Patient-TAILORed Ablation of Persistent AF Guided by Instantaneous Amplitude and Frequency Modulation Maps (TAILOR-AF)

Summary

Pulmonary vein isolation (PVI) is still considered the cornerstone of catheter ablation for patients with persistent atrial fibrillation (AF). However, ablation outcomes in patients with persistent AF are suboptimal with high recurrence rates after a single PVI procedure.

Recently, the investigators developed a new strategy, which enables precise identification of the driver regions allegedly responsible for the maintenance of persistent AF outside the pulmonary veins. This approach uses a conventional electroanatomical mapping system and novel single-signal algorithms based on automatic and accurate analysis of the instantaneous amplitude and frequency modulations displayed by atrial signals during AF (iAM and iFM, respectively) to locate the spatiotemporally stable regions that drive persistent AF (leading drivers).

This strategy also enables to identify highly complex substrates in which targeting leading driver regions with catheter-based ablation may not be feasible or could be potentially associated with a significantly higher risk of complications. In such patients, the iAM/iFM maps obtained in the index catheter mapping and ablation procedure will be used to guide an additional patient-specific, minimally invasive surgical ablation approach via thoracoscopy, aiming to completely but specifically target all leading driver regions.

The main objective of the TAILOR-AF study is to identify (via iAM/iFM maps), target and ablate AF leading drivers in patients with symptomatic persistent AF recurrences despite ≥2 previous PVI procedures. The methods include a percutaneous catheter mapping and ablation approach followed by a minimally invasive surgical approach via thoracoscopy, if necessary. As a secondary objective we will study the association of underlying blood biomarkers, atrial imaging and surface ECG parameters, with advanced remodeling stages requiring a surgical approach to target leading driver regions.

This is a single center study (Hospital Clínico San Carlos, Madrid, Spain) that will recruit 25 patients with symptomatic persistent AF episodes despite having been submitted to ≥2 PVI prior procedures. All patients will undergo subcutaneous implantable loop recorder (ILR) implantation to address AF burden 1 month before the ablation procedure and at least 1 year after the ablation procedure. The primary outcome of the study will be AF freedom after one year of follow-up off antiarrhythmic drugs.

Conditions

• Persistent Atrial Fibrillation

Interventions

DEVICE

Subcutaneous implantable loop recorder (ILR) implantation

All patients will undergo subcutaneous implantable loop recorder (ILR) implantation to quantify AF burden 1 month before the ablation procedure and at least 1 year after the ablation procedure.

PROCEDURE

Mapping and catheter ablation

Driver regions will be identified during persistent AF using a conventional electroanatomical mapping system, multielectrode mapping catheters, and leading-driver maps generated by novel single-signal algorithms based on an automatic and accurate analysis of the instantaneous amplitude and frequency modulations displayed by atrial signals (iAM and iFM, respectively). Such maps enable the location of the spatiotemporally stable regions that drive persistent AF (leading drivers). Leading-driver regions that can be reasonably targeted/isolated with catheter ablation without high-risk of complications upon radiofrequency delivery will be targeted for ablation.

PROCEDURE

Minimally invasive surgical ablation via thoracoscopy

This procedure will be performed only in those patients whose leading-driver maps in the previous mapping and catheter ablation procedure fulfill the following requirements: 1. Extensive atrial remodeling who will not likely get any benefit from catheter-based ablation due to too large atrial leading driver areas (≥10-15% of atrial surface), or 2. Leading drivers located at regions with high-risk of complications upon radiofrequency delivery (e.g. left and right atrial appendages, coronary sinus, in the vicinity \[≤5 mm\] of the cardiac specific conduction system). In such patients, the leading-driver regions not completely targeted or not targeted at all in the previous index mapping and catheter ablation procedure, will be specifically ablated/isolated by minimally invasive surgical ablation techniques via thoracoscopy.

Sponsors & Collaborators

• Fundación Centro Nacional de Investigaciones Cardiovasculares Carlos III

  collaborator OTHER

• Hospital San Carlos, Madrid

  lead OTHER

Principal Investigators

• David Filgueiras-Rama, MD, PhD · Hospital Clínico San Carlos & CNIC

Eligibility

Min Age

18 Years

Max Age

75 Years

Sex

ALL

Healthy Volunteers

No

Timeline & Regulatory

Start

2021-12-01

Primary Completion

2024-06-30

Completion

2024-12-30

Countries

• Spain

Study Locations