{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,15]],"date-time":"2026-09-15T00:40:12Z","timestamp":1789432812904,"version":"build-2803163510"},"reference-count":19,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2022,11,28]],"date-time":"2022-11-28T00:00:00Z","timestamp":1669593600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000002","name":"National Institutes of Health","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100000002","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000002","name":"National Institutes of Health","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100000002","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Cardiovasc. Med."],"abstract":"<jats:sec><jats:title>Introduction<\/jats:title><jats:p>Catheter ablation of persistent AF has not been consistently successful in terminating AF or preventing arrhythmia recurrences. Non-invasive Electrocardiographic Imaging (ECGI) can help to understand recurrences by mapping the mechanisms of pre-ablation AF and comparing them with the patterns of recurrent arrhythmias in the same patient.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Seventeen persistent AF patients underwent ECGI before their first catheter ablation. Time-domain activation maps and phase progression maps were obtained on the bi-atrial epicardium. Location of arrhythmogenic drivers were annotated on the bi-atrial anatomy. Activation and phase movies were examined to understand the wavefront dynamics during AF. Eight patients recurred within 12 months of ablation and underwent a follow-up ECGI. Driver locations and movies were compared for pre- and post-ablation AF.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>A total of 243 focal drivers were mapped during pre-ablation AF. 62% of the drivers were mapped in the left atrium (LA). The pulmonary vein region harbored most of the drivers (43%). 35% of the drivers were mapped in the right atrium (RA). 59% (10\/17) and 53% (9\/17) of patients had repetitive sources in the left pulmonary veins (LPV) and left atrial appendage (LAA), and the lower half of RA, respectively. All patients had focal drivers. 29% (5\/17) of patients had macro-reentry waves. 24% (4\/17) of patients had rotors. Activation patterns during persistent AF varied from single macro-reentry to complex activity with multiple simultaneous wavefronts in both atria, resulting in frequent wave collisions. A total of 76 focal driver activities were mapped in 7\/8 patients during recurrence. 59% of the post-ablation AF drivers were mapped in the LA. The pulmonary vein region harbored 50% of total drivers. 39% of sources were mapped in the RA. AF complexity remained similar post-ablation. 58% (44\/76) of pre-ablation sources persisted during recurrence. 38% (3\/8) of patients had macro-reentry and one patient had rotors.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>ECGI provides patient-specific information on mechanisms of persistent AF and recurrent arrhythmia. More than half pre-ablation sources repeated during post-ablation recurrence. This study provides direct evidence for drivers that persist days and months after the ablation procedure. Patient-tailored bi-atrial ablation is needed to successfully target persistent AF and prevent recurrence. ECGI can potentially predict recurrence and assist in choice of therapy.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fcvm.2022.1052195","type":"journal-article","created":{"date-parts":[[2022,11,28]],"date-time":"2022-11-28T04:35:39Z","timestamp":1669610139000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":8,"title":["Mechanisms of persistent atrial fibrillation and recurrences within 12 months post-ablation: Non-invasive mapping with electrocardiographic imaging"],"prefix":"10.3389","volume":"9","author":[{"given":"Ramya","family":"Vijayakumar","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mitchell N.","family":"Faddis","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Phillip S.","family":"Cuculich","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yoram","family":"Rudy","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2022,11,28]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"2108","DOI":"10.1161\/CIRCULATIONAHA.115.017007","article-title":"Simultaneous Biatrial High-Density (510-512 Electrodes) epicardial mapping of persistent and long-standing persistent atrial fibrillation in patients: New insights into the mechanism of its maintenance.","volume":"132","author":"Lee","year":"2015","journal-title":"Circulation."},{"key":"B2","doi-asserted-by":"crossref","first-page":"628","DOI":"10.1016\/j.jacc.2012.05.022","article-title":"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.","volume":"60","author":"Narayan","year":"2012","journal-title":"J Am Coll Cardiol."},{"key":"B3","doi-asserted-by":"publisher","first-page":"530","DOI":"10.1161\/CIRCULATIONAHA.113.005421","article-title":"Driver domains in persistent atrial fibrillation.","volume":"130","author":"Haissaguerre","year":"2014","journal-title":"Circulation."},{"key":"B4","doi-asserted-by":"publisher","first-page":"525","DOI":"10.1161\/CIRCULATIONAHA.114.011635","article-title":"Ablation of driver domains during persistent atrial fibrillation: a call for more understanding.","volume":"130","author":"Kalifa","year":"2014","journal-title":"Circulation."