Evidence map›Paper›PMID 23563126›Full record

Trial reportJournal of the American College of Cardiology2013

Direct or coincidental elimination of stable rotors or focal sources may explain successful atrial fibrillation ablation: on-treatment analysis of the CONFIRM trial (Conventional ablation for AF with or without focal impulse and rotor modulation).

Sanjiv M Narayan, David E Krummen, Paul Clopton, Kalyanam Shivkumar, John M Miller

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

Trial report in Journal of the American College of Cardiology, 2013. The graph could read no effect estimate from its abstract, so it casts no vote on the map. It is linked to 2 registered trials, which are not on this map. Cited by 111 papers, 3 of them syntheses that pooled it.

0numbers the graph read from it
0cells of the map it votes in
111citing papers in PubMed, 3 pooled it
–field-weighted citation impact
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
NCT02129842 completednot on this mapstarted 2014, after this paper: background citation

A Prospective, Non-randomized, Double Blind Multicenter Study to Assess Endothelial Function Using Endo-PAT2000 and Its Correlation to Clinical Outcome Following Ablation in Patients With Atrial Fibrillation

TypeobservationalSponsorItamar-Medical, IsraelRan2014 to 2016Enrolled150ConditionsAtrial Fibrillation
3 · Its place in the literature

Who cites it

111 citing papers in PubMed, 3 syntheses or guidelines pooled it.

  1. Pooled it
  2. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation.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 · 2018
    Guideline
  3. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design: a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology (ESC) and the European Cardiac Arrhythmia Society (ECAS); and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). Endorsed by the governing bodies of the American College of Cardiology Foundation, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, the Asia Pacific Heart Rhythm Society, and the Heart Rhythm Society.Heart rhythm · 2012
    Guideline
  4. Trial
  5. Randomized evaluation of redo ablation procedures of atrial fibrillation with focal impulse and rotor modulation-guided procedures: the REDO-FIRM 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 · 2023
    Trial
  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
    Trial
  7. Trial
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  9. Trial
  10. Article
  11. Review
  12. Article
  13. Review
  14. Innovations in atrial fibrillation ablation.Journal of interventional cardiac electrophysiology : an international journal of arrhythmias and pacing · 2023
    Review
  15. Article
  16. Article
  17. Article
  18. Article
  19. Article
  20. Article

51 more citing papers are in PubMed but not listed here.

4 · The record

Corrections and comments

5 · Who and what money

Authors and funding

5 authors.

Sanjiv M NarayanDepartment of Medicine, University of California, San Diego, California; Veterans Affairs Medical Center, San Diego, California; University of California, Los Angeles, California. Electronic address: snarayan@ucsd.edu.
David E KrummenDepartment of Medicine, University of California, San Diego, California; Veterans Affairs Medical Center, San Diego, California.
Paul CloptonVeterans Affairs Medical Center, San Diego, California.
Kalyanam ShivkumarUniversity of California, Los Angeles, California.
John M MillerThe Krannert Institute of Cardiology, Indiana University, Indianapolis, Indiana.

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 HL103800NHLBI 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

objectivesThis study sought to determine whether ablation of recently described stable atrial fibrillation (AF) sources, either directly by Focal Impulse and Rotor Modulation (FIRM) or coincidentally when anatomic ablation passes through AF sources, may explain long-term freedom from AF.

backgroundIt is unclear why conventional anatomic AF ablation can be effective in some patients yet ineffective in others with similar profiles.

methodsThe CONFIRM (Conventional Ablation for AF With or Without Focal Impulse and Rotor Modulation) trial prospectively revealed stable AF rotors or focal sources in 98 of 101 subjects with AF at 107 consecutive ablation cases. In 1:2 fashion, subjects received targeted source ablation (FIRM) followed by conventional ablation, or conventional ablation alone. We determined whether ablation lesions on electroanatomic maps passed through AF sources on FIRM maps.

resultsSubjects who completed follow-up (n = 94; 71.2% with persistent AF) showed 2.3 ± 1.1 concurrent AF rotors or focal sources that lay near pulmonary veins (22.8%), left atrial roof (16.0%), and elsewhere in the left (28.2%) and right (33.0%) atria. AF sources were ablated directly in 100% of FIRM cases and coincidentally (e.g., left atrial roof) in 45% of conventional cases (p < 0.05). During a median (interquartile range) of 273 days (138 to 636 days) after one procedure, AF was absent in 80.3% of patients if sources were ablated but in only 18.2% of patients if sources were missed (p < 0.001). Freedom from AF was highest if all sources were ablated, intermediate if some sources were ablated, and lowest if no sources were ablated (p < 0.001).

conclusionsElimination of stable AF rotors and focal sources may explain freedom from AF after diverse approaches to ablation. Patient-specific AF source distributions are consistent with the reported success of specific anatomic lesion sets and of widespread ablation. These results support targeting AF sources to reduce unnecessary ablation, and motivate studies on FIRM-only ablation.

Indexed as

Body Surface Potential MappingAction PotentialsAtrial FibrillationCatheter AblationFemaleFollow-Up StudiesHeart AtriaHeart Conduction SystemHeart ValvesHumansMaleMiddle AgedProspective StudiesPulmonary VeinsRecurrenceTreatment Outcome

Identifiers

PMID23563126
PMCPMC3703494

What OpenQuestion holds

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Read underepoch 390

Registered trials

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.