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Randomized Controlled Trial
. 2023 Nov 1;6(11):e2344535.
doi: 10.1001/jamanetworkopen.2023.44535.

Catheter Ablation With Morphologic Repetitiveness Mapping for Persistent Atrial Fibrillation

Chin-Yu Lin  1   2 , Yenn-Jiang Lin  1   2 , Satoshi Higa  3 , Wen-Chin Tsai  4 , Men-Tzung Lo  5 , Chia-Hsin Chiang  5 , Shih-Lin Chang  1   2 , Li-Wei Lo  1   2 , Yu-Feng Hu  1   2 , Tze-Fan Chao  1   2 , Fa-Po Chung  1   2 , Jo-Nan Liao  1   2 , Ting-Yung Chang  1   2 , Chen Lin  3 , Ta-Chuan Tuan  1   2 , Ling Kuo  1   2 , Cheng-I Wu  1   2 , Chih-Min Liu  1   2 , Shin-Huei Liu  1   2 , Ming-Jen Kuo  1   2 , Ying-Chieh Liao  6 , Chieh-Mao Chuang  7 , Yun-Yu Chen  2   7   8   9 , Yu-Cheng Hsieh  1   7   10 , Shih-Ann Chen  1   2   7   10
Affiliations
Randomized Controlled Trial

Catheter Ablation With Morphologic Repetitiveness Mapping for Persistent Atrial Fibrillation

Chin-Yu Lin et al. JAMA Netw Open. .

Abstract

Importance: Catheter ablation for persistent atrial fibrillation (AF) has shown limited success.

Objective: To determine whether AF drivers could be accurately identified by periodicity and similarity (PRISM) mapping ablation results for persistent AF when added to pulmonary vein isolation (PVI).

Design, setting, and participants: This prospective randomized clinical trial was performed between June 1, 2019, and December 31, 2020, and included patients with persistent AF enrolled in 3 centers across Asia. Data were analyzed on October 1, 2022.

Intervention: Patients were assigned to the PRISM-guided approach (group 1) or the conventional approach (group 2) at a 1:1 ratio.

Main outcomes and measures: The primary outcome was freedom from AF or other atrial arrhythmia for longer than 30 seconds at 6 and 12 months.

Results: A total of 170 patients (mean [SD] age, 62.0 [12.3] years; 136 men [80.0%]) were enrolled (85 patients in group 1 and 85 patients in group 2). More group 1 patients achieved freedom from AF at 12 months compared with group 2 patients (60 [70.6%] vs 40 [47.1%]). Multivariate analysis indicated that the PRISM-guided approach was associated with freedom from the recurrence of atrial arrhythmia (hazard ratio, 0.53 [95% CI, 0.33-0.85]).

Conclusions and relevance: The waveform similarity and recurrence pattern derived from high-density mapping might provide an improved guiding approach for ablation of persistent AF. Compared with the conventional procedure, this novel specific substrate ablation strategy reduced the frequency of recurrent AF and increased the likelihood of maintenance of sinus rhythm.

Trial registration: ClinicalTrials.gov Identifier: NCT05333952.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Y.-J. Lin reported receiving grant funding from Biosense Webster, Inc, during the conduct of the study. Dr Higa reported speaker honoraria from Johnson & Johnson and Medtronic PLC during the conduct of the study and speaker honoraria from Japan Lifeline Co, Ltd, Abbott Laboratories, Bayer AG, Boehringer Ingelheim, Bristol Myers Squibb, Daiichi Sankyo Company Ltd, Eli Lilly and Co, Ono Pharmaceutical Co, Ltd, Pfizer Inc, and Boston Scientific Corporation outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Flowchart Describing Eligibility, Randomization, and Follow-Up of Study Patients
AF indicates atrial fibrillation.
Figure 2.
Figure 2.. Application of Catheter Ablation Based on the Type 1 Periodicity and Similarity (PRISM) Map
A, The PRISM map reveals only a high PRISM area within the left pulmonary vein (PV). B, The recurrent plot demonstrates a high PRISM value (>315 milliseconds) in the left PV and low PRISM value in the anterior wall. C, Pulmonary vein isolation enclosing the PRISM area was performed without substrate modification. The atrial fibrillation was terminated during left PV isolation. Bi indicates bipolar voltage; Carto, 3-dimensional electroanatomical mapping system (CARTO; Biosense Webster, Inc, and Johnson & Johnson); and LSPV, left superior pulmonary vein.
Figure 3.
Figure 3.. The Application of Catheter Ablation Based on the Type 2 Periodicity and Similarity (PRISM) Map
A, The PRISM map reveals a high PRISM area outside the pulmonary vein (PV) or vicinity (appendage, posterior wall, and mitral area). B, The recurrent plot demonstrates a high PRISM value (>315 milliseconds) in the posterior wall and mitral area. Pulmonary vein isolation was performed and the atrial fibrillation (AF) persisted. C, Additional PRISM ablation is performed over the posterior wall and mitral area. After posterior wall ablation, the AF was terminated during ablation over the mitral area. Bi indicates bipolar voltage; Carto, 3-dimensional electroanatomical mapping system (CARTO; Biosense Webster, Inc, and Johnson & Johnson).
See this image and copyright information in PMC

Comment in

References

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