Korean Circ J.  2022 Sep;52(9):699-711. 10.4070/kcj.2022.0113.

Clinical Usefulness of Virtual Ablation Guided Catheter Ablation of Atrial Fibrillation Targeting Restitution Parameter-Guided Catheter Ablation: CUVIA-REGAB Prospective Randomized Study

Affiliations
  • 1Division of Cardiology, Department of Internal Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
  • 2Department of Cardiology, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
  • 3Department of Cardiology, Korea University Cardiovascular Center, Korea University, Seoul, Korea
  • 4Department of Cardiology, Bundang CHA Hospital, CHA College of Medicine, Seoul, Korea

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 postablation 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.

Keyword

Atrial fibrillation; Catheter ablation; Computer simulation; Action potential; Electrophysiology

Figure

  • Figure 1 Study process in the V-Smax group.ABL = ablation; AF = atrial fibrillation; CT = computed tomography; LAT = local activation time; PVI = pulmonary vein isolation; 3D = 3-dimensional.

  • Figure 2 Study enrollment. Included patients were randomly assigned to receive virtual rotor guided ablation or empirical ablation therapy.AF = atrial fibrillation; AFCA = atrial fibrillation catheter ablation; E-ABL = empirical ablation; PVI = pulmonary vein isolation; V-Smax = virtual high maximal slope of the action potential duration restitution curve simulation.

  • Figure 3 Freedom from AF recurrence in the 2 groups. (A) AF freedom in overall patients. (B) AF freedom in AAD-free patients at 3 months after AFCA.AAD = antiarrhythmic drug; AF = atrial fibrillation; AFCA = atrial fibrillation catheter ablation; E-ABL = empirical ablation; V-Smax = virtual high maximal slope of the action potential duration restitution curve simulation.

  • Figure 4 Subgroup analysis according to the Smax level. (A) Freedom from AF in patients with Smax <1 and Smax ≥1 in the V-Smax group. (B) Freedom from AF in patients with Smax <1 and Smax ≥1 in the E-ABL group. Representative virtual Smax maps in patients with high Smax (C) and low Smax (D) values.AF = atrial fibrillation; E-ABL = empirical ablation; V-Smax = virtual high maximal slope of the action potential duration restitution curve simulation.


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