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J Am Coll Cardiol, 2004; 43:2044-2053, doi:10.1016/j.jacc.2003.12.054
© 2004 by the American College of Cardiology Foundation
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CLINICAL RESEARCH: ELECTROPHYSIOLOGY

A new approach for catheter ablation of atrial fibrillation: mapping of the electrophysiologic substrate

Koonlawee Nademanee, MD, FACC*,*, John McKenzie, MD*, Erol Kosar, MD*, Mark Schwab, MD*, Buncha Sunsaneewitayakul, MD{dagger}, Thaveekiat Vasavakul, MD*, Chotikorn Khunnawat, MD* and Tachapong Ngarmukos, MD{ddagger}

* Pacific Rim Electrophysiology Research Institute, Inglewood, California, USA
{dagger} Chulalongkorn University, Bangkok, Thailand
{ddagger} Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

Manuscript received September 23, 2003; revised manuscript received December 9, 2003, accepted December 15, 2003.

* Reprint requests and correspondence: Dr. Koonlawee Nademanee, Pacific Rim Electrophysiology Research Institute, 575 East Hardy Street, Suite 201, Inglewood, California 90301, USA.
wee{at}pacificrimep.com

OBJECTIVES: We sought to test the hypothesis that complex fractionated electrograms (CFAEs) recorded during atrial fibrillation (AF) could be used as target sites for catheter ablation of AF.

BACKGROUND: Mapping of AF in humans has shown that areas of CFAEs correlate with areas of slowed conduction and pivot points of reentrant wavelets. We hypothesized that such areas of CFAEs could be identified in patients with AF and might serve as target sites for catheter ablation to maintain sinus rhythm.

METHODS: The study population included 121 patients (29 females; mean age, 63 years) with refractory AF (57 paroxysmal, 64 chronic). All patients underwent nonfluoroscopic electroanatomic mapping (CARTO) during AF. Using CARTO, the biatrial replica, displayed in a three-dimensional color-coded voltage map, was created during AF, and areas associated with CFAEs were identified. Radiofrequency ablation of the area with CFAEs was performed, aiming to eliminate CFAE and/or convert to sinus rhythm.

RESULTS: Complex fractionated atrial electrograms were found in seven of nine regions of both atria, but were mainly confined to the interatrial septum, pulmonary veins, roof of left atrium, and left posteroseptal mitral annulus and coronary sinus ostium. Ablations of the areas associated with CFAEs resulted in termination of AF without external cardioversion in 115 of the 121 patients (95%); 32 (28%) required concomitant ibutilide treatment. At the one-year follow-up, 110 (91%) patients were free of arrhythmia and symptoms, 92 after one ablation and 18 after two.

CONCLUSIONS: Areas with CFAEs represent a defined electrophysiologic substrate and are ideal target sites for ablations to eliminate AF and maintain normal sinus rhythm.

Abbreviations and Acronyms
  AF = atrial fibrillation
  CAF = chronic atrial fibrillation
  CARTO = electroanatomic mapping
  CFAEs = complex fractionated atrial electrograms
  CS = coronary sinus
  LIPV = left inferior pulmonary vein
  LSPV = left superior pulmonary vein
  PAF = paroxysmal atrial fibrillation
  RIPV = right inferior pulmonary vein
  RSPV = right superior pulmonary vein




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