Circulation: Arrhythmia and Electrophysiology最新文献

{"title":"Late Gadolinium Enhancement Magnetic Resonance Imaging Guided Treatment of Post-Atrial Fibrillation Ablation Recurrent Arrhythmia.","authors":"Franziska Fochler, T. Yamaguchi, Mobin Kheirkahan, E. Kholmovski, A. Morris, N. Marrouche","doi":"10.1161/CIRCEP.119.007174","DOIUrl":"https://doi.org/10.1161/CIRCEP.119.007174","url":null,"abstract":"BACKGROUND\u0000Macroreentrant atrial tachycardia (AT) accounts for 40% to 60% of recurrent atrial arrhythmias after atrial fibrillation (AF) ablation. To describe late gadolinium enhancement magnetic resonance imaging (LGE-MRI)-detected scar-based dechanneling as new ablation strategy to treat ATs after AF ablation.\u0000\u0000\u0000METHODS\u0000Data from 102 patients who underwent initial AF ablation and repeat ablation for recurrent atrial arrhythmia within 1-year follow-up were analyzed. All patients underwent LGE-MRI before initial and repeat ablation. Depending on the recurrent rhythm, patients with AF and AT recurrence were assigned to group 1 or 2, respectively. Group 1 underwent fibrosis homogenization as second procedure. Group 2 underwent LGE-MRI-detected scar-based dechanneling. Both groups underwent reisolation of pulmonary veins if necessary.\u0000\u0000\u0000RESULTS\u0000Forty-six patients (45%) presented with AF, and 56 patients (55%) presented with AT recurrence during follow-up after initial ablation. In the first 25 patients from group 2, the AT was electroanatomically mapped, and a critical isthmus was defined. It was found that those isthmi were located in the regions with nontransmural scarring detected by LGE-MRI. In the last 31 patients from group 2, an empirical LGE-MRI-based dechanneling was performed solely based on the LGE-MRI results. During 1-year follow-up after second ablation, 67% patients in group 1 and 64% patients in group 2 were free from recurrence (log-rank, P=1.000). In group 2, 64% in the electroanatomically guided and 65% in the LGE-MRI dechanneling group were free from recurrence (log-rank, P=0.900).\u0000\u0000\u0000CONCLUSIONS\u0000Anatomic targeting of LGE-MRI-detected gaps and superficial atrial scar is feasible and effective to treat recurrent arrhythmias post-AF ablation. Homogenization of existing scar is the appropriate treatment for recurrent AF, whereas dechanneling of existing isthmi seems the right approach for patients recurring with AT.","PeriodicalId":10167,"journal":{"name":"Circulation: Arrhythmia and Electrophysiology","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2019-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74351032","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Ripple-AT Study.","authors":"V. Luther, S. Agarwal, A. Chow, M. Koa‐Wing, N. Cortez-Dias, L. Carpinteiro, J. de Sousa, R. Balasubramaniam, D. Farwell, S. Jamil-Copley, N. Srinivasan, H. Abbas, James Mason, N. Jones, G. Katritsis, P. Lim, N. Peters, N. Qureshi, Z. Whinnett, N. Linton, P. Kanagaratnam","doi":"10.1161/CIRCEP.118.007394","DOIUrl":"https://doi.org/10.1161/CIRCEP.118.007394","url":null,"abstract":"BACKGROUND\u0000Ripple mapping (RM) is an alternative approach to activation mapping of atrial tachycardia (AT) that avoids electrogram annotation. We tested whether RM is superior to conventional annotation based local activation time (LAT) mapping for AT diagnosis in a randomized and multicenter study.\u0000\u0000\u0000METHODS\u0000Patients with AT were randomized to either RM or LAT mapping using the CARTO3v4 CONFIDENSE system. Operators determined the diagnosis using the assigned 3D mapping arm alone, before being permitted a single confirmatory entrainment manuever if needed. A planned ablation lesion set was defined. The primary end point was AT termination with delivery of the planned ablation lesion set. The inability to terminate AT with this first lesion set, the use of more than one entrainment manuever, or the need to crossover to the other mapping arm was defined as failure to achieve the primary end point.\u0000\u0000\u0000RESULTS\u0000One hundred five patients from 7 centers were recruited with 22 patients excluded due to premature AT termination, noninducibility or left atrial appendage thrombus. Eighty-three patients (pts; RM=42, LAT=41) completed mapping and ablation within the 2 groups of similar characteristics (RM versus LAT: prior ablation or cardiac surgery n=35 [83%] versus n=35 [85%], P=0.80). The primary end point occurred in 38/42 pts (90%) in the RM group and 29/41pts (71%) in the LAT group (P=0.045). This was achieved without any entrainment in 31/42 pts (74%) with RM and 18/41 pts (44%) with LAT (P=0.01). Of those patients who failed to achieve the primary end point, AT termination was achieved in 9/12 pts (75%) in the LAT group following crossover to RM with entrainment, but 0/4 pts (0%) in the RM group crossing over to LAT mapping with entrainment (P=0.04).