Benefits and risks of additional ablation of complex fractionated atrial electrograms for patients with atrial fibrillation: A systematic review and meta-analysis

Wu, Shaohui; Jiang, Weifeng; Gu, Jun; Zhao, Liang; Wang, Yuanlong; Liu, Yugang; Zhou, Li; Gu, Jun; Xu, Kai; Liu, Xu

doi:10.1016/j.ijcard.2013.08.083

Cited by 45 publications

(38 citation statements)

References 24 publications

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“…By forming islands of noncontiguous lesions, extensive CFAE ablation may create areas of slow conduction within the LA, leading to a wider excitable gap and predisposing to macro-re-entrant flutter in the presence of gaps in lines, thereby increasing the proarrhythmic potential (26% versus 3%; P=0.03). 32 Using the Bordeaux stepwise approach, the incidence of postablation AT was ≈50%. 29 A recent metaanalysis identified adjunctive CFAE ablation as a risk for factor for postablation ATs (risk ratio, 1.77).…”

Section: Conventional Cfae Ablation Predisposes To Gaprelated Fluttermentioning

confidence: 99%

“…29 A recent metaanalysis identified adjunctive CFAE ablation as a risk for factor for postablation ATs (risk ratio, 1.77). 32 Successful CFAE ablation is based on the assumption that the fractionated electrograms represent fixed anatomic areas that are critical to the maintenance of AF. Identifying these areas remains challenging, and it is only recently that more sophisticated mapping technologies to perform phase mapping show promise.…”

Section: Conventional Cfae Ablation Predisposes To Gaprelated Fluttermentioning

confidence: 99%

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No Benefit of Complex Fractionated Atrial Electrogram Ablation in Addition to Circumferential Pulmonary Vein Ablation and Linear Ablation

Wong

Paisey

Sopher

et al. 2015

Circ: Arrhythmia and Electrophysiology

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Background— The optimal ablation strategy for persistent atrial fibrillation (AF) remains unclear. Methods and Results— This multicentre randomized study compared circumferential pulmonary vein ablation+linear ablation (control arm) versus circumferential pulmonary vein ablation+linear ablation+complex fractionated atrial electrogram (CFAE) ablation (CFAE arm) in patients with persistent AF. Circumferential pulmonary vein ablation was performed followed by roof and mitral isthmus ablation, before CFAE ablation in the CFAE arm. Ablation strategy was maintained at the first redo procedure. Sixty-five patients were recruited in each arm. The mean age was 61±10 years, 75% were men, median AF duration was 2 years, 42% had long-lasting persistent AF, 68% had associated cardiovascular disease, mean left atrial dimension was 46±6 mm, and median CHA 2 DS 2 -VASc score was 2. Ablation and procedure times were significantly longer in the CFAE arm (70±20 versus 55±17; 201±35 versus 152±45 minutes; P <0.005). After a mean follow-up of 35±5 months, single-procedural success off antiarrhythmic drugs at 12 months (CFAE: 30/65 [46%] versus control: 37/65 [57%]; P =0.29) and multiprocedural success (CFAE: 51/65 [78%] versus control: 52/65 [80%]; P =1.0) were not significantly different. At the first redo procedure, patients in the CFAE arm had a higher incidence of organized atrial tachycardia/flutter (24/33 [73%] versus 11/31 [35%]; P =0.005) and gap-related macro–re-entrant flutter (8/33[24%] versus 1/31[3%]; P =0.03). Early recurrence of atrial arrhythmia was an independent predictor of late recurrence. Conclusions— CFAE ablation did not confer incremental benefit when performed in addition to circumferential pulmonary vein ablation and linear ablation. It was associated with a higher incidence of gap-related flutter. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01711047.

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Section: Conventional Cfae Ablation Predisposes To Gaprelated Fluttermentioning

confidence: 99%

Section: Conventional Cfae Ablation Predisposes To Gaprelated Fluttermentioning

confidence: 99%

No Benefit of Complex Fractionated Atrial Electrogram Ablation in Addition to Circumferential Pulmonary Vein Ablation and Linear Ablation

Wong

Paisey

Sopher

et al. 2015

Circ: Arrhythmia and Electrophysiology

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“…Equally, adjuvant complex fractionated atrial electrogram (CFAE) ablation in addition to standard PVI did not improve outcome in patients with paroxysmal atrial fibrillation [15]. On the contrary, procedure times and fluoroscopy times as well as the risk of adverse atrial tachycardias increased [16]. Also, in repeat procedures for paroxysmal atrial fibrillation, no benefit was shown if additional linear ablation was performed after re-isolation of the PVs [17].…”

