Abstract
BackgroundElectrogram-based identification of the regions maintaining persistent Atrial Fibrillation (AF) is a subject of ongoing debate. Here, we explore the concept of local electrical dyssynchrony to identify AF drivers.Methods and ResultsLocal electrical dyssynchrony was calculated using mean phase coherence. High-density epicardial mapping along with mathematical model were used to explore the link between local dyssynchrony and properties of wave conduction. High-density mapping showed a positive correlation between the dyssynchrony and number of fibrillatory waves (R2 = 0.68, p<0.001). In the mathematical model, virtual ablation at high dyssynchrony regions resulted in conduction regularization. The clinical study consisted of eighteen patients undergoing catheter ablation of persistent AF. High-density maps of left atrial (LA) were constructed using a circular mapping catheter. After pulmonary vein isolation, regions with the top 10% of the highest dyssynchrony in LA were targeted during ablation and followed with ablation of complex atrial electrograms. Catheter ablation resulted in termination during ablation at high dyssynchrony regions in 7 (41%) patients. In another 4 (24%) patients, transient organization was observed. In 6 (35%) there was no clear effect. Long-term follow-up showed 65% AF freedom at 1 year and 22% at 2 years.ConclusionsLocal electrical dyssynchrony provides a reasonable estimator of regional AF complexity defined as the number of fibrillatory waves. Additionally, it points to regions of dynamical instability related with action potential alternans. However, despite those characteristics, its utility in guiding catheter ablation of AF is limited suggesting other factors are responsible for AF persistence.
Highlights
Pulmonary vein isolation (PVI) [1] is the cornerstone of catheter ablation of paroxysmal Atrial Fibrillation (AF), the optimal approach to catheter ablation of persistent atrial fibrillation is yet to be resolved [2]
Regions with the top 10% of the highest dyssynchrony in left atrial (LA) were targeted during ablation and followed with ablation of complex atrial electrograms
Dyssynchrony in Atrial Fibrillation instability related with action potential alternans
Summary
Pulmonary vein isolation (PVI) [1] is the cornerstone of catheter ablation of paroxysmal AF, the optimal approach to catheter ablation of persistent atrial fibrillation (persAF) is yet to be resolved [2]. A series of recent randomized controlled trials have failed to demonstrate an additional clinical benefit of the application of these empirically derived approaches beyond PVI [3,4,5]. In this context, there is a significant interest in the development of novel quantitative electrogram approaches to guide persAF ablation [6, 7]. We sought to conduct a comprehensive computer to catheter laboratory study evaluating the derivation and evaluation of local electrical dyssynchrony as a novel parameter to guide ablation in persistent AF. We explore the concept of local electrical dyssynchrony to identify AF drivers
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