Tina Baykaner

All Publications

• The Esophagus Going Steady. Journal of cardiovascular electrophysiology Baykaner, T., Nguyen, D. T. 2022

  Abstract

  Ablation is a cornerstone of treatment for atrial fibrillation (AF), with increasing data on its safety and efficacy. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1111/jce.15448

  View details for PubMedID 35274790

• Taking the "Pulse" of Pulsed Field Ablation: Real-World Experience. Journal of cardiovascular electrophysiology Baykaner, T., Fazal, M., Verma, A. 1800

  Abstract

  Atrial fibrillation (AF) ablation is the cornerstone of therapy for symptomatic AF, with now increasing data on the safety and efficacy of this approach over medical management in improving quality of life, decreasing rates of stroke, cardiac hospitalizations and providing mortality benefit in several populations This article is protected by copyright. All rights reserved.

  View details for DOI 10.1111/jce.15348

  View details for PubMedID 34978359

• The ENHANCE-AF Clinical Trial to Evaluate an Atrial Fibrillation Shared Decision-Making Pathway: Rationale and Study Design. American heart journal Baykaner, T., Pundi, K., Lin, B., Lu, Y., DeSutter, K., Lhamo, K., Garay, G., Nunes, J. C., Morin, D. P., Sears, S. F., Chung, M. K., Paasche-Orlow, M. K., Sanders, L. M., Bunch, T. J., Hills, M. T., Mahaffey, K. W., Stafford, R. S., Wang, P. J. 2022

  Abstract

  Shared decision making (SDM) may result in treatment plans that best reflect the goals and wishes of patients, increasing patient satisfaction with the decision-making process.  There is a knowledge gap to support the use of decision aids in SDM for anticoagulation therapy in patients with atrial fibrillation (AF). We describe the development and testing of a new decision aid, including a multicenter, randomized, controlled, 2-arm, open-label ENHANCE-AF clinical trial (Engaging Patients to Help Achieve Increased Patient Choice and Engagement for AF Stroke Prevention) to evaluate its effectiveness in 1,200 participants.Participants will be randomized to either usual care or to a shared decision-making pathway incorporating a digital tool designed to simplify the complex concepts surrounding AF in conjunction with a clinician tool and a non-clinician navigator to guide the participants through each step of the tool. The participant-determined primary outcome for this study is the Decisional Conflict Scale, measured at 1 month after the index visit during which a decision was made regarding anticoagulation use. Secondary outcomes at both 1 and 6 months will include other decision making related scales as well as participant and clinician satisfaction, oral anticoagulation adherence, and a composite rate of major bleeding, death, stroke, or transient ischemic attack. The study will be conducted at four sites selected for their ability to enroll participants of varying racial and ethnic backgrounds, health literacy, and language skills. Participants will be followed in the study for 6 months.The results of the ENHANCE-AF trial will determine whether a decision aid facilitates high quality shared decision making in anticoagulation discussions for stroke reduction in AF. An improved shared decision-making experience may allow patients to make decisions better aligned with their personal values and preferences, while improving overall AF care.

  View details for DOI 10.1016/j.ahj.2022.01.013

  View details for PubMedID 35092723

• Shared Decision-Making in Cardiac Electrophysiology Procedures and Arrhythmia Management. Circulation. Arrhythmia and electrophysiology Chung, M. K., Fagerlin, A., Wang, P. J., Ajayi, T. B., Allen, L. A., Baykaner, T., Benjamin, E. J., Branda, M., Cavanaugh, K. L., Chen, L. Y., Crossley, G. H., Delaney, R. K., Eckhardt, L. L., Grady, K. L., Hargraves, I. G., True Hills, M., Kalscheur, M. M., Kramer, D. B., Kunneman, M., Lampert, R., Langford, A. T., Lewis, K. B., Lu, Y., Mandrola, J. M., Martinez, K., Matlock, D. D., McCarthy, S. R., Montori, V. M., Noseworthy, P. A., Orland, K. M., Ozanne, E., Passman, R., Pundi, K., Roden, D. M., Saarel, E. V., Schmidt, M. M., Sears, S. F., Stacey, D., Stafford, R. S., Steinberg, B. A., Youn Wass, S., Wright, J. M. 2021: CIRCEP121007958

  Abstract

  Shared decision-making (SDM) has been advocated to improve patient care, patient decision acceptance, patient-provider communication, patient motivation, adherence, and patient reported outcomes. Documentation of SDM is endorsed in several society guidelines and is a condition of reimbursement for selected cardiovascular and cardiac arrhythmia procedures. However, many clinicians argue that SDM already occurs with clinical encounter discussions or the process of obtaining informed consent and note the additional imposed workload of using and documenting decision aids without validated tools or evidence that they improve clinical outcomes. In reality, SDM is a process and can be done without decision tools, although the process may be variable. Also, SDM advocates counter that the low-risk process of SDM need not be held to the high bar of demonstrating clinical benefit and that increasing the quality of decision-making should be sufficient. Our review leverages a multidisciplinary group of experts in cardiology, cardiac electrophysiology, epidemiology, and SDM, as well as a patient advocate. Our goal is to examine and assess SDM methodology, tools, and available evidence on outcomes in patients with heart rhythm disorders to help determine the value of SDM, assess its possible impact on electrophysiological procedures and cardiac arrhythmia management, better inform regulatory requirements, and identify gaps in knowledge and future needs.

  View details for DOI 10.1161/CIRCEP.121.007958

  View details for PubMedID 34865518

• Ibrutinib-associated atrial fibrillation treatment with catheter ablation. HeartRhythm case reports Kapoor, R., Fazal, M., Cheng, P., Witteles, R., Rhee, J., Baykaner, T. 2021; 7 (11): 713-716

  View details for DOI 10.1016/j.hrcr.2021.08.003

  View details for PubMedID 34820264

• Virtual Transformation and the Use of Social Media: Cardiac Electrophysiology Education in the Post-COVID-19 Era CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE Han, J. K., Baykaner, T., DeSimone, C., Etheridge, S. P., Futyma, P., Saha, S. A., Stiles, M. K., Gopinathannair, R., Kabra, R., Merchant, F. M. 2021; 23 (11): 70

  Abstract

  The COVID-19 pandemic has significantly impacted the delivery of education for all specialties, including cardiac electrophysiology. This review will provide an overview of the COVID-19 spurred digital transformation of electrophysiology education for practicing clinicians and trainees in electrophysiology and cover the use of social media in these educational efforts.Major international, national, and local meetings and electrophysiology fellowship-specific educational sessions have transitioned rapidly to virtual and distanced learning, enhanced by social media. This has allowed for participation in educational activities by electrophysiologists on a wider, more global scale. Social media has also allowed rapid dissemination of new advances, techniques, and research findings in real time and to a global audience, but caution must be exercised as pitfalls also exist.The digital and social media transformation of cardiac electrophysiology education has arrived and revolutionized the way education is delivered and consumed. Continued hybrid in-person and virtual modalities will provide electrophysiologists the flexibility to choose the best option to suit their individual needs and preferences for continuing education.

  View details for DOI 10.1007/s11936-021-00948-9

  View details for Web of Science ID 000708449000001

  View details for PubMedID 34690486

  View details for PubMedCentralID PMC8523345

• Is There Rule to the Chaos: Defining Stable Patterns in Atrial Fibrillation. Journal of cardiovascular electrophysiology Baykaner, T., Fazal, M., Patel, S., Zaman, J. 2021

  View details for DOI 10.1111/jce.15169

  View details for PubMedID 34260124

• IDENTIFICATION OF AREAS OF ORGANIZED 1:1 ACTIVITY IN ATRIAL FIBRILLATION IN PATIENTS POST MAZE SURGERY Bhatia, N. K., Shah, R., Ganesan, P., Rogers, A., Pong, T., Purewal, S., Baykaner, T., Wang, P., Lee, A., Rappel, W., Narayan, S. ELSEVIER SCIENCE INC. 2021: 333

  View details for Web of Science ID 000647487500333

• NON-INVASIVE TRACKING OF ATRIAL FIBRILLATION PREDICTS ACUTE TERMINATION BY ABLATION Rodrigo, M., Baykaner, T., Rappel, W., Narayan, S. ELSEVIER SCIENCE INC. 2021: 280

  View details for Web of Science ID 000647487500280

• Electrical Substrate Ablation for Refractory Ventricular Fibrillation: Results of the AVATAR Study. Circulation. Arrhythmia and electrophysiology Krummen, D. E., Ho, G. n., Hoffmayer, K. S., Schweis, F. n., Baykaner, T. n., Rogers, A. J., Han, F. T., Hsu, J. C., Viswanathan, M. N., Wang, P. J., Rappel, W. J., Narayan, S. M. 2021

  Abstract

  Background - Refractory ventricular fibrillation (VF) is a challenging clinical entity, for which ablation of triggering premature ventricular complexes (PVCs) is described. When PVCs are infrequent and multifocal, the optimal treatment strategy is uncertain. Methods - We prospectively enrolled consecutive patients presenting with multiple ICD shocks for VF refractory to antiarrhythmic drug therapy, exhibiting infrequent (≤3%), multifocal PVCs (≥3 morphologies). Procedurally, VF was induced with rapid pacing and mapped, identifying sites of conduction slowing and rotation or rapid focal activation. VF electrical substrate ablation (VESA) was then performed. Outcomes were compared against reference patients with VF who were unable or unwilling to undergo catheter ablation. The primary outcome was a composite of ICD shock, electrical storm, or all-cause mortality. Results - VF was induced and mapped in 6 patients (60±10 y, LVEF 46±19%) with ischemic (n=3) and nonischemic cardiomyopathy. An average of 3.3±0.5 sites of localized reentry during VF were targeted for radiofrequency ablation (38.3±10.9 minutes) during sinus rhythm, rendering VF non-inducible with pacing. Freedom from the primary outcome was 83% in the VF ablation group versus 17% in 6 non-ablation reference patients at a median of 1.0 years (IQR 0.5-1.5 years, p=0.046) follow-up. Conclusions - VESA is associated with a reduction in the combined endpoint compared with the non-ablation reference group. Additional work is required to understand the precise pathophysiologic changes which promote VF in order to improve preventative and therapeutic strategies.

