Unraveling the Underlying Arrhythmia Mechanism in Persistent Atrial Fibrillation: Results From the STARLIGHT Study

Nicholas Child; Richard H Clayton; Caroline H Roney; Jacob I Laughner; Allan Shuros; Petr Neuzil; Jan Petru; Tom Jackson; Bradley Porter; Julian Bostock; Steven A Niederer; Reza S Razavi; Christopher A Rinaldi; Peter Taggart; Matthew J Wright; Jaswinder Gill

doi:10.1161/CIRCEP.117.005897

Unraveling the Underlying Arrhythmia Mechanism in Persistent Atrial Fibrillation: Results From the STARLIGHT Study

Nicholas Child, Richard H Clayton, Caroline H Roney, Jacob I Laughner, Allan Shuros, Petr Neuzil, Jan Petru, Tom Jackson, Bradley Porter, Julian Bostock, Steven A Niederer, Reza S Razavi, Christopher A Rinaldi, Peter Taggart, Matthew J Wright, Jaswinder Gill

Department of Imaging Sciences and Biomedical Engineering, King's College London, United Kingdom (N.C., C.R.R., T.J., B.P., S.A.N., R.S.R.). [email protected].
University of Sheffield
Department of Imaging Sciences and Biomedical Engineering, King's College London, United Kingdom (N.C., C.R.R., T.J., B.P., S.A.N., R.S.R.).
Boston Scientific Corp, St. Paul, MN (J.I.L., A.S.).
Department of Cardiology, Na Holmolce Hospital, Prague, Czech Republic (P.N., J.P.).
Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (J.B., C.A.R., M.J.W., J.G.).
UCL University College London

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Abstract

BACKGROUND: The mechanisms that initiate and sustain persistent atrial fibrillation are not well characterized. Ablation results remain significantly worse than in paroxysmal atrial fibrillation in which the mechanism is better understood and subsequent targeted therapy has been developed. The aim of this study was to characterize and quantify patterns of activation during atrial fibrillation using contact mapping.

METHODS: Patients with persistent atrial fibrillation (n=14; mean age, 61±8 years; ejection fraction, 59±10%) underwent simultaneous biatrial contact mapping with 64 electrode catheters. The atrial electrograms were transformed into phase, and subsequent spatiotemporal mapping was performed to identify phase singularities (PSs).

RESULTS: PSs were located in both atria, but we observed more PSs in the left atrium compared with the right atrium (779±302, 552±235; P=0.015). Although some PSs of duration sufficient to complete >1 rotation were detected, the maximum PS duration was only 1150 ms, and the vast majority (97%) of PSs persisted for too short a period to complete a full rotation. Although in selected patients there was evidence of PS local clustering, overall, PSs were distributed globally throughout both chambers with no clear anatomic predisposition. In a subset of patients (n=7), analysis was repeated using an alternative established atrial PS mapping technique, which confirmed our initial findings.

CONCLUSIONS: No sustained rotors or localized drivers were detected, and instead, the mechanism of arrhythmia maintenance was consistent with the multiple wavelet hypothesis, with passive activation of short-lived rotational activity.

CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01765075.

Original language	English
Pages (from-to)	e005897
Journal	Circulation. Arrhythmia and electrophysiology
Volume	11
Issue number	6
Early online date	1 Jun 2018
DOIs	https://doi.org/10.1161/CIRCEP.117.005897
Publication status	Published - Jun 2018

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10.1161/CIRCEP.117.005897

Unravelling the Underlying Arrhythmia_CHILD_Publishedonline1June2018_GREEN AAMAccepted author manuscript, 3.19 MB

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Child, N., Clayton, R. H., Roney, C. H., Laughner, J. I., Shuros, A., Neuzil, P., Petru, J., Jackson, T., Porter, B., Bostock, J., Niederer, S. A., Razavi, R. S., Rinaldi, C. A., Taggart, P., Wright, M. J., & Gill, J. (2018). Unraveling the Underlying Arrhythmia Mechanism in Persistent Atrial Fibrillation: Results From the STARLIGHT Study. Circulation. Arrhythmia and electrophysiology, 11(6), e005897. https://doi.org/10.1161/CIRCEP.117.005897

@article{c841bb055d5640c3853ae3761ef49612,

title = "Unraveling the Underlying Arrhythmia Mechanism in Persistent Atrial Fibrillation: Results From the STARLIGHT Study",

abstract = "BACKGROUND: The mechanisms that initiate and sustain persistent atrial fibrillation are not well characterized. Ablation results remain significantly worse than in paroxysmal atrial fibrillation in which the mechanism is better understood and subsequent targeted therapy has been developed. The aim of this study was to characterize and quantify patterns of activation during atrial fibrillation using contact mapping.METHODS: Patients with persistent atrial fibrillation (n=14; mean age, 61±8 years; ejection fraction, 59±10%) underwent simultaneous biatrial contact mapping with 64 electrode catheters. The atrial electrograms were transformed into phase, and subsequent spatiotemporal mapping was performed to identify phase singularities (PSs).RESULTS: PSs were located in both atria, but we observed more PSs in the left atrium compared with the right atrium (779±302, 552±235; P=0.015). Although some PSs of duration sufficient to complete >1 rotation were detected, the maximum PS duration was only 1150 ms, and the vast majority (97%) of PSs persisted for too short a period to complete a full rotation. Although in selected patients there was evidence of PS local clustering, overall, PSs were distributed globally throughout both chambers with no clear anatomic predisposition. In a subset of patients (n=7), analysis was repeated using an alternative established atrial PS mapping technique, which confirmed our initial findings.CONCLUSIONS: No sustained rotors or localized drivers were detected, and instead, the mechanism of arrhythmia maintenance was consistent with the multiple wavelet hypothesis, with passive activation of short-lived rotational activity.CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01765075.",

