Key result
Adding CFAE ablation to CPVI and linear ablation fails to reduce clinical recurrence in L-PeAF.
Why the study?
Does additional CFAE-guided ablation after CPVI and linear ablation reduce clinical recurrence in patients with long-standing persistent atrial fibrillation?
RCT (n=137)
Does additional CFAE-guided ablation after CPVI and linear ablation reduce clinical recurrence in patients with long-standing persistent atrial fibrillation?
Absolute Event Rate: 32.1% vs 18.5%
p-value: p=0.166
Additional CFAE-guided ablation after CPVI and linear ablation does not improve clinical outcomes or reduce recurrence in patients with long-standing persistent atrial fibrillation.
Additional CFAE ablation does not reduce recurrence in L-PeAF; challenges its routine addition to CPVI and linear ablation.
BACKGROUND: Although circumferential pulmonary vein isolation (CPVI) catheter ablation may not be sufficient for long-standing persistent atrial fibrillation (L-PeAF), it is not clear which ablation strategy is beneficial in addition to CPVI. We sought to investigate whether additional complex fractionated atrial electrogram (CFAE)-guided ablation improves clinical outcomes in L-PeAF patients who exhibit continuous atrial fibrillation (AF) after CPVI and linear ablation (Line). METHODS AND RESULTS: This study enrolled 137 L-PeAF patients (71.4% male, 61.6±10.9 years old) who underwent radiofrequency catheter ablation. We conducted CPVI+Line based on the Dallas lesion set (posterior box+anterior line) after baseline CFAE mapping in all patients. If AF was defragmented (terminated or changed to atrial tachycardia), the procedure was stopped (AF-Defrag group, n=29). If AF was maintained after CPVI+Line, we mapped the CFAE again and randomly assigned the patient to the CPVI+Line group (n=54) or the additional CFAE ablation group (CPVI+Line+CFAE group, n=54). L-PeAF was defragmented during CPVI+Line in 21.2% of patients (29/137, AF-Defrag group). The mean CFAE cycle length was prolonged (P<0.001), and CFAE area (CFAE cycle length <120 milliseconds) was reduced (P<0.001) after CPVI+Line in the remaining patients. Procedure time was longer in the CPVI+Line+CFAE group than the CPVI+Line group (P=0.023), but procedure-related complication rates did not vary. During 22.3±13.2 months of follow-up, the clinical recurrence rates were 17.2% in the AF-Defrag group, 18.5% in the CPVI+Line group, and 32.1% in the CPVI+Line+CFAE group (log rank, P=0.166). CONCLUSIONS: Although CPVI+Line reduces and localizes CFAE area, additional CFAE ablation after CPVI+Line does not improve the clinical outcomes of catheter ablation in patients with L-PeAF.
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Kim et al. (2017) conducted an RCT in Long-standing persistent atrial fibrillation (L-PeAF) (n=137). Additional complex fractionated atrial electrogram (CFAE) ablation vs. Circumferential pulmonary vein isolation (CPVI) and linear ablation alone was evaluated on Clinical recurrence (p=0.166). Additional CFAE ablation after CPVI and linear ablation did not reduce clinical recurrence compared to CPVI and linear ablation alone in L-PeAF patients (32.1% vs 18.5%, P=0.166).
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