Does Electrogram Guided Substrate Ablation Add to the Success of Pulmonary Vein Isolation in Patients with Paroxysmal Atrial Fibrillation? A Prospective, Randomized Study

Deisenhofer, Isabel; Estner, Heidi; Reents, Tilko; Fichtner, Stephanie; Bauer, Axel; Wu, Jinjin; Kolb, Christof; Zrenner, Bernhard; Schmitt, Claus; Hessling, Gabriele

doi:10.1111/j.1540-8167.2008.01379.x

Cited by 68 publications

(60 citation statements)

References 31 publications

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“…7,[15][16][17][18][19][20][21] A careful review of their reference list provided 4 more entries that were selected after revision of the full text. [22][23][24][25] Manual searches also provided 1 last entry, a randomized controlled trial recently published in a Hot-Line Session at a major cardiovascular meeting. 8 The selection process is illustrated in Figure 1.…”

Section: Search Resultsmentioning

confidence: 99%

“…Some studies used automatic algorithms incorporated into 3-dimensional mapping systems, 7,8,16,18,20,24 whereas others relied on operator-guided analysis of electrograms. 15,17,19,[21][22][23]25 Data about outpatient treatment, relapse definition, and follow-up in the different studies are shown in Table 3. Mean follow-up duration was >12 months in the majority of studies.…”

Section: What Is Knownmentioning

confidence: 99%

“…7,8,17,[19][20][21][22][23][24] Of the 5 multicenter trials, 7,8,16,17,22 only 1 16 was nonrandomized. Quality assessment of the included studies is shown in Table I in the Data Supplement.…”

Section: What Is Knownmentioning

confidence: 99%

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Is There Still a Role for Complex Fractionated Atrial Electrogram Ablation in Addition to Pulmonary Vein Isolation in Patients With Paroxysmal and Persistent Atrial Fibrillation?

Providência

Lambiase

Srinivasan

et al. 2015

Circ: Arrhythmia and Electrophysiology

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Background-Ablation of complex fractionated atrial electrograms (CFAEs) has been proposed as a strategy to improve outcomes in atrial fibrillation (AF) catheter ablation, but the use of this technique remains contentious. We aimed to assess the impact of CFAE ablation in addition to pulmonary vein isolation (PVI) in patients undergoing ablation for AF. Methods and Results-We performed a random effects meta-analysis of studies comparing PVI versus PVI+CFAE ablation.The outcomes of freedom from AF/atrial tachycardia after 1 or several ablation procedures and acute procedural-related complications were assessed. Studies were searched on MEDLINE, EMBASE, COCHRANE, and clinicaltrials.gov, and sensitivity analyses were performed. Thirteen studies including a total of 1415 patients were considered eligible.

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Section: Search Resultsmentioning

confidence: 99%

Section: What Is Knownmentioning

confidence: 99%

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Is There Still a Role for Complex Fractionated Atrial Electrogram Ablation in Addition to Pulmonary Vein Isolation in Patients With Paroxysmal and Persistent Atrial Fibrillation?

Providência

Lambiase

Srinivasan

et al. 2015

Circ: Arrhythmia and Electrophysiology

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“…It has been further proposed that these fractionated sites are important in sustaining AF, 53 and that targeting fractionated electrograms with ablation can terminate AF and prevent its re-induction or recurrence. 52,[54][55][56][57][58][59][60] The data supporting these conclusions are rather weak overall, with only a few small, randomised clinical trials providing guidance, and different studies have arrived at disparate conclusions regarding the importance, or lack thereof, of fractionated electrograms in the pathogenesis of AF.…”