\u0000\u0000\u0000CONCLUSIONS\u0000RM is superior to LAT mapping on the CARTO3v4 CONFIDENSE system in guiding ablation to terminate AT with the first lesion set and with reduced entrainment to assist diagnosis.\u0000\u0000\u0000CLINICAL TRIALS REGISTRATION\u0000https://www.clinicaltrials.gov. Unique identifier: NCT02451995.","PeriodicalId":10167,"journal":{"name":"Circulation: Arrhythmia and Electrophysiology","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2019-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89939347","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Endovascular Occlusion Balloon for Treatment of Superior Vena Cava Tears During Transvenous Lead Extraction.","authors":"R. Azarrafiy, D. Tsang, B. Wilkoff, R. Carrillo","doi":"10.1161/CIRCEP.119.007266","DOIUrl":"https://doi.org/10.1161/CIRCEP.119.007266","url":null,"abstract":"BACKGROUND\u0000Superior vena cava (SVC) tears are one of the most lethal complications in transvenous lead extraction. An endovascular balloon can occlude the SVC in the event of a laceration, preventing blood loss and offering a more controlled surgical field for repair. An early study demonstrated that proper use of this device is associated with reduced mortality. Thereafter, high-volume extractors at the Eleventh Annual Lead Management Symposium developed a best practice protocol for the endovascular balloon.\u0000\u0000\u0000METHODS\u0000We collected data on adverse events in lead extraction from July 1, 2016, to July 31, 2018. Data were prospectively collected from both a US Food and Drug Administration-maintained database and physician reports of adverse events as they occurred. We gathered case details directly from extracting physicians. Confirmed SVC tears were analyzed for patient demographics, case details, and index hospitalization mortality.\u0000\u0000\u0000RESULTS\u0000From July 1, 2016, to July 31, 2018, 116 confirmed SVC events were identified, of which 44.0% involved proper balloon use and 56.0% involved no use or improper use. When an endovascular balloon was properly used, 45 of 51 patients (88.2%) survived in comparison to 37 of 65 patients (56.9%) when a balloon was not used or improperly used (P=0.0002). Furthermore, multivariate regression modeling found that proper balloon deployment was an independent, negative predictor of in-hospital mortality for patients who experienced an SVC laceration (odds ratio, 0.13; 95% CI, 0.04-0.40; P<0.001).\u0000\u0000\u0000CONCLUSIONS\u0000From July 1, 2016, through July 31, 2018, patients undergoing lead extraction were more likely to survive SVC tears when treatment included an endovascular balloon.","PeriodicalId":10167,"journal":{"name":"Circulation: Arrhythmia and Electrophysiology","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2019-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"78475169","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Letter by Zamani and Wininger Regarding Article, \"Efficacy of Pharmacologic and Cardiac Implantable Electronic Device Therapies in Patients With Heart Failure and Reduced Ejection Fraction: A Systematic Review and Network Meta-Analysis\".","authors":"Mark Zamani, M. Wininger","doi":"10.1161/CIRCEP.119.007667","DOIUrl":"https://doi.org/10.1161/CIRCEP.119.007667","url":null,"abstract":"","PeriodicalId":10167,"journal":{"name":"Circulation: Arrhythmia and Electrophysiology","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2019-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88649854","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Feasibility, Safety, and Efficacy of Posterior Wall Isolation During Atrial Fibrillation Ablation.","authors":"A. Thiyagarajah, K. Kadhim, D. Lau, M. Emami, D. Linz, K. Khokhar, D. Munawar, R. Mishima, V. Malik, C. O’Shea, R. Mahajan, P. Sanders","doi":"10.1161/CIRCEP.118.007005","DOIUrl":"https://doi.org/10.1161/CIRCEP.118.007005","url":null,"abstract":"BACKGROUND\u0000The posterior left atrium is an arrhythmogenic substrate that contributes to the initiation and maintenance of atrial fibrillation (AF); however, the feasibility, safety, and efficacy of posterior wall isolation (PWI) as an AF ablation strategy has not been widely reported.\u0000\u0000\u0000METHODS\u0000We undertook a systematic review and meta-analysis of studies performing PWI to assess (1) acute procedural success including the ability to achieve PWI and the number of procedure-related complications, (2) Long-term, clinical success including rates of arrhythmia recurrence and posterior wall reconnection, and (3) The efficacy of PWI compared with pulmonary vein isolation on preventing arrhythmia recurrence. MEDLINE, EMBASE, and Web of Science databases were searched in May 2018 to retrieve relevant studies. Results were pooled using a random effects model.