From the Myocardial Pathophysiology Area, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (J.G.Q., J.M.A.-A., J.J., D.F.-R.).
Arrhythmia Unit, Cardiology Department, Cardiovascular Institute, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain (J.G.Q., N.P.-C., J.P.-V., D.F.-R.).
Circ Res. 2019 Aug 30;125(6):609-627. doi: 10.1161/CIRCRESAHA.119.314930. Epub 2019 Aug 1.
Costly proprietary panoramic multielectrode (64-256) acquisition systems are being increasingly used together with conventional electroanatomical mapping systems for persistent atrial fibrillation (PersAF) ablation. However, such approaches target alleged drivers (rotational/focal) regardless of their activation frequency dynamics.
To test the hypothesis that stable regions of higher than surrounding instantaneous frequency modulation (iFM) drive PersAF and determine whether rotational activity is specific for such regions.
First, novel single-signal algorithms based on instantaneous amplitude modulation (iAM) and iFM to detect rotational-footprints without panoramic multielectrode acquisition systems were tested in 125 optical movies from 5 ex vivo Langendorff-perfused PersAF sheep hearts (sensitivity/specificity, 92.6/97.5%; accuracy, 2.5-mm) and in computer simulations. Then, 16 pigs underwent high-rate atrial pacing to develop PersAF. After a median (interquartile range [IQR]) of 4.4 (IQR, 2.5-9.9) months of high-rate atrial pacing followed by 4.1 (IQR, 2.7-5.4) months of self-sustained PersAF, pigs underwent in vivo high-density electroanatomical atrial mapping (4920 [IQR, 4435-5855] 8-second unipolar signals per map). The first 4 out of 16 pigs were used to adapt ex vivo optical proccessing of iFM/iAM to in vivo electrical signals. In the remaining 12 out of 16 pigs, regions of higher than surrounding average iFM were considered leading-drivers. Two leading-driver + rotational-footprint maps were generated 2.6 (IQR, 2.4-2.9) hours apart to test leading-driver spatiotemporal stability and guide ablation. Leading-driver regions (2.5 [IQR, 2.0-4.0] regions/map) exactly colocalized (95.7%) in the 2 maps, and their ablation terminated PersAF in 92.3% of procedures (radiofrequency until termination, 16.9 [IQR, 9.2-35.8] minutes; until nonsustainability, 20.4 [IQR, 12.8-44.0] minutes). Rotational-footprints were found at every leading-driver region, albeit most (76.8% [IQR, 70.5%-83.6%]) were located outside. Finally, the translational ability of this approach was tested in 3 PersAF redo patients.
Both rotational-footprints and spatiotemporally stable leading-driver regions can be located using iFM/iAM algorithms without panoramic multielectrode acquisition systems. In pigs, ablation of leading-driver regions usually terminates PersAF and prevents its sustainability. Rotational activations are sensitive but not specific to such regions. Single-signal iFM/iAM algorithms could be integrated into conventional electroanatomical mapping systems to improve driver detection accuracy and reduce the cost of patient-tailored/mechanistic approaches.
昂贵的专有全景多电极（64-256）采集系统越来越多地与传统的电生理标测系统一起用于持续性心房颤动（PersAF）消融。然而，这种方法针对的是所谓的驱动灶（旋转/局灶），而不管其激活频率的动态。
检验稳定的高于周围瞬时频率调制（iFM）的区域驱动 PersAF 的假说，并确定旋转活动是否对这些区域具有特异性。
首先，基于瞬时幅度调制（iAM）和 iFM 的新型单信号算法，在 5 个离体 Langendorff 灌流 PersAF 绵羊心脏的 125 个光学电影（敏感性/特异性，92.6/97.5%；准确性，2.5-mm）和计算机模拟中测试了检测旋转足迹而无需全景多电极采集系统的能力。然后，16 只猪接受高心率心房起搏以诱发 PersAF。在高心率心房起搏 4.4（IQR，2.5-9.9）个月后中位数（IQR，2.7-5.4）个月的自行维持 PersAF后，猪接受了体内高密度电生理心房标测（4920[IQR，4435-5855]8 秒单极信号/图）。前 16 只猪中的 4 只用于适应离体光学处理 iFM/iAM 到体内电信号。在 16 只猪中的其余 12 只中，高于周围平均 iFM 的区域被认为是主导驱动灶。在 2.6（IQR，2.4-2.9）小时的间隔生成了 2 个主导驱动灶+旋转足迹图，以测试主导驱动灶的时空稳定性并指导消融。在 2 张图中，主导驱动灶区域（2.5[IQR，2.0-4.0]个/图）完全重合（95.7%），其消融终止了 92.3%的程序中的 PersAF（射频直至终止，16.9[IQR，9.2-35.8]分钟；直至不可持续性，20.4[IQR，12.8-44.0]分钟）。在每个主导驱动灶区域都发现了旋转足迹，尽管大多数（76.8%[IQR，70.5%-83.6%]）位于其外部。最后，在 3 例 PersAF 再手术患者中测试了这种方法的可转移性。
无需全景多电极采集系统，即可使用 iFM/iAM 算法定位旋转足迹和时空稳定的主导驱动灶区域。在猪中，消融主导驱动灶区域通常可终止 PersAF 并防止其持续性。旋转激活对这些区域敏感但不具有特异性。单信号 iFM/iAM 算法可以集成到传统的电生理标测系统中，以提高驱动灶检测的准确性并降低针对患者的/基于机制的方法的成本。
