Evidence map›Paper›PMID 22818076›Full record

Trial reportJournal of the American College of Cardiology2012

Treatment of atrial fibrillation by the ablation of localized sources: CONFIRM (Conventional Ablation for Atrial Fibrillation With or Without Focal Impulse and Rotor Modulation) trial.

Sanjiv M Narayan, David E Krummen, Kalyanam Shivkumar, Paul Clopton, Wouter-Jan Rappel, John M Miller

8 registry-linked trialsAbstract readClinical Trial
PubMed Full text at PMC Publisher
In one paragraph

Trial report in Journal of the American College of Cardiology, 2012. The graph could read no effect estimate from its abstract, so it casts no vote on the map. It is linked to 8 registered trials, which are not on this map. Cited by 480 papers, 2 of them syntheses that pooled it.

0numbers the graph read from it
0cells of the map it votes in
480citing papers in PubMed, 2 pooled it
61.7field-weighted citation impact, top 1% of its field
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

NCT01008722 completednot on this map

The Dynamics of Human Atrial Fibrillation

TypeobservationalSponsorUniversity of California, San DiegoRan2009 to 2014Enrolled98ConditionsAtrial Fibrillation, Atrial Tachyarrhythmia
NCT02169037 naunknown statusnot on this mapstarted 2016, after this paper: background citation

Substrate Ablation (Focal Impulse and Rotor Modulation) Compared to Pulmonary Vein Isolation to Eliminate Paroxysmal Atrial Fibrillation: A Randomized Clinical Trial

TypeinterventionalSponsorUniversity of California, San DiegoRan2016 to 2022Enrolled120ConditionsAtrial FibrillationArmsFIRM Ablation, Conventional AF ablation with PVI
NCT02456233 nacompletednot on this mapstarted 2016, after this paper: background citation

Randomized Evaluation of Conventional Ablation With or Without Focal Impulse and Rotor Modulation to Eliminate Human Atrial Fibrillation (RECONFIRM): A Randomized Clinical Trial

TypeinterventionalSponsorStanford UniversityRan2016 to 2025Enrolled84ConditionsAtrial FibrillationArmsConventional AF Ablation with PVI, FIRM-guided ablation plus PVI
NCT02758002 nawithdrawnnot on this mapstarted 2016, after this paper: background citation

Inhibition of Atrial Fibrillation by Elimination of Transitional Mechanisms

TypeinterventionalSponsorUniversity of California, San DiegoRan2016 to 2018Enrolled0ConditionsAtrial Fibrillation, ArrhythmiaArmsFirm ablation for transitional AF rotors
NCT02918396 naterminatednot on this mapstarted 2016, after this paper: background citation

The Substrate and Intervention Mechanisms for Persistent Atrial Fibrillation (SIMPle AF) Trial

TypeinterventionalSponsorJohns Hopkins UniversityRan2016 to 2017Enrolled5ConditionsPersistent Atrial FibrillationArmsScar-Based Radio-frequency Ablation, Rotor Anchors Radio-frequency Ablation, Conventional PVI by Radio-frequency Ablation
NCT02997254 recruitingnot on this mapstarted 2016, after this paper: background citation

COMparison of Physiological Algorithms for Real-time Evaluation of Atrial Fibrillation

TypeobservationalSponsorStanford UniversityRan2016 to 2027Enrolled1,000ConditionsAtrial Fibrillation, Abnormal Heart Rhythms
NCT05845034 naunknown statusnot on this mapstarted 2023, after this paper: background citation

A New Theory of Electrophysiological Mechanism of Atrial Fibrillation and Catheter Ablation Therapy for Atrial Fibrillation

TypeinterventionalSponsorThe Second Affiliated Hospital of Kunming Medical UniversityRan2023 to 2025Enrolled100ConditionsAtrial FibrillationArmsPVI + SPEs ablation, PVI ablation
NCT06364215 naterminatednot on this mapstarted 2024, after this paper: background citation

Posterior Wall Substrate Modification Using Irreversible Electroporation for the Treatment of Paroxysmal Atrial Fibrillation

TypeinterventionalSponsorJorge RomeroRan2024 to 2025Enrolled198ConditionsAtrial Fibrillation ParoxysmalArmsFarapulse PFA, Pulmonary Vein Isolation alone, Farapulse PFA, Pulmonary Vein Isolation and Left atrial Posterior Wall Isolation
3 · Its place in the literature

Who cites it

480 citing papers in PubMed, 2 syntheses or guidelines pooled it, 1,098 citations in OpenAlex.

