title: Multicentre evaluation of non-invasive biatrial mapping for persistent atrial fibrillation ablation: the AFACART study.
abstract: OBJECTIVE
  Non-invasive electrocardiogram (ECG) mapping allows the activation of the entire atrial epicardium to be recorded simultaneously, potentially identifying mechanisms critical for atrial fibrillation (AF) persistence. We sought to evaluate the utility of ECG mapping as a practical tool prior to ablation of persistent AF (PsAF) in centres with no practical experience of the system.
  
  
  RESULTS
  A total of 118 patients with continuous AF duration <1 year were prospectively studied at 8 European centres. Patients were on a median of 1 antiarrhythmic drug (AAD) that had failed to restore sinus rhythm. Electrocardiogram mapping (ECVUE™, CardioInsight, USA) was performed prior to ablation to map AF drivers (local re-entrant circuits or focal breakthroughs). Ablation targeted drivers depicted by the system, followed by pulmonary vein (PV) isolation, and finally left atrial linear ablation if AF persisted. The primary endpoint was AF termination. Totally, 4.9 ± 1.0 driver sites were mapped per patient with a cumulative mapping time of 16 ± 2 s. Of these, 53% of drivers were located in the left atrium, 27% in the right atrium, and 20% in the anterior interatrial groove. Driver-only ablation resulted in AF termination in 75 of the 118 patients (64%) with a mean radiofrequency (RF) duration of 46 ± 28 min. Acute termination rates were not significantly different amongst all 8 centres (P = 0.672). Ten additional patients terminated with PV isolation and lines resulting in a total AF termination rate of 72%. Total RF duration was 75 ± 27 min. At 1-year follow-up, 78% of the patients were off AADs and 77% of the patients were free from AF recurrence. Of the patients with no AF recurrence, 49% experienced at least one episode of atrial tachycardia (AT) which required either continued AAD therapy, cardioversion, or repeat ablation.
  
  
  CONCLUSIONS
  Non-invasive mapping identifies biatrial drivers that are critical in PsAF. This is validated by successful AF termination in the majority of patients treated in centres with no experience of the system. Ablation targeting these drivers results in favourable AF-free survival at 1 year, albeit with a significant rate of AT recurrence requiring further management.
authors.affiliation: CHU-Brugmann, Brussels, Belgium.|Department of Cardiology, AZ Sint-Jan, Ruddershove 10, 8000 Brugge, Belgium.
authors.forename: Sébastien
authors.initials: S
authors.lastname: Knecht
authors.affiliation: CHU-Brugmann, Brussels, Belgium.|Department of Cardiology, AZ Sint-Jan, Ruddershove 10, 8000 Brugge, Belgium.
authors.forename: Manav
authors.initials: M
authors.lastname: Sohal
authors.affiliation: Deutsches Herzzentrum München, Munich, Germany.
authors.forename: Isabelle
authors.initials: I
authors.lastname: Deisenhofer
authors.affiliation: Clinique Pasteur, Toulouse, France.
authors.forename: Jean-Paul
authors.initials: JP
authors.lastname: Albenque
authors.affiliation: Universitäts Herzzentrum Freiburg, Bad Krozingen, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Arentz
authors.affiliation: Kerkhoff Klinik, Bad Nauheim, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Neumann
authors.affiliation: Clinique Ambroise Paré, Paris, France.
authors.forename: Bruno
authors.initials: B
authors.lastname: Cauchemez
authors.affiliation: Department of Cardiology, AZ Sint-Jan, Ruddershove 10, 8000 Brugge, Belgium.
authors.forename: Mattias
authors.initials: M
authors.lastname: Duytschaever
authors.affiliation: CHU-Brugmann, Brussels, Belgium.
authors.forename: Khaled
authors.initials: K
authors.lastname: Ramoul
authors.affiliation: CHU-Brugmann, Brussels, Belgium.
authors.forename: Thierry
authors.initials: T
authors.lastname: Verbeet
authors.affiliation: Deutsches Herzzentrum München, Munich, Germany.
authors.forename: Sonia
authors.initials: S
authors.lastname: Thorsten
authors.affiliation: Universitäts Herzzentrum Freiburg, Bad Krozingen, Germany.
authors.forename: Amir
authors.initials: A
authors.lastname: Jadidi
authors.affiliation: Clinique Pasteur, Toulouse, France.
authors.forename: Stephane
authors.initials: S
authors.lastname: Combes
authors.affiliation: Department of Cardiology, AZ Sint-Jan, Ruddershove 10, 8000 Brugge, Belgium.
authors.forename: René
authors.initials: R
authors.lastname: Tavernier
authors.affiliation: Department of Cardiology, AZ Sint-Jan, Ruddershove 10, 8000 Brugge, Belgium.
authors.forename: Yves
authors.initials: Y
authors.lastname: Vandekerckhove
authors.affiliation: Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, Imperial College, London, UK.
authors.forename: Sabine
authors.initials: S
authors.lastname: Ernst
authors.affiliation: Mayo Clinic, Rochester, NY, USA.
authors.forename: Douglas
authors.initials: D
authors.lastname: Packer
authors.affiliation: II. Medizinische Klinik und Poliklinik, Universitätsmedizin Mainz, Mainz, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Rostock
mesh_terms: D000200:Action Potentials; D000368:Aged; D001281:Atrial Fibrillation / Q000175:diagnosis* / Q000503:physiopathology / Q000601:surgery*; D018780:Body Surface Potential Mapping / Q000295:instrumentation / Q000379:methods*; D017115:Catheter Ablation / Q000009:adverse effects; D018572:Disease-Free Survival; D005060:Europe; D005240:Feasibility Studies; D005260:Female; D006339:Heart Rate; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011446:Prospective Studies; D011667:Pulmonary Veins / Q000503:physiopathology / Q000601:surgery*; D012008:Recurrence; D015203:Reproducibility of Results; D012307:Risk Factors; D013617:Tachycardia, Supraventricular / Q000175:diagnosis / Q000209:etiology; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
keywords: Ablation; Multicentre evaluation; Non-invasive mapping; Persistent atrial fibrillation