Identification of active atrial fibrillation sources and their discrimination from passive rotors using electrographical flow mapping

Barbara Bellmann 1, Tina Lin 2, Peter Ruppersberg 3, Marit Zettwitz 1, Selma Guttmann 1, Verena Tscholl 1, Patrick Nagel 1, Mattias Roser 1, Ulf Landmesser 2, Andreas Rillig 4

Background: The optimal ablation approach for the treatment of persistent atrial fibrillation (AF) is still under debate; however, the identification and elimination of AF sources is thought to play a key role. Currently available technologies for the identification of AF sources are not able to differentiate between active rotors or focal impulse (FI) and passive circular turbulences as generated by the interaction of a wave front with a functional obstacle such as fibrotic tissue.

Objectives: This study introduces electrographic flow (EGF) mapping as a novel technology for the identification and characterization of AF sources in humans.

Methods: Twenty-five patients with AF (persistent: n = 24, long-standing persistent: n = 1; mean age 70.0 ± 8.3 years, male: n = 17) were included in this prospective study. Focal impulse and Rotor-Mapping (FIRM) was performed in addition to pulmonary vein isolation using radiofrequency in conjunction with a 3D-mapping-system. One-minute epochs were exported from the EP-recording-system and re-analyzed using EGF mapping after the procedure.

Results: 44 potential AF sources (43 rotors and one FI) were identified with FIRM and 39 of these rotors were targeted for ablation. EGF mapping verified 40 of these patterns and identified 24/40 (60%) as active sources while 16/40 (40%) were classified as passive circular turbulences. Four rotors were not identified by EGF mapping.

Conclusion: EGF is the first method to identify active AF sources during AF ablation procedures in humans and discriminate them from passive rotational phenomena, which occur if the excitation wavefront passes conduction bariers. EGF mapping may allow improved guidance of AF ablation procedures.

Keywords: Active; Atrial fibrillation; Atrial fibrillation drivers; Atrial fibrillation sources; Catheter ablation; Electrographic flow mapping; Focal impulse and rotor modification; Passive; Radiofrequency; Rotor.