Mapping and ablation of non-pulmonary vein drivers of persistent atrial
fibrillation: Has a STAR been born?
Abstract
While pulmonary vein isolation (PVI) remains the cornerstone for
invasive treatment of atrial fibrillation (AF), patients with persistent
AF still have a high rate of recurrence with this method. Stochastic
Trajectory Analysis of Ranked signals (STAR) mapping uses data from
multiple individual wavefronts during ongoing AF to identify local
drivers of persistent AF. In this non-randomized study, STAR mapping and
ablation showed significantly lower recurrence of atrial arrhythmias
compared to a consecutive PVI-only cohort and a propensity-matched
‘conventional ablation’ cohort (consisting of PVI plus complex
fractionated atrial electrogram ablation or linear ablation). This
benefit was driven by a much lower rate of AF recurrence in the STAR
(6.2%) cohort vs PVI-only (44%) or ‘conventional’ (40%) with no
significant difference in atrial tachycardia recurrence. Additionally,
AF termination rates during ablation were approximately three times
higher in the STAR cohort. While the analysis is retrospective and not
randomized, the STAR cohort was also the only cohort with complete
cessation of anti-arrhythmic drugs at three months and Holter monitoring
at 6 and 12 months post-ablation per protocol. While STAR mapping
appears to be a very promising new tool for treating persistent AF,
history predicts at least some regression to the mean when future
randomized comparisons are made. The authors have planned a multicenter
randomized trial of PVI plus STAR mapping vs PVI-only for persistent AF.
The global community of electrophysiologists and patients with AF
eagerly awaits the results.