Drivers in AF colocate to sites of electrogram organization and rapidity: Potential synergy between spectral analysis and STAR mapping approaches in prioritizing drivers for ablation

INTRODUCTION: Stochastic trajectory analysis of ranked signals (STAR) mapping has recently been used to ablate persistent atrial fibrillation (AF) with high rates of AF termination and long-term freedom from AF in small, single-arm studies. We hypothesized that rapidity and organization markers would correlate with early sites of activation (ESA). METHODS: Patients undergoing persistent AF ablation as part of the STAR mapping study were included. Five-minute unipolar basket recordings used to create STAR maps were used to determine the minimum-cycle length (Min-CL) and CL variability (CLV) at each electrode to identify the site of the fastest Min-CL and lowest CLV across the left atrium (LA). The location of ESA targeted with ablation was compared with these sites. Dominant frequency was assessed at ESA and compared with that of neighboring electrodes to assess for regional gradients. RESULTS: Thirty-two patients were included with 83 ESA ablated, with an ablation response at 73 sites (24 AF termination and 49 CL slowing ≥30 ms). Out of these, 54 (74.0%) and 56 (76.7%) colocated to sites of fastest Min-CL and lowest CLV, respectively. Regional CL and frequency gradients were demonstrable at majority of ESA. ESA colocating to sites of fastest Min-CL and lowest CLV were more likely to terminate AF with ablation (odds ratio, 34 and 29, respectively, P = .02). These showed a moderate sensitivity (74.0% Min-CL and 75.3% CLV) and specificity (66.7% Min-CL and 76.9% CLV) in predicting ESA with an ablation response. CONCLUSIONS: ESA correlate with rapidity and organization markers. Further work is needed to clarify any role for spectral analysis in prioritizing driver ablation.