Centrifugal gradients of rate and organization in human atrial fibrillation.
BACKGROUND
Animal studies show that atrial fibrillation (AF) may emanate from sites of high rate and regularity, with fibrillatory conduction to adjacent areas. We used simultaneous mapping to find evidence for potential drivers in human AF defined as sites with higher rate and regularity than surrounding tissue.


METHODS
In 24 patients (age 61+/-10 years; 12 persistent), we recorded AF simultaneously from 32 left atrial bipolar basket electrodes in addition to pulmonary veins (PV), coronary sinus, and right atrial electrodes. We measured AF cycle length (CL) by Fourier transform and electrogram regularity at each electrode, referenced to patient-specific atrial anatomy.


RESULTS
We analyzed 10,298 electrode-periods. Evidence for potential AF drivers was found in 11 patients (five persistent). In persistent AF, these sites lay at the coronary sinus and left atrial roof but not PVs, while in paroxysmal AF six of nine sites lay at PVs (P<0.05). During ablation, a subset of patients experienced AF CL prolongation or termination with a focal lesion; in each case this lesion mapped to potential driver sites on blinded analysis. Conversely, sequential mapping failed to reveal these sites, possibly due to fluctuations in dominant frequency at driver locations in the context of migratory AF.


CONCLUSIONS
Simultaneous multisite recordings in human AF reveal evidence for drivers that lie near PVs in paroxysmal but not persistent AF, and were sites where ablation slowed or terminated AF in a subset of patients. The future work should determine if real-time ablation of AF-maintaining regions defined in this fashion eliminates AF.
Krummen
David E
DE
University of California San Diego and VA San Diego Healthcare System, San Diego, California 92161, USA. dkrummen@ucsd.edu
Peng
Kevin A
KA
Bullinga
John R
JR
Narayan
Sanjiv M
SM
D001281:Atrial Fibrillation / Q000175:diagnosis* / Q000503:physiopathology*; D001683:Biological Clocks; D018780:Body Surface Potential Mapping; D054326:Coronary Sinus / Q000503:physiopathology*; D005260:Female; D006325:Heart Atria / Q000503:physiopathology*; D006329:Heart Conduction System / Q000503:physiopathology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011667:Pulmonary Veins / Q000503:physiopathology*