  View details for DOI 10.1161/CIRCEP.120.008868

  View details for PubMedID 33550811

• Blood Thinners for Atrial Fibrillation Stroke Prevention. Circulation. Arrhythmia and electrophysiology Pundi, K., Baykaner, T., True Hills, M., Lin, B., Morin, D. P., Sears, S. F., Wang, P. J., Stafford, R. S. 2021: CIRCEP120009389

  View details for DOI 10.1161/CIRCEP.120.009389

  View details for PubMedID 34111936

• Arrhythmia Patterns in Patients on Ibrutinib. Frontiers in cardiovascular medicine Fazal, M., Kapoor, R., Cheng, P., Rogers, A. J., Narayan, S. M., Wang, P., Witteles, R. M., Perino, A. C., Baykaner, T., Rhee, J. 1800; 8: 792310

  Abstract

  Introduction: Ibrutinib, a Bruton's tyrosine kinase inhibitor (TKI) used primarily in the treatment of hematologic malignancies, has been associated with increased incidence of atrial fibrillation (AF), with limited data on its association with other tachyarrhythmias. There are limited reports that comprehensively analyze atrial and ventricular arrhythmia (VA) burden in patients on ibrutinib. We hypothesized that long-term event monitors could reveal a high burden of atrial and VAs in patients on ibrutinib. Methods: A retrospective data analysis at a single center using electronic medical records database search tools and individual chart review was conducted to identify consecutive patients who had event monitors while on ibrutinib therapy. Results: Seventy-two patients were included in the analysis with a mean age of 76.9 ± 9.9 years and 13 patients (18%) had a diagnosis of AF prior to the ibrutinib therapy. During ibrutinib therapy, most common arrhythmias documented were non-AF supraventricular tachycardia (n = 32, 44.4%), AF (n = 32, 44%), and non-sustained ventricular tachycardia (n = 31, 43%). Thirteen (18%) patients had >1% premature atrial contraction burden; 16 (22.2%) patients had >1% premature ventricular contraction burden. In 25% of the patients, ibrutinib was held because of arrhythmias. Overall 8.3% of patients were started on antiarrhythmic drugs during ibrutinib therapy to manage these arrhythmias. Conclusions: In this large dataset of ambulatory cardiac monitors on patients treated with ibrutinib, we report a high prevalence of atrial and VAs, with a high incidence of treatment interruption secondary to arrhythmias and related symptoms. Further research is warranted to optimize strategies to diagnose, monitor, and manage ibrutinib-related arrhythmias.

  View details for DOI 10.3389/fcvm.2021.792310

  View details for PubMedID 35047578

• Machine Learned Cellular Phenotypes Predict Outcome in Ischemic Cardiomyopathy. Circulation research Rogers, A. J., Selvalingam, A., Alhusseini, M. I., Krummen, D. E., Corrado, C., Abuzaid, F., Baykaner, T., Meyer, C., Clopton, P., Giles, W. R., Bailis, P., Niederer, S. A., Wang, P. J., Rappel, W., Zaharia, M., Narayan, S. M. 2020

  Abstract

  RATIONALE: Susceptibility to ventricular arrhythmias (VT/VF) is difficult to predict in patients with ischemic cardiomyopathy either by clinical tools or by attempting to translate cellular mechanisms to the bedside.OBJECTIVE: To develop computational phenotypes of patients with ischemic cardiomyopathy, by training then interpreting machine learning (ML) of ventricular monophasic action potentials (MAPs) to reveal phenotypes that predict long-term outcomes.METHODS AND RESULTS: We recorded 5706 ventricular MAPs in 42 patients with coronary disease (CAD) and left ventricular ejection fraction (LVEF) {less than or equal to}40% during steady-state pacing. Patients were randomly allocated to independent training and testing cohorts in a 70:30 ratio, repeated K=10 fold. Support vector machines (SVM) and convolutional neural networks (CNN) were trained to 2 endpoints: (i) sustained VT/VF or (ii) mortality at 3 years. SVM provided superior classification. For patient-level predictions, we computed personalized MAP scores as the proportion of MAP beats predicting each endpoint. Patient-level predictions in independent test cohorts yielded c-statistics of 0.90 for sustained VT/VF (95% CI: 0.76-1.00) and 0.91 for mortality (95% CI: 0.83-1.00) and were the most significant multivariate predictors. Interpreting trained SVM revealed MAP morphologies that, using in silico modeling, revealed higher L-type calcium current or sodium calcium exchanger as predominant phenotypes for VT/VF.CONCLUSIONS: Machine learning of action potential recordings in patients revealed novel phenotypes for long-term outcomes in ischemic cardiomyopathy. Such computational phenotypes provide an approach which may reveal cellular mechanisms for clinical outcomes and could be applied to other conditions.

  View details for DOI 10.1161/CIRCRESAHA.120.317345

  View details for PubMedID 33167779

• Safety and Efficacy of Minimal- versus Zero-fluoroscopy Radiofrequency Catheter Ablation for Atrial Fibrillation: A Multicenter, Prospective Study. The Journal of innovations in cardiac rhythm management Zei, P. C., Quadros, K. K., Clopton, P., Thosani, A., Ferguson, J., Brodt, C., O'Riordan, G., Ramsis, M., Mitra, R., Baykaner, T. 2020; 11 (11): 4281–91

  Abstract

  Radiofrequency catheter ablation (CA) is an effective treatment for atrial fibrillation (AF) that traditionally requires fluoroscopic imaging to guide catheter movement and positioning. However, advances in electroanatomic mapping (EAM) technology and intracardiac echocardiography (ICE) have reduced procedural reliance on fluoroscopy. We conducted a prospective registry study of 162 patients enrolled at five centers proficient in high-volume, minimal-fluoroscopy CA between March 2016 and March 2018 for the CA of symptomatic, drug-refractory paroxysmal, or persistent AF that sought to assess the safety and efficacy of minimal- versus zero-fluoroscopy AF CA. We evaluated procedural details, acute procedural outcomes and complications, and one-year follow-up data. All operators used an EAM system (CARTO; Biosense Webster, Irvine, CA, USA) and ICE. Ultimately, two patients did not pursue CA postenrollment. A total of 104 (66%) patients had paroxysmal AF with a mean ejection fraction of 58% ± 9%. Twenty-six (16.3%) patients were scheduled for repeat ablation. A total of 100 (63%) procedures were performed with zero fluoroscopy. The mean fluoroscopy time in the minimal-fluoroscopy group was 1.7 minutes ± 2.8 minutes. Further, the mean procedure duration was 192 minutes ± 37 minutes in the zero-fluoroscopy group and 201 minutes ± 29 minutes in the minimal-fluoroscopy group (p = 0.96). Pulmonary vein isolation was achieved in 153 patients (100%), with an acute procedural complication rate of 1.8%. One-year follow-up data were available for 152 (95%) patients with a mean follow-up time of 11.3 months ± 1.8 months. A total of 118 (76%) patients remained free from arrhythmia for up to 12 months, with no difference between the minimal- and zero-fluoroscopy cohorts (p = 0.18).

  View details for DOI 10.19102/icrm.2020.111105

  View details for PubMedID 33262896

• Left atrial posterior wall isolation in conjunction with pulmonary vein isolation using cryoballoon for treatment of persistent atrial fibrillation (PIVoTAL): study rationale and design. Journal of interventional cardiac electrophysiology : an international journal of arrhythmias and pacing Aryana, A., Pujara, D. K., Allen, S. L., Baker, J. H., Espinosa, M. A., Buch, E. F., Srivatsa, U., Ellis, E., Makati, K., Kowalski, M., Lee, S., Tadros, T., Baykaner, T., Al-Ahmad, A., d'Avila, A., Di Biase, L., Okishige, K., Natale, A. 2020

  Abstract

  BACKGROUND: There is growing evidence in support of pulmonary vein isolation (PVI) with concomitant posterior wall isolation (PWI) for the treatment of patients with symptomatic persistent atrial fibrillation (persAF). However, there is limited data on the safety and efficacy of this approach using the cryoballoon.OBJECTIVE: The aim of this multicenter, investigational device exemption trial (G190171) is to prospectively evaluate the acute and long-term outcomes of PVI versus PVI+PWI using the cryoballoon in patients with symptomatic persAF.METHODS: The PIVoTAL is a prospective, randomized controlled study ( ClinicalTrials.gov : NCT04505163) in which patients with symptomatic persAF refractory/intolerant to ≥1 class I-IV antiarrhythmic drug, undergoing first-time catheter ablation, will be randomized to PVI (n=183) versus PVI+PWI (n=183) using the cryoballoon in a 1:1 fashion. The design will be double-blind until randomization immediately after PVI, beyond which the design will transform into a single-blind. PVI using cryoballoon will be standardized using a pre-specified dosing algorithm. Other empiric ablations aside from documented arrhythmias/arrhythmias spontaneously induced during the procedure will not be permitted. The primary efficacy endpoint is defined as AF recurrence at 12months, after a single procedure and a 90-day blanking period. Arrhythmia outcomes will be assessed by routine electrocardiograms and 7-14day ambulatory electrocardiographic monitoring at 3, 6, and 12months post-ablation.CONCLUSION: The PIVoTAL is a prospective, randomized controlled trial designed to evaluate the outcomes of PVI alone versus PVI+PWI using the cryoballoon, in patients with symptomatic persAF. We hypothesize that PVI+PWI will prove to be superior to PVI alone for prevention of AF recurrence.

