Korean Circulation Journal

The Korean Society of Cardiology (대한심장학회)
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Clinical Usefulness of Virtual Ablation Guided Catheter Ablation of Atrial Fibrillation Targeting Restitution Parameter-Guided Catheter Ablation: CUVIA-REGAB Prospective Randomized Study

  • Young Choi (Division of Cardiology, Department of Internal Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea) ;
  • Byounghyun Lim (Department of Cardiology, Yonsei University College of Medicine, Yonsei University Health System) ;
  • Song-Yi Yang (Department of Cardiology, Yonsei University College of Medicine, Yonsei University Health System) ;
  • So-Hyun Yang (Department of Cardiology, Yonsei University College of Medicine, Yonsei University Health System) ;
  • Oh-Seok Kwon (Department of Cardiology, Yonsei University College of Medicine, Yonsei University Health System) ;
  • Daehoon Kim (Department of Cardiology, Yonsei University College of Medicine, Yonsei University Health System) ;
  • Yun Gi Kim (Department of Cardiology, Korea University Cardiovascular Center, Korea University) ;
  • Je-Wook Park (Department of Cardiology, Yonsei University College of Medicine, Yonsei University Health System) ;
  • Hee Tae Yu (Department of Cardiology, Yonsei University College of Medicine, Yonsei University Health System) ;
  • Tae-Hoon Kim (Department of Cardiology, Yonsei University College of Medicine, Yonsei University Health System) ;
  • Pil-Sung Yang (Department of Cardiology, Bundang CHA Hospital, CHA College of Medicine) ;
  • Jae-Sun Uhm (Department of Cardiology, Yonsei University College of Medicine, Yonsei University Health System) ;
  • Jamin Shim (Department of Cardiology, Korea University Cardiovascular Center, Korea University) ;
  • Sung Hwan Kim (Division of Cardiology, Department of Internal Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea) ;
  • Jung-Hoon Sung (Department of Cardiology, Bundang CHA Hospital, CHA College of Medicine) ;
  • Jong-il Choi (Department of Cardiology, Korea University Cardiovascular Center, Korea University) ;
  • Boyoung Joung (Department of Cardiology, Yonsei University College of Medicine, Yonsei University Health System) ;
  • Moon-Hyoung Lee (Department of Cardiology, Yonsei University College of Medicine, Yonsei University Health System) ;
  • Young-Hoon Kim (Department of Cardiology, Korea University Cardiovascular Center, Korea University) ;
  • Yong-Seog Oh (Division of Cardiology, Department of Internal Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea) ;
  • Hui-Nam Pak (Department of Cardiology, Yonsei University College of Medicine, Yonsei University Health System) ;
  • CUVIA-REGAB Investigators (CUVIA-REGAB)
  • Received : 2022.04.11
  • Accepted : 2022.06.08
  • Published : 2022.09.01
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Abstract

Background and Objectives: We investigated whether extra-pulmonary vein (PV) ablation targeting a high maximal slope of the action potential duration restitution curve (Smax) improves the rhythm outcome of persistent atrial fibrillation (PeAF) ablation. Methods: In this open-label, multi-center, randomized, and controlled trial, 178 PeAF patients were randomized with 1:1 ratio to computational modeling-guided virtual Smax ablation (V-Smax) or empirical ablation (E-ABL) groups. Smax maps were generated by computational modeling based on atrial substrate maps acquired during clinical procedures in sinus rhythm. Smax maps were generated during the clinical PV isolation (PVI). The V-Smax group underwent an additional extra-PV ablation after PVI targeting the virtual high Smax sites. Results: After a mean follow-up period of 12.3±5.2 months, the clinical recurrence rates (25.6% vs. 23.9% in the V-Smax and the E-ABL group, p=0.880) or recurrence appearing as atrial tachycardia (11.1% vs. 5.7%, p=0.169) did not differ between the 2 groups. The post-ablation cardioversion rate was higher in the V-Smax group than E-ABL group (14.4% vs. 5.7%, p=0.027). Among antiarrhythmic drug-free patients (n=129), the AF freedom rate was 78.7% in the V-Smax group and 80.9% in the E-ABL group (p=0.776). The total procedure time was longer in the V-Smax group (p=0.008), but no significant difference was found in the major complication rates (p=0.497) between the groups. Conclusions: Unlike a dominant frequency ablation, the computational modeling-guided V-Smax ablation did not improve the rhythm outcome of the PeAF ablation and had a longer procedure time.

Keywords

Acknowledgement

We would like to thank Mr. John Martin for his linguistic assistance.

