title: Panoramic electrophysiological mapping but not electrogram morphology identifies stable sources for human atrial fibrillation: stable atrial fibrillation rotors and focal sources relate poorly to fractionated electrograms.
abstract: BACKGROUND
  The foundation for successful arrhythmia ablation is the mapping of electric propagation to identify underlying mechanisms. In atrial fibrillation (AF), however, mapping is difficult so that ablation has often targeted electrogram features, with mixed results. We hypothesized that wide field-of-view (panoramic) mapping of both atria would identify causal mechanisms for AF and allow interpretation of local electrogram features, including complex fractionated atrial electrograms (CFAE).
  
  
  RESULTS
  Contact mapping was performed using biatrial multipolar catheters in 36 AF subjects (29 persistent). Stable AF rotors (spiral waves) or focal sources were seen in 35 of 36 cases and targeted for ablation (focal impulse and rotor modulation) before pulmonary vein isolation. In 31 of 36 subjects (86.1%), AF acutely terminated (n=20; 16 to sinus rhythm) or organized (n=11; 19±8% slowing) with 2.5 minutes focal impulse and rotor modulation (interquartile range, 1.0-3.1) at one source, defined as the primary source. Subjects exhibited 2.1±1.0 concurrent AF sources of which the primary, by phase mapping, precessed in limited areas (persistent 2.5±1.7 versus paroxysmal 1.7±0.5 cm(2); P=0.30). Notably, source regions showed mixed electrogram amplitudes and CFAE grades that did not differ from surrounding atrium (P=NS). AF sources were not consistently surrounded by CFAE (P=0.67).
  
  
  CONCLUSIONS
  Stable rotors and focal sources for human AF were revealed by contact panoramic mapping (focal impulse and rotor modulation mapping), but not by electrogram footprints. AF sources precessed within areas of ≈2 cm(2), with diverse voltage characteristics poorly correlated with CFAE. Most CFAE sites lie remote from AF sources and are not suitable targets for catheter ablation of AF.
authors: University of California and Veterans' Affairs Medical Centers, San Diego, CA 92161, USA. snarayan@ucsd.edu
authors: Sanjiv M
authors: SM
authors: Narayan
authors: Kalyanam
authors: K
authors: Shivkumar
authors: David E
authors: DE
authors: Krummen
authors: John M
authors: JM
authors: Miller
authors: Wouter-Jan
authors: WJ
authors: Rappel
mesh_terms: D000200:Action Potentials; D000368:Aged; D001281:Atrial Fibrillation / Q000175:diagnosis* / Q000503:physiopathology / Q000601:surgery; D002140:California; D062906:Cardiac Catheters; D017115:Catheter Ablation; D016009:Chi-Square Distribution; D022062:Electrophysiologic Techniques, Cardiac / Q000295:instrumentation; D005260:Female; D006329:Heart Conduction System / Q000503:physiopathology* / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012815:Signal Processing, Computer-Assisted; D013997:Time Factors; D056969:Voltage-Sensitive Dye Imaging / Q000295:instrumentation
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