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(Circulation. 2009;120:467-476.)
© 2009 American Heart Association, Inc.

Arrhythmia/Electrophysiology

Termination of Atrial Fibrillation Using Pulsed Low-Energy Far-Field Stimulation

Flavio H. Fenton, PhD^*; Stefan Luther, PhD^*; Elizabeth M. Cherry, PhD; Niels F. Otani, PhD; Valentin Krinsky, PhD; Alain Pumir, PhD; Eberhard Bodenschatz, PhD; Robert F. Gilmour, Jr, PhD

From the Department of Biomedical Sciences (F.H.F., S.L., E.M.C., N.F.O., R.F.G.) and Laboratory of Solid State Physics and Department of Mechanical and Aerospace Engineering (E.B.), Cornell University, Ithaca, NY; Max Planck Institute for Dynamics and Self-Organization, Göttingen, Germany (S.L., E.B.); Institute Non Lineáire de Nice, Valbonne, France (V.K.); and Laboratoire de Physique, Ecole Normale Supérieure de Lyon, Lyon, France (A.P.).

Correspondence to Flavio H. Fenton, PhD, Department of Biomedical Sciences, T7 012C Veterinary Research Tower, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853 (E-mail fhf3{at}cornell.edu), or Stefan Luther, PhD, Max Planck Institute for Dynamics and Self-Organization, Am Fassberg 17, D-37077, Göttingen, Germany (E-mail stefan.luther@ds.mpg.de).

Received September 29, 2008; accepted June 5, 2009.

Background— Electrically based therapies for terminating atrial fibrillation (AF) currently fall into 2 categories: antitachycardia pacing and cardioversion. Antitachycardia pacing uses low-intensity pacing stimuli delivered via a single electrode and is effective for terminating slower tachycardias but is less effective for treating AF. In contrast, cardioversion uses a single high-voltage shock to terminate AF reliably, but the voltages required produce undesirable side effects, including tissue damage and pain. We propose a new method to terminate AF called far-field antifibrillation pacing, which delivers a short train of low-intensity electric pulses at the frequency of antitachycardia pacing but from field electrodes. Prior theoretical work has suggested that this approach can create a large number of activation sites ("virtual" electrodes) that emit propagating waves within the tissue without implanting physical electrodes and thereby may be more effective than point-source stimulation.

Methods and Results— Using optical mapping in isolated perfused canine atrial preparations, we show that a series of pulses at low field strength (0.9 to 1.4 V/cm) is sufficient to entrain and subsequently extinguish AF with a success rate of 93% (69 of 74 trials in 8 preparations). We further demonstrate that the mechanism behind far-field antifibrillation pacing success is the generation of wave emission sites within the tissue by the applied electric field, which entrains the tissue as the field is pulsed.

Conclusions— AF in our model can be terminated by far-field antifibrillation pacing with only 13% of the energy required for cardioversion. Further studies are needed to determine whether this marked reduction in energy can increase the effectiveness and safety of terminating atrial tachyarrhythmias clinically.

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Clinical Summaries
Circulation 2009 120: 459-460. [Extract] [Full Text]