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

Abstract

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.)

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?

“…However, Hunter et al think that CFAE ablation is not merely debulking the atria and have proposed that grading CFAEs according to the degree of fractionation may be of importance, as not all CFAEs seem to play the same role in AF perpetuation. 30 The results of that study, and the recent SELECT-AF trial, 33 seem to show that selectively targeting areas of complex continuous fractionated electrograms may impact positively AF ablation results in the acute and midterm setting. However, this technique requires further investigation and confirmation from large randomized studies, especially in light of the results of this meta-analysis.…”

Indices of bipolar complex fractionated atrial electrograms correlate poorly with each other and atrial fibrillation substrate complexity

“…Interestingly, a recent multicenter randomized trial (SELECT-AF) demonstrated that adjuvant CFAE ablation guided by ICL yielded better outcome than did selective CEA ablation. 26 Taken together, it is likely that electrophysiologists have been targeting different "substrate" sites when guided by different bipolar algorithms, resulting in variable outcomes.…”

Mechanisms of Atrial Fibrillation – Reentry, Rotors and Reality

“…74 As of yet, there are no clinical trial data to suggest that specific types of CFAEs are especially critical to the pathogenesis or maintenance of AF, or that targeting specific types of CFAEs can improve outcomes after catheter ablation.…”