What Is The Electrophysiological Mechanism Of De-novo Post Operative Atrial Fibrillation? Does It Impact Long-term Recurrence?
Marek Ehrlich1, Tandis Aref1, Iuliana Coti1, Martin Andreas1, Günther Laufer1, Niv Ad2.
1Medical University of Vienna, Vienna, Austria, 2West Virginia University Heart and Vascular Institute, Morgantown, WV, USA.
Objective: Postoperative atrial fibrillation (POAF) is very common following cardiac surgery and associated with inferior early and long-term outcome. Medically treated patients usually respond well. However, no study designed to capture the electrophysiological mechanism to improve our understanding and treatment option has been done. Hereby, the mechanism of POAF was assessed for the first time using a noninvasive 3-dimensional, beat-by-beat 3D mapping. Patients and Methods: In this pilot trial, 9 patients (4 male; mean age 75 ± 5 years) with POAF were mapped with the non-invasive surface system (ECVUE™, Cardioinsight, Medtronic). This group was compared with 10 patients (6 male; mean age 70 ± 10 years) with documented persistent atrial fibrillation (PEAF) and were candidates for valve surgery or CABG. The mechanism of AF was compared via the nature and location of focal triggers, rotors and macro-reentry activity in the different atrial regions using the validated Bordeaux classification. Results: Pre- as well as postoperative mapping was successful in all patients with clear identification of the potential mechanism of AF. Bi-atrial pathology was recognized in both groups. Rotor and macro-reentry activity was present in all patients whereas focal activity was only demonstrated in two patients with POAF. In total, 275 (mean 55 ± 12) rotors were mapped in the POAF group, and 289 (mean 28± 22) rotors in the PEAF group. The most prominent driver regions in both groups were the pulmonary vein area accounting for 41% of all drivers (POAF group 104/275; PEAF group 130/289). Furthermore, rotor activity in the right atrium was documented in all patients.Conclusion: This is the first report on the use of the ECUVE™ in surgical candidates with primary diagnosed postoperative atrial fibrillation. Rotor and macro re-entry activity is similar in persistent or de-novo postoperative AF, focal activity only concerned two patients with POAF which may reflect on no atrial remodeling in this group. Pre- as well as postoperative mapping carries the potential to significantly improve our understanding in the pathophysiology of atrial fibrillation and dictate long term follow up and treatment management. 
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