Two Independent Mapping Techniques Identify Rotational Activity Patterns at Sites of Local Termination During Persistent Atrial Fibrillation

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Therapy for persistent atrial fibrillation (AF) is limited by uncertainty in its mechanisms, and even extensive ablation may not improve the moderate success of pulmonary vein isolation (PVI).1 However, mechanistic uncertainty stems in part from mapping studies in diverse populations, using diverse mapping techniques with varying technical or clinical validation. For arrhythmias such as atrial macroreentry, the accuracy of mapping can be gauged by its ability to identify sites where arrhythmia is terminated by ablation. Conversely, in AF, few studies have compared AF mapping techniques in the same patients, and even fewer have been referenced to a defined clinical endpoint.
Some recent mapping studies2 propose that rotational or focal drivers in localized regions maintain AF, with promising results by ablating such sites at independent centers.4 This concurs with optical mapping of AF in human atria.9 However, other studies disagree. First, AF mapping historically shows disorganized waves with no10 or very few11 drivers, typically in patients with permanent AF at nonarrhythmia surgery. Second, some studies show organized drivers on dominant frequency analysis12 that may be unstable by activation13 or phase14 mapping. Third, AF‐driver ablation outcomes are disappointing at some centers.17 It is unresolved if conflicting results reflect patient selection, methodology or intercenter variations in the results of any approach to AF ablation.20
We hypothesized that AF mechanisms may be clarified if independent mapping techniques were compared in the same patients, referenced to the endpoint of AF termination. We report on an early cohort of patients at our institution in whom limited ablation guided by one mapping technique (Focal Impulse and Rotor Mapping, FIRM) terminated persistent AF prior to pulmonary vein (PV) isolation, and compared the results with a distinct second mapping technique applied to the same clinical data.
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