Author + information
- Received June 19, 2019
- Revision received June 10, 2020
- Accepted June 12, 2020
- Published online August 26, 2020.
- ↵∗Address for correspondence:
Dr. Dipen C. Shah, Cardiology Division, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland.
Objectives This study sought to study the relation between outcomes of modified stepwise atrial fibrillation (AF) substrate ablation and dynamic electrogram characteristics in the coronary sinus (CS) and right atrium (RA).
Background Identifying patients with persistent AF who will benefit from limited lesion sets versus those requiring extensive substrate modification is challenging.
Methods We studied 70 patients undergoing persistent AF ablation, 43 with acute success (successful ablation [sABL], AF termination, or noninducibility) and 27 with failure (failed ablation [fABL], no termination, or induced AF of >5 minutes). Dominant frequency (DF) and sample entropy (SampEn, increasing with signal complexity) were measured on 30-second recordings of wide-coverage simultaneous RA and CS electrograms during baseline AF and induced AF post–pulmonary vein isolation and after left-sided electrogram-guided ablation steps (on the CS with or without the left atrium [LA]).
Results At baseline AF, patients with sABL exhibited lower RA SampEn (p = 0.023) and lower CS DF (p = 0.030) compared to fABL. A positive RA-to-CS SampEn gradient predicted ablation failure (48% vs. 19% for patients in fABL vs. sABL; p = 0.015). A positive RA-to-CS DF gradient developed in patients with fABL after extra–pulmonary vein substrate modification, unlike patients with sABL (p = 0.0008). At 24 months, 76% of patients were AF free, and 68% were arrhythmia free. sABL was associated with fewer AF recurrences (hazard ratio: 0.31; 95% confidence interval: 0.12–0.84; p = 0.021). A negative RA-to-CS SampEn gradient at baseline was associated with freedom from AF (–0.14 ± 0.19 vs. 0.04 ± 0.18; p = 0.002).
Conclusions RA greater than CS electrogram complexity gradients at baseline or developing during ablation are associated with unfavorable acute and long-term outcomes of persistent AF ablation. These parameters allow monitoring of the effects of left-sided substrate ablation and, therefore, a rational choice of additional RA substrate modification.
↵∗ Drs. Johner and Shah contributed equally to this work.
Funded by the Swiss National Science Foundation (grant no. 173007), Department of Medicine Scholarship, and the University Hospital of Geneva. Dr. Johner has received educational grants from Boston Scientific, Abbott, and Cardinal Health. Dr. Namdar has received consultant fees and travel grants from Boston Scientific, Biotronik, and Biosense Webster. Dr. Shah has received consultant fees from Biosense Webster, Biotronik, St. Jude Medical, and Boston Scientific; research grants from Biosense Webster, St. Jude Medical, and Boston Scientific via the Cardiology Division; and Speakers Bureau member fees from Biosense Webster, St. Jude Medical, and Boston Scientific.
The 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 June 19, 2019.
- Revision received June 10, 2020.
- Accepted June 12, 2020.
- 2020 American College of Cardiology Foundation
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