  View details for DOI 10.1007/s10840-020-00885-w

  View details for PubMedID 33009645

• Machine Learning to Classify Intracardiac Electrical Patterns during Atrial Fibrillation. Circulation. Arrhythmia and electrophysiology Alhusseini, M. I., Abuzaid, F., Rogers, A. J., Zaman, J. A., Baykaner, T., Clopton, P., Bailis, P., Zaharia, M., Wang, P. J., Rappel, W., Narayan, S. M. 2020

  Abstract

  Background - Advances in ablation for atrial fibrillation (AF) continue to be hindered by ambiguities in mapping, even between experts. We hypothesized that convolutional neural networks (CNN) may enable objective analysis of intracardiac activation in AF, which could be applied clinically if CNN classifications could also be explained. Methods - We performed panoramic recording of bi-atrial electrical signals in AF. We used the Hilbert-transform to produce 175,000 image grids in 35 patients, labeled for rotational activation by experts who showed consistency but with variability (kappa=0.79). In each patient, ablation terminated AF. A CNN was developed and trained on 100,000 AF image grids, validated on 25,000 grids, then tested on a separate 50,000 grids. Results - In the separate test cohort (50,000 grids), CNN reproducibly classified AF image grids into those with/without rotational sites with 95.0% accuracy (CI 94.8-95.2%). This accuracy exceeded that of support vector machines, traditional linear discriminant and k-nearest neighbor statistical analyses. To probe the CNN, we applied Gradient-weighted Class Activation Mapping which revealed that the decision logic closely mimicked rules used by experts (C-statistic 0.96). Conclusions - Convolutional neural networks improved the classification of intracardiac AF maps compared to other analyses, and agreed with expert evaluation. Novel explainability analyses revealed that the CNN operated using a decision logic similar to rules used by experts, even though these rules were not provided in training. We thus describe a scaleable platform for robust comparisons of complex AF data from multiple systems, which may provide immediate clinical utility to guide ablation.

  View details for DOI 10.1161/CIRCEP.119.008160

  View details for PubMedID 32631100

• PREDICTING SUDDEN CARDIAC DEATH BY MACHINE LEARNING OF VENTRICULAR ACTION POTENTIALS Selvalingam, A., Alhusseini, M., Rogers, A. J., Krummen, D., Abuzaid, F. M., Baykaner, T., Clopton, P., Bailis, P., Zaharia, M., Wang, P., Narayan, S. ELSEVIER SCIENCE INC. 2020: 427

  View details for Web of Science ID 000522979100416

• LARGER ORGANIZED AREAS IN PERSISTENT ATRIAL FIBRILLATION PREDICTS TERMINATION DURING ABLATION Ravi, N., Rogers, A. J., Bhatia, N., Tung, J. S., Krummen, D., Sauer, W., Alhusseini, M., Baykaner, T., Wang, P., Rappel, W., Narayan, S. ELSEVIER SCIENCE INC. 2020: 279

  View details for Web of Science ID 000522979100273

• The interconnected atrium: Acute impact of pulmonary vein isolation on remote atrial tissue. Journal of cardiovascular electrophysiology Rogers, A. J., Baykaner, T. n., Narayan, S. M. 2020

  View details for DOI 10.1111/jce.14389

  View details for PubMedID 32090385

• Non-Invasive Assessment of Complexity of Atrial Fibrillation: Correlation with Contact Mapping and Impact of Ablation. Circulation. Arrhythmia and electrophysiology Rodrigo, M. n., Climent, A. M., Hernández-Romero, I. n., Liberos, A. n., Baykaner, T. n., Rogers, A. J., Alhusseini, M. n., Wang, P. J., Fernández-Avilés, F. n., Guillem, M. S., Narayan, S. M., Atienza, F. n. 2020

  Abstract

  Background - It is difficult to non-invasively phenotype atrial fibrillation (AF) in a way that reflects clinical endpoints such as response to therapy. We set out to map electrical patterns of disorganization and regions of reentrant activity in AF from the body surface using electrocardiographic imaging (ECGI), calibrated to panoramic intracardiac recordings and referenced to AF termination by ablation. Methods - Bi-atrial intracardiac electrograms of 47 AF patients at ablation (30 persistent, 29 male, 63±9 years) were recorded with 64-pole basket catheters and simultaneous 57-lead body surface ECGs. Atrial epicardial electrical activity was reconstructed and organized sites were invasively and non-invasively tracked in 3D using phase singularity (PS). In a subset of 17 patients, sites of AF organization were targeted for ablation. Results - Body surface mapping showed greater AF organization near intracardially-detected drivers than elsewhere, both in PS density (2.3±2.1 vs 1.9±1.6, p=0.02) and number of drivers (3.2±2.3 vs 2.7±1.7, p=0.02). Complexity, defined as the number of stable AF reentrant sites, was concordant between non-invasive and invasive methods (r2 =0.5, CC=0.71). In the subset receiving targeted ablation, AF complexity showed lower values in those in whom AF terminated than those in whom AF did not terminate (p<0.01). Conclusions - AF complexity tracked non-invasively correlates well with organized and disorganized regions detected by panoramic intracardiac mapping, and correlates with the acute outcome by ablation. This approach may assist in bedside monitoring of therapy or in improving the efficacy of ongoing ablation procedures.

  View details for DOI 10.1161/CIRCEP.119.007700

  View details for PubMedID 32078374

• Termination of persistent atrial fibrillation by ablating sites that control large atrial areas. Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology Bhatia, N. K., Rogers, A. J., Krummen, D. E., Hossainy, S. n., Sauer, W. n., Miller, J. M., Alhusseini, M. I., Peszek, A. n., Armenia, E. n., Baykaner, T. n., Brachmann, J. n., Turakhia, M. P., Clopton, P. n., Wang, P. J., Rappel, W. J., Narayan, S. M. 2020

  Abstract

  Persistent atrial fibrillation (AF) has been explained by multiple mechanisms which, while they conflict, all agree that more disorganized AF is more difficult to treat than organized AF. We hypothesized that persistent AF consists of interacting organized areas which may enlarge, shrink or coalesce, and that patients whose AF areas enlarge by ablation are more likely to respond to therapy.We mapped vectorial propagation in persistent AF using wavefront fields (WFF), constructed from raw unipolar electrograms at 64-pole basket catheters, during ablation until termination (Group 1, N = 20 patients) or cardioversion (Group 2, N = 20 patients). Wavefront field mapping of patients (age 61.1 ± 13.2 years, left atrium 47.1 ± 6.9 mm) at baseline showed 4.6 ± 1.0 organized areas, each separated by disorganization. Ablation of sites that led to termination controlled larger organized area than competing sites (44.1 ± 11.1% vs. 22.4 ± 7.0%, P < 0.001). In Group 1, ablation progressively enlarged unablated areas (rising from 32.2 ± 15.7% to 44.1 ± 11.1% of mapped atrium, P < 0.0001). In Group 2, organized areas did not enlarge but contracted during ablation (23.6 ± 6.3% to 15.2 ± 5.6%, P < 0.0001).Mapping wavefront vectors in persistent AF revealed competing organized areas. Ablation that progressively enlarged remaining areas was acutely successful, and sites where ablation terminated AF were surrounded by large organized areas. Patients in whom large organized areas did not emerge during ablation did not exhibit AF termination. Further studies should define how fibrillatory activity is organized within such areas and whether this approach can guide ablation.

  View details for DOI 10.1093/europace/euaa018

  View details for PubMedID 32243508

• The New Normal. JACC. Clinical electrophysiology Nguyen, D. T., Baykaner, T. n. 2020; 6 (6): 693–95

  View details for DOI 10.1016/j.jacep.2020.03.009

  View details for PubMedID 32553220

• Mapping and Ablation of Rotational and Focal Drivers in Atrial Fibrillation. Cardiac electrophysiology clinics Zaman, J., Baykaner, T., Narayan, S. M. 2019; 11 (4): 583–95

  Abstract

  Drivers are increasingly studied ablation targets for atrial fibrillation (AF). However, results from ablation remain controversial. First, outcomes vary between centers and patients. Second, it is unclear how best to perform driver ablation. Third, there is a lack of practical guidance on how to identify critical from secondary sites using different AF mapping methods. This article addresses each of these issues.

