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Address reprint requests and correspondence: Dr T. Jared Bunch, Intermountain Heart Rhythm Specialists, Intermountain Medical Center, Eccles Outpatient Care Center, 5169 Cottonwood St, Suite 510, Murray, UT 84107.
In patients with symptomatic atrial fibrillation (AF), durable pulmonary vein isolation
(PVI) remains the goal for ablation procedures. In patients with more advanced AF
subtypes or recurrences of AF after PVI, there remains the need to identify and treat
extrapulmonary vein drivers. The precise identification of drivers requires comparison
to a reference point, which can be challenging in AF. Using the concept of searching
the core of centrifugal activation, similar to that used for a focal atrial tachycardia,
Matsunaga and Takano (DOI: http://10.1016/j.hrcr.2017.10.015) described a novel approach to AF driver mapping with self-reference. For a focal
AF driver to impact arrhythmia, there needs to be local propagation of a wavefront
in the absence of a functional or anatomic barrier. Using a PentaRay multipolar catheter
(ThermoCool SmartTouch SF, Biosense Webster, Inc., Diamond Bar, CA), the operators
annotated the earliest site of local activation and a reference tag was placed. The
multipolar catheter was then moved to the reference tag and the process repeated.
Ultimately, they identified clusters of early circumferential activation and AF drivers
were targeted with ablation. After ablation of all triggers and isolation of the pulmonary
veins, AF was no longer inducible. The next step is to examine this approach in a
large series of patients and provide long-term outcomes.
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