Key result
Stable CFAE ablation with PVI achieves ~42% 1-year freedom from AF.
Why the study?
Previous studies of high frequency and CFAE ablation in AF produced conflicting results, and significant temporal variability at these sites calls into question the effectiveness of sequential mapping.
Does 64-electrode basket catheter mapping-guided ablation of temporally stable high frequency and CFAE sites combined with intra-procedural intravenous flecainide identify critical AF sites and maintain sinus rhythm at 12 months in patients with persistent atrial fibrillation?
Observational (n=12)
Does 64-electrode basket catheter mapping-guided ablation of temporally stable high frequency and CFAE sites combined with intra-procedural intravenous flecainide identify critical AF sites and maintain sinus rhythm at 12 months in patients with persistent atrial fibrillation?
In persistent AF, 64-electrode basket mapping shows widespread bi-atrial repetitive CFAEs and less frequent high-frequency sites, while IV flecainide reduces CFAE burden without identifying critical ablation targets, yielding a 42% 12-month AF-free rate.
Answers are grounded in this paper and cite their sources.
Targeted ablation plus flecainide does not identify critical sites in persistent AF; leaves open optimal mapping strategies for randomized trials.
Introduction: Previous studies assessing the role of high frequency and complex fractionated atrial electrogram (CFAE) ablation in patients with atrial fibrillation (AF) have produced conflicting results. In addition, both high frequency and CFAE sites have been shown to exhibit significant temporal variability which calls into question the effectiveness of sequential mapping in identifying these sites. The aims of this study were: (1) To investigate the distribution and effectiveness of ablating temporally stable high frequency and highly repetitive CFAE sites in patients with persistent AF using a 64-electrode basket catheter to collect data simultaneously from multiple atrial sites; (2) To assess the utility of intra-procedural flecainide in identifying sites critical to the maintenance of AF. Methods: Twelve consecutive patients (ten longstanding persistent AF; mean age 56 ± 8 years; mean AF duration 21 ± 11 months) undergoing their first ablation procedure for AF were studied. Transverse and longitudinal atrial dimensions were obtained using transthoracic echocardiography two weeks prior to ablation to enable appropriate sizing of the basket catheter. Electroanatomical maps were created using the EnSite Velocity cardiac mapping system. The basket catheter was deployed sequentially in both atria and 1-minute recordings collected from one/two positions in each atrium to ensure satisfactory coverage of the chamber. Separate recordings were collected from the coronary sinus and pulmonary veins. Sites that exhibited high frequency (mean dominant frequency ≥8Hz) and/or highly repetitive complex fractionated activity (interval confidence level ≥120) throughout the recordings were identified. All patients underwent pulmonary vein isolation using wide area circumferential ablation and the eleven who remained in AF received intravenous flecainide (2mg/kg – maximum 150mg). Further recordings from the original basket catheter positions in both atria were collected. High frequency and highly repetitive CFAE sites were ablated and patients who remained in AF after ablation underwent electrical cardioversion. Results: High frequency sites were identified in 4/12 (33%) patients: 32 right atrium (RA) and 31 left atrium (LA). Highly repetitive CFAEs were identified in all 12 patients and were more commonly found in the right (n = 377) compared to the left atrium (n = 296). Flecainide reduced CFAE burden significantly (85% RA; 79% LA). None of the patients cardioverted to sinus rhythm during high frequency or CFAE ablation and five (42%) were free of AF at 12-months. Conclusions: Highly repetitive CFAEs are distributed throughout both atria in persistent AF. High frequency sites (≥8Hz) are less commonly identified. Flecainide significantly reduces CFAE burden but does not help identify critical AF sites. Twelve-month outcome was similar to that reported with other substrate ablation techniques in this patient cohort.
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Raine et al. (2016) conducted an observational in Persistent atrial fibrillation (including 10 with longstanding persistent AF) (n=12). 64-electrode basket catheter mapping, pulmonary vein isolation, intravenous flecainide, and ablation of temporally stable high frequency and highly repetitive CFAE sites was evaluated on Freedom from atrial fibrillation at 12 months. Ablation of temporally stable high-frequency and CFAE sites with PVI resulted in 42% freedom from AF at 12 months, while IV flecainide reduced CFAE burden by 85% (RA) and 79% (LA).
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