  View details for DOI 10.1016/j.ccep.2019.08.010

  View details for PubMedID 31706467

• Safety and efficacy of zero fluoroscopy transseptal puncture with different approaches. Pacing and clinical electrophysiology : PACE Baykaner, T., Quadros, K., Thosani, A., Yasmeh, B., Mitra, R., Liu, E., Belden, W., Liu, Z., Costea, A., Brodt, C., Zei, P. 2019

  Abstract

  INTRODUCTION: AF ablation requires access to the left atrium (LA) via transseptal puncture (TP). TP is traditionally performed with fluoroscopic guidance. Use of intracardiac echocardiography (ICE) and 3D mapping allows for zero fluoroscopy TP.OBJECTIVE: To demonstrate safety and efficacy of zero fluoroscopy TP using multiple procedural approaches.METHODS: Patients undergoing AF ablation between 1/2015 and 11/2017 at 5 institutions were included. ICE and 3D mapping were used for sheath positioning and TP. Variable technical approaches were used across centers including placement of J wire in the SVC with ICE guidance followed by dragging down the transseptal sheath into the interatrial septum; or guiding the transseptal sheath directly to the interatrial septum by localizing the ablation catheter with 3D mapping and replacing it with the transseptal needle once in position. In patients with PM/ICD leads, pre/post-study device interrogation was performed.RESULTS: A total of 747 transseptal punctures were performed (646 patients, age 63.1±13.1, 67.5% male, LA volume index 34.5±15.8ml/m2 , EF 57.7±10.9%) with 100% success. No punctures required fluoroscopy. 2 pericardial effusions, 2 pericardial tamponades requiring pericardiocentesis and 1 TIA were observed during the overall ablation procedure, with a total complication rate of 0.7%. There were no other periprocedural complications related to TP, including intrathoracic bleeding, stroke or death both immediately following TP and within 30 days of the procedure. In patients with intracardiac devices, no device-related complications were observed.CONCLUSION: Transseptal puncture can be safely and effectively performed without the need for fluoroscopy. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1111/pace.13841

  View details for PubMedID 31736095

• Another Method That Shows Organization in Persistent AF? That's a RAAP. Journal of cardiovascular electrophysiology Baykaner, T., Zaman, J. A. 2019

  Abstract

  Atrial fibrillation (AF) ablation by pulmonary vein isolation (PVI) is the cornerstone of therapy for symptomatic AF, improving quality of life and prolonging survival in several populations (1,2). Nevertheless, the long term success of PVI is still in the range of 40-70% in patients with paroxysmal and persistent AF (3). A better understanding of mechanisms of fibrillatory conduction, beyond targeting the triggers initiating AF; should contribute to the ultimate goal to improve ablation outcomes for AF patients. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1111/jce.14215

  View details for PubMedID 31588642

• Electrographic flow mapping in persistent atrial fibrillation Baykaner, T., Alhusseini, M., Rogers, A., Sauer, W., Ruppersberg, P., Narayan, S. WILEY. 2019: 1745–46

  View details for Web of Science ID 000485280500073

• Wavefront Field Mapping Reveals a Physiologic Network Between Drivers Where Ablation Terminates Atrial Fibrillation. Circulation. Arrhythmia and electrophysiology Leef, G., Shenasa, F., Bhatia, N. K., Rogers, A. J., Sauer, W., Miller, J. M., Swerdlow, M., Tamboli, M., Alhusseini, M. I., Armenia, E., Baykaner, T., Brachmann, J., Turakhia, M. P., Atienza, F., Rappel, W., Wang, P. J., Narayan, S. M. 2019; 12 (8): e006835

  Abstract

  BACKGROUND: Localized drivers are proposed mechanisms for persistent atrial fibrillation (AF) from optical mapping of human atria and clinical studies of AF, yet are controversial because drivers fluctuate and ablating them may not terminate AF. We used wavefront field mapping to test the hypothesis that AF drivers, if concurrent, may interact to produce fluctuating areas of control to explain their appearance/disappearance and acute impact of ablation.METHODS: We recruited 54 patients from an international registry in whom persistent AF terminated by targeted ablation. Unipolar AF electrograms were analyzed from 64-pole baskets to reconstruct activation times, map propagation vectors each 20 ms, and create nonproprietary phase maps.RESULTS: Each patient (63.6±8.5 years, 29.6% women) showed 4.0±2.1 spatially anchored rotational or focal sites in AF in 3 patterns. First, a single (type I; n=7) or, second, paired chiral-antichiral (type II; n=5) rotational drivers controlled most of the atrial area. Ablation of 1 to 2 large drivers terminated all cases of types I or II AF. Third, interaction of 3 to 5 drivers (type III; n=42) with changing areas of control. Targeted ablation at driver centers terminated AF and required more ablation in types III versus I (P=0.02 in left atrium).CONCLUSIONS: Wavefront field mapping of persistent AF reveals a pathophysiologic network of a small number of spatially anchored rotational and focal sites, which interact, fluctuate, and control varying areas. Future work should define whether AF drivers that control larger atrial areas are attractive targets for ablation.

  View details for DOI 10.1161/CIRCEP.118.006835

  View details for PubMedID 31352796

• MACHINE LEARNING IDENTIFIES SITES WHERE ABLATION TERMINATES PERSISTENT ATRIAL FIBRILLATION Alhusseini, M., Abuzaid, F., Clopton, P., Rogers, A., Rodrigo, M., Baykaner, T., Wang, P., Rappel, W., Narayan, S. ELSEVIER SCIENCE INC. 2019: 301

  View details for Web of Science ID 000460565900301

• SITES THAT CONTROL LARGER AREAS DURING ATRIAL FIBRILLATION MAY DETERMINE TERMINATION DURING ABLATION Bhatia, N. K., Hossainy, S., Rogers, A., Alhusseini, M., Brodt, C., Moosvi, N., Baykaner, T., Wang, P., Rappel, W., Narayan, S. ELSEVIER SCIENCE INC. 2019: 400

  View details for Web of Science ID 000460565900400

• INTRACLASS CORRELATIONS OF VOLTAGE, FRACTIONATED ELECTROGRAMS, AND DOMINANT FREQUENCY IN PATIENTS WHERE LOCALIZED ABLATION TERMINATED PERSISTENT ATRIAL FIBRILLATION Rogers, A. J., Moosvi, N., Singh, A., Alhusseini, M., Baykaner, T., Clopton, P., Rappel, W., Wang, P., Narayan, S. ELSEVIER SCIENCE INC. 2019: 521

  View details for Web of Science ID 000460565900521

• Electroporation: The End of the Thermal Ablation Era? Journal of the American College of Cardiology Narayan, S. M., Baykaner, T. n. 2019; 74 (3): 327–29

  View details for DOI 10.1016/j.jacc.2019.06.013

  View details for PubMedID 31319914

• It is time for Turkish Cardiologists to start engaging on Twitter. Turk Kardiyoloji Dernegi arsivi : Turk Kardiyoloji Derneginin yayin organidir Çinier, G. n., Akgün, T. n., Baykaner, T. n., Mutlu, B. n. 2019; 47 (6): 427–30

  View details for DOI 10.5543/tkda.2019.57277

  View details for PubMedID 31483310

• Low-fluoroscopy atrial fibrillation ablation with contact force and ultrasound technologies: a learning curve. Pragmatic and observational research Zei, P. C., Hunter, T. D., Gache, L. M., O'Riordan, G., Baykaner, T., Brodt, C. R. 2019; 10: 1–7

  Abstract

  Background: Fluoroscopy exposure during catheter ablation is a health hazard to patients and operators. This study presents the results of implementing a low-fluoroscopy workflow using modern contact force (CF) technologies in paroxysmal atrial fibrillation (PAF) ablation.Methods: A fluoroscopy reduction workflow was implemented and subsequent catheter ablations for PAF were evaluated. After vascular access with ultrasound guidance, a THERMOCOOL SMARTTOUCH Catheter (ST) was advanced into the right atrium. The decapolar catheter was placed without fluoroscopy. A double-transseptal puncture was performed under intracardiac echocardiography guidance. ST and mapping catheters were advanced into the left atrium. A left atrial map was created, and pulmonary vein (PV) isolation was confirmed via entrance and exit block before and after the administration of isoproterenol or adenosine.Results: Forty-three patients underwent PAF ablation with fluoroscopy reduction workflow (mean age: 66±9 years; 70% male), performed by five operators. Acute success rate (PV isolation) was 96.5% of PVs. One case of pericardial effusion, not requiring intervention, was the only acute complication. Mean procedure time was 217±42 minutes. Mean fluoroscopy time was 2.3±3.0 minutes, with 97.7% of patients having < 10 minutes and 86.0% having < 5 minutes. A significant downward trend over time was observed, suggesting a rapid learning curve for fluoroscopy reduction. Freedom from any atrial arrhythmias without reablation was 80.0% after a mean follow-up of 12±3 months.Conclusion: Low fluoroscopy time is achievable with CF technologies after a short learning curve, without compromising patient safety or effectiveness.