\u0000\u0000\u0000RESULTS\u0000Seventeen studies (13 box isolation, 3 single ring isolation, and 1 debulking ablation) comprising 1643 patients (31.3% paroxysmal AF, left atrial diameter 41±3.1 mm) were included in the final analysis. In studies focusing specifically on PWI, the acute procedural success rate for achieving PWI was 94.1% (95% CI, 87.2%-99.3%). Single-procedure 12-month freedom from atrial arrhythmia was 65.3% (95% CI, 57.7%-73.9%) overall and 61.9% (54.2%-70.8%) for persistent AF. Randomized control trials comparing PWI to pulmonary vein isolation (3 studies, 444 patients) yielded conflicting results and could not confirm an incremental benefit to PWI. Fifteen major complications (0.1%), including 2 atrio-esophageal fistulas, were reported.\u0000\u0000\u0000CONCLUSIONS\u0000PWI as an end point of AF ablation can be achieved in a large proportion of cases with good rates of 12-month freedom from atrial arrhythmia. Although the procedure-related complication rate is low, it did not eliminate the risk of atrio-esophageal fistula. Registration: URL: http://www.crd.york.ac.uk/prospero. PROSPERO registration number: CRD42018107212.","PeriodicalId":10167,"journal":{"name":"Circulation: Arrhythmia and Electrophysiology","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2019-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80043666","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Dechanneling Left Atrial Late Gadolinium Enhancement.","authors":"S. Nazarian, F. Marchlinski","doi":"10.1161/CIRCEP.119.007683","DOIUrl":"https://doi.org/10.1161/CIRCEP.119.007683","url":null,"abstract":"Beginning with initial reports of catheter ablation with high-energy direct current shocks for focal and simple arrhythmias in the early 1980s,1 catheter ablation technology and our understanding of arrhythmia mechanisms have rapidly evolved. The identification of left atrial muscular extensions in the pulmonary veins (PVs) by Haïssaguerre et al2 in 1998 opened the era of catheter ablation for suppression of atrial fibrillation (AF). The initial strategy of focal PV trigger ablation was limited by the variability in induction and mapping of the foci, as well as PV stenoses after ablation deep in the veins. To eliminate the need for identification and ablation of individual foci deep in the PVs, ostial isolation of the PV was pursued. Over time, this approach has evolved to an antral PV isolation technique resulting in wide-area circumferential ablation, which mitigates the likelihood of PV stenosis, includes more potential triggers within the isolation zone, and is more likely to modify periatrial autonomic inputs. With wide-area circumferential ablation, however, the ablation circumference has increased, thus increasing the potential for inadvertent gaps in ablation lesions. In addition, strategies such as linear ablation have been implemented in difficult cases, thus adding to the possibility that gaps may exist, and paths for initiation and maintenance of fixed reentry may be created after the procedure. The observation of reentrant atrial tachycardia (AT) after AF ablation is therefore not only related to the burden of de novo scar but also the presence of gaps in linear lesions or wide-area circumferential ablation. Approximately two thirds of post-AF ablation patients with an AT immediately after their ablation will have persistent AT after the healing period. Entrainment mapping strategies can be successfully applied to identify and target these circuits.3 Cardiac imaging with computed tomography or cardiac magnetic resonance (CMR) has long been implemented for creation of 3-dimensional segmentations for enhanced procedural guidance. Most commonly, this approach can be used to tailor lesion delivery to individual variations in left atrial geometry and PV anatomy. In 2007, a study from Peters et al4 suggested that late gadolinium enhancement (LGE) CMR could visualize left atrial lesions after PV isolation. LGE CMR was later championed by Marrouche et al5 to enhance the stratification of potential candidates for AF ablation. In this issue of Circulation: Arrhythmia and Electrophysiology, Fochler et al6 describe LGE CMR-based dechanneling as a strategy to treat reentrant AT after AF ablation. They report a retrospective analysis of 102 patients who underwent EP study and mapping after an initial AF ablation with CMR before each ablation. The authors confirm that a strategy of left atrial linear lesion sets at the index procedure associated with AT after ablation. Of 102 patients, 46 presented with AF only EDITORIAL","PeriodicalId":10167,"journal":{"name":"Circulation: