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Ablation of Focal Impulses and Rotational Sources: What Can Be Learned from Differing Procedural Outcomes?

  • Arrhythmias (J. Bunch, Section Editor)
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Abstract

Introduction

There is considerable interest in identifying potential drivers for human atrial fibrillation (AF), in order to improve therapy. Ablation via pulmonary vein isolation (PVI) is broadly used, yet is insufficient in many patients yet its outcomes are unimproved by adding extensive ablation of lines or complex electrogram sites, particularly in patients with persistent AF.

Novelty

Rotational and focal sources for AF represent novel mechanistic and therapeutic targets, often remote from the PVs and proven to drive AF in many studies. This chapter discusses this issue.

Aspects of Clinical Relevance

AF sources can now routinely be identified clinically by many methods, yet discrepant results have been reported. AF drivers identified by Focal Impulse and Rotor Mapping (FIRM), the most widely applied method, are also seen in simultaneous optical maps of human atria and have now been detected by other mapping methods applied to the exact same signals. In proof-of-concept studies, ablation of drivers can terminate persistent AF and, in over a thousand patients reported thus far, yield favorable long-term outcomes versus PVI alone. Nevertheless, some centers show disappointing results. This review focuses on discrepant results, which may reflect challenging patients, operator unfamiliarity with basket catheter use, or the technical ablation of drivers, amongst other factors. We discuss challenges, potential solutions, and future directions for map-guided AF driver ablation including basket-data collection, interpreting AF maps, ablation guidance, and extent.

Conclusions

Mapping and ablation of AF drivers is a rapidly growing field which, with continued scientific discovery and procedural advances, offers a strong mechanistic foundation to improve patient-tailored ablation for complex arrhythmias.

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Author information

Authors and Affiliations

  1. Stanford University, 780 Welch, Suites CF250J/CV01-09 Stanford, Palo Alto, CA, 94305, USA

    Sanjiv M. Narayan, Miguel Rodrigo, Christopher A. B. Kowalewski, Fatemah Shenasa, Gabriela L. Meckler, Mohan N. Vishwanathan, Tina Baykaner, Junaid A.B. Zaman & Paul J. Wang

  2. National Heart Lung and Blood Institute, Imperial College, London, UK

    Junaid A.B. Zaman

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  1. Sanjiv M. Narayan
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  2. Miguel Rodrigo
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Correspondence to Sanjiv M. Narayan.

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Conflict of Interest

This work was supported by grants from the National Institutes of Health to Dr. Narayan (HL83359, HL103800). Dr. Zaman is supported by a Fulbright foundation award. Dr. Baykaner is supported by a fellowship from the Heart Rhythm Society. Dr. Narayan is co-author of intellectual property owned by the University of California Regents and licensed to Topera Inc., and has held equity in Topera. Dr. Narayan reports consulting fees and honoraria from the American College of Cardiology, Medtronic, St. Jude, Abbott and Uptodate. Dr. Viswanathan reports clinical studies from Medtronic and St. Jude Medical. Dr. Wang reports Honoraria/Consultant from Janssen, St. Jude Medical, Amgen, Medtronic; Fellowship support from Biosense Webster, Boston Scientific, Medtronic, St. Jude Medical; Clinical studies from Medtronic, Siemens, Cardiofocus, ARCA; and Stock options from Vytronus. Drs. Rodrigo and Baykaner, Mr. Kowalewski, Ms. Shenasa and Ms. Meckler report no conflicts.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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Narayan, S.M., Rodrigo, M., Kowalewski, C.A.B. et al. Ablation of Focal Impulses and Rotational Sources: What Can Be Learned from Differing Procedural Outcomes?. Curr Cardiovasc Risk Rep 11, 27 (2017). https://doi.org/10.1007/s12170-017-0552-7

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