While current approaches for the ablation of
atrial fibrillation are often effective, they are only partially rooted in
mechanistic understanding. Accordingly, they are unable to identify which patients will or will not
do well after a single procedure, and which lesions sets should or should not
be performed. Mechanistic thinking
in AF falls into one of 2 dominant schools of thought – the first proposing disorganized
activity that self-sustains with no ‘driver’, and the second describing drivers
that cause secondary disorganization. This dichotomy has come to a head in the
setting of a plateauing of ablation success and greater demand for efficacious
intervention to treat AF by patients and funding agencies. Differences in
mapping may explain these schools of thought, with proponents of the
disorganized hypothesis studying small atrial areas at high resolution, and proponents
of the driver model studying wide fields-of-view at sometimes lower
resolution. Focal impulse and
rotor modulation (FIRM) mapping combines wide field of view with novel physiologically
based signal filtering and phase analysis, and has revealed that human AF is
often sustained by rotors and focal sources. In the CONFIRM Trial, targeting stable AF rotors/sources for
ablation improved the single-procedure efficacy for paroxysmal and persistent
AF over conventional ablation alone, as confirmed by independent laboratories. FIRM gives a theoretical foundation to explain
why certain lesion sets are effective in a given patient, by intersecting AF
sources in patient-specific locations. FIRM also explains why even extensive ablation may be ineffective, by
missing AF sources particularly in the right atrium. These insights have reinvigorated interest in the physiology
of human AF, and rotors with varying characteristics have now been identified by
many groups. Rationalizing these findings
will help catalyze the understanding AF substrates, and translate into even
better therapy for our AF patients.
Credits: Junaid A. B. Zaman, MD; Amir Schricker, MD; Gautam G. Lalani, MD; Tina Baykaner, MD; David E. Krummen, MD; Sanjiv M. Narayan, MD, PhD