Complexity and Distribution of Drivers in Relation to Duration of Persistent Atrial Fibrillation

• Published in: Journal of the American College of Cardiology Vol. 69; no. 10; pp. 1257 - 1269
• Main Authors: Lim, Han S., MBBS, PhD, Hocini, Mélèze, MD, Dubois, Remi, PhD, Denis, Arnaud, MD, Derval, Nicolas, MD, Zellerhoff, Stephan, MD, Yamashita, Seigo, MD, Berte, Benjamin, MD, Mahida, Saagar, MBChB, Komatsu, Yuki, MD, Daly, Matthew, MBChB, Jesel, Laurence, MD, Pomier, Carole, PhD, Meillet, Valentin, MSc, Amraoui, Sana, MD, Shah, Ashok J., MD, Cochet, Hubert, MD, Sacher, Frédéric, MD, Jaïs, Pierre, MD, Haïssaguerre, Michel, MD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 14.03.2017; Elsevier Limited
• Subjects: Algorithms; Atrial Fibrillation - diagnosis; Atrial Fibrillation - physiopathology; Atrial Fibrillation - surgery; Body Surface Potential Mapping - methods; Cardiac arrhythmia; Cardiology; Cardiovascular; Cardiovascular disease; Catheter Ablation - methods; complexity; Diabetes; drivers; Female; Follow-Up Studies; Heart Atria - physiopathology; Heart Conduction System - physiopathology; Heart Conduction System - surgery; Heart failure; Humans; Hypertension; Internal Medicine; Male; Methods; Middle Aged; panoramic mapping; Patients; persistent atrial fibrillation; Prospective Studies; Studies; Time Factors; Tomography; Tomography, X-Ray Computed; complexity; DF; right pulmonary vein; persistent atrial fibrillation; PV; interquartile range; panoramic mapping; atrial fibrillation; persistent atrial fibrillation presenting in sinus rhythm; longstanding persistent atrial fibrillation with continuous atrial fibrillation >12 months; RPV; left atrial appendage; left atrium; AF; Pers>12m; Pers<12m; IQR; LAA; PsAF; RA; LA; right atrium; pulmonary vein; dominant frequency; drivers; PersSR; persistent atrial fibrillation with the longest episode of continuous atrial fibrillation lasting <12 months
• ISSN: 0735-1097; 1558-3597
• DOI: 10.1016/j.jacc.2017.01.014

Abstract Background The underlying mechanisms sustaining human persistent atrial fibrillation (PsAF) is poorly understood. Objectives This study sought to investigate the complexity and distribution of AF drivers in PsAF of varying durations. Methods Of 135 consecutive patients with PsAF, 105 patients referred for de novo ablation of PsAF were prospectively recruited. Patients were divided into 3 groups according to AF duration: PsAF presenting in sinus rhythm (AF induced), PsAF <12 months, and PsAF >12 months. Patients wore a 252-electrode vest for body surface mapping. Localized drivers (re-entrant or focal) were identified using phase-mapping algorithms. Results In this patient cohort, the most prominent re-entrant driver regions included the pulmonary vein (PV) regions and inferoposterior left atrial wall. Focal drivers were observed in 1 or both PV regions in 75% of patients. Comparing between the 3 groups, with longer AF duration AF complexity increased, reflected by increased number of re-entrant rotations (p < 0.05), number of re-entrant rotations and focal events (p < 0.05), and number of regions harboring re-entrant (p < 0.01) and focal (p < 0.05) drivers. With increased AF duration, a higher proportion of patients had multiple extra-PV driver regions, specifically in the inferoposterior left atrium (p < 0.01), superior right atrium (p < 0.05), and inferior right atrium (p < 0.05). Procedural AF termination was achieved in 70% of patients, but decreased with longer AF duration. Conclusions The complexity of AF drivers increases with prolonged AF duration. Re-entrant and focal drivers are predominantly located in the PV antral and adjacent regions. However, with longer AF duration, multiple drivers are distributed at extra-PV sites. AF termination rate declines as patients progress to longstanding PsAF, underscoring the importance of early intervention.