Section: Limitations Of Targeting Rotors With Ablation For the Treatmmentioning

confidence: 96%

Mechanisms of Atrial Fibrillation – Reentry, Rotors and Reality

Waks

Josephson²

2014

Arrhythmia &Amp; Electrophysiology Review

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Atrial fibrillation (AF), the most common sustained arrhythmia, is a leading cause of stroke, and is associated with significant morbidity and mortality worldwide. Despite its frequency, clinical importance, and advances in technology and our knowledge of the molecular, ionic and physiological fundamentals of cardiac electrophysiology, our limited understanding of the mechanisms that initiate and sustain AF has prevented us from being able to truly cure this arrhythmia with antiarrhythmic drugs and/or ablation. This contrasts with other arrhythmias, such as AV nodal tachycardia or circus movement tachycardia using an accessory pathway, which have well-defined mechanisms and circuits that can be safely targeted with high rates of cure. The observations that AF may have different mechanisms in different patients, and that paroxysmal, persistent and permanent forms of AF may differ in how they are initiated and sustained, only serves to reinforce our lack of understanding of this ubiquitous arrhythmia. Historical Mechanisms of Atrial Fibrillation and the Multiple Wavelet HypothesisInterest and understanding of the mechanism of AF began to take form in the early 1900s. Given the chaotic and irregular nature of AF on the surface electrocardiogram, rapid firing of automatic atrial foci was considered a potential mechanism. However, after the seminal work of Mayer 1 , Mines 2 and Garrey 3 in laying the foundation for describing and understanding reentrant arrhythmias, atrial reentrant circuits emerged as the likely drivers of AF.4-7 Although these theories were conceptually sound, it was impossible to prove a specific mechanism with the technology of the time. Moe et al. demonstrated that it was probabilistically unlikely that a large number of simultaneous wavefronts would all die out simultaneously, and AF would therefore perpetuate. However, if the number of simultaneous wavelets were small and/or below a critical value (between 15 and 30 in Moe's computer model), 9 at some point all reentrant wavefronts would be simultaneously extinguished, and AF would therefore terminate. 8,9 Allessie et al. provided experimental evidence supporting this mechanism in a canine heart model of AF where four to six simultaneous reentrant wavelets were needed to sustain arrhythmia. 10 Further evidence supporting multiple wavelets in AF was demonstrated in a separate model, which evaluated the effect of various antiarrhythmic drugs on canine myocardium. This model demonstrated that termination of AF was associated with a reduction AbstractAtrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice, yet our understanding of the mechanisms that initiate and sustain this arrhythmia remains quite poor. Over the last 50 years, various mechanisms of AF have been proposed, yet none has been consistently observed in both experimental studies and in humans. Recently, there has been increasing interest in understanding how spiral waves or rotors -which are specific, organised forms of functional reentry -su...

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“…Full text assessment of the 10 potentially relevant articles resulted in 7 eligible controlled studies ( Figure 1). The reasons for exclusion were as follows: CFAEs ablation was used as a stand-alone strategy for AF ablation 11 ; data of sinus rhythm maintenance after 1 ablation procedure was not offered 12 ; the sites of additional CFAE ablation formed lines along the left atrial septum, roof, posterior mitral annulus, and/or anterior wall, therefore the CFAE ablation was in fact linear ablation procedure. 13 Eventually, 7 trials with a total of 662 subjects were included in the meta-analysis.…”

Section: Search Resultsmentioning

confidence: 99%

Additional Ablation of Complex Fractionated Atrial Electrograms After Pulmonary Vein Isolation in Patients With Atrial Fibrillation

Yang

Zhang

et al. 2011

Circ: Arrhythmia and Electrophysiology

122

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Background-The efficacy of additional complex fractionated atrial electrogram (CFAE) ablation after pulmonary vein antrum isolation (PVAI) in patients with atrial fibrillation (AF) remains controversial. This meta-analysis was performed to assess the additional efficacy of CFAEs ablation after a single procedure without antiarrhythmic drugs. Methods and Results-Trials were identified in MEDLINE, Cochrane Library, Embase, Google Scholar, reviews, and reference lists of relevant papers. Controlled cohort studies comparing the long-term efficacy of combined CFAEs plus PVAI ablation with PVAI alone were included. The primary end point was the maintenance of sinus rhythm without antiarrhythmic drugs. Seven controlled trials (9 comparisons) with a total of 622 participants (332 patients underwent PVAI plus CFAE ablation and 330 patients underwent PVAI alone) were included in the meta-analysis. In an overall pooled estimate, compared with PVI alone, long-term rates of sinus rhythm maintenance (relative risk, 1.17, 95% confidence interval, 1.03 to 1.33, Pϭ0.019) were increased by additional CFAE ablation. Subgroup analysis demonstrated that additional CFAEs ablation increased rates of sinus rhythm maintenance in nonparoxysmal AF (relative risk, 1.35; 95% confidence interval, 1.04 to 1.75; Pϭ0.022), whereas had no effect on patients with paroxysmal AF (relative risk, 1.04; 95% confidence interval, 0.92 to 1.18; Pϭ0.528). Conclusions-Adjuvant CFAE ablation in addition to standard PVAI increases the rate of long-term sinus rhythm maintenance in nonparoxysmal AF patients after a single procedure without antiarrhythmic drugs but does not provide additional benefit to sinus rhythm maintenance in paroxysmal AF patients. (Circ Arrhythm Electrophysiol. 2011;4:143-148.)

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Does Electrogram Guided Substrate Ablation Add to the Success of Pulmonary Vein Isolation in Patients with Paroxysmal Atrial Fibrillation? A Prospective, Randomized Study

Abstract: In the intention-to-treat analysis, additional CFAE ablation did not improve the success rate of PVI in patients with paroxysmal AF. However, during long-term follow-up, patients with still inducible AF after PVI seemed to profit from additional CFAE ablation.

Cited by 68 publications

References 31 publications

Is There Still a Role for Complex Fractionated Atrial Electrogram Ablation in Addition to Pulmonary Vein Isolation in Patients With Paroxysmal and Persistent Atrial Fibrillation?

Is There Still a Role for Complex Fractionated Atrial Electrogram Ablation in Addition to Pulmonary Vein Isolation in Patients With Paroxysmal and Persistent Atrial Fibrillation?

Mechanisms of Atrial Fibrillation – Reentry, Rotors and Reality

Additional Ablation of Complex Fractionated Atrial Electrograms After Pulmonary Vein Isolation in Patients With Atrial Fibrillation

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