Abstract
The relationship between atrial fibrillation (AF) and underlying functional and structural abnormalities has received substantial attention in the research literature over the past decade. Significant progress has been made in identifying these changes using non-invasive imaging, voltage mapping, and electrical recordings. Advances in computed tomography and cardiac magnetic resonance imaging can now provide insight regarding the presence and extent of cardiac fibrosis. Additionally, multiple technologies able to identify electrical targets during AF have emerged. However, an organized strategy to employ these resources in the targeted treatment of AF remains elusive. In this work, we will discuss the basis for mechanistic importance of atrial fibrosis and scar as potential sites promoting AF and emerging technologies to identify and target these structural and functional substrates in the electrophysiology laboratory. We also propose an approach to the use of such technologies to serve as a basis for ongoing work in the field.
Highlights
Atrial fibrillation (AF) is the most common cardiac arrhythmia in the United States (Chugh et al, 2014)
Localized ablation terminated atrial fibrillation (AF), which was subsequently non-inducible. In this patient with normal structural substrate, the AF was likely driven by an electrical driver from the pulmonary veins, as classically described (Haïssaguerre et al, 1998)
In this patient with significant atrial fibrosis, extra-pulmonary vein drivers arising from the fibrotic substrate likely contributed to AF maintenance
Summary
Atrial fibrillation (AF) is the most common cardiac arrhythmia in the United States (Chugh et al, 2014). Localized ablation terminated AF, which was subsequently non-inducible In this patient with normal structural substrate, the AF was likely driven by an electrical driver from the pulmonary veins, as classically described (Haïssaguerre et al, 1998). Limited ablation in the region of this driver terminated AF (Figure 2C), and the patient has remained in sinus rhythm during follow-up In this patient with significant atrial fibrosis, extra-pulmonary vein drivers arising from the fibrotic substrate likely contributed to AF maintenance. While the AF source in the first patient would have been accounted for with guideline-directed pulmonary vein isolation (Haïssaguerre et al, 1998; Narayan et al, 2008), the driver located at the left atrial roof in patient 2 would not Such examples, prevalent in the literature (Narayan et al, 2012a; Shivkumar et al, 2012) demonstrate the need for additional guidance regarding the use of patient-specific mapping and targeting strategies to treat AF. Abnormal electrical substrate underlying AF may exist with or without the presence of fibrosis, and can be divided into 3 phases: initiation, transition and maintenance (Heijman et al, 2014; Krummen et al, 2015)
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