A new treatment for atrial fibrillation based on spectral analysis to guide the catheter RF-ablation.
BACKGROUND
By studying the spectrum of atrial potentials by fast Fourier transform (FFT) we have found two types of atrial muscle: the compact (CM) and the fibrillar (FM) myocardium. The former presents normal in-phase conduction inferring a great number of cellular connections, long-lasting refractoriness and leftward FFT-shift. The latter shows anisotropic out-of-phase conduction, fewer cellular connections, short refractoriness and a segmented right-FFT-shift. The compact is the normal predominant muscle and the fibrillar is different and may be neural input, vein insertion, interatrial (1A) septum, left atrial (LA) roof, etc. or pathological tissue, being so by loss of cellular connections this is a possible mechanism for conversion of compact into fibrillar-like myocardium. During atrial fibrillation (AF), clusters of FM (AF nests) present higher frequencies than any surrounding tissue.


OBJECTIVE
The purpose was to describe a new method for paroxysmal AF RF-ablation targeting AF nests.


METHODS
Forty patients, six control and 34 having idiopathic drug-refractory paroxysmal or persistent AF were studied and treated. Two catheters were placed in the LA by transseptal approach. RF (30-40 J/60-70 degrees C) was applied to all sites outside the pulmonary veins (PV) presenting right-FFT-shift (AF nests).


RESULTS
Numerous AF nests were found in 34/34 AF patients and only in 1/6 controls (only in this case it was possible to induce AF despite an absence of AF history). The main FM sites were: LA roof, LA septum, close to the insertion of the superior PV, near the insertion of the inferior PV, LA posterior wall, RA near the superior vena cava insertion, RA lateral and anterior wall and the right IA septum. Ablation of all AF nests near PV insertions resulted in 35 PV isolations. After 9.9 +/- 5 months only two AF patients presented relapse of a different AF form (coarse AF) which was very well controlled with medication previously ineffective. The AF was more frequent as the ratio FM/CM increased.


CONCLUSIONS
The RF-ablation of AF nests decreasing the fibrillar/compact myocardium ratio eliminated 94% of the paroxysmal AF in patients in the FU of 9.9 +/- 5 months. The AF nests may be easily identified by spectral analysis and seem to be the real AF substrate. Paroxysmal AF may be cured or controlled by applying RF in several places outside the PV and, thereby, avoiding PV stenosis.
Pachon M
Jose C
JC
Dante Pazzanese Cardiology Institute and Sao Paulo Heart Hospital, Pacemaker and Arrhythmias, Acoce, 515/31, Indianopolis, 04075023 Sao Paulo, SP, Brazil. jcpachon@hotmail.com
Pachon M
Enrique I
EI
Pachon M
Juan C
JC
Lobo
Tasso J
TJ
Pachon
Maria Z
MZ
Vargas
Remy N A
RN
Pachon
Denilda Q V
DQ
Lopez M
Francisco J
FJ
Jatene
Adib D
AD
D000328:Adult; D001281:Atrial Fibrillation / Q000503:physiopathology / Q000628:therapy*; D017115:Catheter Ablation; D022062:Electrophysiologic Techniques, Cardiac; D005260:Female; D005583:Fourier Analysis; D006325:Heart Atria / Q000503:physiopathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D009206:Myocardium / Q000166:cytology