Approaches for Focal Impulse and Rotor Mapping in Complex Patients: A US Private Practice Perspective

The long-term clinical success of atrial fibrillation (AF) ablation remains relatively low in certain difficult-to-treat patient groups such as those with persistent AF. As a result, pulmonary vein isolation with substrate-based ablation approaches are being utilized in an effort to improve long-term outcomes in such patients. In hopes of improving long-term clinical outcomes in complex AF patients, focal impulse and rotor mapping (FIRM)-guided rotor ablation was incorporated in our practice over 1 year ago. Our purpose is to present some practical considerations from a series of patients with primarily persistent AF and repeat ablation after failed pulmonary vein isolation with additional ablation undergoing their first FIRM-guided procedure. Our experience from 56 consecutive patients who underwent FIRM-guided rotor ablation over a period of approximately 1 year is described. The majority of patients consisted of those with persistent AF (34%) or long-standing persistent AF (43%), large atria, and/or complex co-morbidities. AF rotors were identified with FIRM mapping in all patients (a mean of 3.4 1.2 per patient). Non-paroxysmal AF was associated with a significantly higher number of rotors in both atria, and patients with either a failed prior ablation or enlarged left atrial volume had a significantly higher number of right atrial rotors. With a mean follow up of 7.73.0 months, 82.1% of patients remained free of AF recurrence. Among the patients with non-paroxysmal AF, 79.1% remained free of AF recurrence. The mean procedure time was similar to other substrate-based ablation approaches. It is feasible to incorporate FIRM-guided rotor ablation in a non-academic community hospital setting for the treatment of complex AF in patients with good medium-term clinical outcomes and minimal impact on procedure time compared with other substrate-based ablation approaches.