AF Ablation Guided by Spatiotemporal Electrogram Dispersion Without Pulmonary Vein Isolation: A Wholly Patient-Tailored Approach

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• 作者：Julien Seitz ; MD^a ; ^{jseitz@hopital-saint-joseph.fr} ; Clé ; ment Bars ; MD^a ; ^b ; Guillaume Thé ; odore ; MD^c ; Sylvain Beurtheret ; MD^a ; Nicolas Lellouche ; MD ; PhD^d ; Michel Bremondy ; MD^a ; Ange Ferracci ; MD^a ; Jacques Faure ; MD^a ; Guillaume Penaranda^e ; Masatoshi Yamazaki ; MD ; PhD^f ; Uma Mahesh R. Avula ; MD^f ; Laurence Curel ; MS^a ; Sabrina Siame^a ; Omer Berenfeld ; PhD^f ; André ; Pisapia ; MD^a ; Jé ; rô ; me Kalifa ; MD ; PhD^f
• 关键词：cycle length ; dispersion driver ; fractionated ; mapping ; sinus rhythm
• 刊名：Journal of the American College of Cardiology
• 出版年：2017
• 出版时间：24 January 2017
• 年：2017
• 卷：69
• 期：3
• 页码：303-321
• 全文大小：5367 K
• 卷排序：69

文摘

The use of intracardiac electrograms to guide atrial fibrillation (AF) ablation has yielded conflicting results.ObjectivesThe authors evaluated the usefulness of spatiotemporal dispersion, a visually recognizable electric footprint of AF drivers, for the ablation of all forms of AF.MethodsThe authors prospectively enrolled 105 patients admitted for AF ablation. AF was sequentially mapped in both atria with a 20-pole PentaRay catheter. The authors tagged and ablated only regions displaying electrogram dispersion during AF. Results were compared to a validation set in which a conventional ablation approach was used (pulmonary vein isolation/stepwise approach). To establish the mechanism underlying spatiotemporal dispersion of AF electrograms, the authors conducted realistic numerical simulations of AF drivers in a 2-dimensional model and optical mapping of ovine atrial scar-related AF.ResultsAblation at dispersion areas terminated AF in 95% of the 105 patients. After ablation of 17 ± 10% of the left atrial surface and 18 months of follow-up, the atrial arrhythmia recurrence rate was 15% after 1.4 ± 0.5 procedures per patient versus 41% in the validation set after 1.5 ± 0.5 procedures per patient (arrhythmia free-survival: 85% vs. 59%; log-rank p < 0.001). Compared with the validation set, radiofrequency times (49 ± 21 min vs. 85 ± 34.5 min; p = 0.001) and procedure times (168 ± 42 min vs. 230 ± 67 min; p < 0.0001) were shorter. In simulations and optical mapping experiments, virtual PentaRay recordings demonstrated that electrogram dispersion is mostly recorded in the vicinity of a driver.ConclusionsThe clustering of intracardiac electrograms exhibiting spatiotemporal dispersion is indicative of AF drivers. Their ablation allows for a nonextensive and patient-tailored approach to AF ablation. (Substrate Ablation Guided by High Density Mapping in Atrial Fibrillation [SUBSTRATE HD]; NCT02093949)