title: Impact of biatrial defragmentation in patients with paroxysmal atrial fibrillation: results from a randomized prospective study.
abstract: BACKGROUND
  Single procedure success rates of pulmonary vein isolation (PVI) in patients with paroxysmal atrial fibrillation (PAF) are still unsatisfactory. In patients with persistent atrial fibrillation (AF), ablation of complex fractionated atrial electrograms (CFAEs) after PVI results in improved outcomes.
  
  
  OBJECTIVE
  We aimed to investigate if PAF-patients with intraprocedurally sustained AF after PVI might benefit from additional CFAE ablation.
  
  
  METHODS
  A total of 1134 consecutive patients underwent a first catheter ablation procedure of PAF between June 2008 and December 2012. In most patients, AF was either not inducible or terminated during PVI. In 68 patients (6%), AF sustained after successful PVI. These patients were randomized to either cardioversion (PVI-alone group; n = 33) or additional CFAE ablation (PVI+CFAE group; n = 35) and followed up every 1-3 months and serial Holter recordings were also obtained. The primary end point was the recurrence of AF/atrial tachycardia (AT) after a blanking period of 3 months.
  
  
  RESULTS
  Procedure duration (127 ± 6 minutes vs 174 ± 10 minutes), radiofrequency application time (44 ± 3 minutes vs 74 ± 5 minutes), and fluoroscopy time (26 ± 2 minutes vs 41 ± 3 minutes) were longer in the PVI+CFAE group (all P < .001). In 30 of 35 patients (86%) in the PVI+CFAE group, ablation terminated AF. There was no significant group difference with respect to freedom from AF/AT (22 of 33 [67%] vs 22 of 35 [63%]; P = .66). Subsequently, 10 of 11 patients in the PVI-alone group (91%) and 11 of 13 patients in PVI+CFAE group (85%) underwent repeat ablation (P = 1.00). Overall, 29 of 33 [88%] vs 30 of 35 [86%] patients (P = 1.00) were free from AF/AT after 1.4 ± 0.1 vs 1.4 ± 0.2 (P = .87) procedures.
  
  
  CONCLUSIONS
  Patients with sustained AF after PVI in a PAF cohort are rare. Regarding AF/AT recurrence, these patients did not benefit from further CFAE ablation compared to PVI alone, but are exposed to longer procedure duration, fluoroscopy time, and radiofrequency application time.
authors.affiliation: Department of Electrophysiology, University Heart Center, University Hospital Eppendorf, Hamburg, Germany. Electronic address: j.nuehrich@uke.de.
authors.forename: Jana Mareike
authors.initials: JM
authors.lastname: Nührich
authors.affiliation: Department of Electrophysiology, University Heart Center, University Hospital Eppendorf, Hamburg, Germany.
authors.forename: Daniel
authors.initials: D
authors.lastname: Steven
authors.affiliation: Electrophysiology Bremen, Klinikum Links der Weser, Germany.
authors.forename: Imke
authors.initials: I
authors.lastname: Berner
authors.affiliation: Department of Electrophysiology, University Hospital, Johannes Gutenberg University, Mainz, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Rostock
authors.affiliation: Department of Electrophysiology, University Heart Center, University Hospital Eppendorf, Hamburg, Germany.
authors.forename: Boris
authors.initials: B
authors.lastname: Hoffmann
authors.affiliation: Department of Electrophysiology, University Heart Center, University Hospital Eppendorf, Hamburg, Germany.
authors.forename: Helge
authors.initials: H
authors.lastname: Servatius
authors.affiliation: Department of Electrophysiology, University Heart Center, University Hospital Eppendorf, Hamburg, Germany.
authors.forename: Arian
authors.initials: A
authors.lastname: Sultan
authors.affiliation: Department of Electrophysiology, University Heart Center, University Hospital Eppendorf, Hamburg, Germany.
authors.forename: Jakob
authors.initials: J
authors.lastname: Lüker
authors.affiliation: Department of Biometrics and Epidemiology, University Hospital Eppendorf, Hamburg, Germany.
authors.forename: András
authors.initials: A
authors.lastname: Treszl
authors.affiliation: Department of Biometrics and Epidemiology, University Hospital Eppendorf, Hamburg, Germany.
authors.forename: Karl
authors.initials: K
authors.lastname: Wegscheider
authors.affiliation: Department of Electrophysiology, University Heart Center, University Hospital Eppendorf, Hamburg, Germany.
authors.forename: Stephan
authors.initials: S
authors.lastname: Willems
mesh_terms: D001281:Atrial Fibrillation / Q000503:physiopathology / Q000628:therapy*; D017115:Catheter Ablation / Q000379:methods*; D004554:Electric Countershock / Q000379:methods*; D022062:Electrophysiologic Techniques, Cardiac / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006329:Heart Conduction System / Q000503:physiopathology* / Q000601:surgery; D006339:Heart Rate / Q000502:physiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011667:Pulmonary Veins / Q000601:surgery*; D013614:Tachycardia, Paroxysmal / Q000503:physiopathology* / Q000601:surgery; D013997:Time Factors; D016896:Treatment Outcome
keywords: Atrial fibrillation; Catheter ablation; Defragmentation; Paroxysmal