  1. Pooled it
  2. Pulmonary vein isolation with adjunctive left atrial ganglionic plexus ablation for treatment of atrial fibrillation: a meta-analysis of randomized controlled trials.Journal of interventional cardiac electrophysiology : an international journal of arrhythmias and pacing · 2023
    Pooled it
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  6. Focal Impulse and Rotor Modulation Ablation vs. Pulmonary Vein isolation for the treatment of paroxysmal Atrial Fibrillation: results from the FIRMAP AF study.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 · 2021
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  14. Ablation of atrial fibrillation sources identified through sequential high-density mapping: in silico comparison against anatomy-based approaches.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 · 2026
    Article
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420 more citing papers are in PubMed but not listed here.

4 · The record

Corrections and comments

5 · Who and what money

Authors and funding

6 authors at 4 institutions in 1 country.

Sanjiv M NarayanDepartment of Medicine, University of California at San Diego, San Diego, California 92161, USA. snarayan@ucsd.edu
David E Krummen
Kalyanam Shivkumar
Paul Clopton
Wouter-Jan Rappel
John M Miller
San Francisco VA Medical Center · USCenter for Theoretical Biological Physics · USIndiana University – Purdue University Indianapolis · USUniversity of California, Los Angeles · US

Funding

The Dynamics of Human Atrial FibrillationR01HL083359 · NHLBI · UNIVERSITY OF CALIFORNIA, SAN DIEGO · PI Sanjiv M Narayan · 2008 to 2026
$7.9M
The Maintenance of Human Atrial FibrillationK24HL103800 · NHLBI · UNIVERSITY OF CALIFORNIA, SAN DIEGO · PI NARAYAN, SANJIV M · 2010 to 2019
$1.9M
The Pathophysiology of T-wave AlternansK23HL070529 · NHLBI · UNIVERSITY OF CALIFORNIA SAN DIEGO · PI NARAYAN, SANJIV M · 2001 to 2005
$716k
NHLBI NIH HHS HL70529NHLBI NIH HHS HL83359NHLBI NIH HHS HL83359-S1NHLBI NIH HHS K23 HL070529NHLBI NIH HHS K24 HL103800NHLBI NIH HHS R01 HL083359
6 · The paper itself

Abstract

objectivesWe hypothesized that human atrial fibrillation (AF) may be sustained by localized sources (electrical rotors and focal impulses), whose elimination (focal impulse and rotor modulation [FIRM]) may improve outcome from AF ablation.

backgroundCatheter ablation for AF is a promising therapy, whose success is limited in part by uncertainty in the mechanisms that sustain AF. We developed a computational approach to map whether AF is sustained by several meandering waves (the prevailing hypothesis) or localized sources, then prospectively tested whether targeting patient-specific mechanisms revealed by mapping would improve AF ablation outcome.

methodsWe recruited 92 subjects during 107 consecutive ablation procedures for paroxysmal or persistent (72%) AF. Cases were prospectively treated, in a 2-arm 1:2 design, by ablation at sources (FIRM-guided) followed by conventional ablation (n = 36), or conventional ablation alone (n = 71; FIRM-blinded).

resultsLocalized rotors or focal impulses were detected in 98 (97%) of 101 cases with sustained AF, each exhibiting 2.1 ± 1.0 sources. The acute endpoint (AF termination or consistent slowing) was achieved in 86% of FIRM-guided cases versus 20% of FIRM-blinded cases (p < 0.001). FIRM ablation alone at the primary source terminated AF in a median 2.5 min (interquartile range: 1.0 to 3.1 min). Total ablation time did not differ between groups (57.8 ± 22.8 min vs. 52.1 ± 17.8 min, p = 0.16). During a median 273 days (interquartile range: 132 to 681 days) after a single procedure, FIRM-guided cases had higher freedom from AF (82.4% vs. 44.9%; p < 0.001) after a single procedure than FIRM-blinded cases with rigorous, often implanted, electrocardiography monitoring. Adverse events did not differ between groups.

conclusionsLocalized electrical rotors and focal impulse sources are prevalent sustaining mechanisms for human AF. FIRM ablation at patient-specific sources acutely terminated or slowed AF, and improved outcome. These results offer a novel mechanistic framework and treatment paradigm for AF. (Conventional Ablation for Atrial Fibrillation With or Without Focal Impulse and Rotor Modulation [CONFIRM]; NCT01008722).

Indexed as

Catheter AblationModels, CardiovascularAgedAtrial FibrillationDecision Making, Computer-AssistedFemaleHeart Conduction SystemHumansMaleMiddle AgedProspective StudiesTreatment Outcome

Identifiers

PMID22818076
PMCPMC3416917
OpenAlexW25713472

What OpenQuestion holds

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Read underepoch 390

Registered trials

and 2 more above

Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.