Arrhythmia and Electrophysiology","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2019-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74954738","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Road to the Summit May Follow an Eccentric Path.","authors":"K. Motonaga, H. Hsia","doi":"10.1161/CIRCEP.119.007691","DOIUrl":"https://doi.org/10.1161/CIRCEP.119.007691","url":null,"abstract":"The left ventricular (LV) ostium or LV summit is the most superior aspect of the LV outflow tract (LVOT). Ventricular arrhythmias (VAs) arising from this region represent one of the most common sites of origin of idiopathic VAs.1 The LV summit is anatomically defined as the epicardial LV surface bounded by an arc from the left anterior descending coronary artery superior to the first septal perforating branch anterior to the left circumflex coronary artery laterally.2 The LV summit is transected laterally by the great cardiac vein (GCV) at its junction with the anterior interventricular vein, dividing the LV summit into what has traditionally been called the basal (inaccessible) and apical (accessible) segments.2–4 Not surprisingly, arrhythmias originating from the basal (inaccessible) LV summit have a significantly lower rate of ablation success (≈50%) compared with those originating from the apical (accessible) LV summit (≈100%).4 Catheter ablation in this region is challenging because of the complex and variable anatomy in close proximity to critical structures as well as intramural foci that are often encountered.5–7 To aid in determining the site of origin of VAs in the LV summit, several ECG and electrophysiological characteristics have been described, and various ablation strategies have been proposed.3,4,8,9 ECG findings are consistent with the more septal and superior location of the basal LV summit in relationship to the apical LV summit. Compared with the apical segment, arrhythmias originating from the basal segment typically have a left bundle branch block pattern, shorter QRS duration (≤175 ms), greater R-wave amplitude in the inferior leads, smaller R-wave ratio in III/II and Q wave ratio in aVL/aVR, and a later precordial transition.4 A direct ablation approach through the cardiac venous system is usually recommended when an early ventricular activation is recorded within the distal GCV.4,10 This approach can be problematic secondary to difficulty in passing the ablation catheter to the site of interest, inability to achieve adequate power, and proximity to coronary arteries. Alternatively, an anatomic approach from the adjacent endocardial site closest to the LV summit arrhythmia origin can be used, such as from the aortomitral continuity, LVOT, or coronary cusps.4 Predictors of successful ablation using an anatomic approach include a Q-wave ratio of <1.45 in leads aVL/aVR and a close anatomic distance <13.5 mm from the earliest activation site in the GCV.8 Importantly, anatomic proximity and not activation timing dictates the success of an anatomic approach.11 Finally, a percutaneous epicardial approach can be considered when a direct or anatomic ablation approach is unsuccessful. Unfortunately, this approach is only successful in a minority of patients (14%–17%), limited by proximity to major coronary arteries, the left atrial appendage, and poor energy delivery due to the presence of thick epicardial fat.3,4,9 EDITORIAL","PeriodicalId":10167,"journal":{"name":"Circulation: Arrhythmia and Electrophysiology","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2019-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84972786","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Response by Tseng et al to Letter Regarding Article, \"Efficacy of Pharmacologic and Cardiac Implantable Electronic Device Therapies in Patients With Heart Failure and Reduced Ejection Fraction: A Systematic Review and Network Meta-Analysis\".","authors":"A. Tseng, K. Kunze, S. Mulpuru","doi":"10.1161/CIRCEP.119.007710","DOIUrl":"https://doi.org/10.1161/CIRCEP.119.007710","url":null,"abstract":"August 2019 1 Andrew S. Tseng, MD Katie L. Kunze, PhD Siva K. Mulpuru, MD In Response: We greatly appreciate the commentary by Zamani and Wininger in regard to our recent network meta-analysis on pharmacological and cardiac implantable electronic device therapies in heart failure with reduced ejection fraction.1 Their response to our article was meticulous and insightful, and we are privileged to be able to respond to their concerns. We agree with the commentators on the limitations of our design for Figure 6 and acknowledge errors in its construction. Figure 6 attempts to visually represent the temporal relationship between the number of pharmacological versus device studies and mean all-cause mortality