  View details for PubMedID 30666175

• Urinary tract infection after catheter ablation of atrial fibrillation. Pacing and clinical electrophysiology : PACE Cluckey, A. n., Perino, A. C., Fan, J. n., Askari, M. n., Nasir, J. n., Marcus, G. M., Baykaner, T. n., Narayan, S. M., Wang, P. J., Turakhia, M. P. 2019

  Abstract

  Urinary tract infection (UTI) is common after surgical procedures and a quality improvement target. For non-surgical procedures such as catheter ablation of atrial fibrillation (AF), UTI risk has not been characterized. We sought to determine incidence and risk factors of UTI after AF ablation and risk variation across sites.Using Marketscan commercial claims databases, we performed a retrospective cohort study of patients that underwent AF ablation from 2007 to 2011. The primary outcome was UTI diagnosis within 30 days after ablation. We performed multivariate analyses to determine risk factors for UTI and risk of sepsis within 30 days after ablation with UTI as the predictor variable. Median odds ratio was used to quantify UTI site variation.Among 21,091 patients (age 59.2±10.9; 29.1% female; CHA2 DS2 -VASc 2.0±1.6), 622 (2.9%) were diagnosed with UTI within 30 days. In multivariate analyses, UTI was independently associated with age, female sex, prior UTI, and general anesthesia (all p < 0.01). UTI diagnosis was associated with a substantial increased risk of sepsis within 30 days (5.0% vs. 0.3%; OR 17.5; 95% CI 10.8 - 28.2; p < 0.0001). Among 416 sites, 211 had at least one UTI. Among these 211 sites, the incidence of post-ablation UTI ranged from 0.7%-26.7% (median: 5.4%; IQR: 3.0%-7.1%; 95th percentile: 14.3%; median odds ratio: 1.45; 95% CI 1.41-1.50).UTI after AF ablation is not uncommon and varies substantially across sites. Consideration of UTI as a quality measure and interventions targeted at high-risk patients or sites warrant consideration. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1111/pace.13738

  View details for PubMedID 31168821

• Online webinar training to analyse complex atrial fibrillation maps: A randomized trial. PloS one Mesquita, J. n., Maniar, N. n., Baykaner, T. n., Rogers, A. J., Swerdlow, M. n., Alhusseini, M. I., Shenasa, F. n., Brizido, C. n., Matos, D. n., Freitas, P. n., Santos, A. R., Rodrigues, G. n., Silva, C. n., Rodrigo, M. n., Dong, Y. n., Clopton, P. n., Ferreira, A. M., Narayan, S. M. 2019; 14 (7): e0217988

  Abstract

  Specific tools have been recently developed to map atrial fibrillation (AF) and help guide ablation. However, when used in clinical practice, panoramic AF maps generated from multipolar intracardiac electrograms have yielded conflicting results between centers, likely due to their complexity and steep learning curve, thus limiting the proper assessment of its clinical impact.The main purpose of this trial was to assess the impact of online training on the identification of AF driver sites where ablation terminated persistent AF, through a standardized training program. Extending this concept to mobile health was defined as a secondary objective.An online database of panoramic AF movies was generated from a multicenter registry of patients in whom targeted ablation terminated non-paroxysmal AF, using a freely available method (Kuklik et al-method A) and a commercial one (RhythmView-method B). Cardiology Fellows naive to AF mapping were enrolled and randomized to training vs no training (control). All participants evaluated an initial set of movies to identify sites of AF termination. Participants randomized to training evaluated a second set of movies in which they received feedback on their answers. Both groups re-evaluated the initial set to assess the impact of training. This concept was then migrated to a smartphone application (App).12 individuals (median age of 30 years (IQR 28-32), 6 females) read 480 AF maps. Baseline identification of AF termination sites by ablation was poor (40%±12% vs 42%±11%, P = 0.78), but similar for both mapping methods (P = 0.68). Training improved accuracy for both methods A (P = 0.001) and B (p = 0.012); whereas controls showed no change in accuracy (P = NS). The Smartphone App accessed AF maps from multiple systems on the cloud to recreate this training environment.Digital online training improved interpretation of panoramic AF maps in previously inexperienced clinicians. Combining online clinical data, smartphone apps and other digital resources provides a powerful, scalable approach for training in novel techniques in electrophysiology.

  View details for DOI 10.1371/journal.pone.0217988

  View details for PubMedID 31269029

• Comparison of phase-mapping and electrogram-based driver mapping for catheter ablation in atrial fibrillation. Pacing and clinical electrophysiology : PACE Lin, C., Lin, Y., Narayan, S. M., Baykaner, T., Lo, M., Chung, F., Chen, Y., Chang, S., Lo, L., Hu, Y., Liao, J., Tuan, T., Chao, T., Te, A. L., Kuo, L., Vicera, J. J., Chang, T., Salim, S., Chien, K., Chen, S. 2018

  Abstract

  INTRODUCTION: Adjunctive driver-guided ablation in addition to pulmonary vein isolation has been proposed as a strategy to improve procedural success and outcomes for various populations with atrial fibrillation (AF). This study firstly aimed to evaluate the different mapping techniques for driver/rotor identification and secondly to evaluate the benefit of driver/rotor guided ablation in patients with paroxysmal and persistent AF.METHODS: We searched the electronic database in PubMed using the keywords "atrial fibrillation", "rotor", "rotational driver", "atrial fibrillation source", and "drivers" for both randomized controlled trials and observational controlled trials. Clinical studies reporting efficacy or safety outcomes of driver-guided ablation for paroxysmal AF (PAF) or PerAF were identified. We performed subgroup analyses comparing different driver mapping methods in patients with PerAF. The odds ratios (OR) with random-effects were analyzed.RESULTS: Out of 175 published articles, 7 met the inclusion criteria, of which 2 were randomized controlled trials, 1 quasi-experimental study, and four observational studies (three case-controlled studies and one cross-sectional study). Overall, adjunctive driver-guided ablation was associated with higher rates of acute AF termination (OR: 4.62, 95% confidence interval [CI]: 2.12-10.08; P<0.001), lower recurrence of any atrial arrhythmia (OR: 0.44, 95% CI: 0.30-0.065; P<0.001), and comparable complication incidence.CONCLUSIONS: Adjunctive driver-guided catheter ablation suggested increased freedom from AF/AT relative to conventional strategies, irrespective of the mapping technique. Furthermore, phase-mapping appears to be superior to electrogram-based driver mapping in PerAF ablation. This article is protected by copyright. All rights reserved.

  View details for PubMedID 30536679

• Atypical flutter following lung transplantation involving recipient-to-donor tissue connections. HeartRhythm case reports Baykaner, T., Cooper, J. M. 2018; 4 (11): 548–52

  View details for PubMedID 30479958

• Interaction of Localized Drivers and Disorganized Activation in Persistent Atrial Fibrillation: Reconciling Putative Mechanisms Using Multiple Mapping Techniques CIRCULATION-ARRHYTHMIA AND ELECTROPHYSIOLOGY Kowalewski, C. B., Shenasa, F., Rodrigo, M., Clopton, P., Meckler, G., Alhusseini, M. I., Swerdlow, M. A., Joshi, V., Hossainy, S., Zaman, J. B., Baykaner, T., Rogers, A. J., Brachmann, J., Miller, J. M., Krummen, D. E., Sauer, W. H., Peters, N. S., Wang, P. J., Narayan, S. M. 2018; 11 (6): e005846

  Abstract

  Mechanisms for persistent atrial fibrillation (AF) are unclear. We hypothesized that putative AF drivers and disorganized zones may interact dynamically over short time scales. We studied this interaction over prolonged durations, focusing on regions where ablation terminates persistent AF using 2 mapping methods.We recruited 55 patients with persistent AF in whom ablation terminated AF prior to pulmonary vein isolation from a multicenter registry. AF was mapped globally using electrograms for 360±45 cycles using (1) a published phase method and (2) a commercial activation/phase method.Patients were 62.2±9.7 years, 76% male. Sites of AF termination showed rotational/focal patterns by methods 1 and 2 (51/55 vs 55/55; P=0.13) in spatially conserved regions, yet fluctuated over time. Time points with no AF driver showed competing drivers elsewhere or disordered waves. Organized regions were detected for 61.6±23.9% and 70.6±20.6% of 1 minute per method (P=nonsignificant), confirmed by automatic phase tracking (P<0.05). To detect AF drivers with >90% sensitivity, 8 to 32 s of AF recordings were required depending on driver definition.Sites at which persistent AF terminated by ablation show organized activation that fluctuate over time, because of collision from concurrent organized zones or fibrillatory waves, yet recur in conserved spatial regions. Results were similar by 2 mapping methods. This network of competing mechanisms should be reconciled with existing disorganized or driver mechanisms for AF, to improve clinical mapping and ablation of persistent AF.URL: http://www.clinicaltrials.gov. Unique identifier: NCT02997254.

  View details for PubMedID 29884620

• Cost effectiveness of focal impulse and rotor modulation guided ablation added to pulmonary vein isolation for atrial fibrillation JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY Baykaner, T., Duff, S., Hasegawa, J. T., Mafilios, M. S., Turakhia, M. P. 2018; 29 (4): 526–36

  Abstract

  Although ablation with focal impulse and rotor modulation (FIRM), as an adjunct to pulmonary vein isolation (PVI), has been shown to decrease atrial fibrillation (AF) recurrence, cost-effectiveness has not been assessed.We aimed to evaluate the cost effectiveness of FIRM-guided ablation when added to PVI in a mixed AF population.We used a Markov model to estimate the costs, quality-adjusted survival, and cost effectiveness of adding FIRM ablation to PVI. AF recurrence rates were based on 3-year data from the CONFIRM trial. Model inputs for event probabilities and utilities were obtained from literature review. Costs were based on Medicare reimbursement, wholesale acquisition costs, and literature review. Three-year total costs FIRM+PVI versus PVI alone were $27,686 versus $26,924. QALYs were 2.338 versus 2.316, respectively, resulting in an incremental cost-effectiveness ratio (ICER) of $34,452 per QALY gained. Most of the cost (65-81%) was related to the index ablation procedure. Lower AF recurrence generated cost offsets of $4,266, primarily due to a reduced need for medications and repeat ablation. Probabilistic sensitivity analysis demonstrated ICER below $100,000/QALY in 74% of simulations.Based on data from the CONFIRM study, the addition of FIRM to PVI does have the potential to be cost-effective due to higher quality-adjusted life years and lower follow-up costs. Value is sensitive to the incremental reduction in AF recurrence, and FIRM may have the greatest economic value in patients with greater AF symptom severity. Results from ongoing randomized trials will provide further clarity.

