Author + information
- Received June 6, 2016
- Revision received November 28, 2016
- Accepted November 29, 2016
- Published online March 6, 2017.
- John M. Miller, MD∗ (, )
- Vikas Kalra, MD,
- Mithilesh K. Das, MD,
- Rahul Jain, MD, MPH,
- Jason B. Garlie, MD,
- Jordan A. Brewster, MD and
- Gopi Dandamudi, MD
- Krannert Institute of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
- ↵∗Address for correspondence:
Dr. John M. Miller, Krannert Institute of Cardiology, Department of Medicine, Indiana University, 1800 North Capitol Avenue, E-488, Indianapolis, Indiana 46202.
Background Mounting evidence shows that localized sources maintain atrial fibrillation (AF). However, it is unclear in unselected “real-world” patients if sources drive persistent atrial fibrillation (PeAF), long-standing persistent atrial fibrillation (LPeAF), or paroxysmal atrial fibrillation (PAF); if right atrial sites are important; and what the long-term success of source ablation is.
Objectives The aim of this study was to analyze the role of rotors and focal sources in a large academic registry of consecutive patients undergoing source mapping for AF.
Methods One hundred seventy consecutive patients (mean age 59 ± 12 years, 79% men) with PAF (37%), PeAF (31%), or LPeAF (32%). Of these, 73 (43%) had undergone at least 1 prior ablation attempt (mean 1.9 ± 0.8; range: 1 to 4). Focal impulse and rotor modulation (FIRM) with an endocardial basket catheter was used in all cases.
Results FIRM analysis revealed sources in the right atrium in 85% of patients (1.8 ± 1.3) and in the left atrium in 90% of patients (2.0 ± 1.3). FIRM ablation terminated AF to sinus rhythm or atrial flutter or tachycardia in 59% (PAF), 37% (PeAF), and 19% (LPeAF) of patients, with 15 of 67 terminations due to right atrial ablation. On follow-up, freedom from AF after a single FIRM procedure for the entire series was 95% (PAF), 83% (PeAF), and 82% (LPeAF) at 1 year and freedom from all atrial arrhythmias was 77% (PAF), 75% (PeAF), and 57% (LPeAF).
Conclusions In the Indiana University FIRM registry, FIRM-guided ablation produced high single-procedure success, mostly in patients with nonparoxysmal AF. Data from mapping, acute terminations, and outcomes strongly support the mechanistic role of biatrial rotors and focal sources in maintaining AF in diverse populations. Randomized trials of FIRM-guided ablation and mechanistic studies to determine how rotors form, progress, and regress are needed.
This work was supported by institutional funds. Dr. Miller has received honoraria from Medtronic, St. Jude Medical, Biotronik, Biosense Webster, and Boston Scientific; and has been a scientific advisor to Abbott/Topera (modest, <$10,000). Dr. Dandamudi has received honoraria from Medtronic and Biosense Webster. Dr. Jain has received honoraria from Biosense Webster. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received June 6, 2016.
- Revision received November 28, 2016.
- Accepted November 29, 2016.
- American College of Cardiology Foundation