Effect of pulmonary vein isolation on the distribution of complex fractionated electrograms in humans

Roux, Jean François; Gojraty, Sattar; Bala, Rupa; Liu, Christopher F.; Dixit, Sanjay; Hutchinson, Mathew D.; García, Fermin C.; Lin, David; Callans, David J.; Riley, Michael P.; Marchlinski, Francis E.; Gerstenfeld, Edward P.

doi:10.1016/j.hrthm.2008.10.046

Cited by 60 publications

(71 citation statements)

References 19 publications

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“…As mentioned above, evidence has shown that the size of CFAE regions may be decreased after PVI. 20 Thus, the total amount of CFAE ablation time may have been reduced in group I had PVI been performed first. Presumably, the size of CEA areas may also have been reduced post-PVI as well, so the relative difference in ablation time may have remained constant.…”

Section: Study Limitationsmentioning

confidence: 99%

“…Performing PV antral isolation before CFAE ablation has been shown to reduce the total amount of CFAE, thus performing PV isolation first may eliminate some unimportant CFAE sites. 20 Some have proposed administration of intravenous antiarrhythmics as a way of organizing passively activated areas while highlighting critical regions of CFAE. 21 Others have proposed targeting overlapping ; however, the role of dominant frequency in AF ablation remains unsettled.…”

Section: Selective Versus Generalized Cfae Regionsmentioning

confidence: 99%

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Selective Complex Fractionated Atrial Electrograms Targeting for Atrial Fibrillation Study (SELECT AF)

Verma

Sanders

Champagne

et al. 2014

Circ: Arrhythmia and Electrophysiology

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Background-This study compared generalized complex fractionated atrial electrograms (CFAE) ablation versus a selective CFAE ablation strategy targeting areas of continuous electric activity. Methods and Results-Subjects with symptomatic, persistent/high-burden paroxysmal atrial fibrillation (AF) were enrolled at 6 centers (n=86) and randomized to 1 of 2 arms. For group I, all CFAE regions with an interval confidence level >7 were ablated followed by pulmonary vein isolation (PVI). For group II, only CFAE sites with continuous electric activity were ablated followed by PVI. For PVI, all 4 PV antra were isolated with confirmed entrance block. Subjects were followed for 1 year with a visit, ECG, and 48-hour Holter every 3 months. Symptoms were confirmed by loop recording. The primary end point was freedom from arrhythmia >30 seconds at 1 year. For both group I and II, CFAE ablation prolonged AF cycle length (25±33 versus 23±33 ms; P=0.78) and resulted in similar rates of AF termination (37% versus 28%; P=0.42). Radiofrequency duration during CFAE ablation was significantly less in group II (23±20 versus 38±20 minutes; P=0.002). At 1-year follow-up, freedom from AF/atrial flutter/atrial tachycardia recurrence was significantly higher in group I versus group II after 1 procedure (50% versus 28%; P=0.03). There were also significantly fewer repeat procedures in group I (13% versus 36%; P=0.021). Conclusions-Continuous electric activity ablation+PVI result in a similar incidence of acute AF termination with significantly less radiofrequency time. However, incidence of repeat procedures and long-term recurrence of AF/atrial flutter/atrial tachycardia are significantly lower using generalized CFAE ablation+PVI. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00926783 (Circ Arrhythm Electrophysiol. 2014;7:55-62.)

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Section: Study Limitationsmentioning

confidence: 99%

Section: Selective Versus Generalized Cfae Regionsmentioning

confidence: 99%

Selective Complex Fractionated Atrial Electrograms Targeting for Atrial Fibrillation Study (SELECT AF)

Verma

Sanders

Champagne

et al. 2014

Circ: Arrhythmia and Electrophysiology

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“…[90][91][92] Extensive ablation of atrial substrate may result in prolonged procedures, however, and increased risk of complications. 93,94 Moreover, while fractionation may be recorded close to the core of an AF-perpetuating rotor, it may also be recorded at sites not actively participating in the AF process, did not reduce AF recurrence after PVI in patients with persistent AF. 34 These negative results could be explained by the amount of ablation that increases the iatrogenic arrhythmia rate.…”