  View details for PubMedID 29436112

• Independent mapping methods reveal rotational activation near pulmonary veins where atrial fibrillation terminates before pulmonary vein isolation. Journal of cardiovascular electrophysiology Navara, R., Leef, G., Shenasa, F., Kowalewski, C., Rogers, A. J., Meckler, G., Zaman, J. A., Baykaner, T., Park, S., Turakhia, M. P., Zei, P., Viswanathan, M., Wang, P. J., Narayan, S. M. 2018

  Abstract

  OBJECTIVE: To investigate mechanisms by which atrial fibrillation (AF) may terminate during ablation near the pulmonary veins before the veins are isolated (PVI).INTRODUCTION: It remains unstudied how AF may terminate during ablation before PVs are isolated, or how patients with PV reconnection can be arrhythmia-free. We studied patients in whom PV antral ablation terminated AF before PVI, using two independent mapping methods.METHODS: We studied patients with AF referred for ablation, in whom biatrial contact basket electrograms were studied by both an activation/phase mapping method and by a second validated mapping method reported not to create false rotational activity.RESULTS: In 22 patients (age 60.1 ± 10.4, 36% persistent AF), ablation at sites near the PVs terminated AF (77% to sinus rhythm) prior to PVI. AF propagation revealed rotational (n=20) and focal (n=2) patterns at sites of termination by mapping method 1 and method 2. Both methods showed organized sites that were spatially concordant (P<0.001) with similar stability (P<0.001). Vagal slowing was not observed at sites of AF termination.DISCUSSION: PV antral regions where ablation terminated AF before PVI exhibited rotational and focal activation by two independent mapping methods. These data provide an alternative mechanism for the success of PVI, and may explain AF termination before PVI or lack of arrhythmias despite PV reconnection. Mapping such sites may enable targeted PV lesion sets and improved freedom from AF.

  View details for PubMedID 29377478

• Identification and Characterization of Sites Where Persistent Atrial Fibrillation Is Terminated by Localized Ablation CIRCULATION-ARRHYTHMIA AND ELECTROPHYSIOLOGY Zaman, J. B., Sauer, W. H., Alhusseini, M. I., Baykaner, T., Borne, R. T., Kowalewski, C. B., Busch, S., Zei, P. C., Park, S., Viswanathan, M. N., Wang, P. J., Brachmann, J., Krummen, D. E., Miller, J. M., Rappel, W., Narayan, S. M., Peters, N. S. 2018; 11 (1): e005258

  Abstract

  The mechanisms by which persistent atrial fibrillation (AF) terminates via localized ablation are not well understood. To address the hypothesis that sites where localized ablation terminates persistent AF have characteristics identifiable with activation mapping during AF, we systematically examined activation patterns acquired only in cases of unequivocal termination by ablation.We recruited 57 patients with persistent AF undergoing ablation, in whom localized ablation terminated AF to sinus rhythm or organized tachycardia. For each site, we performed an offline analysis of unprocessed unipolar electrograms collected during AF from multipolar basket catheters using the maximum -dV/dt assignment to construct isochronal activation maps for multiple cycles. Additional computational modeling and phase analysis were used to study mechanisms of map variability. At all sites of AF termination, localized repetitive activation patterns were observed. Partial rotational circuits were observed in 26 of 57 (46%) cases, focal patterns in 19 of 57 (33%), and complete rotational activity in 12 of 57 (21%) cases. In computer simulations, incomplete segments of partial rotations coincided with areas of slow conduction characterized by complex, multicomponent electrograms, and variations in assigning activation times at such sites substantially altered mapped mechanisms.Local activation mapping at sites of termination of persistent AF showed repetitive patterns of rotational or focal activity. In computer simulations, complete rotational activation sequence was observed but was sensitive to assignment of activation timing particularly in segments of slow conduction. The observed phenomena of repetitive localized activation and the mechanism by which local ablation terminates putative AF drivers require further investigation.

  View details for PubMedID 29330332

  View details for PubMedCentralID PMC5769709

• Clinical Implications of Ablation of Drivers for Atrial Fibrillation: A Systematic Review and Meta-Analysis. Circulation. Arrhythmia and electrophysiology Baykaner, T. n., Rogers, A. J., Meckler, G. L., Zaman, J. n., Navara, R. n., Rodrigo, M. n., Alhusseini, M. n., Kowalewski, C. A., Viswanathan, M. N., Narayan, S. M., Clopton, P. n., Wang, P. J., Heidenreich, P. A. 2018; 11 (5): e006119

  Abstract

  The outcomes from pulmonary vein isolation (PVI) for atrial fibrillation (AF) are suboptimal, but the benefits of additional lesion sets remain unproven. Recent studies propose ablation of AF drivers improves outcomes over PVI, yet with conflicting reports in the literature. We undertook a systematic literature review and meta-analysis to determine outcomes from ablation of AF drivers in addition to PVI or as a stand-alone procedure.Database search was done using the terms atrial fibrillation and ablation or catheter ablation and driver or rotor or focal impulse or FIRM (Focal Impulse and Rotor Modulation). We pooled data using random effects model and assessed heterogeneity with I2 statistic.Seventeen studies met inclusion criteria, in a cohort size of 3294 patients. Adding AF driver ablation to PVI reported freedom from AF of 72.5% (confidence interval [CI], 62.1%-81.8%; P<0.01) and from all arrhythmias of 57.8% (CI, 47.5%-67.7%; P<0.01). AF driver ablation when added to PVI or as stand-alone procedure compared with controls produced an odds ratio of 3.1 (CI, 1.3-7.7; P=0.02) for freedom from AF and an odds ratio of 1.8 (CI, 1.2-2.7; P<0.01) for freedom from all arrhythmias in 4 controlled studies. AF termination rate was 40.5% (CI, 30.6%-50.9%) and predicted favorable outcome from ablation(P<0.05).In controlled studies, the addition of AF driver ablation to PVI supports the possible benefit of a combined approach of AF driver ablation and PVI in improving single-procedure freedom from all arrhythmias. However, most studies are uncontrolled and are limited by substantial heterogeneity in outcomes. Large multicenter randomized trials are needed to precisely define the benefits of adding driver ablation to PVI.

  View details for PubMedID 29743170

• Ablation of Atrial Fibrillation Drivers ARRHYTHMIA & ELECTROPHYSIOLOGY REVIEW Baykaner, T., Zaman, J. B., Wang, P. J., Narayan, S. M. 2017; 6 (4): 195–201

  Abstract

  Pulmonary vein isolation (PVI) is central to ablation approaches for atrial fibrillation (AF), yet many patients still have arrhythmia recurrence after one or more procedures, despite evolving technologies for PVI. Ablation of localised AF drivers, which lie outside the pulmonary veins in many patients, is a practical approach that has been shown to improve success by many groups. Such localised drivers lie in atrial regions shown mechanistically to sustain AF in optical mapping and clinical studies of human AF, as well as computational and animal studies. Clinical studies now verify rotational activation by multiple mapping approaches in the same patients, at sites where ablation terminates persistent AF. This review article provides a mechanistic and clinical rationale to ablate localised drivers, and describes successful techniques for their ablation as well as pitfalls to avoid, which may explain discrepancies between results from some centres. We hope that this review will serve as a platform for future improvements in the patient-tailored ablation for complex arrhythmias.

  View details for PubMedID 29326835

  View details for PubMedCentralID PMC5739904

• The continuous challenge of AF ablation: From foci to rotational activity. Revista portuguesa de cardiologia : orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology : an official journal of the Portuguese Society of Cardiology Narayan, S. M., Vishwanathan, M. N., Kowalewski, C. A., Baykaner, T., Rodrigo, M., Zaman, J. A., Wang, P. J. 2017; 36 Suppl 1: 9–17

  Abstract

  Pulmonary vein isolation (PVI) is central to ablation approaches for atrial fibrillation (AF), yet many patients still have arrhythmia recurrence after one or more procedures despite the latest technology for PVI. Ablation of rotational or focal sources for AF, which lie outside the pulmonary veins in many patients, is a practical approach that has been shown to improve success by many groups. Localized sources lie in atrial regions shown mechanistically to sustain AF in optical mapping and clinical studies of human AF, as well as computational and animal studies. Because they arise in localized atrial regions, AF sources may explain central paradoxes in clinical practice - such as how limited ablation in patient specific sites can terminate persistent AF yet extensive anatomical ablation at stereotypical locations, which should extinguish disordered waves, does not improve success in clinical trials. Ongoing studies may help to resolve many controversies in the field of rotational sources for AF. Studies now verify rotational activation by multiple mapping approaches in the same patients, at sites where ablation terminates persistent AF. However, these studies also show that certain mapping methods are less effective for detecting AF sources than others. It is also recognized that the success of AF source ablation is technique dependent. This review article provides a mechanistic and clinical rationale to ablate localized sources (rotational and focal), and describes successful techniques for their ablation as well as pitfalls to avoid. We hope that this review will serve as a platform for future improvements in the patient-tailored ablation for complex arrhythmias.

