Author + information
- Received February 28, 2019
- Revision received April 23, 2019
- Accepted April 24, 2019
- Published online July 15, 2019.
- Shohreh Honarbakhsh, MBBS, BSc,
- Ross J. Hunter, PhD,
- Waqas Ullah, PhD,
- Emily Keating, BAppSc, IBHRE, CCDS,
- Malcolm Finlay, BA(Oxon), PhD and
- Richard J. Schilling, MD∗ ()
- ↵∗Address for correspondence:
Prof. Richard J. Schilling, Barts Heart Centre, Barts Health National Health Service Trust, West Smithfield, London EC1A 7BE, United Kingdom.
Objectives The aim of this study was to demonstrate that a stochastic vector-based mapping approach could guide ablation of atrial fibrillation (AF) drivers as evidenced by ablation response and long-term follow-up outcomes.
Background The optimal method for mapping and ablation of AF drivers is yet to be defined.
Methods Patients undergoing persistent AF ablation were recruited. Patients underwent pulmonary vein isolation (PVI) with further ablation guided by the stochastic trajectory analysis of ranked signals (STAR) mapping method. The proportion of the time an electrode’s activation was seen to precede its neighboring electrodes activation was used to determine early sites of activation (ESA). A positive ablation response at ESA was defined as AF termination or cycle length slowing of ≥30 ms. Clinical outcome was defined as recurrence of AF/atrial tachycardia (AT) during a follow-up of 12 months.
Results Thirty-five patients were included (AF duration of 14.4 ± 5.3 months). After PVI, an average of 2.6 ± 0.8 ESA were ablated per patient with study-defined ablation response achieved in all patients. Of the 86 STAR maps created post-PVI, the same ESA was identified on 73.8 ± 26.1% of maps. ESA that resulted in AF termination were more likely to be identified on both pre- and post-PVI maps than those associated with cycle length slowing (23 of 24 vs. 16 of 49; p < 0.001). During a follow-up of 18.5 ± 3.7 months, 28 (80%) patients were free from AF/AT.
Conclusions The ablation response at ESA suggests they may be drivers of AF. Ablation guided by STAR mapping produced a favorable clinical outcome and warrants testing through a randomized controlled trial. (Identification, Electro-mechanical Characterisation and Ablation of Driver Regions in Persistent Atrial Fibrillation [STAR MAPPING]; NCT02950844)
This work was funded by the British Heart Foundation (grant PG/16/10/32016). Dr. Hunter has received travel grants from Medtronic. Prof. Schilling has received speaker and travel grants from Biosense Webster; research grants from Biosense Webster and Boston Scientific. Drs. Honarbakhsh, Hunter, and Finlay and Prof. Schilling are shareholders and co-inventors of the STAR mapping system. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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 February 28, 2019.
- Revision received April 23, 2019.
- Accepted April 24, 2019.
- 2019 The Authors