Background: It is unclear why conventional anatomic AF ablation can be effective in some patients yet ineffective in others with similar profiles. Methods: The CONFIRM (Conventional Ablation for AF With or Without Focal Impulse and Rotor Modulation) trial prospectively revealed stable AF rotors or focal sources in 98 of 101 subjects with AF at 107 consecutive ablation cases. In 1:2 fashion, subjects received targeted source ablation (FIRM) followed by conventional ablation, or conventional ablation alone. We determined whether ablation lesions on electroanatomic maps passed through AF sources on FIRM maps. Results: Subjects who completed follow-up (n = 94; 71.2{\%} with persistent AF) showed 2.3 ± 1.1 concurrent AF rotors or focal sources that lay near pulmonary veins (22.8{\%}), left atrial roof (16.0{\%}), and elsewhere in the left (28.2{\%}) and right (33.0{\%}) atria. AF sources were ablated directly in 100{\%} of FIRM cases and coincidentally (e.g., left atrial roof) in 45{\%} of conventional cases (p < 0.05). During a median (interquartile range) of 273 days (138 to 636 days) after one procedure, AF was absent in 80.3{\%} of patients if sources were ablated but in only 18.2{\%} of patients if sources were missed (p < 0.001). Freedom from AF was highest if all sources were ablated, intermediate if some sources were ablated, and lowest if no sources were ablated (p < 0.001). Conclusions: Elimination of stable AF rotors and focal sources may explain freedom from AF after diverse approaches to ablation. Patient-specific AF source distributions are consistent with the reported success of specific anatomic lesion sets and of widespread ablation. These results support targeting AF sources to reduce unnecessary ablation, and motivate studies on FIRM-only ablation. (The Dynamics of Human Atrial Fibrillation; NCT01008722)",
keywords = "ablation, atrial fibrillation, FIRM, focal source, rotor, treatment",
author = "Narayan, {Sanjiv M.} and Krummen, {David E.} and Paul Clopton and Kalyanam Shivkumar and John Miller",
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T1 - Direct or coincidental elimination of stable rotors or focal sources may explain successful atrial fibrillation ablation

T2 - On-treatment analysis of the CONFIRM trial (Conventional Ablation for AF with or Without Focal Impulse and Rotor Modulation)

AU - Narayan, Sanjiv M.

AU - Krummen, David E.

AU - Clopton, Paul

AU - Shivkumar, Kalyanam

AU - Miller, John

PY - 2013/7/9

Y1 - 2013/7/9

N2 - Objectives: This study sought to determine whether ablation of recently described stable atrial fibrillation (AF) sources, either directly by Focal Impulse and Rotor Modulation (FIRM) or coincidentally when anatomic ablation passes through AF sources, may explain long-term freedom from AF. Background: It is unclear why conventional anatomic AF ablation can be effective in some patients yet ineffective in others with similar profiles. Methods: The CONFIRM (Conventional Ablation for AF With or Without Focal Impulse and Rotor Modulation) trial prospectively revealed stable AF rotors or focal sources in 98 of 101 subjects with AF at 107 consecutive ablation cases. In 1:2 fashion, subjects received targeted source ablation (FIRM) followed by conventional ablation, or conventional ablation alone. We determined whether ablation lesions on electroanatomic maps passed through AF sources on FIRM maps. Results: Subjects who completed follow-up (n = 94; 71.2% with persistent AF) showed 2.3 ± 1.1 concurrent AF rotors or focal sources that lay near pulmonary veins (22.8%), left atrial roof (16.0%), and elsewhere in the left (28.2%) and right (33.0%) atria. AF sources were ablated directly in 100% of FIRM cases and coincidentally (e.g., left atrial roof) in 45% of conventional cases (p < 0.05). During a median (interquartile range) of 273 days (138 to 636 days) after one procedure, AF was absent in 80.3% of patients if sources were ablated but in only 18.2% of patients if sources were missed (p < 0.001). Freedom from AF was highest if all sources were ablated, intermediate if some sources were ablated, and lowest if no sources were ablated (p < 0.001). Conclusions: Elimination of stable AF rotors and focal sources may explain freedom from AF after diverse approaches to ablation. Patient-specific AF source distributions are consistent with the reported success of specific anatomic lesion sets and of widespread ablation. These results support targeting AF sources to reduce unnecessary ablation, and motivate studies on FIRM-only ablation. (The Dynamics of Human Atrial Fibrillation; NCT01008722)

AB - Objectives: This study sought to determine whether ablation of recently described stable atrial fibrillation (AF) sources, either directly by Focal Impulse and Rotor Modulation (FIRM) or coincidentally when anatomic ablation passes through AF sources, may explain long-term freedom from AF. Background: It is unclear why conventional anatomic AF ablation can be effective in some patients yet ineffective in others with similar profiles. Methods: The CONFIRM (Conventional Ablation for AF With or Without Focal Impulse and Rotor Modulation) trial prospectively revealed stable AF rotors or focal sources in 98 of 101 subjects with AF at 107 consecutive ablation cases. In 1:2 fashion, subjects received targeted source ablation (FIRM) followed by conventional ablation, or conventional ablation alone. We determined whether ablation lesions on electroanatomic maps passed through AF sources on FIRM maps. Results: Subjects who completed follow-up (n = 94; 71.2% with persistent AF) showed 2.3 ± 1.1 concurrent AF rotors or focal sources that lay near pulmonary veins (22.8%), left atrial roof (16.0%), and elsewhere in the left (28.2%) and right (33.0%) atria. AF sources were ablated directly in 100% of FIRM cases and coincidentally (e.g., left atrial roof) in 45% of conventional cases (p < 0.05). During a median (interquartile range) of 273 days (138 to 636 days) after one procedure, AF was absent in 80.3% of patients if sources were ablated but in only 18.2% of patients if sources were missed (p < 0.001). Freedom from AF was highest if all sources were ablated, intermediate if some sources were ablated, and lowest if no sources were ablated (p < 0.001). Conclusions: Elimination of stable AF rotors and focal sources may explain freedom from AF after diverse approaches to ablation. Patient-specific AF source distributions are consistent with the reported success of specific anatomic lesion sets and of widespread ablation. These results support targeting AF sources to reduce unnecessary ablation, and motivate studies on FIRM-only ablation. (The Dynamics of Human Atrial Fibrillation; NCT01008722)

KW - ablation

KW - atrial fibrillation

KW - FIRM

KW - focal source

KW - rotor

KW - treatment

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