title: Acute termination of human atrial fibrillation by identification and catheter ablation of localized rotors and sources: first multicenter experience of focal impulse and rotor modulation (FIRM) ablation.
abstract: BACKGROUND
  Catheter ablation of atrial fibrillation (AF) currently relies on eliminating triggers, and no reliable method exists to map the arrhythmia itself to identify ablation targets. The aim of this multicenter study was to define the use of Focal Impulse and Rotor Modulation (FIRM) for identifying ablation targets.
  
  
  METHODS
  We prospectively enrolled the first (n = 14, 11 males) consecutive patients undergoing FIRM-guided ablation for persistent (n = 11) and paroxysmal AF at 5 centers. A 64-pole basket catheter was used for panoramic right and left atrial mapping during AF. AF electrograms were analyzed using a novel system to identify sustained rotors (spiral waves), or focal beats (centrifugal activation to surrounding atrium). Ablation was performed first at identified sources. The primary endpoints were acute AF termination or organization (>10% cycle length prolongation). Conventional ablation was performed only after FIRM-guided ablation.
  
  
  RESULTS
  Twelve out of 14 cases were mapped. AF sources were demonstrated in all patients (average of 1.9 ± 0.8 per patient). Sources were left atrial in 18 cases, and right atrial in 5 cases, and 21/23 were rotors. FIRM-guided ablation achieved the acute endpoint in all patients, consisting of AF termination in n = 8 (4.9 ± 3.9 minutes at the primary source), and organization in n = 4. Total FIRM time for all patients was 12.3 ± 8.6 minutes.
  
  
  CONCLUSIONS
  FIRM-guided ablation revealed localized AF rotors/focal sources in patients with paroxysmal, persistent and longstanding persistent AF. Brief targeted FIRM-guided ablation at a priori identified sites terminated or substantially organized AF in all cases prior to any other ablation.
authors.affiliation: UCLA Cardiac Arrhythmia Center, Los Angeles, California, USA. kshivkumar@mednet.ucla.edu
authors.forename: Kalyanam
authors.initials: K
authors.lastname: Shivkumar
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Ellenbogen
authors.forename: John D
authors.initials: JD
authors.lastname: Hummel
authors.forename: John M
authors.initials: JM
authors.lastname: Miller
authors.forename: Jonathan S
authors.initials: JS
authors.lastname: Steinberg
mesh_terms: D000328:Adult; D000368:Aged; D001281:Atrial Fibrillation / Q000175:diagnosis* / Q000601:surgery*; D018780:Body Surface Potential Mapping / Q000379:methods*; D017115:Catheter Ablation / Q000379:methods*; D005260:Female; D006329:Heart Conduction System / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D016896:Treatment Outcome; D014481:United States