title: Identifying the relationship between the non-PV triggers and the critical CFAE sites post-PVAI to curtail the extent of atrial ablation in longstanding persistent AF.
abstract: BACKGROUND
  Complex fractionated atrial electrograms (CFAE) ablation has been performed in addition to pulmonary veins (PV) isolation to increase the success rate of atrial fibrillation (AF) ablation in patients with longstanding (LS) persistent AF. The mechanism underlying the clinical benefit of CFAE ablation remains, however, poorly understood.
  
  
  OBJECTIVE
  We compared the impact of CFAE ablation on the prevalence of non-PV atrial triggers inducing AF in 2 groups of patients with LS persistent AF. One group underwent PVAI alone, and the other group underwent PVAI plus CFAE ablation. In addition, we correlated the site of non-PV triggers with the presence of CFAE.
  
  
  METHODS
  A total of 98 consecutive patients with symptomatic drug refractory LS persistent AF presenting for ablation had a preablation electroanatomic CFAE map. Patients randomized to either isolation of the PVs and posterior wall (PVAI) (group I, n = 48 pts) or PVAI and biatrial ablation of CFAEs (group II, 50 pts). After ablation, infusion of isoproterenol up to 30 mcg/min was given to reveal non PV foci inducing AF. Those foci were mapped and correlated with CFAE regions and ablated.
  
  
  RESULTS
  A total of 19 patients (76%) with PV foci inducing AF were associated with either stable or transient CFAE after PVAI, respectively, in 12 patients (48%) and 7 patients (28%). A total of 20 (42%) non-PV triggers were observed in group I versus 5 (10%) in group II (P < 0.001) in 18 and 5 patients, respectively. After a mean f/u of 17.2 ± 5.2 months, 33 (69%) patients in group I and 36 (72%) patients in group II were in SR (P = NS).
  
  
  CONCLUSIONS
  Non-PV triggers inducing AF post-PVAI were associated with the presence of stable or transient CFAE in 48% and 28% of cases, respectively, in LS persistent AF. CFAE ablation after PVAI was associated with a significantly higher elimination of those non-PV triggers. This suggests that at least part of the beneficial effect achieved by CFAE ablation reflects elimination of non-PV AF triggers.
authors.affiliation: University of Kentucky, Lexington, Kentucky, USA.
authors.forename: Claude S
authors.initials: CS
authors.lastname: Elayi
authors.forename: Luigi
authors.initials: L
authors.lastname: DI Biase
authors.forename: Rong
authors.initials: R
authors.lastname: Bai
authors.forename: J David
authors.initials: JD
authors.lastname: Burkhardt
authors.forename: Prasant
authors.initials: P
authors.lastname: Mohanty
authors.forename: Javier
authors.initials: J
authors.lastname: Sanchez
authors.forename: Pasquale
authors.initials: P
authors.lastname: Santangeli
authors.forename: Richard
authors.initials: R
authors.lastname: Hongo
authors.forename: G Joseph
authors.initials: GJ
authors.lastname: Gallinghouse
authors.forename: Rodney
authors.initials: R
authors.lastname: Horton
authors.forename: Shane
authors.initials: S
authors.lastname: Bailey
authors.forename: Jason
authors.initials: J
authors.lastname: Zagrodzky
authors.forename: Salwa
authors.initials: S
authors.lastname: Beheiry
authors.forename: Andrea
authors.initials: A
authors.lastname: Natale
mesh_terms: D000318:Adrenergic beta-Agonists; D000368:Aged; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D017115:Catheter Ablation; D016009:Chi-Square Distribution; D004351:Drug Resistance; D022062:Electrophysiologic Techniques, Cardiac; D005260:Female; D006329:Heart Conduction System / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D007545:Isoproterenol; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011667:Pulmonary Veins / Q000503:physiopathology / Q000601:surgery*; D012008:Recurrence; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000318:Adrenergic beta-Agonists; D000889:Anti-Arrhythmia Agents; D007545:Isoproterenol