title: Direct or coincidental elimination of stable rotors or focal sources may explain successful atrial fibrillation ablation: on-treatment analysis of the CONFIRM trial (Conventional ablation for AF with or without focal impulse and rotor modulation).
abstract: OBJECTIVE
  This study sought to determine whether ablation of recently described stable atrial fibrillation (AF) sources, either directly by Focal Impulse and Rotor Modulation (FIRM) or coincidentally when anatomic ablation passes through AF sources, may explain long-term freedom from AF.
  
  
  BACKGROUND
  It is unclear why conventional anatomic AF ablation can be effective in some patients yet ineffective in others with similar profiles.
  
  
  METHODS
  The CONFIRM (Conventional Ablation for AF With or Without Focal Impulse and Rotor Modulation) trial prospectively revealed stable AF rotors or focal sources in 98 of 101 subjects with AF at 107 consecutive ablation cases. In 1:2 fashion, subjects received targeted source ablation (FIRM) followed by conventional ablation, or conventional ablation alone. We determined whether ablation lesions on electroanatomic maps passed through AF sources on FIRM maps.
  
  
  RESULTS
  Subjects who completed follow-up (n = 94; 71.2% with persistent AF) showed 2.3 ± 1.1 concurrent AF rotors or focal sources that lay near pulmonary veins (22.8%), left atrial roof (16.0%), and elsewhere in the left (28.2%) and right (33.0%) atria. AF sources were ablated directly in 100% of FIRM cases and coincidentally (e.g., left atrial roof) in 45% of conventional cases (p < 0.05). During a median (interquartile range) of 273 days (138 to 636 days) after one procedure, AF was absent in 80.3% of patients if sources were ablated but in only 18.2% of patients if sources were missed (p < 0.001). Freedom from AF was highest if all sources were ablated, intermediate if some sources were ablated, and lowest if no sources were ablated (p < 0.001).
  
  
  CONCLUSIONS
  Elimination of stable AF rotors and focal sources may explain freedom from AF after diverse approaches to ablation. Patient-specific AF source distributions are consistent with the reported success of specific anatomic lesion sets and of widespread ablation. These results support targeting AF sources to reduce unnecessary ablation, and motivate studies on FIRM-only ablation.
authors.affiliation: Department of Medicine, University of California, San Diego, California; Veterans Affairs Medical Center, San Diego, California; University of California, Los Angeles, California. Electronic address: snarayan@ucsd.edu.
authors.forename: Sanjiv M
authors.initials: SM
authors.lastname: Narayan
authors.affiliation: Department of Medicine, University of California, San Diego, California; Veterans Affairs Medical Center, San Diego, California.
authors.forename: David E
authors.initials: DE
authors.lastname: Krummen
authors.affiliation: Veterans Affairs Medical Center, San Diego, California.
authors.forename: Paul
authors.initials: P
authors.lastname: Clopton
authors.affiliation: University of California, Los Angeles, California.
authors.forename: Kalyanam
authors.initials: K
authors.lastname: Shivkumar
authors.affiliation: The Krannert Institute of Cardiology, Indiana University, Indianapolis, Indiana.
authors.forename: John M
authors.initials: JM
authors.lastname: Miller
mesh_terms: D000200:Action Potentials / Q000502:physiology; D001281:Atrial Fibrillation / Q000503:physiopathology / Q000601:surgery*; D018780:Body Surface Potential Mapping; D017115:Catheter Ablation / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006325:Heart Atria / Q000503:physiopathology / Q000601:surgery; D006329:Heart Conduction System / Q000503:physiopathology / Q000601:surgery; D006351:Heart Valves / Q000503:physiopathology / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011667:Pulmonary Veins / Q000503:physiopathology / Q000601:surgery; D012008:Recurrence; D016896:Treatment Outcome
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