incidence rates. We did not intend for Figure 6 to answer the question on overall comparative efficacy of medications versus devices in reducing all-cause mortality. The sole purpose of this supporting figure is to visually demonstrate the trend of all-cause mortality rates in heart failure trials over time. To more accurately represent the data and our intentions with this figure, we have revised the figure to be a bubbleplot, weighted by study sample size and study duration (in person-years). We also thank the commentators for mentioning the misattribution of the study years with the publication years, and we have rectified this in our new figure. Regrettably, Figure 6 had included additional studies from an older version of the data, and in the final publication, Figure 6 had not been updated to reflect only those studies included in the final analysis. All other figures and analyses in the article were derived from the final data. The revised figure is provided here and online (Figure). The raw data used to construct the figure have been provided online (https://drive.google.com/drive/folders/15YnklLuvORw 0oYSPLOcSYMk2WAuuAeGL?usp=sharing). Overall, our study is intended to assist clinicians and researchers generate hypotheses for the various roles of medications and devices in the treatment of heart failure with reduced ejection fraction. We thank the commentators for their thoughtful analysis and comments and believe that the revised figure more accurately represents the data and the intended scope of the figure.","PeriodicalId":10167,"journal":{"name":"Circulation: Arrhythmia and Electrophysiology","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2019-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88500489","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Wavefront Field Mapping Reveals a Physiologic Network Between Drivers Where Ablation Terminates Atrial Fibrillation.","authors":"George Leef, F. Shenasa, N. Bhatia, A. Rogers, W. Sauer, John M. Miller, Mark Swerdlow, M. Tamboli, M. Alhusseini, E. Armenia, T. Baykaner, J. Brachmann, M. Turakhia, F. Atienza, W. Rappel, Paul J. Wang, S. Narayan","doi":"10.1161/CIRCEP.118.006835","DOIUrl":"https://doi.org/10.1161/CIRCEP.118.006835","url":null,"abstract":"BACKGROUND\u0000Localized drivers are proposed mechanisms for persistent atrial fibrillation (AF) from optical mapping of human atria and clinical studies of AF, yet are controversial because drivers fluctuate and ablating them may not terminate AF. We used wavefront field mapping to test the hypothesis that AF drivers, if concurrent, may interact to produce fluctuating areas of control to explain their appearance/disappearance and acute impact of ablation.\u0000\u0000\u0000METHODS\u0000We recruited 54 patients from an international registry in whom persistent AF terminated by targeted ablation. Unipolar AF electrograms were analyzed from 64-pole baskets to reconstruct activation times, map propagation vectors each 20 ms, and create nonproprietary phase maps.\u0000\u0000\u0000RESULTS\u0000Each patient (63.6±8.5 years, 29.6% women) showed 4.0±2.1 spatially anchored rotational or focal sites in AF in 3 patterns. First, a single (type I; n=7) or, second, paired chiral-antichiral (type II; n=5) rotational drivers controlled most of the atrial area. Ablation of 1 to 2 large drivers terminated all cases of types I or II AF. Third, interaction of 3 to 5 drivers (type III; n=42) with changing areas of control. Targeted ablation at driver centers terminated AF and required more ablation in types III versus I (P=0.02 in left atrium).\u0000\u0000\u0000CONCLUSIONS\u0000Wavefront field mapping of persistent AF reveals a pathophysiologic network of a small number of spatially anchored rotational and focal sites, which interact, fluctuate, and control varying areas. Future work should define whether AF drivers that control larger atrial areas are attractive targets for ablation.","PeriodicalId":10167,"journal":{"name":"Circulation: Arrhythmia and Electrophysiology","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2019-07-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88368571","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Effect of Contact Vector Direction on Achieving Pulmonary Vein Isolation.","authors":"Tadashi Hoshiyama, H. Fukushima, K. Noda, S. Oshima, K. Ashikaga, T. Ikeda, K. Sakamoto, K. Tsujita","doi":"10.1161/CIRCEP.119.007320","DOIUrl":"https://doi.org/10.1161/CIRCEP.119.007320","url":null,"abstract":"","PeriodicalId":10167,"journal":{"name":"Circulation: Arrhythmia and Electrophysiology","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2019-07-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"87470086","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}