Ablation of persistent atrial fibrillation based on high density voltage mapping and complex fractionated atrial electrograms

Abstract

Introduction: Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) catheter ablation. However, a PVI alone has been considered insufficient for persistent AF. This study aimed to evaluate the efficacy of persistent AF ablation targeting complex fractionated atrial electrogram (CFAE) areas within low voltage zones identified by high-resolution mapping in addition to the PVI.Methods: We randomized 50 patients (mean age 58.4 ± 9.5 years old, 86.0% males) with persistent AF to a PVI + CFAE group and PVI only group in a 1:1 ratio. CFAE and voltage mapping was performed simultaneously using a Pentaray Catheter with the CARTO3 CONFIDENSE module (Biosense Webster, CA, USA). The PVI + CFAE group, in addition to the PVI, underwent ablation targeting low voltage areas (<0.5 mV during AF) containing CFAEs.Results: The mean persistent AF duration was 24.0 ± 23.1 months and mean left atrial dimension 4.9 ± 0.5 cm. In the PVI + CFAE group, AF converted to atrial tachycardia (AT) or sinus rhythm in 15 patients (60%) during the procedure. The PVI + CFAE group had a higher 1-year AF free survival (84.0% PVI + CFAE vs 44.0 PVI only, P = .006) without antiarrhythmic drugs. However, there was no difference in the AF/AT free survival (60.0% PVI + CFAE vs 40.0% PVI only, P = .329). Conclusion:Persistent AF ablation targeting CFAE areas within low voltage zones using high-density voltage mapping had a higher AF free survival than a PVI only. Although recurrence with AT was frequent in the PVI+CFAE group, the sinus rhythm maintenance rate after redo procedures was 76%. Abbreviations: AF = atrial fibrillation, AT = atrial tachycardia, CFAE = complex fractionated atrial electrogram, CTI = cavotricuspid isthmus, ECG = electrocardiogram, ICL = interval confidence level, LA = left atrium, PeAF = persistent AF, PVI = pulmonary vein isolation, RA = right atrium, SCI = shortest complex interval.

Efficacy of left atrial low-voltage area-guided catheter ablation of atrial fibrillation: An updated systematic review and meta-analysis

“…After screening, 52 studies were identified as potentially relevant, and their full-text manuscripts were carefully reviewed for possible inclusion. Finally, 16 articles fulfilled the inclusion criteria and were analyzed in our meta-analysis ( 9 , 13 – 15 , 21 – 32 ) ( Supplementary Figure 1 ).…”

“…Overall, 1942 patients (mean age of 61 ± 10 years, 69% male) from 16 studies [six RCT ( 13 , 15 , 21 , 28 – 30 ), three prospective studies ( 9 , 23 , 26 ), and seven retrospective studies ( 14 , 22 , 24 , 25 , 27 , 31 , 32 )] were identified. The sample sizes ranged from 50 to 229, and the mean duration of follow-up was 18.9 months, ranging from 9.3 to 48 months.…”

“…In this context, in Rolf et al initially proposed LVA-guided ablation as an atrial substrate modification approach ( 9 ). To date, numerous studies have investigated the feasibility and effectiveness of LVA-guided substrate modification in AF ablation given the theoretical and practical rationality ( 13 – 15 ). However, their results were surprisingly conflicting.…”

“…The endpoint of LVA ablation was defined as the absence of local electrical potential using high output pacing at the ablation site or elimination of the local potentials. Total procedural time was reported in 14 studies(9,13,15,21,(23)(24)(25)(26)(27)(28)(29)(30)(31)(32), and there were no statistically significant differences between the LAV ablation group and the control group (194.24 min vs. 189.26 min,…”

Percutaneous Treatment Approaches in Atrial Fibrillation: Current Landscape and Future Perspectives

“…Complex-fractionated atrial electrograms (CFAEs) are electrograms with highly fractionated potentials or with a very short cycle length (<120 ms), which represent potential AF substrate sites requiring ablation. The combination of CFAE ablation with high-density voltage mapping resulted in higher rates of freedom from AF compared to PVI alone [ 110 ]. Further documentation of CFAE ablation efficacy was present in another study, where the combination of PVI, CFAE, and linear ablation resulted in a greater freedom from atrial arrhythmia in comparison to sole PVI (HR 1.56, 95% CI 1.04–2.34) [ 111 ].…”