Abstract 18489: Increasing Complexity and Distribution of Drivers with Prolonged Duration Human Persistent Atrial Fibrillation: Implications for Therapeutic Intervention
Introduction: There is accumulating evidence on localized reentrant (rotors) and focal drivers in persistent atrial fibrillation (PsAF).
Hypothesis: We hypothesized that the complexity and distribution of AF drivers identified by noninvasive phase mapping would increase with prolonged durations of PsAF.
Methods: One-hundred-and-five consecutive patients referred for denovo ablation of PsAF were prospectively studied. The left (LA) and right atria (RA) were divided into 7-regions. Driver regions were identified with noninvasive body-surface-mapping. Cardiac potentials were reconstructed on biatrial geometry acquired from noncontrast thoracic computed tomography scan. Patients were divided into PsAF presenting in sinus rhythm, PsAF <12 months duration and longstanding PsAF >12 months duration.
Results: The AF complexity increased with AF duration, with increased number of rotor rotations (p=0.027), number of rotor rotations and foci (p=0.020), number of regions harboring rotors (p<0.001) and number of regions harboring focal drivers (p=0.032). Prominent rotor regions included the pulmonary vein (PV) regions and inferoposterior LA wall (left-PV/LA-appendage region in 90% of patients, right-PV/septal region 87%, and inferoposterior-LA 78%). Other regions were more individually distributed (superior-RA 67%, inferior-RA 19%, anterior-LA 20% and anteroseptal region 29%). Focal drivers were observed in one/both PV regions in 75%. With longer AF duration, a higher proportion of patients had multiple extra-PV driver regions, specifically in the inferoposterior LA (p<0.001), superior-RA (p=0.026), inferior-RA (p=0.032) and anteroseptal regions (p=0.044). Procedural AF termination was achieved in 70% of patients, but declined with AF duration.
Conclusions: The complexity of AF drivers increases with prolonged AF duration. Rotors and focal drivers are predominantly located in the PV antral regions and adjacent inferoposterior LA wall in patients with PsAF without prior LA ablation. However, with longer AF duration, multiple drivers are located at extra-PV sites. A sharp decline in AF termination rate is noted in patients with longstanding persistent AF, underscoring the need for early intervention.
Author Disclosures: H.S. Lim: None. M. Hocini: Ownership Interest; Significant; Cardioinsight Inc. S. Zellerhoff: None. S. Yamashita: None. N. Derval: None. S. Mahida: None. B. Benjamin: None. A. Denis: None. Y. Komatsu: None. M. Daly: None. L. Jesel: None. C. Pomier: Employment; Significant; Cardioinsight Inc.. V. Meillet: None. S. Amraoui: None. A. Shah: Consultant/Advisory Board; Modest; Cardioinsight Inc. F. Sacher: None. P. Jais: Ownership Interest; Significant; Cardioinsight Inc. R. Dubois: Consultant/Advisory Board; Modest; Cardioinsight Inc. M. Haissaguerre: Ownership Interest; Significant; Cardioinsight Inc.
- © 2014 by American Heart Association, Inc.