Section: Paroxysmal Atrial Fibrillation: Pulmonary Vein Isolation Only?mentioning

confidence: 99%

“…The results of some but not all studies suggested better outcome of adjuvant CFAE ablation in addition to PVI [6,15,16]. Yet, the risk of postablation atrial tachycardias was increased as well as procedure duration, fluoroscopy times and radiofrequency application times [6,16]. CFAE ablation alone seems to be an inadequate strategy [6].…”

Section: Persistent Atrial Fibrillation: Is Atrial Substrate Modificamentioning

confidence: 99%

What have we learned of ablation procedures for atrial fibrillation?

Maurer

Tilz

et al. 2016

J Intern Med

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“…Substrate modification by additional CFAE ablation is controversial in paroxysmal AF. Wu's systematic review and meta-analysis including 11 trials (seven RCTs and four MCTs) showed that adjunctive CFAE ablation conferred additional benefit for non-paroxysmal AF but not for paroxysmal AF after a single procedure, with an increased rate of untraceable AT post-procedure [61]. The RCTs in the above meta-analyses, including that of Oral [25], excluded some patients who did not have inducible AF after CPVI plus linear ablation in the posterior LA and mitral isthmus.…”

Section: Comparison With Previous Researches and Meta-analysesmentioning

confidence: 99%

A decade of complex fractionated electrograms catheter-based ablation for atrial fibrillation: Literature analysis, meta-analysis and systematic review

Chen

Lin

Chen

et al. 2014

IJC Heart & Vessels

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Background: It has been a decade since the complex fractionated atrial electrograms (CFAEs) were first established following the publication of Nademanee's standards. However, the status and focus of CFAE research are unclear, as is the efficacy of additional CFAE ablation in atrial fibrillation (AF). This literature review and metaanalysis were designed to determine the status of CFAE research and the efficacy and complications of CFAE ablation alone, pulmonary vein isolation (PVI) alone and PVI plus CFAE ablation in AF. Methods: With the assistance from reference librarians and investigators trained in systematic review, we conducted a literature search of MEDLINE (via PubMed), Embase, the Cochrane Library, ScienceDirect, Wiley Blackwell and Web of Knowledge, using "complex fractionated atrial electrograms" for MeSH and keyword search. Results: The literature on CFAEs increased from 2007, mainly focusing on mapping studies, with mechanism studies increasing significantly from 2012. Fifteen trials with 1525 patients were qualified for our meta-analysis. Success rates were as follows. Overall (P b 0.001): CFAE ablation alone, 23.5-26.2%; PVI, 64.7%; PVI plus CFAE ablation, 67.0%. Single ablation: PVI, 60.4%; PVI plus CFAEs, 68.8% (OR 1.53, 95% CI 1.07-2.20, P = 0.02). Reablation: PVI, 69.0%; PVI plus CFAEs, 77.2% (OR 1.54, 95% CI 1.06-2.24, P = 0.02). Paroxysmal AF: PVI, 76.7%; PVI plus CFAEs, 79.1% (OR 1.20, 95% CI 0.79-1.81, P = 0.39). Persistent or permanent AF: PVI, 47.9%; PVI plus CFAEs, 58.7% (OR = 1.59, 95% CI 1.13-2.24, P = 0.008). Complication rates: PVI, 2.6%; PVI plus CFAEs, 3.4% (OR 1.22, 95% CI 0.58-2.57, P = 0.61). Conclusions: In the literature, CFAE mapping studies preceded mechanism studies. CFAE ablation alone is insufficient for the treatment of AF. Additional CFAE ablation after adequate PVI or PVI plus linear ablation improves the outcome of single ablation and re-ablation without increasing complications, especially in persistent or permanent AF. There are insufficient data to support a similar improvement in paroxysmal AF or inducible AF after PVI for paroxysmal AF.

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Benefits and risks of additional ablation of complex fractionated atrial electrograms for patients with atrial fibrillation: A systematic review and meta-analysis

Cited by 45 publications

References 24 publications

No Benefit of Complex Fractionated Atrial Electrogram Ablation in Addition to Circumferential Pulmonary Vein Ablation and Linear Ablation

No Benefit of Complex Fractionated Atrial Electrogram Ablation in Addition to Circumferential Pulmonary Vein Ablation and Linear Ablation

What have we learned of ablation procedures for atrial fibrillation?

A decade of complex fractionated electrograms catheter-based ablation for atrial fibrillation: Literature analysis, meta-analysis and systematic review

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