Retrospective analysis of FIRM-guided ablation in patients with recurrent atrial fibrillation: a single-center study

Retrospektive Analyse der FIRM-gestützen Ablation von Vorhofflimmern bei Redo-Patienten – Eine Singlecenter-Studie

Abstract

Background

Ablation of recurrent atrial fibrillation (AF) is common. Studies indicate that AF recurrence is primarily due to pulmonary vein (PV) re-conduction. This retrospective analysis characterized and evaluated recurrent AF patients using focal impulse and rotor mapping (FIRM) plus PV re-isolation, with follow up at 3, 6, 12, and 24 months after the repeat ablation.

Methods and results

Patients (consecutive, n = 100) underwent FIRM-guided ablation followed by conventional PV re-isolation for recurrent AF treatment. All FIRM patients had failed one or more conventional ablation procedures (1.4 ± 0.08) for paroxysmal (14%), persistent (15%), and long-standing persistent (71%) AF. Stable rotors were identified in 97/100 patients: 60% in the right atrium (RA) and 82% in left atrium (LA) (mean 1.5 ± 0.8 and 2.1 ± 1.2 per patient, respectively). No correlation was noted between the previous number of ablations, AF duration, or LA diameter to the number of rotors (R2 = 0.0039, R2 = 0.0017, and R2 = 0.006, respectively). In this limited observation, only 22% of identified rotors were associated with proximity to low voltage areas. The 12- and 24-month arrhythmia free rate was 93% (13/14) and 92% (12/13) for paroxysmal AF, 60% (9/15) and 47% (7/15) for persistent AF, and 70% (48/69) and 64% (43/67) for long-standing persistent AF, respectively, after a single FIRM procedure and re-isolation of the veins.

Conclusions

The data show a benefit for FIRM-guided ablation in recurrent AF at 12 months. No correlation was found between rotors and tissue characterization, AF duration, or previous number of ablations, suggesting that rotors may play an independent role in maintaining recurrent AF after prior failed ablation.

Zusammenfassung

Hintergrund

Rezidive nach vorangegangener Ablation von Vorhofflimmern (VHF) sind häufig. Studien zeigen, dass Vorhofflimmerrezidive in erster Linie auf die erneute Leitungsfähigkeit einer oder mehrerer Pulmonalvenen (PV) zurückzuführen sind. Diese retrospektive Analyse charakterisiert Patienten mit VHF-Rezidiv, die mit fokalem Impuls- und Rotor-Mapping (FIRM) plus PV-Reisolation behandelt wurden. Follow-up-Untersuchungen erfolgten nach 3, 6, 12 und 24 Monaten.

Methoden und Ergebnisse

Insgesamt 100 konsekutive Patienten unterzogen sich einer FIRM-gestützten Ablation, gefolgt von einer konventionellen PV-Reisolation zur Behandlung von rezidivierendem VHF. Alle FIRM-Patienten hatten zuvor eine oder mehrere erfolglose konventionelle Ablationen (1,4 ± 0,08) bei paroxysmalem (14 %), persistierendem (15 %) oder lang persistierendem Vorhofflimmern (71 %) erhalten. Stabile Rotoren wurden bei 97/100 Patienten identifiziert: 60 % im rechten Vorhof (RA) und 82 % im linken Vorhof (LA), durchschnittlich 1,5 ± 0,8 bzw. 2,1 ± 1,2 Rotoren pro Patient. Es wurde keine Korrelation zwischen der vorherigen Anzahl der Ablationen, der Dauer des Vorhofflimmerns oder des LA-Durchmessers und der Anzahl der Rotoren festgestellt (R2 = 0,0039, R2 = 0,0017 bzw. R2 = 0,006). Lediglich 22 % der identifizierten Rotoren befanden sich in der Nähe zu Low-voltage-Arealen. Die Arrhythmiefreiheitsrate nach 12 bzw. 24 Monaten betrug 93 % (13/14) bzw. 92 % (12/13) bei paroxysmalem VHF, 60 % (9/15) bzw. 47 % (7/15) bei persistierendem VHF und 70 % (48/69) bzw. 64 % (43/67) bei lang persistierendem Vorhofflimmern nach einer einzelnen FIRM-gestützten Rotorablation und erneuten PV-Isolation.

Schlussfolgerungen

Unsere Daten zeigen einen Nutzen der FIRM-gestützten Ablation bei rezidivierendem VHF nach 12 Monaten. Es fand sich keine Korrelation zwischen den Rotoren und der Gewebecharakterisierung, der Dauer des VHF oder der vorherigen Anzahl der Ablationen, was darauf hindeutet, dass die Rotoren eine unabhängige Rolle bei der Aufrechterhaltung des rezidivierenden VHF nach einer zuvor fehlgeschlagenen Ablation spielen könnten.

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Acknowledgements

The authors are grateful to Shlomo Shpun, D.Sc., for help with drafting an earlier version of the manuscript and for very helpful comments and support in finalizing the manuscript.

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Contributions

SGS devised the project and the main conceptual ideas. AL worked out the technical details. CR and MZ analyzed the data. SGS, LK, and AL contributed to the interpretation of the results. SGS and AL took the lead in writing the manuscript. All authors provided critical feedback and helped shape the research, analysis, and manuscript.

Corresponding author

Correspondence to Stefan Georg Spitzer MD, FESC, FHRS.

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Conflict of interest

S.G. Spitzer has received speaker fees and support from Medtronic, St. Jude Medical, Abbott, and Topera, and participated in clinical trials for Abbott and Medtronic. L. Károlyi has received speaker fees from Abbott and participated in clinical trials for Abbott and Medtronic. A. Langbein has received speaker fees and travel support from Medtronic, Abbott, and Boston Scientific, and participated in clinical trials for Abbott and Medtronic. C. Rämmler and M. Zieschank declare that they have no competing interests.

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1975 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

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Spitzer, S.G., Károlyi, L., Rämmler, C. et al. Retrospective analysis of FIRM-guided ablation in patients with recurrent atrial fibrillation: a single-center study. Herzschr Elektrophys (2020). https://doi.org/10.1007/s00399-020-00724-5

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Keywords

  • Atrial fibrillation
  • Catheter ablation
  • Rotor
  • Pulmonary vein isolation
  • FIRM

Schlüsselwörter

  • Vorhofflimmern
  • Katheterablation
  • Rotor
  • Pulmonalvenenisolation
  • FIRM