  View details for PubMedID 29126896

• Predicting Determinants of Atrial Fibrillation or Flutter for Therapy Elucidation in Patients at Risk for Thromboembolic Events (PREDATE AF) Study. Heart rhythm Nasir, J. M., Pomeroy, W., Marler, A., Hann, M., Baykaner, T., Jones, R., Stoll, R., Hursey, K., Meadows, A., Walker, J., Kindsvater, S. 2017

  Abstract

  Atrial fibrillation (AF) is the most common clinically significant cardiac rhythm disorder. There is considerable interest in screening for AF, as it is a leading cause of stroke, and oral anticoagulants (OACs) have been shown to significantly reduce the risk of stroke in patients with AF. Improved screening for AF with subsequent treatment may help improve long-term outcomes, but the optimal patient population and screening intensity are unknown.In this study, we prospectively evaluated the use of the CHA2DS2-VASc score for the prediction of new-onset AF using insertable cardiac monitors (ICMs) and examined whether this screening led to the initiation of OAC therapy.We enrolled 245 subjects with no history of AF and CHA2DS2-VASc score ≥2 to be screened for AF with an ICM. The ICMs were programmed to record AF episodes ≥6 minutes in duration. Subjects were followed for 18 months with monthly remote interrogations and all events adjudicated by cardiologists. In subjects diagnosed with AF, medical records were reviewed to determine subsequent care.During a mean follow-up of 451 ± 185 days, the incidence of AF was 22.4% (95% confidence interval 17.2%-27.7%) with a mean time to detection of 141.3 ± 139.5 days. Among subjects newly diagnosed with AF, 76.4% were prescribed anticoagulation with either a novel OAC (n = 38) or warfarin (n = 4).In this large prospective cohort of subjects with CHA2DS2-VASc scores ≥2, 22.4% were newly diagnosed with AF and the majority of these subjects were given OACs, suggesting a potential role of ICMs in AF screening.

  View details for DOI 10.1016/j.hrthm.2017.04.026

  View details for PubMedID 28506913

• Multicentre safety of adding Focal Impulse and Rotor Modulation (FIRM) to conventional ablation for atrial fibrillation. Europace Krummen, D. E., Baykaner, T., Schricker, A. A., Kowalewski, C. A., Swarup, V., Miller, J. M., Tomassoni, G. F., Park, S., Viswanathan, M. N., Wang, P. J., Narayan, S. M. 2017; 19 (5): 769-774

  Abstract

  Focal Impulse and Rotor Modulation (FIRM) uses 64-electrode basket catheters to identify atrial fibrillation (AF)-sustaining sites for ablation, with promising results in many studies. Accordingly, new basket designs are being tested by several groups. We set out to determine the procedural safety of adding basket mapping and map-guided ablation to conventional pulmonary vein isolation (PVI).We collected 30 day procedural safety data in five US centres for consecutive patients undergoing FIRM plus PVI (FIRM-PVI) compared with contemporaneous controls undergoing PVI without FIRM. A total of 625 cases were included in this analysis: 325 FIRM-PVI and 300 PVI-controls. FIRM-PVI patients were more likely than PVI-controls to be male (83% vs. 66%, P < 0.001) and have long-standing persistent AF (26% vs. 13%, P < 0.001) reflecting patients referred for FIRM. Total ablation time was greater for FIRM-PVI (62 ± 22 min) vs. PVI-controls (52 ± 18 min, P = 0.03). The complication rate for FIRM-PVI procedures (4.3%) was similar to controls (4.0%, P = 1) for both major and minor complications; no deaths were reported. The rate of complications potentially attributable to the basket catheter was small and did not differ between basket types (Constellation 2.8% vs. FIRMap 1.8%, P = 0.7) or between cases in which basket catheters were and were not used (P = 0.5). Complication rates did not differ between centres (P = 0.6).Procedural complications from the use of the basket catheters for AF mapping are low, and thus procedural safety appears similar between FIRM-PVI and PVI-controls in a large multicentre cohort. Future studies are required to determine the optimal approach to maximize the efficacy of FIRM-guided ablation.

  View details for DOI 10.1093/europace/euw377

  View details for PubMedID 28339546

• Spatial relationship of organized rotational and focal sources in human atrial fibrillation to autonomic ganglionated plexi. International journal of cardiology Baykaner, T., Zografos, T. A., Zaman, J. A., Pantos, I., Alhusseini, M., Navara, R., Krummen, D. E., Narayan, S. M., Katritsis, D. G. 2017

  Abstract

  One approach to improve ablation for atrial fibrillation (AF) is to focus on physiological targets including focal or rotational sources or ganglionic plexi (GP). However, the spatial relationship between these potential mechanisms has never been studied. We tested the hypothesis that rotors and focal sources for AF may co-localize with ganglionated plexi (GP).We prospectively identified locations of AF rotors and focal sources, and correlated these to GP sites in 97 consecutive patients (age 59.9±11.4, 73% persistent AF). AF was recorded with 64-pole catheters with activation/phase mapping, and related to anatomic GP sites on electroanatomic maps.AF sources arose in 96/97 (99%) patients for 2.6±1.4 sources per patient (left atrium: 1.7±0.9 right atrium: 1.1±0.8), each with an area of 2-3cm(2). On area analyses, the probability of an AF source randomly overlapping a GP area was 26%. Left atrial sources were seen in 94 (97%) patients, in whom ≥1 source co-localized with GP in 75 patients (80%; p<0.05). AF sources were more likely to colocalize with left vs right GPs (p<0.05), and colocalization was more likely in patients with higher CHADS2VASc scores (age>65, diabetes; p<0.05).This is the first study to demonstrate that clinically detected AF focal and rotational sources in the left atrium often colocalize with regions of autonomic innervation. Studies should define if the role of AF sources differs by their anatomical location.

  View details for DOI 10.1016/j.ijcard.2017.02.152

  View details for PubMedID 28433558

• Mechanistic targets for the ablation of atrial fibrillation. Global cardiology science & practice Zaman, J. A., Baykaner, T., Schricker, A. A., Krummen, D. E., Narayan, S. M. 2017; 2017 (1): e201707

  Abstract

  The mechanisms responsible for sustaining atrial fibrillation are a key debate in cardiovascular pathophysiology, and directly influence the approach to therapy including ablation Clinical and basic studies have split AF mechanisms into two basic camps: 'spatially distributed disorganization' and 'localized sources'. Recent data suggest that these mechanisms can also be separated by the method for mapping - with nearly all traditional electrogram analyses showing spatially distributed disorganization and nearly all optical mapping studies showing localized sources We will review this dichotomy in light of these recently identified differences in mapping, and in the context of recent clinical studies in which localized ablation has been shown to impact AF, also lending support to the localized source hypothesis. We will conclude with other concepts on mechanism-based ablation and areas of ongoing research that must be addressed to continue improving our knowledge and treatment of AF.

  View details for DOI 10.21542/gcsp.2017.7

  View details for PubMedID 28971106

  View details for PubMedCentralID PMC5621726

• Electrocardiographic spatial loops indicate organization of atrial fibrillation minutes before ablation-related transitions to atrial tachycardia. Journal of electrocardiology Baykaner, T., Trikha, R., Zaman, J. A., Krummen, D. E., Wang, P. J., Narayan, S. M. 2017

  Abstract

  During ablation for atrial fibrillation (AF), it is challenging to anticipate transitions to organized tachycardia (AT). Defining indices of this transition may help to understand fibrillatory conduction and help track therapy.To determine the timescale over which atrial fibrillation (AF) organizes en route to atrial tachycardia (AT) using the ECG referenced to intracardiac electrograms.In 17 AF patients at ablation (58.7±9.6years; 53% persistent AF) we analyzed spatial loops of atrial activity on the ECG and intracardiac electrograms over successive timepoints. Loops were tracked at precisely 15, 10, 5, 3 and 1min prior to defined transitions of AF to AT.Organizational indices reliably quantified changes from AF to AT. Spatiotemporal AF organization on the ECG was identifiable at least 15min before AT was established (p=0.02).AF shows anticipatory global organization on the ECG minutes before AT is clinically evident. These results offer a foundation to establish when AF therapy is on an effective path, and for a quantitative classification separating AT from AF.

