Author + information
- Received January 11, 2017
- Revision received April 26, 2017
- Accepted May 26, 2017
- Published online November 20, 2017.
- Simon Kochhäuser, MDa,b,
- Atul Verma, MDa,
- Rupin Dalvi, MScc,
- Adrian Suszko, MScc,
- Pouria Alipour, BSca,
- Prashanthan Sanders, MBBS, PhDd,
- Jean Champagne, MDe,
- Laurent Macle, MDf,
- Girish M. Nair, MBBS, MScg,
- Hugh Calkins, MDh,
- David J. Wilber, MDi and
- Vijay S. Chauhan, MDc,∗ ()
- aSouthlake Regional Health Centre, Newmarket, Ontario, Canada
- bDivision of Electrophysiology, Department of Cardiovascular Medicine, University of Münster, Münster, Germany
- cPeter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- dUniversity of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia, Australia
- eInstitut de Cardiologie et Pneumologie de l’Université Laval, Quebec City, Quebec, Canada
- fMontreal Heart Institute, Montreal, Quebec, Canada
- gUniversity of Ottawa Heart Institute, Ottawa, Ontario, Canada
- hJohns Hopkins University Hospital, Baltimore, Maryland
- iLoyola University Medical Center, Maywood, Illinois
- ↵∗Address for correspondence:
Dr. Vijay S. Chauhan, 3-522 Gerrard Wing, Peter Munk Cardiac Center, University Health Network, 150 Gerrard Street West, Toronto, Ontario M5G 2C4, Canada.
Objectives This study sought to evaluate the spatial relationships of focal electrical sources (FSs) to complex fractionated atrial electrograms (CFAE) and continuous electrical activity (CEA).
Background Fractionated atrial electrograms have been associated with atrial fibrillation (AF) drivers in computational studies and represent ablation targets in the management of persistent AF.
Methods We included a subset of 66 patients (age: 63 [56, 67] years, 69% persistent AF) with electroanatomic data from the SELECT AF (Selective complex fractionated atrial electrograms targeting for atrial fibrillation) randomized control trial that compared the efficacy of CFAE with CEA ablation in AF patients undergoing pulmonary vein antral ablation. Focal sources were identified based on bipolar electrogram periodicity and QS unipolar electrogram morphology.
Results A total of 77 FSs (median: 1 [1st quartile, 3rd quartile: 1, 2] per patient) were identified most commonly in the pulmonary vein antrum and left atrial appendage. The proportions of FSs inside CFAE and CEA regions were similar (13% vs. 1.3%, respectively; p = 0.13). Focal sources were more likely to be on the border zone of CFAEs than in CEAs (49% vs. 7.8%, respectively; p = 0.012). Following ablation, 53% of patients had ≥1 unablated extrapulmonary vein FS. The median number of unablated FS was higher in patients with AF recurrence post ablation than in patients without (median: 1 [0, 1] vs. 0 [0, 1], respectively; p = 0.026).
Conclusions One-half of the FSs detected during AF localized to the border of CFAE areas, whereas most of the FSs were found outside CEA areas. CFAE or CEA ablation leaves a number of FS unablated, which is associated with AF recurrence. These findings suggest that many CFAEs may arise from passive wave propagation, remote from FS, which may limit their therapeutic efficacy in AF substrate modification.
This study was supported by Heart and Stroke Foundation of Canada Grant-in-Aid G-14-0006112, the Pennycook Arrhythmia Research fund, and Heart and Stroke Foundation of Ontario Career Award MC 7577 to Dr. Chauhan. Dr. Verma has received support from and is an advisory board member of Boehringer Ingelheim and Bayer. Dr. Sanders is supported by practitioner fellowships from the National Health and Medical Research Council of Australia and the National Heart Foundation of Australia; has served on the advisory boards of and received lecture and consulting fees from Biosense Webster, Medtronic, St. Jude Medical, Boston Scientific, and CathRx; and has received research funding from Medtronic, St. Jude Medical, Boston Scientific, Biotronik, and Sorin. Dr. Kochhäuser was supported by a research grant from the German Cardiac Society. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Francis E. Marchlinski, MD, served as Guest Editor for this paper.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received January 11, 2017.
- Revision received April 26, 2017.
- Accepted May 26, 2017.
- 2017 American College of Cardiology Foundation