Identification of High Priority Focal Activations in Persistent Atrial
Fibrillation Using A Novel Mapping Strategy
Abstract
Introduction: Focal activation is believed to be an atrial fibrillation
(AF) driver; however, little is known about whether all focal
activations are necessary for AF persistence. The purpose of this study
was to assess the electrical nature of focal activation and identify
high-priority focal activations using a novel mapping system
(CARTOFINDER). Methods: Thirty-five patients with persistent AF who
underwent catheter ablation were assessed. Cycle length (CL) and CL
standard deviation (CLSD) on unipolar recordings and voltage amplitude
and electrogram morphologies on bipolar recordings were evaluated at all
points of interest. The most frequent CL at each mapping site was
defined as the dominant CL. We identified dominant focal activations
(DFAs) that had a shorter dominant CL on the integrated CARTOFINDER map.
The effect of elimination of DFAs on AF maintenance was assessed by the
composite endpoint (termination to sinus rhythm, organization of the
rhythm to atrial tachycardia, and AF CL slowing). Results: In all, 450
focal activations were identified among 10,868 points, and 50.4% of
focal activations were DFAs. Focal activations showed relatively long CL
and regularity with short CLSD. Most focal activations showed an
isoelectric baseline and were located outside of the fractionated
electrogram area. Both DFAs and non-DFAs were typically observed in
normal voltage range. Elimination of DFAs was achieved in 19 (54.3%)
patients, with a remarkable impact on AF maintenance (68.4% vs. 25.0%,
p = 0.018). Conclusions: DFAs may play an important role in AF
maintenance and could be an attractive therapeutic target for AF.