title: Does electrogram guided substrate ablation add to the success of pulmonary vein isolation in patients with paroxysmal atrial fibrillation? A prospective, randomized study.
abstract: BACKGROUND
  Pulmonary vein isolation (PVI) is an established treatment for paroxysmal atrial fibrillation (AF). The ablation of complex fractionated atrial electrograms (CFAE) has emerged as a novel treatment approach. We sought to evaluate the additional effect of CFAE ablation to PVI in paroxysmal AF.
  
  
  RESULTS
  Ninety-eight patients with paroxysmal AF (57 +/- 10 years, 74 male) were randomized to the PVI (n = 48) or PVI + CFAE group (n = 50). After PVI, CFAE ablation was performed in patients with inducible AF in the PVI + CFAE group. The primary endpoint was combined objective (7-day Holter ECG) and subjective (symptoms) freedom of atrial tachyarrhythmia 3 months after ablation. Long-term follow-up (19 +/- 8 months) was available in 94 of 98 patients. CFAE ablation was performed in 30 of 50 patients of the PVI + CFAE group. After 3 months, 36 of 48 patients (75%) in the PVI group and 38 of 50 patients (76%) in the PVI + CFAE group were in stable sinus rhythm (P = NS). During long-term follow-up (19 +/- 8 months), 34 of 46 patients (74%) in the PVI group and 40 of 48 patients (83%) in the PVI + CFAE group were in sinus rhythm (P = 0.08). In a subgroup analysis, a significantly better long-term outcome was achieved if inducible AF after PVI had been treated by additional CFAE ablation as compared with PVI only (sinus rhythm in 25/28 patients; 89% vs 22/30 patients 73%; P = 0.003).
  
  
  CONCLUSIONS
  In the intention-to-treat analysis, additional CFAE ablation did not improve the success rate of PVI in patients with paroxysmal AF. However, during long-term follow-up, patients with still inducible AF after PVI seemed to profit from additional CFAE ablation.
authors.affiliation: Deutsches Herzzentrum München and 1. Medizinische Klinik, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany. deisenhofer@dhm.mhn.de
authors.forename: Isabel
authors.initials: I
authors.lastname: Deisenhofer
authors.forename: Heidi
authors.initials: H
authors.lastname: Estner
authors.forename: Tilko
authors.initials: T
authors.lastname: Reents
authors.forename: Stephanie
authors.initials: S
authors.lastname: Fichtner
authors.forename: Axel
authors.initials: A
authors.lastname: Bauer
authors.forename: Jinjin
authors.initials: J
authors.lastname: Wu
authors.forename: Christof
authors.initials: C
authors.lastname: Kolb
authors.forename: Bernhard
authors.initials: B
authors.lastname: Zrenner
authors.forename: Claus
authors.initials: C
authors.lastname: Schmitt
authors.forename: Gabriele
authors.initials: G
authors.lastname: Hessling
mesh_terms: D001281:Atrial Fibrillation / Q000175:diagnosis* / Q000601:surgery*; D018780:Body Surface Potential Mapping / Q000379:methods*; D005260:Female; D006329:Heart Conduction System / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011667:Pulmonary Veins / Q000601:surgery*; D012680:Sensitivity and Specificity; D025321:Surgery, Computer-Assisted / Q000379:methods*; D016896:Treatment Outcome