author = "Nicholas Child and Clayton, {Richard H} and Roney, {Caroline H} and Laughner, {Jacob I} and Allan Shuros and Petr Neuzil and Jan Petru and Tom Jackson and Bradley Porter and Julian Bostock and Niederer, {Steven A} and Razavi, {Reza S} and Rinaldi, {Christopher A} and Peter Taggart and Wright, {Matthew J} and Jaswinder Gill",

note = "{\textcopyright} 2018 American Heart Association, Inc.",

year = "2018",

month = jun,

doi = "10.1161/CIRCEP.117.005897",

language = "English",

volume = "11",

pages = "e005897",

journal = "Circulation. Arrhythmia and electrophysiology",

issn = "1941-3149",

publisher = "LIPPINCOTT WILLIAMS & WILKINS",

number = "6",

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Child, N, Clayton, RH, Roney, CH, Laughner, JI, Shuros, A, Neuzil, P, Petru, J, Jackson, T , Porter, B, Bostock, J, Niederer, SA , Razavi, RS, Rinaldi, CA, Taggart, P, Wright, MJ & Gill, J 2018, 'Unraveling the Underlying Arrhythmia Mechanism in Persistent Atrial Fibrillation: Results From the STARLIGHT Study', Circulation. Arrhythmia and electrophysiology, vol. 11, no. 6, pp. e005897. https://doi.org/10.1161/CIRCEP.117.005897

TY - JOUR

T1 - Unraveling the Underlying Arrhythmia Mechanism in Persistent Atrial Fibrillation

T2 - Results From the STARLIGHT Study

AU - Child, Nicholas

AU - Clayton, Richard H

AU - Roney, Caroline H

AU - Laughner, Jacob I

AU - Shuros, Allan

AU - Neuzil, Petr

AU - Petru, Jan

AU - Jackson, Tom

AU - Porter, Bradley

AU - Bostock, Julian

AU - Niederer, Steven A

AU - Razavi, Reza S

AU - Rinaldi, Christopher A

AU - Taggart, Peter

AU - Wright, Matthew J

AU - Gill, Jaswinder

PY - 2018/6

Y1 - 2018/6

N2 - BACKGROUND: The mechanisms that initiate and sustain persistent atrial fibrillation are not well characterized. Ablation results remain significantly worse than in paroxysmal atrial fibrillation in which the mechanism is better understood and subsequent targeted therapy has been developed. The aim of this study was to characterize and quantify patterns of activation during atrial fibrillation using contact mapping.METHODS: Patients with persistent atrial fibrillation (n=14; mean age, 61±8 years; ejection fraction, 59±10%) underwent simultaneous biatrial contact mapping with 64 electrode catheters. The atrial electrograms were transformed into phase, and subsequent spatiotemporal mapping was performed to identify phase singularities (PSs).RESULTS: PSs were located in both atria, but we observed more PSs in the left atrium compared with the right atrium (779±302, 552±235; P=0.015). Although some PSs of duration sufficient to complete >1 rotation were detected, the maximum PS duration was only 1150 ms, and the vast majority (97%) of PSs persisted for too short a period to complete a full rotation. Although in selected patients there was evidence of PS local clustering, overall, PSs were distributed globally throughout both chambers with no clear anatomic predisposition. In a subset of patients (n=7), analysis was repeated using an alternative established atrial PS mapping technique, which confirmed our initial findings.CONCLUSIONS: No sustained rotors or localized drivers were detected, and instead, the mechanism of arrhythmia maintenance was consistent with the multiple wavelet hypothesis, with passive activation of short-lived rotational activity.CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01765075.

AB - BACKGROUND: The mechanisms that initiate and sustain persistent atrial fibrillation are not well characterized. Ablation results remain significantly worse than in paroxysmal atrial fibrillation in which the mechanism is better understood and subsequent targeted therapy has been developed. The aim of this study was to characterize and quantify patterns of activation during atrial fibrillation using contact mapping.METHODS: Patients with persistent atrial fibrillation (n=14; mean age, 61±8 years; ejection fraction, 59±10%) underwent simultaneous biatrial contact mapping with 64 electrode catheters. The atrial electrograms were transformed into phase, and subsequent spatiotemporal mapping was performed to identify phase singularities (PSs).RESULTS: PSs were located in both atria, but we observed more PSs in the left atrium compared with the right atrium (779±302, 552±235; P=0.015). Although some PSs of duration sufficient to complete >1 rotation were detected, the maximum PS duration was only 1150 ms, and the vast majority (97%) of PSs persisted for too short a period to complete a full rotation. Although in selected patients there was evidence of PS local clustering, overall, PSs were distributed globally throughout both chambers with no clear anatomic predisposition. In a subset of patients (n=7), analysis was repeated using an alternative established atrial PS mapping technique, which confirmed our initial findings.CONCLUSIONS: No sustained rotors or localized drivers were detected, and instead, the mechanism of arrhythmia maintenance was consistent with the multiple wavelet hypothesis, with passive activation of short-lived rotational activity.CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01765075.

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U2 - 10.1161/CIRCEP.117.005897

DO - 10.1161/CIRCEP.117.005897

M3 - Article

C2 - 29858382

SN - 1941-3149

VL - 11

SP - e005897

JO - Circulation. Arrhythmia and electrophysiology

JF - Circulation. Arrhythmia and electrophysiology

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Unraveling the Underlying Arrhythmia Mechanism in Persistent Atrial Fibrillation: Results From the STARLIGHT Study

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