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While pulmonary vein isolation (PVI) remains the cornerstone for invasive treatment of atrial fibrillation (AF), patients with persistent AF still have a high rate of recurrence with this method. Stochastic Trajectory Analysis of Ranked signals (STAR) mapping uses data from multiple individual wavefronts during ongoing AF to identify local drivers of persistent AF. In this non-randomized study, STAR mapping and ablation showed significantly lower recurrence of atrial arrhythmias compared to a consecutive PVI-only cohort and a propensity-matched ‘conventional ablation’ cohort (consisting of PVI plus complex fractionated atrial electrogram ablation or linear ablation). This benefit was driven by a much lower rate of AF recurrence in the STAR (6.2%) cohort vs PVI-only (44%) or ‘conventional’ (40%) with no significant difference in atrial tachycardia recurrence. Additionally, AF termination rates during ablation were approximately three times higher in the STAR cohort. While the analysis is retrospective and not randomized, the STAR cohort was also the only cohort with complete cessation of anti-arrhythmic drugs at three months and Holter monitoring at 6 and 12 months post-ablation per protocol. While STAR mapping appears to be a very promising new tool for treating persistent AF, history predicts at least some regression to the mean when future randomized comparisons are made. The authors have planned a multicenter randomized trial of PVI plus STAR mapping vs PVI-only for persistent AF. The global community of electrophysiologists and patients with AF eagerly awaits the results.

Multipolar mapping has primarily been studied in complex arrhythmia substrates or re-entrant circuits. Chieng et al. use a Case-Control design to compare multipolar mapping and point-by-point mapping with an ablation catheter for focal atrial and ventricular tachycardias, showing reduced procedure times and earlier electrograms in the multipolar mapping group but no difference in clinical outcomes. It is plausible that faster mapping and better delineation of earliest signals may translate to improved clinical outcomes if studied in a randomized trial in a larger population. Future multipolar mapping systems will guide the operator toward the focus in real-time and may even triangulate the source in three dimensions, giving an estimate of depth within the myocardium or likely focus in the opposite chamber.