First-in-human demonstration of 18-month spatiotemporal stability of active atrial fibrillation source detected by electrographic flow mapping in persistent atrial fibrillation

Figures

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  Figure 1. A: Initial electrographic flow (EGF) Summary map over 1 minute of recording detects an active source at GH2 (red spot with cross-hairs). Ablation at that location led to organization into a 2:1 atrial tachycardia. Note the white cloud at DE34 indicating a passive rotational phenomenon. B: EGF Segment map displays flow patterns over 2 seconds and shows divergent action potential flow emanating from the source at GH2. The passive rotational flow is also visible at DE34 as accepting flow, but not generating flow. C: Electroanatomic map indicates that the active source at GH2 is located near the anterior roof insertion of the left atrial appendage (LAA) while the passive rotational phenomenon at DE34 is located inferior to the base of the LAA in the lateral left atrium above the mitral annulus. D: Streamline plot shows main source of flow emanating from H2 and flowing down and around the dome of the basket around the mitral valve. E: Unipolar electrograms (EGMs) around active source at H2 showing atrial fibrillation cycle length of 210 ms. F: Unipolar EGMs around passive rotational phenomenon at DE34 are characteristically different than those corresponding to the active source at GH2.

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  Figure 2. A: Eighteen months after the first procedure, the electrographic flow (EGF) Summary map over 1 minute of recording shows an active source at EF3. Activity is lower than in Figure 1A (source spot is less red). B: Two-second EGF Segment maps show divergent action potential flow originating from EF3. C: Electroanatomic map again shows that the active source at EF34 is located near the anterior roof insertion of the left atrial appendage (LAA). D: Streamline plot shows main source of electrographic flow at EF3 with flow going downward and around the mitral valve, just as was seen during the first procedure. Note also the presence of the same passive rotational phenomenon located inferior to the base of the LAA in the lateral left atrium above the mitral annulus. E: Unipolar electrograms around active source at EF3 showing atrial fibrillation (AF) cycle length of 180 ms and activation from E3 to D3 to C4, consistent with the streamline plot of electrographic flow in panel D. F: Corresponding 12-lead electrocardiogram shows AF. G: Serial EGF Summary maps acquired during radiofrequency application document progressive elimination of source activity at EF3.

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  Figure 3. A: After ablation of EF3 the patient remained in persistent atrial fibrillation (AF) and the electrographic flow (EGF) Summary map shows no active source remaining (no red spot). A passive phenomenon is now present at D3. B: EGF Segment maps show chaotic action potential flow with no driving source emanating flow remaining. C: Electroanatomic map shows the location of all radiofrequency ablation applications to reisolate the right inferior pulmonary vein and to eliminate the focal source detected and localized to the anterior roof insertion of the left atrial appendage (LAA). D: Likewise, the Streamline plot no longer shows origination of electrographic flow from the LAA and postablation the direction of flow has reversed—starting from the proximal portion of the basket near the interatrial septum and flowing upward toward the left atrial roof. E: Unipolar electrograms (EGMs) in the region around the previously active source at EF3 now shows AF cycle length of 210 ms and reversal of activation from C4 toward F7. F: The passive rotation previously noted at the time of the first procedure 18 months prior still remains inferior to the base of the LAA in the lateral left atrium above…