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Available online 1 March 2024
Subjective identification and ablation of drivers improves rhythm control in patients with persistent atrial fibrillation. The CHAOS-AF study
La identificación subjetiva y ablación de impulsores auriculares mejora el control del ritmo en la fibrilación auricular persistente. Estudio CHAOS-AF
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Eduardo Francoa,b,
Corresponding author
efranco@academiamir.com

Corresponding author.
, Cristina Lozano-Graneroa,b, Roberto Matía Francésa, Antonio Hernández-Madrida, Inmaculada Sánchezc, José Luis Zamoranoa,b, Javier Morenoa,b
a Departamento de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain
b Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
c Departamento de Cardiología Pediátrica, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Table 1. Baseline characteristics in the 1:1 propensity score-matched cohort
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Abstract
Introduction and objectives

The optimal approach for persistent atrial fibrillation (AF) ablation remains unknown. In patients with persistent AF, we compared an ablation strategy based on pulmonary vein isolation (PVI) plus ablation of drivers (PVI+D), with a conventional PVI-only approach performed in a 1:1 propensity score-matched cohort.

Methods

Drivers were subjectively identified using conventional high-density mapping catheters (IntellaMap ORION, PentaRay NAV or Advisor HD Grid), without dedicated software, as fractionated continuous or quasicontinuous electrograms on 1 to 2 adjacent bipoles, which were ablated first; and as sites with spatiotemporal dispersion (the entire cycle length comprised within the mapping catheter) plus noncontinuous fractionation, which were only targeted in patients without fractionated continuous electrograms, or without AF conversion after ablation of fractionated continuous electrograms. Ablation included PVI plus focal or linear ablation targeting drivers.

Results

A total of 50 patients were included in each group (61±10 years, 25% women). Fractionated continuous electrograms were found and ablated in 21 patients from the PVI+D group (42%), leading to AF conversion in 7 patients. In the remaining 43 patients, 143 sites with spatiotemporal dispersion plus noncontinuous fractionation were targeted. Globally, AF conversion was achieved in 21 patients (42%). The PVI+D group showed lower atrial arrhythmia recurrences at 1 year of follow-up (30.6% vs 48%; P=.048) and at the last follow-up (46% vs 72%; P=.013), and less progression to permanent AF (10% vs 40%; P=.001).

Conclusions

Subjective identification and ablation of drivers, added to PVI, increased 1-year freedom from atrial arrhythmia and decreased long-term recurrences and progression to permanent AF.

Keywords:
Atrial fibrillation
Catheter ablation
High-density mapping
Cardiac electrophysiologic technics
Abbreviations:
AF
AT
FCE
PVI
PVI+D
STD+F
Resumen
Introducción y objetivos

Se desconoce la mejor estrategia de ablación en la fibrilación auricular (FA) persistente. Se compararon en pacientes con FA persistente una estrategia de ablación basada en aislamiento de venas pulmonares (AVP) más ablación de impulsores (drivers) (AVP+I) con una estrategia de solo AVP realizada en una cohorte de pacientes emparejada 1:1 por puntuación de propensión.

Métodos

Se identificaron los impulsores utilizando catéteres de mapeo de alta densidad convencionales (IntellaMap ORION, PentaRay NAV, Advisor HD Grid), sin software dedicado, como estos 2 patrones: electrogramas fraccionados continuos o cuasicontinuos (EFC) en 1-2 bipolos adyacentes, que se ablacionaron primero, y lugares con dispersión espaciotemporal (toda la longitud de ciclo dentro del catéter de mapeo) más fragmentación no continua, que se ablacionaron en los pacientes sin EFC, o sin conversión de FA tras la ablación de EFC. La ablación incluyó AVP más ablación focal o lineal de impulsores.

Resultados

Se incluyó a 50 pacientes en cada grupo (edad, 61±10 años; el 25% mujeres). Un total de 21 pacientes del grupo AVP+I mostraron 40 sitios con EFC, cuya ablación consiguió la conversión de la FA en 7 pacientes. En los 43 pacientes restantes, se encontraron 143 sitios con dispersión espaciotemporal. La tasa de conversión de la FA fue del 42%. La estrategia AVP+I redujo las recurrencias arrítmicas a 1 año (el 30,6 frente al 48%; p=0,048) y al final del seguimiento (el 46 frente al 72%; p=0,013), así como la progresión a FA permanente (el 10 frente al 40%; p=0,001).

Conclusiones

La identificación subjetiva y la ablación de los impulsores añadida al AVP redujeron las recurrencias de arritmias auriculares y la progresión a FA permanente.

Palabras clave:
Fibrilación auricular
Ablación con catéter
Cartografía de alta densidad
Técnicas de electrofisiología cardiaca

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