Relationship between clinical outcomes and unintentional pulmonary vein isolation during substrate ablation of atrial fibrillation guided solely by complex fractionated atrial electrogram mapping

Abstract

CFAE-ablation terminates AF without isolating PVs in a high percentage of patients, and yields excellent clinical outcomes.

Recent Observations in Mapping of Complex Fractionated Atrial Electrograms in Atrial Fibrillation

“…After 1 year of the follow-up period and only a single procedure, 65% of their patients remained arrhythmia free (11%) with antiarrhythmic drug. Iriki et al's [26] findings are in sharp contrast with those of Dibase et al [25]. The factors underlying the differences in both acute and long-term outcomes between these two studies and ours are more likely to be many which will be discussed later below.…”

“…After a 1-year follow-up period, only 12% of the patients who received CFAE ablation alone were free of recurrent AF/AT with no antiarrhythmic drugs compared to 74% and 76% in the PVI and PVI with CFAE ablation respectively. By contrast Iriki et al [26] reported excellent outcomes in 54 PAF patients who underwent CFAE ablation alone: Conversion of AF to sinus rhythm could be achieved in this study in 98% of the 54 patients during ablation without DC cardioversion; 30% of the patients, however, received Nikefalant (a class III antiarrhythmic drug) meaning that 68% AF terminated by ablation without drug. Furthermore, in the Iriki et al [26] study the investigators also examined whether PVs were isolated and interestingly only 8% of the PV were unintentionally isolated implying that the success of their procedures were not due to isolation of the pulmonary veins.…”

“…By contrast Iriki et al [26] reported excellent outcomes in 54 PAF patients who underwent CFAE ablation alone: Conversion of AF to sinus rhythm could be achieved in this study in 98% of the 54 patients during ablation without DC cardioversion; 30% of the patients, however, received Nikefalant (a class III antiarrhythmic drug) meaning that 68% AF terminated by ablation without drug. Furthermore, in the Iriki et al [26] study the investigators also examined whether PVs were isolated and interestingly only 8% of the PV were unintentionally isolated implying that the success of their procedures were not due to isolation of the pulmonary veins. After 1 year of the follow-up period and only a single procedure, 65% of their patients remained arrhythmia free (11%) with antiarrhythmic drug.…”

“…While Iriki et al's study [26] is comparable to our studies [9,16], it's clear that outcomes of AF ablation by targeting CFAEs as a sole strategy is not easy to replicate. Although it is unclear what the differences are among these studies and ours, one or more of the following key variables may help explain the differences between these studies [33,34]: 1 Right atrial ablation.…”

“…Similar to the Oral study, acute termination of AF to sinus rhythm during ablation procedure is very low in Estner et al's study; only 2 out of the 23 patients (9%) who underwent CFAE ablation alone and 15 out of 54 patients in the CFAE ablation + PVI group (28%) had AF termination during the ablative procedure. In contrast, Iriki et al [26] converted AF to sinus rhythm during ablation procedure without cardioversion in 80% and 55% of the patients with persistent AF (57% with Nikefalant) and long-standing persistent AF (83% with Nikefalant), respectively. After a mean follow-up of 23 months, 54% of persistent and 45% of long-standing persistent AF patients were AF free after one session of the ablative procedure.…”