},{"key":"B5","doi-asserted-by":"publisher","first-page":"1364","DOI":"10.1161\/CIRCULATIONAHA.110.945709","article-title":"Noninvasive characterization of epicardial activation in humans with diverse atrial fibrillation patterns.","volume":"122","author":"Cuculich","year":"2010","journal-title":"Circulation."},{"key":"B6","doi-asserted-by":"publisher","first-page":"e125","DOI":"10.1161\/CIR.0000000000000719","article-title":"2019 AHA\/ACC\/HRS Focused Update of the 2014 AHA\/ACC\/HRS Guideline for the Management of Patients With Atrial Fibrillation: A report of the american college of cardiology\/american heart association task force on clinical practice guidelines and the heart rhythm society in collaboration with the society of thoracic surgeons.","volume":"140","author":"January","year":"2019","journal-title":"Circulation."},{"key":"B7","doi-asserted-by":"publisher","first-page":"1812","DOI":"10.1056\/NEJMoa1408288","article-title":"Approaches to catheter ablation for persistent atrial fibrillation.","volume":"372","author":"Verma","year":"2015","journal-title":"N Engl J Med."},{"key":"B8","doi-asserted-by":"publisher","first-page":"422","DOI":"10.1038\/nm1011","article-title":"Noninvasive electrocardiographic imaging for cardiac electrophysiology and arrhythmia.","volume":"10","author":"Ramanathan","year":"2004","journal-title":"Nat Med."},{"key":"B9","doi-asserted-by":"publisher","first-page":"1302","DOI":"10.1093\/europace\/euw168","article-title":"Multicentre evaluation of non-invasive biatrial mapping for persistent atrial fibrillation ablation: the AFACART study.","volume":"19","author":"Knecht","year":"2017","journal-title":"Europace."},{"key":"B10","doi-asserted-by":"publisher","first-page":"875","DOI":"10.1016\/j.hrthm.2022.01.042","article-title":"Noninvasive electrocardiographic imaging-guided targeting of drivers of persistent atrial fibrillation: The TARGET-AF1 trial.","volume":"19","author":"Honarbakhsh","year":"2022","journal-title":"Heart Rhythm."},{"key":"B11","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCEP.116.004409","article-title":"Methodology considerations in phase mapping of human cardiac arrhythmias.","volume":"9","author":"Vijayakumar","year":"2016","journal-title":"Circ Arrhythmia Electrophysiol."},{"key":"B12","doi-asserted-by":"publisher","first-page":"6309","DOI":"10.1073\/pnas.0601533103","article-title":"Activation and repolarization of the normal human heart under complete physiological conditions.","volume":"103","author":"Ramanathan","year":"2006","journal-title":"Proc Natl Acad Sci USA."},{"key":"B13","doi-asserted-by":"crossref","first-page":"863","DOI":"10.1161\/CIRCRESAHA.112.279315","article-title":"Noninvasive electrocardiographic imaging of arrhythmogenic substrates in humans.","volume":"112","author":"Rudy","year":"2013","journal-title":"Circ Res."},{"key":"B14","doi-asserted-by":"publisher","first-page":"655","DOI":"10.1016\/B978-0-323-44733-1.00070-5","article-title":"Noninvasive Electrocardiographic Imaging (ECGI) of Arrhythmogenic Substrates and Ventricular Arrhythmias in Patients.","author":"Rudy","year":"2017","journal-title":"Cardiac Electrophysiology: From Cell to Bedside."},{"key":"B15","doi-asserted-by":"publisher","first-page":"1316","DOI":"10.1016\/j.hrthm.2009.11.009","article-title":"Noninvasive real-time mapping of an incomplete pulmonary vein isolation using electrocardiographic imaging.","volume":"7","author":"Cuculich","year":"2010","journal-title":"Heart Rhythm."},{"key":"B16","doi-asserted-by":"crossref","first-page":"e275","DOI":"10.1016\/j.hrthm.2017.05.012","article-title":"2017 HRS\/EHRA\/ECAS\/APHRS\/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation.","volume":"14","author":"Calkins","year":"2017","journal-title":"Heart Rhythm."},{"key":"B17","doi-asserted-by":"publisher","DOI":"10.1161\/JAHA.117.005922","article-title":"Three-dimensional Integrated functional, structural, and computational mapping to define the structural \u201cfingerprints\u201d of heart-specific atrial fibrillation drivers in human heart ex vivo.","volume":"6","author":"Zhao","year":"2017","journal-title":"J Am Heart Assoc."},{"key":"B18","doi-asserted-by":"publisher","first-page":"194","DOI":"10.1161\/01.CIR.101.2.194","article-title":"Stable microreentrant sources as a mechanism of atrial fibrillation in the isolated sheep heart.","volume":"101","author":"Mandapati","year":"2000","journal-title":"Circulation."},{"key":"B19","doi-asserted-by":"publisher","first-page":"816","DOI":"10.1093\/cvr\/cvq336","article-title":"Time course and mechanisms of endo-epicardial electrical dissociation during atrial fibrillation in the goat.","volume":"89","author":"Eckstein","year":"2011","journal-title":"Cardiovasc Res."}],"container-title":["Frontiers in Cardiovascular Medicine"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fcvm.2022.1052195\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,11,28]],"date-time":"2022-11-28T04:35:43Z","timestamp":1669610143000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fcvm.2022.1052195\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,11,28]]},"references-count":19,"alternative-id":["10.3389\/fcvm.2022.1052195"],"URL":"https:\/\/doi.org\/10.3389\/fcvm.2022.1052195","relation":{},"ISSN":["2297-055X"],"issn-type":[{"value":"2297-055X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,11,28]]},"article-number":"1052195"}}