Section: Mechanism Of Actionmentioning

confidence: 99%

Pharmacological Tests in Atrial Fibrillation Ablation

Gourraud

Andrade

Macle

et al. 2016

Arrhythmia &Amp; Electrophysiology Review

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Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia observed in clinical practice, occurring in approximately 2 % of the general population.1-3 A progressive increase in both the prevalence and incidence of AF has been demonstrated in recent years, defining AF as a major economic and public health issue. 1 The identification of sites of AF initiation and/or maintenance within the pulmonary veins (PVs) has led to the development of percutaneous procedures to electrically isolate the PVs from the left atrium (LA). 4 Large observational studies and multiple randomised-controlled trials have demonstrated that catheter ablation is universally superior to anti-arrhythmic drugs (AADs) for the maintenance of sinus rhythm (66-89 % versus 9-58 %, respectively) and results in a greater improvement in arrhythmia-related symptoms, exercise capacity and quality of life.1,2,5-8 As a result, catheter ablation has become the 'standard of care' for the maintenance of sinus rhythm in symptomatic patients in whom drugs are ineffective or poorly tolerated.While the results of ablation are unequivocally superior to medical therapy, they are unfortunately not flawless: approximately 30 % of paroxysmal AF patients will experience arrhythmia recurrence after a single ablation procedure.8 As most recurrences are in association with PV reconnection or as a result of non-PV triggers, several pharmacological challenges have been proposed to improve outcomes. [9][10][11][12] This article reviews the pathophysiological background and evidence for the use of pharmacological challenges during catheter ablation procedures. Pathophysiology of Atrial Fibrillation and Atrial Fibrillation Catheter AblationDespite decades of progress, there is no comprehensive pathophysiological explanation of AF. Early hypotheses postulated that AF resulted from the co-existence of multiple independent wavelets propagating randomly throughout the left and right atria (the 'multiple wavelet hypothesis'). 13,14 This hypothesis suggested that as long as the atria had a sufficient electrical mass, and an adequately short refractory period, AF could be initiated and indefinitely perpetuated. 15 Based on this theory, the early surgical interventions for AF were designed to reduce the excitable mass of atrial tissue by compartmentalising the atria into smaller regions incapable of sustaining a critical number of circulating wavelets. 16 Unfortunately this strategy has proved to be of limited efficacy and has been associated with a substantial risk of major complications. 17In the late 1990s, Haïssaguerre and colleagues demonstrated that AF is a triggered arrhythmia initiated by rapid repetitive discharges, predominantly from the proximal aspect of the PVs. 4 This discovery led to the development of percutaneous procedures to directly eliminate spontaneous focal ectopic activity within the PVs. However, early AF recurrences from the targeted and other nontargeted PVs led to modification of the ablation strategy to electrically isolate all of the PV...

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“…27 Previous studies have shown that CFAE ablation, when used as a stand-alone strategy, results in low sinus rhythm maintenance rate, 11,14,20 indicating that CFAE is not the key maintenance mechanism of nonparoxysmal AF. For example, PVAI results in a significant decrease in both PV and non-PV areas of CFAEs, 28 during catheter ablation of CFAEs, persistent AF may convert to ATs, and spectral component analysis has found that ATs observed during ablation of AF is often drivers of AF that become manifest after elimination of higher-frequency sources and fibrillatory conduction. 29 Studies have indicated that left atrial ATs after PVAI can be due to a macroreentrant or focal mechanism, 30 and approximately 90% of ATs after PVAI are reentrant, and nearly all are related to gaps in prior ablation lines.…”

Section: Et Al Additional Cfae Meta-analysismentioning

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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Effect of pulmonary vein isolation on the distribution of complex fractionated electrograms in humans

Cited by 60 publications

References 19 publications

Selective Complex Fractionated Atrial Electrograms Targeting for Atrial Fibrillation Study (SELECT AF)

Selective Complex Fractionated Atrial Electrograms Targeting for Atrial Fibrillation Study (SELECT AF)

Pharmacological Tests in Atrial Fibrillation Ablation

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

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