  View details for DOI 10.1016/j.jelectrocard.2017.01.007

  View details for PubMedID 28108014

• Editorial commentary: What can lung transplantation teach us about the mechanisms of atrial arrhythmias? Trends in cardiovascular medicine Baykaner, T. n., Rogers, A. J., Zaman, J. A., Narayan, S. M. 2017

  View details for PubMedID 28893519

• Recurrent Post-Ablation Paroxysmal Atrial Fibrillation Shares Substrates With Persistent Atrial Fibrillation : An 11-Center Study. JACC. Clinical electrophysiology Zaman, J. A., Baykaner, T. n., Clopton, P. n., Swarup, V. n., Kowal, R. C., Daubert, J. P., Day, J. D., Hummel, J. n., Schricker, A. A., Krummen, D. E., Mansour, M. n., Tomassoni, G. F., Wheelan, K. R., Vishwanathan, M. n., Park, S. n., Wang, P. J., Narayan, S. M., Miller, J. M. 2017; 3 (4): 393–402

  Abstract

  The role of atrial fibrillation (AF) substrates is unclear in patients with paroxysmal AF (PAF) that recurs after pulmonary vein isolation (PVI). We hypothesized that patients with recurrent post-ablation (redo) PAF despite PVI have electrical substrates marked by rotors and focal sources, and structural substrates that resemble persistent AF more than patients with (de novo) PAF at first ablation.In 175 patients at 11 centers, we compared AF substrates in both atria using 64 pole-basket catheters and phase mapping, and indices of anatomical remodeling between patients with de novo or redo PAF and first ablation for persistent AF.Sources were seen in all patients. More patients with de novo PAF (78.0%) had sources near PVs than patients with redo PAF (47.4%, p=0.005) or persistent AF (46.9%, p=0.001). The total number of sources per patient (p=0.444), and number of non-PV sources (p=0.701) were similar between groups, indicating that redo PAF patients had residual non-PV sources after elimination of PV sources by prior PVI. Structurally, left atrial size did not separate de novo from redo PAF (49.5±9.5 vs. 49.0±7.1mm, p=0.956) but was larger in patients with persistent AF (55.2±8.4mm, p=0.001).Patients with paroxysmal AF despite prior PVI show electrical substrates that resemble persistent AF more closely than patients with paroxysmal AF at first ablation. Notably, these subgroups of paroxysmal AF are indistinguishable by structural indices. These data motivate studies of trigger versus substrate mechanisms for patients with recurrent paroxysmal AF after PVI.

  View details for PubMedID 28596994

• Spatial relationship of sites for atrial fibrillation drivers and atrial tachycardia in patients with both arrhythmias. International journal of cardiology Baykaner, T. n., Zaman, J. A., Rogers, A. J., Navara, R. n., AlHusseini, M. n., Borne, R. T., Park, S. n., Wang, P. J., Krummen, D. E., Sauer, W. H., Narayan, S. M. 2017; 248: 188–95

  Abstract

  Atrial fibrillation (AF) often converts to and from atrial tachycardia (AT), but it is undefined if these rhythms are mechanistically related in such patients. We tested the hypothesis that critical sites for AT may be related to regional AF sources in patients with both rhythms, by mapping their locations and response to ablation on transitions to and from AF.From 219 patients undergoing spatial mapping of AF prior to ablation at 3 centers, we enrolled 26 patients in whom AF converted to AT by ablation (n=19) or spontaneously (n=7; left atrial size 42±6cm, 38% persistent AF). Both atria were mapped in both rhythms by 64-electrode baskets, traditional activation maps and entrainment.Each patient had a single mapped AT (17 reentrant, 9 focal) and 3.7±1.7 AF sources. The mapped AT spatially overlapped one AF source in 88% (23/26) of patients, in left (15/23) or right (8/23) atria. AF transitioned to AT by 3 mechanisms: (a) ablation anchoring AF rotor to AT (n=13); (b) residual, unablated AF source producing AT (n=6); (c) spontaneous slowing of AF rotor leaving reentrant AT at this site without any ablation (n=7). Electrogram analysis revealed a lower peak-to-peak voltage at overlapping sites (0.36±0.2mV vs 0.49±0.2mV p=0.03).Mechanisms responsible for AT and AF may arise in overlapping atrial regions. This mechanistic inter-relationship may reflect structural and/or functional properties in either atrium. Future work should delineate how acceleration of an organized AT may produce AF, and whether such regions can be targeted a priori to prevent AT recurrence post AF ablation.

  View details for PubMedID 28733070

• Terminating atrial fibrillation by cooling the heart. Heart rhythm Narayan, S. M., Baykaner, T., Sahli Costabal, F., Kuhl, E. 2016; 13 (11): 2259-2260

  View details for DOI 10.1016/j.hrthm.2016.07.017

  View details for PubMedID 27435588

• Can Cardiac Conduction System Disease Be Prevented? JAMA internal medicine Narayan, S. M., Baykaner, T., Maron, D. J. 2016; 176 (8): 1093-1094

  View details for DOI 10.1001/jamainternmed.2016.2863

  View details for PubMedID 27367299

• Organized Sources Are Spatially Conserved in Recurrent Compared to Pre-Ablation Atrial Fibrillation: Further Evidence for Non-Random Electrical Substrates JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY Lalani, G. G., Coysh, T., Baykaner, T., Zaman, J., Hopper, K., Schricker, A. A., Trikha, R., Clopton, P., Krummen, D. E., Narayan, S. M. 2016; 27 (6): 661-669

  Abstract

  CONSERVED ROTORS IN RECURRENT AF.Recurrent atrial fibrillation (AF) after ablation is associated with reconnection of initially isolated pulmonary vein (PV) trigger sites. Substrates are often targeted in addition to PVI, but it is unclear how substrates progress over time. We studied if substrates in recurrent AF are conserved or have developed de novo from pre-ablation AF.Of 137 patients undergoing Focal Impulse and Rotor Mapping (FIRM) at their index procedure for AF, 29 consecutive patients (60±8 years, 79% persistent) recurred and were also mapped at repeat procedure (21±20 months later) using carefully placed 64-pole baskets and RhythmView(TM) (Topera, Menlo Park, CA) to identify AF sources and disorganized zones. Compared to index AF, recurrent AF had a longer cycle length (177±21 vs. 167±19ms, p = 0.01). All patients (100%) had one or more conserved AF rotors between procedures with surrounding disorganization. The number of sources was similar for recurrent AF post-PVI versus index AF (3.2±1.4 vs. 3.1±1.0, p = 0.79), but was lower for recurrent AF after FIRM+PVI versus index AF (4.4±1.4 vs. 2.9±1.7, p = 0.03). Overall, 81% (61/75) of AF sources lay in conserved regions, while 19% (14/75) were detected de novo.Electrical propagation patterns for recurrent AF after unsuccessful ablation are similar in individual patients to their index AF. These data support temporospatial stability of AF substrates over 1-2 years. Trials should determine the relative benefit of adding substrate-mapping and ablation to PVI for recurrent AF. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1111/jce.12964

  View details for Web of Science ID 000378396900001

  View details for PubMedID 26918971

• New Mechanism-based Approaches to Ablating Persistent AF: Will Drug Therapy Soon Be Obsolete? JOURNAL OF CARDIOVASCULAR PHARMACOLOGY Zaman, J. A., Baykaner, T., Narayan, S. M. 2016; 67 (1): 1-8

  View details for DOI 10.1097/FJC.0000000000000270

  View details for Web of Science ID 000368504500001

• Atrial Fibrillation: Can Electrograms Be Interpreted Without Repolarization Information? Heart rhythm : the official journal of the Heart Rhythm Society Narayan, S. M., Zaman, J., Baykaner, T., Franz, M. R. 2015

  View details for DOI 10.1016/j.hrthm.2015.12.025

  View details for PubMedID 26711801

• Modifying Ventricular Fibrillation by Targeted Rotor Substrate Ablation: Proof-of-Concept from Experimental Studies to Clinical VF JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY Krummen, D. E., Hayase, J., Vampola, S. P., Ho, G., Schricker, A. A., Lalani, G. G., Baykaner, T., Coe, T. M., Clopton, P., Rappel, W., Omens, J. H., Narayan, S. M. 2015; 26 (10): 1117-1126

  View details for DOI 10.1111/jce.12753

  View details for PubMedID 26179310

• Stability of Rotors and Focal Sources for Human Atrial Fibrillation: Focal Impulse and Rotor Mapping (FIRM) of AF Sources and Fibrillatory Conduction JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY Swarup, V., Baykaner, T., Rostamian, A., Daubert, J. P., Hummel, J., Krummen, D. E., Trikha, R., Miller, J. M., Tomassoni, G. F., Narayan, S. M. 2014; 25 (12): 1284-1292

  Abstract

  Several groups report electrical rotors or focal sources that sustain atrial fibrillation (AF) after it has been triggered. However, it is difficult to separate stable from unstable activity in prior studies that examined only seconds of AF. We applied phase-based focal impulse and rotor mapping (FIRM) to study the dynamics of rotors/sources in human AF over prolonged periods of time.We prospectively mapped AF in 260 patients (169 persistent, 61 ± 12 years) at 6 centers in the FIRM registry, using baskets with 64 contact electrodes per atrium. AF was phase mapped (RhythmView, Topera, Menlo Park, CA, USA). AF propagation movies were interpreted by each operator to assess the source stability/dynamics over tens of minutes before ablation.Sources were identified in 258 of 260 of patients (99%), for 2.8 ± 1.4 sources/patient (1.8 ± 1.1 in left, 1.1 ± 0.8 in right atria). While AF sources precessed in stable regions, emanating activity including spiral waves varied from collision/fusion (fibrillatory conduction). Each source lay in stable atrial regions for 4,196 ± 6,360 cycles, with no differences between paroxysmal versus persistent AF (4,290 ± 5,847 vs. 4,150 ± 6,604; P = 0.78), or right versus left atrial sources (P = 0.26).Rotors and focal sources for human AF mapped by FIRM over prolonged time periods precess ("wobble") but remain within stable regions for thousands of cycles. Conversely, emanating activity such as spiral waves disorganize and collide with the fibrillatory milieu, explaining difficulties in using activation mapping or signal processing analyses at fixed electrodes to detect AF rotors. These results provide a rationale for targeted ablation at AF sources rather than fibrillatory spiral waves.

  View details for DOI 10.1111/jce.12559

  View details for Web of Science ID 000346020800004

  View details for PubMedID 25263408