Early temporal and spatial regularization of persistent atrial fibrillation predicts termination and arrhythmia-free outcome

Background

Termination of persistent atrial fibrillation (AF) is a valuable ablation endpoint but is difficult to anticipate. We evaluated whether temporal and spatial indices of AF regularization predict intraprocedural AF termination and outcome.

Objective

The purpose of this study was to test whether temporospatial organization of AF after pulmonary vein isolation (PVI) predicts whether subsequent stepwise ablation will terminate persistent AF or predict outcome.

Methods

In 75 patients with persistent AF, we measured AF cycle length (AFCL), temporal regularity index (TRI, a spectral measure of timing regularity), and spatial regularity index (SRI, cycle-to-cycle variations in spatial vector) between right atrial appendage and proximal and distal coronary sinus before and during stepwise ablation to the endpoint of AF termination.

Results

AF termination was achieved in 59 patients (79%) by ablation. AF terminated during PVI in 11 patients, who were excluded from analysis. In the remaining 48 patients, TRI and SRI increased during stepwise ablation, as compared with 16 patients without termination (P<.05). AFCL was prolonged in both groups. From receiver operating characteristics analysis of the first 22 patients (training set), a post-PVI TRI increase predicted AF termination in the latter 42 patients (test set) with a positive predictive value of 96%, negative predictive value of 53%, sensitivity of 71%, and specificity of 91%. Results were similar for SRI. After 36 months, higher arrhythmia-free outcome was observed in patients in whom PVI caused temporospatial regularization in AF.

Conclusions

Temporal and spatial regularization of persistent AF after PVI identifies patients in whom stepwise ablation subsequently terminates AF and prevents recurrence.

Keywords: Atrial fibrillation, Ablation, Termination, Organization, Spectral analysis, Signal processing

Abbreviations: AF, atrial fibrillation, AFCL, AF cycle length, AUC, area under the curve, CFAE, complex fractionated atrial electrogram, CI, confidence interval, CL, cycle length, CS, coronary sinus, DF, dominant frequency, ECG, electrocardiogram, LA, left atrial, OR, odds ratio, PVI, pulmonary vein isolation, RA, right atrial atrium, ROC, receiver operating characteristics, SRI, spatial regularity index, TRI, temporal regularity index