References

  1. Kannel WB, Abbott RD, Savage DD, McNamara PM. Epidemiologic features of chronic atrial fibrillation: the Framingham study. N Engl J Med 1982;306:1018-22.
  2. Packer DL, Mark DB, Robb RA, et al. Effect of catheter ablation vs antiarrhythmic drug therapy on mortality, stroke, bleeding, and cardiac arrest among patients with atrial fibrillation: the CABANA randomized clinical trial. JAMA 2019;321:1261-74.
  3. Kim D, Yang PS, Sung JH, et al. Less dementia after catheter ablation for atrial fibrillation: a nationwide cohort study. Eur Heart J 2020;41:4483-93.
  4. Verma A, Jiang CY, Betts TR, et al. Approaches to catheter ablation for persistent atrial fibrillation. N Engl J Med 2015;372:1812-22.
  5. Pak HN, Park JW, Yang SY, et al. Cryoballoon versus high-power, short-duration radiofrequency ablation for pulmonary vein isolation in patients with paroxysmal atrial fibrillation: a single-center, prospective, randomized study. Circ Arrhythm Electrophysiol 2021;14:e010040.
  6. Lee JM, Shim J, Park J, et al. The electrical isolation of the left atrial posterior wall in catheter ablation of persistent atrial fibrillation. JACC Clin Electrophysiol 2019;5:1253-61.
  7. Narayan SM, Krummen DE, Shivkumar K, Clopton P, Rappel WJ, Miller JM. Treatment of atrial fibrillation by the ablation of localized sources: CONFIRM (Conventional Ablation for Atrial Fibrillation With or Without Focal Impulse and Rotor Modulation) trial. J Am Coll Cardiol 2012;60:628-36.
  8. Kim IS, Lim B, Shim J, et al. Clinical usefulness of computational modeling-guided persistent atrial fibrillation ablation: updated outcome of multicenter randomized study. Front Physiol 2019;10:1512.
  9. Shim J, Hwang M, Song JS, et al. Virtual in-silico modeling guided catheter ablation predicts effective linear ablation lesion set for longstanding persistent atrial fibrillation: multicenter prospective randomized study. Front Physiol 2017;8:792.
  10. Baek YS, Kwon OS, Lim B, et al. Clinical outcomes of computational virtual mapping-guided catheter ablation in patients with persistent atrial fibrillation: a multicenter prospective randomized clinical trial. Front Cardiovasc Med 2021;8:772665.
  11. Krummen DE, Bayer JD, Ho J, et al. Mechanisms of human atrial fibrillation initiation: clinical and computational studies of repolarization restitution and activation latency. Circ Arrhythm Electrophysiol 2012;5:1149-59.
  12. Narayan SM, Kazi D, Krummen DE, Rappel WJ. Repolarization and activation restitution near human pulmonary veins and atrial fibrillation initiation: a mechanism for the initiation of atrial fibrillation by premature beats. J Am Coll Cardiol 2008;52:1222-30.
  13. Qu Z, Weiss JN, Garfinkel A. Cardiac electrical restitution properties and stability of reentrant spiral waves: a simulation study. Am J Physiol 1999;276:H269-83.
  14. Weiss JN, Garfinkel A, Karagueuzian HS, Qu Z, Chen PS. Chaos and the transition to ventricular fibrillation: a new approach to antiarrhythmic drug evaluation. Circulation 1999;99:2819-26.
  15. Kim BS, Kim YH, Hwang GS, et al. Action potential duration restitution kinetics in human atrial fibrillation. J Am Coll Cardiol 2002;39:1329-36.
  16. Lim B, Kim J, Hwang M, et al. In situ procedure for high-efficiency computational modeling of atrial fibrillation reflecting personal anatomy, fiber orientation, fibrosis, and electrophysiology. Sci Rep 2020;10:2417.
  17. Kim TH, Uhm JS, Kim JY, Joung B, Lee MH, Pak HN. Does additional electrogram-guided ablation after linear ablation reduce recurrence after catheter ablation for longstanding persistent atrial fibrillation? A prospective randomized study. J Am Heart Assoc 2017;6:6.
  18. Marrouche NF, Wilber D, Hindricks G, et al. Association of atrial tissue fibrosis identified by delayed enhancement MRI and atrial fibrillation catheter ablation: the DECAAF study. JAMA 2014;311:498-506.
  19. Lim B, Hwang M, Song JS, et al. Effectiveness of atrial fibrillation rotor ablation is dependent on conduction velocity: an in-silico 3-dimensional modeling study. PLoS One 2017;12:e0190398.
  20. Li C, Lim B, Hwang M, et al. The spatiotemporal stability of dominant frequency sites in in-silico modeling of 3-dimensional left atrial mapping of atrial fibrillation. PLoS One 2016;11:e0160017.
  21. Hwang I, Park JW, Kwon OS, et al. Spatial changes in the atrial fibrillation wave-dynamics after using antiarrhythmic drugs: a computational modeling study. Front Physiol 2021;12:733543.
  22. Park JW, Lim B, Hwang I, et al. Restitution slope affects the outcome of dominant frequency ablation in persistent atrial fibrillation: CUVIA-AF2 post-hoc analysis based on computational modeling study. Fron Cardiovasc Med 2022;9:838646.