Author + information
- Received December 29, 2013
- Revision received February 4, 2014
- Accepted February 5, 2014
- Published online May 6, 2014.
- Sanjiv M. Narayan, MD, PhD∗,†∗ (, )
- Tina Baykaner, MD∗,†,
- Paul Clopton, MS†,
- Amir Schricker, MD∗,†,
- Gautam G. Lalani, MD∗,†,
- David E. Krummen, MD∗,†,
- Kalyanam Shivkumar, MD, PhD‡ and
- John M. Miller, MD§
- ∗Department of Medicine, University of California, San Diego, San Diego, California
- †Veterans Affairs Medical Center, San Diego, California
- ‡University of California, Los Angeles, Los Angeles, California
- §The Krannert Institute of Cardiology, Indiana University, Indianapolis, Indiana
- ↵∗Reprint requests and correspondence:
Dr. Sanjiv M. Narayan, University of California and Veterans Affairs Medical Center, San Diego, Cardiology/111A, 3350 La Jolla Village Drive, San Diego, California 92161.
Objectives The aim of this study was to determine if ablation that targets patient-specific atrial fibrillation (AF)–sustaining substrates (rotors or focal sources) is more durable than trigger ablation alone at preventing late AF recurrence.
Background Late recurrence substantially limits the efficacy of pulmonary vein isolation for AF and is associated with pulmonary vein reconnection and the emergence of new triggers.
Methods Three-year follow-up was performed of the CONFIRM (Conventional Ablation for Atrial Fibrillation With or Without Focal Impulse and Rotor Modulation) trial, in which 92 consecutive patients with AF (70.7% persistent) underwent novel computational mapping. Ablation comprised source (focal impulse and rotor modulation [FIRM]) and then conventional ablation in 27 patients (FIRM guided) and conventional ablation alone in 65 patients (FIRM blinded). Patients were followed with implanted electrocardiographic monitors when possible (85.2% of FIRM-guided patients, 23.1% of FIRM-blinded patients).
Results FIRM mapping revealed a median of 2 (interquartile range: 1 to 2) rotors or focal sources in 97.7% of patients during AF. During a median follow-up period of 890 days (interquartile range: 224 to 1,563 days), compared to FIRM-blinded therapy, patients receiving FIRM-guided ablation maintained higher freedom from AF after 1.2 ± 0.4 procedures (median 1; interquartile range: 1 to 1) (77.8% vs. 38.5%, p = 0.001) and a single procedure (p < 0.001) and higher freedom from all atrial arrhythmias (p = 0.003). Freedom from AF was higher when ablation directly or coincidentally passed through sources than when it missed sources (p < 0.001).
Conclusions FIRM-guided ablation is more durable than conventional trigger-based ablation in preventing 3-year AF recurrence. Future studies should investigate how ablation of patient-specific AF-sustaining rotors and focal sources alters the natural history of arrhythmia recurrence. (The Dynamics of Human Atrial Fibrillation; NCT01008722)
This work was supported by grants to Dr. Narayan from the National Institutes of Health (HL70529, HL83359, and HL83359-S1) and the Doris Duke Charitable Foundation and from the National Institutes of Health to Dr. Shivkumar (R01 HL084261). Dr. Narayan is a coauthor of intellectual property owned by the University of California Regents and licensed to Topera Inc. Topera does not sponsor any research, including that presented here. Dr. Narayan holds equity in Topera; and has received honoraria from Medtronic, St. Jude Medical, and Biotronik. Dr. Miller has received honoraria from Medtronic, St. Jude Medical, Biotronik, Biosense Webster, and Boston Scientific; and is a scientific advisor to Topera. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. John D. Hummel, MD, acted as Guest Editor for this report.
- Received December 29, 2013.
- Revision received February 4, 2014.
- Accepted February 5, 2014.
- American College of Cardiology Foundation