Instantaneous Amplitude and Frequency Modulations Detect the Footprint of Rotational Activity and Reveal Stable Driver Regions as Targets for Persistent Atrial Fibrillation Ablation

被引:26
作者
Quintanilla, Jorge G. [1 ,2 ,3 ]
Manuel Alfonso-Almazan, Jose [1 ]
Perez-Castellano, Nicasio [2 ,3 ]
Pandit, Sandeep, V [4 ]
Jalife, Jose [1 ,3 ,4 ]
Perez-Villacastin, Julian [2 ,3 ]
Filgueiras-Rama, David [1 ,2 ,3 ]
机构
[1] CNIC, Myocardial Pathophysiol Area, Madrid, Spain
[2] Inst Invest Sanit Hosp Clin San Carlos IdISSC, Cardiovasc Inst, Cardiol Dept, Arrhythmia Unit, Madrid, Spain
[3] Ctr Invest Biomed Red Enfermedades Cardiovasc CIB, Madrid, Spain
[4] Univ Michigan, Dept Internal Med, Ctr Arrhythmia Res, Ann Arbor, MI 48109 USA
关键词
ablation; algorithms; atrial fibrillation; driver; mapping; rotor; PULMONARY VEIN ISOLATION; DOMINANT FREQUENCY; CATHETER ABLATION; LOCALIZATION; MECHANISMS; PATTERNS; BEHAVIOR; ROTORS; SHEEP;
D O I
10.1161/CIRCRESAHA.119.314930
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
Rationale: Costly proprietary panoramic multielectrode (64-256) acquisition systems are being increasingly used together with conventional electroanatomical mapping systems for persistent atrial fibrillation (PersAF) ablation. However, such approaches target alleged drivers (rotational/focal) regardless of their activation frequency dynamics. Objectives: To test the hypothesis that stable regions of higher than surrounding instantaneous frequency modulation (iFM) drive PersAF and determine whether rotational activity is specific for such regions. Methods and Results: First, novel single-signal algorithms based on instantaneous amplitude modulation (iAM) and iFM to detect rotational-footprints without panoramic multielectrode acquisition systems were tested in 125 optical movies from 5 ex vivo Langendorff-perfused PersAF sheep hearts (sensitivity/specificity, 92.6/97.5%; accuracy, 2.5-mm) and in computer simulations. Then, 16 pigs underwent high-rate atrial pacing to develop PersAF. After a median (interquartile range [IQR]) of 4.4 (IQR, 2.5-9.9) months of high-rate atrial pacing followed by 4.1 (IQR, 2.7-5.4) months of self-sustained PersAF, pigs underwent in vivo high-density electroanatomical atrial mapping (4920 [IQR, 4435-5855] 8-second unipolar signals per map). The first 4 out of 16 pigs were used to adapt ex vivo optical proccessing of iFM/iAM to in vivo electrical signals. In the remaining 12 out of 16 pigs, regions of higher than surrounding average iFM were considered leading-drivers. Two leading-driver + rotational-footprint maps were generated 2.6 (IQR, 2.4-2.9) hours apart to test leading-driver spatiotemporal stability and guide ablation. Leading-driver regions (2.5 [IQR, 2.0-4.0] regions/map) exactly colocalized (95.7%) in the 2 maps, and their ablation terminated PersAF in 92.3% of procedures (radiofrequency until termination, 16.9 [IQR, 9.2-35.8] minutes; until nonsustainability, 20.4 [IQR, 12.8-44.0] minutes). Rotational-footprints were found at every leading-driver region, albeit most (76.8% [IQR, 70.5%-83.6%]) were located outside. Finally, the translational ability of this approach was tested in 3 PersAF redo patients. Conclusions: Both rotational-footprints and spatiotemporally stable leading-driver regions can be located using iFM/iAM algorithms without panoramic multielectrode acquisition systems. In pigs, ablation of leading-driver regions usually terminates PersAF and prevents its sustainability. Rotational activations are sensitive but not specific to such regions. Single-signal iFM/iAM algorithms could be integrated into conventional electroanatomical mapping systems to improve driver detection accuracy and reduce the cost of patient-tailored/mechanistic approaches. Visual Overview: An online visual overview is available for this article.
引用
收藏
页码:609 / 627
页数:19
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