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

J Am Coll Cardiol. 2017 Mar 14;69(10):1257-1269. 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.

Keywords: complexity; drivers; panoramic mapping; persistent atrial fibrillation.

MeSH terms

  • Atrial Fibrillation / diagnosis
  • Atrial Fibrillation / physiopathology*
  • Atrial Fibrillation / surgery
  • Body Surface Potential Mapping / methods*
  • Catheter Ablation / methods*
  • Female
  • Follow-Up Studies
  • Heart Atria / physiopathology*
  • Heart Conduction System / physiopathology*
  • Heart Conduction System / surgery
  • Humans
  • Male
  • Middle Aged
  • Prospective Studies
  • Time Factors
  • Tomography, X-Ray Computed