The use of non-invasive mapping in persistent AF to predict acute procedural outcome

ECG imaging (ECGI) with phase mapping has been used to identify rotational activity non-invasively that can be targeted during atrial fibrillation (AF) ablation. Acute termination of AF using this method has shown improved clinical outcomes. In this study we sought to evaluate whether patterns of rotational density are associated with acute procedural outcomes when using a step-wise ablation strategy.

50 patients with persistent or long-standing persistent AF underwent non-invasive 3D mapping with CardioInsight™ prior to AF ablation. Composite maps of rotational activity were created and prioritized based on the density of rotations on a biatrial model. Stepwise ablation of pulmonary vein isolation (PVI) ± rotations ± linear lesions was done with AF termination as the procedural endpoint.

Acute termination of AF was achieved in 34 patients (68%). Median number of rotations in the left atrium (LA), interatrial septum and right atrium (RA) were 22.2 (9.4 to 29.3), 12.0 (4.3 to 13.4), 25.0 (14.5 to 31.3), respectively. In patients with acute AF termination, a higher number of rotations in the LA was observed, 20.3 (10.0 to 37.1) compared to 10.6 (7.7 to 17.2) in the RA (p = 0.02). Additionally, high density of rotations in the posterior inferior right atrium (segment 2B on the biatrial model) was observed in patients without acute AF termination (p = 0.02).

Acute termination of persistent and long-standing persistent AF using rotational ablation guided by ECGI phase mapping can be achieved in a high percentage of both index and re-do cases. The distribution and pattern of these rotations may be associated with procedural outcomes and could potentially be used to stratify patients.