title: AF Ablation Guided by Spatiotemporal Electrogram Dispersion Without Pulmonary Vein Isolation: A Wholly Patient-Tailored Approach.
abstract: BACKGROUND
  The use of intracardiac electrograms to guide atrial fibrillation (AF) ablation has yielded conflicting results.
  
  
  OBJECTIVE
  The authors evaluated the usefulness of spatiotemporal dispersion, a visually recognizable electric footprint of AF drivers, for the ablation of all forms of AF.
  
  
  METHODS
  The authors prospectively enrolled 105 patients admitted for AF ablation. AF was sequentially mapped in both atria with a 20-pole PentaRay catheter. The authors tagged and ablated only regions displaying electrogram dispersion during AF. Results were compared to a validation set in which a conventional ablation approach was used (pulmonary vein isolation/stepwise approach). To establish the mechanism underlying spatiotemporal dispersion of AF electrograms, the authors conducted realistic numerical simulations of AF drivers in a 2-dimensional model and optical mapping of ovine atrial scar-related AF.
  
  
  RESULTS
  Ablation at dispersion areas terminated AF in 95% of the 105 patients. After ablation of 17 ± 10% of the left atrial surface and 18 months of follow-up, the atrial arrhythmia recurrence rate was 15% after 1.4 ± 0.5 procedures per patient versus 41% in the validation set after 1.5 ± 0.5 procedures per patient (arrhythmia free-survival: 85% vs. 59%; log-rank p < 0.001). Compared with the validation set, radiofrequency times (49 ± 21 min vs. 85 ± 34.5 min; p = 0.001) and procedure times (168 ± 42 min vs. 230 ± 67 min; p < 0.0001) were shorter. In simulations and optical mapping experiments, virtual PentaRay recordings demonstrated that electrogram dispersion is mostly recorded in the vicinity of a driver.
  
  
  CONCLUSIONS
  The clustering of intracardiac electrograms exhibiting spatiotemporal dispersion is indicative of AF drivers. Their ablation allows for a nonextensive and patient-tailored approach to AF ablation. (Substrate Ablation Guided by High Density Mapping in Atrial Fibrillation [SUBSTRATE HD]; NCT02093949).
authors.affiliation: Unité de Rythmologie Interventionnelle, Hôpital Saint Joseph Marseille, France. Electronic address: jseitz@hopital-saint-joseph.fr.
authors.forename: Julien
authors.initials: J
authors.lastname: Seitz
authors.affiliation: Unité de Rythmologie Interventionnelle, Hôpital Saint Joseph Marseille, France; Service de Cardiologie, Institut Mutualiste Montsouris, Paris, France.
authors.forename: Clément
authors.initials: C
authors.lastname: Bars
authors.affiliation: Service de Cardiologie, CHU, Nice, France.
authors.forename: Guillaume
authors.initials: G
authors.lastname: Théodore
authors.affiliation: Unité de Rythmologie Interventionnelle, Hôpital Saint Joseph Marseille, France.
authors.forename: Sylvain
authors.initials: S
authors.lastname: Beurtheret
authors.affiliation: Service de Cardiologie, CHU Henri Mondor, Creteil, France.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Lellouche
authors.affiliation: Unité de Rythmologie Interventionnelle, Hôpital Saint Joseph Marseille, France.
authors.forename: Michel
authors.initials: M
authors.lastname: Bremondy
authors.affiliation: Unité de Rythmologie Interventionnelle, Hôpital Saint Joseph Marseille, France.
authors.forename: Ange
authors.initials: A
authors.lastname: Ferracci
authors.affiliation: Unité de Rythmologie Interventionnelle, Hôpital Saint Joseph Marseille, France.
authors.forename: Jacques
authors.initials: J
authors.lastname: Faure
authors.affiliation: Département Statistique, Laboratoire Alphabio, Marseille, France.
authors.forename: Guillaume
authors.initials: G
authors.lastname: Penaranda
authors.affiliation: Center for Arrhythmia Research, Cardiovascular Research Center, Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor, Michigan.
authors.forename: Masatoshi
authors.initials: M
authors.lastname: Yamazaki
authors.affiliation: Center for Arrhythmia Research, Cardiovascular Research Center, Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor, Michigan.
authors.forename: Uma Mahesh R
authors.initials: UM
authors.lastname: Avula
authors.affiliation: Unité de Rythmologie Interventionnelle, Hôpital Saint Joseph Marseille, France.
authors.forename: Laurence
authors.initials: L
authors.lastname: Curel
authors.affiliation: Unité de Rythmologie Interventionnelle, Hôpital Saint Joseph Marseille, France.
authors.forename: Sabrina
authors.initials: S
authors.lastname: Siame
authors.affiliation: Center for Arrhythmia Research, Cardiovascular Research Center, Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor, Michigan.
authors.forename: Omer
authors.initials: O
authors.lastname: Berenfeld
authors.affiliation: Unité de Rythmologie Interventionnelle, Hôpital Saint Joseph Marseille, France.
authors.forename: André
authors.initials: A
authors.lastname: Pisapia
authors.affiliation: Center for Arrhythmia Research, Cardiovascular Research Center, Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor, Michigan.
authors.forename: Jérôme
authors.initials: J
authors.lastname: Kalifa
mesh_terms: D055011:Ablation Techniques / Q000379:methods*; D001281:Atrial Fibrillation / Q000503:physiopathology / Q000601:surgery*; D004562:Electrocardiography; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012008:Recurrence
keywords: cycle length; dispersion driver; fractionated; mapping; sinus rhythm