Persistent Atrial Fibrillation FromtheOnset

Ad 10 Fa Po Le He He an Dr co Me the co tro fun All Ma OBJECTIVES This study sought to characterize the clinical characteristics, atrial substrate, and prognosis in a subgroup of patients with persistent atrial fibrillation (AF) from the onset (PsAFonset). BACKGROUND Patients with AF frequently progress from trigger-driven paroxysmal arrhythmias to substratedependent persistent arrhythmias. METHODS Patients referred for persistent AF (PsAF) ablation were enrolled from 3 centers. Consecutive patients with PsAFonset (n 1⁄4 129) were compared with patients with PsAF that progressed from paroxysmal AF (n 1⁄4 231). In addition, 90 patients (30 patients with PsAFonset and 60 control subjects) were studied with noninvasive mapping to characterize the AF drivers. The degree of fractionation and endocardial voltages were assessed invasively. RESULTS Patients with PsAFonset were younger (p 1⁄4 0.047) and more obese (p < 0.001); there were more men (p1⁄40.034), more patients with hypertension (p1⁄40.044), and these patients had larger left (p<0.05) and right atria (p< 0.05). Baseline AF cycle length was shorter in the PsAFonset group (p< 0.01); the degree of fractionation was higher (p< 0.001 for both atria), and the endocardial voltagewas lower (p<0.05 for both atria). Patients with PsAFonset had higher a number of re-entrant driver regions (p < 0.001) and extrapulmonary vein regions that had re-entrant drivers (p < 0.05), whereas control subjects displayed more focal driver regions (p 1⁄4 0.029). The acute AF termination rate was lower in the PsAFonset group (42% vs. 81%; p< 0.001). During a mean follow-up of 17 11 months from the last procedure, patients with PsAFonset had significantly higher AF, atrial tachycardia (AT), and AF/AT recurrence rates (p < 0.01). CONCLUSIONS Patients with PsAFonset represent a distinct subgroup defined by specific demographics, underlying diffuse biatrial substrate disease, and worse clinical outcome. The findings highlight the importance of defining criteria for early detection of atrial substrate disease. (J Am Coll Cardiol EP 2016;2:129–39) © 2016 by the American College of Cardiology Foundation. A lthough the role of triggers in the initiation of paroxysmal atrial fibrillation (AF) is wellestablished, the underlying mechanisms sustaining persistent AF (PsAF) remain poorly elaide Hospital, Adelaide, Australia. This work was supported by the Agenc -IAHU-04, ANR Tempo, Leducq Foundation and European Frame Progra irley Early Career Fellowship from the National Health and Medical Rese stdoctoral Fellowship from the National Health and Medical Research Co o J. Mahar Lectureship from the University of Adelaide. Dr. Sanders is supp alth and Medical Research Council of Australia; is the Knapman art Foundation of Australia; is on the advisory board of and receives d St. Jude Medical; and has received research funding fromMedtronic, St. . Boveda has consulted for Medtronic and Boston Scientific. Dr. Pomie nsultant for CardioInsight. Dr. Sacher has received lecture honoraria from dical and Sorin. Dr. Jais is a stockholder in CardioInsight. Dr. Hocini is a sto advisory board for Biosense-Webster,Medtronic, St. JudeMedical, Sanofinsulting fees from Biosense-Webster, Medtronic, and St. Jude Medical; ha nic, St. Jude Medical, Boston Scientific, Merck, Sharpe, and Dohme, Biotr ding fromMedtronic, St. JudeMedical, Boston Scientific, Biotronik, and So other authors have reported that they have no relationships relevant to th nuscript received July 6, 2015; revised manuscript received November 30 understood (1). It is unclear why certain patients remain in paroxysmal AF (PAF) for an extended period of time, whereas others progress rapidly to a persistent form of AF (2–5). Atrial electrical remodeling e Nationale de la Recherche (ANR) under grant ANRmme 7. Dr. Lim is supported by the Neil Hamilton arch Council of Australia. Dr. Lau is supported by a uncil of Australia. Dr. Mahajan is supported by the orted by a Practitioner Fellowship from the National Chair of Cardiology Research from the National consulting fees from Biosense-Webster, Medtronic, Jude Medical, Boston Scientific, Biotronik, and Sorin. r is an employee of CardioInsight. Dr. Dubois is a Biosense-Webster; and is a consultant for St. Jude ckholder in CardioInsight. Dr. Sanders is a member of Aventis, andMerck, Sharpe, andDohme; has received s received lecture fees from Biosense-Webster, Medonik, and Sanofi-Aventis; and has received research rin. Dr. Haissaguerre is a stockholder in CardioInsight. e contents of this paper to disclose. , 2015, accepted December 27, 2015. AB BR EV I A T I O N S