Abstract
BackgroundAblation of persistent atrial fibrillation (AF) remains challenging. Identification and ablation of localized AF drivers may offer the possibility for improved outcomes. Ripple map is a novel software algorithm that may allow improved localization of possible AF drivers through the whole chamber graphical display of continuously recorded bipolar electrograms. The objective of this study was to determine whether regions of high‐frequency Ripple activation (HFRA) observed on Ripple map provide useful ablation targets in patients with persistent AF.Methods and ResultsConsecutive patients underwent the first‐time ablation of persistent AF (n = 162) using a standard stepwise (n = 105) or a Ripple map guided approach (n = 57). Ripple map guided patients underwent pulmonary vein antral isolation followed by ablation of HFRA sites. Acute termination of AF was observed in 91.2% of the Ripple‐guided patients vs 52.4% in the stepwise approach, P < .0001. Following a single ablation procedure, after 18 months 98.2% of Ripple map guided patients were free of AF, compared with 81.4% of standard stepwise ablation (P = .005). Freedom from atrial tachycardia (54.4% Ripple map vs 52.4% standard, P = .9) or any atrial arrhythmia (52.6% Ripple map vs 39.0% standard, P = .10) did not differ between the two strategies. In a subset analysis (n = 30 of 56), Ripple map regions corresponded to sites with spatiotemporal dispersion in all atrial locations. No differences were observed in the rate of procedural complications.ConclusionsAblation of HFRA sites identified with Ripple map resulted in a higher rate of acute termination and improved freedom from AF compared to a standard stepwise approach.
Highlights
Ablation of persistent atrial fibrillation (AF) remains challenging
After 18 months, significantly more patients in the Ripple map guided strategy were free of AF, compared to the standard stepwise strategy (98.2% vs 81.9, P = .005). (Table 2) This difference remained after adjusting for sex
After an average of 1.4 ablation procedures, freedom from both AF (98.2% vs 88.6%, P = .03) and any atrial arrhythmia (84.2 vs 69.5%, P = .04) were significantly higher in the Ripple group compared to the standard group
Summary
Ablation of persistent atrial fibrillation (AF) remains challenging. Identification and ablation of localized AF drivers may offer the possibility for improved outcomes. Ripple map is a novel software algorithm that may allow improved localization of possible AF drivers through the whole chamber graphical display of continuously recorded bipolar electrograms. Conclusions: Ablation of HFRA sites identified with Ripple map resulted in a higher rate of acute termination and improved freedom from AF compared to a standard stepwise approach. Evidence in support of localized drivers maintaining AF include experimental[8,9] and clinical findings.[10,11,12] Ablation of these sources with a procedural endpoint of AF termination may improve freedom from AF recurrence in both patients with persistent AF and the subset of patients with paroxysmal AF driven by non‐PV AF sources.[12,13].
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