Evidence map›Paper›PMID 24632280›Full record

Trial reportJournal of the American College of Cardiology2014

Ablation of rotor and focal sources reduces late recurrence of atrial fibrillation compared with trigger ablation alone: extended follow-up of the CONFIRM trial (Conventional Ablation for Atrial Fibrillation With or Without Focal Impulse and Rotor Modulation).

Sanjiv M Narayan, Tina Baykaner, Paul Clopton, Amir Schricker, Gautam G Lalani, David E Krummen, Kalyanam Shivkumar, John M Miller

5 registry-linked trialsAbstract readMulticenter StudyRandomized Controlled Trial
PubMed Full text at PMC Publisher
In one paragraph

Trial report in Journal of the American College of Cardiology, 2014. The graph could read no effect estimate from its abstract, so it casts no vote on the map. It is linked to 5 registered trials, which are not on this map. Cited by 162 papers, 7 of them syntheses that pooled it.

0numbers the graph read from it
0cells of the map it votes in
162citing papers in PubMed, 7 pooled it
34.5field-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
3 · Its place in the literature

Who cites it

162 citing papers in PubMed, 7 syntheses or guidelines pooled it, 354 citations in OpenAlex.

  1. Guideline
  2. Guideline
  3. Pooled it
  4. 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
  5. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation: Executive summary.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
  6. Pooled it
  7. 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
  8. Trial
  9. Trial
  10. Article
  11. Article
  12. Review
  13. Article
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102 more citing papers are in PubMed but not listed here.

4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

8 authors at 3 institutions in 1 country.

Sanjiv M NarayanDepartment of Medicine, University of California, San Diego, San Diego, California; Veterans Affairs Medical Center, San Diego, California. Electronic address: snarayan@ucsd.edu.
Tina BaykanerDepartment of Medicine, University of California, San Diego, San Diego, California; Veterans Affairs Medical Center, San Diego, California.
Paul CloptonVeterans Affairs Medical Center, San Diego, California.
Amir SchrickerDepartment of Medicine, University of California, San Diego, San Diego, California; Veterans Affairs Medical Center, San Diego, California.
Gautam G LalaniDepartment of Medicine, University of California, San Diego, San Diego, California; Veterans Affairs Medical Center, San Diego, California.
David E KrummenDepartment of Medicine, University of California, San Diego, San Diego, California; Veterans Affairs Medical Center, San Diego, California.
Kalyanam ShivkumarUniversity of California, Los Angeles, Los Angeles, California.
John M MillerThe Krannert Institute of Cardiology, Indiana University, Indianapolis, Indiana.
San Francisco VA Medical Center · 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
ELECTROPHYSIOLOGICAL EFFECTS OF NEURAL REMODELING OF THE VENTRICLESR01HL084261 · NHLBI · UNIVERSITY OF CALIFORNIA LOS ANGELES · PI SHIVKUMAR, KALYANAM · 2006 to 2016
$3.4M
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 HL083359NHLBI NIH HHS R01 HL084261
6 · The paper itself

Abstract

objectivesThe aim of this study was to determine if ablation that targets patient-specific atrial fibrillation (AF)-sustaining substrates (rotors or focal sources) is more durable than trigger ablation alone at preventing late AF recurrence.

backgroundLate recurrence substantially limits the efficacy of pulmonary vein isolation for AF and is associated with pulmonary vein reconnection and the emergence of new triggers.

methodsThree-year follow-up was performed of the CONFIRM (Conventional Ablation for Atrial Fibrillation With or Without Focal Impulse and Rotor Modulation) trial, in which 92 consecutive patients with AF (70.7% persistent) underwent novel computational mapping. Ablation comprised source (focal impulse and rotor modulation [FIRM]) and then conventional ablation in 27 patients (FIRM guided) and conventional ablation alone in 65 patients (FIRM blinded). Patients were followed with implanted electrocardiographic monitors when possible (85.2% of FIRM-guided patients, 23.1% of FIRM-blinded patients).

resultsFIRM mapping revealed a median of 2 (interquartile range: 1 to 2) rotors or focal sources in 97.7% of patients during AF. During a median follow-up period of 890 days (interquartile range: 224 to 1,563 days), compared to FIRM-blinded therapy, patients receiving FIRM-guided ablation maintained higher freedom from AF after 1.2 ± 0.4 procedures (median 1; interquartile range: 1 to 1) (77.8% vs. 38.5%, p = 0.001) and a single procedure (p < 0.001) and higher freedom from all atrial arrhythmias (p = 0.003). Freedom from AF was higher when ablation directly or coincidentally passed through sources than when it missed sources (p < 0.001).

conclusionsFIRM-guided ablation is more durable than conventional trigger-based ablation in preventing 3-year AF recurrence. Future studies should investigate how ablation of patient-specific AF-sustaining rotors and focal sources alters the natural history of arrhythmia recurrence. (The Dynamics of Human Atrial Fibrillation; NCT01008722).

Indexed as

Atrial FibrillationCatheter AblationElectrocardiographyFemaleFollow-Up StudiesHeart Conduction SystemHumansMaleMiddle AgedProspective StudiesPulmonary VeinsSecondary PreventionTime FactorsTreatment Outcomeablationatrial fibrillationclinical trialelectrical rotorsFIRM

Identifiers

PMID24632280
PMCPMC4008643
OpenAlexW1895194522

What OpenQuestion holds

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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.