No Benefit of Complex Fractionated Atrial Electrogram Ablation in Addition to Circumferential Pulmonary Vein Ablation and Linear Ablation: Benefit of Complex Ablation Study.
BACKGROUND
The optimal ablation strategy for persistent atrial fibrillation (AF) remains unclear.


RESULTS
This multicentre randomized study compared circumferential pulmonary vein ablation+linear ablation (control arm) versus circumferential pulmonary vein ablation+linear ablation+complex fractionated atrial electrogram (CFAE) ablation (CFAE arm) in patients with persistent AF. Circumferential pulmonary vein ablation was performed followed by roof and mitral isthmus ablation, before CFAE ablation in the CFAE arm. Ablation strategy was maintained at the first redo procedure. Sixty-five patients were recruited in each arm. The mean age was 61±10 years, 75% were men, median AF duration was 2 years, 42% had long-lasting persistent AF, 68% had associated cardiovascular disease, mean left atrial dimension was 46±6 mm, and median CHA2DS2-VASc score was 2. Ablation and procedure times were significantly longer in the CFAE arm (70±20 versus 55±17; 201±35 versus 152±45 minutes; P<0.005). After a mean follow-up of 35±5 months, single-procedural success off antiarrhythmic drugs at 12 months (CFAE: 30/65 [46%] versus control: 37/65 [57%]; P=0.29) and multiprocedural success (CFAE: 51/65 [78%] versus control: 52/65 [80%]; P=1.0) were not significantly different. At the first redo procedure, patients in the CFAE arm had a higher incidence of organized atrial tachycardia/flutter (24/33 [73%] versus 11/31 [35%]; P=0.005) and gap-related macro-re-entrant flutter (8/33[24%] versus 1/31[3%]; P=0.03). Early recurrence of atrial arrhythmia was an independent predictor of late recurrence.


CONCLUSIONS
CFAE ablation did not confer incremental benefit when performed in addition to circumferential pulmonary vein ablation and linear ablation. It was associated with a higher incidence of gap-related flutter.


BACKGROUND
URL: http://www.clinicaltrials.gov. Unique identifier: NCT01711047.
From the Department of Cardiology, Oxford University Hospitals NHS Trust, Oxford, United Kingdom (K.C.K.W., M.J., N.Q., C.R.H., M.R.G., K.R., Y.B., T.R.B.); Department of Cardiology, Royal Bournemouth and Christchurch Hospitals NHS Trust, Dorset, United Kingdom (J.R.P., M.S., R.B.); and Department of Cardiology, Changi General Hospital, Singapore, Singapore (K.C.K.W.).
Kelvin C K
KC
Wong
From the Department of Cardiology, Oxford University Hospitals NHS Trust, Oxford, United Kingdom (K.C.K.W., M.J., N.Q., C.R.H., M.R.G., K.R., Y.B., T.R.B.); Department of Cardiology, Royal Bournemouth and Christchurch Hospitals NHS Trust, Dorset, United Kingdom (J.R.P., M.S., R.B.); and Department of Cardiology, Changi General Hospital, Singapore, Singapore (K.C.K.W.).
John R
JR
Paisey
From the Department of Cardiology, Oxford University Hospitals NHS Trust, Oxford, United Kingdom (K.C.K.W., M.J., N.Q., C.R.H., M.R.G., K.R., Y.B., T.R.B.); Department of Cardiology, Royal Bournemouth and Christchurch Hospitals NHS Trust, Dorset, United Kingdom (J.R.P., M.S., R.B.); and Department of Cardiology, Changi General Hospital, Singapore, Singapore (K.C.K.W.).
Mark
M
Sopher
From the Department of Cardiology, Oxford University Hospitals NHS Trust, Oxford, United Kingdom (K.C.K.W., M.J., N.Q., C.R.H., M.R.G., K.R., Y.B., T.R.B.); Department of Cardiology, Royal Bournemouth and Christchurch Hospitals NHS Trust, Dorset, United Kingdom (J.R.P., M.S., R.B.); and Department of Cardiology, Changi General Hospital, Singapore, Singapore (K.C.K.W.).
Richard
R
Balasubramaniam
From the Department of Cardiology, Oxford University Hospitals NHS Trust, Oxford, United Kingdom (K.C.K.W., M.J., N.Q., C.R.H., M.R.G., K.R., Y.B., T.R.B.); Department of Cardiology, Royal Bournemouth and Christchurch Hospitals NHS Trust, Dorset, United Kingdom (J.R.P., M.S., R.B.); and Department of Cardiology, Changi General Hospital, Singapore, Singapore (K.C.K.W.).
Michael
M
Jones
From the Department of Cardiology, Oxford University Hospitals NHS Trust, Oxford, United Kingdom (K.C.K.W., M.J., N.Q., C.R.H., M.R.G., K.R., Y.B., T.R.B.); Department of Cardiology, Royal Bournemouth and Christchurch Hospitals NHS Trust, Dorset, United Kingdom (J.R.P., M.S., R.B.); and Department of Cardiology, Changi General Hospital, Singapore, Singapore (K.C.K.W.).
Norman
N
Qureshi
From the Department of Cardiology, Oxford University Hospitals NHS Trust, Oxford, United Kingdom (K.C.K.W., M.J., N.Q., C.R.H., M.R.G., K.R., Y.B., T.R.B.); Department of Cardiology, Royal Bournemouth and Christchurch Hospitals NHS Trust, Dorset, United Kingdom (J.R.P., M.S., R.B.); and Department of Cardiology, Changi General Hospital, Singapore, Singapore (K.C.K.W.).
Chris R
CR
Hayes
From the Department of Cardiology, Oxford University Hospitals NHS Trust, Oxford, United Kingdom (K.C.K.W., M.J., N.Q., C.R.H., M.R.G., K.R., Y.B., T.R.B.); Department of Cardiology, Royal Bournemouth and Christchurch Hospitals NHS Trust, Dorset, United Kingdom (J.R.P., M.S., R.B.); and Department of Cardiology, Changi General Hospital, Singapore, Singapore (K.C.K.W.).
Matthew R
MR
Ginks
From the Department of Cardiology, Oxford University Hospitals NHS Trust, Oxford, United Kingdom (K.C.K.W., M.J., N.Q., C.R.H., M.R.G., K.R., Y.B., T.R.B.); Department of Cardiology, Royal Bournemouth and Christchurch Hospitals NHS Trust, Dorset, United Kingdom (J.R.P., M.S., R.B.); and Department of Cardiology, Changi General Hospital, Singapore, Singapore (K.C.K.W.).
Kim
K
Rajappan
From the Department of Cardiology, Oxford University Hospitals NHS Trust, Oxford, United Kingdom (K.C.K.W., M.J., N.Q., C.R.H., M.R.G., K.R., Y.B., T.R.B.); Department of Cardiology, Royal Bournemouth and Christchurch Hospitals NHS Trust, Dorset, United Kingdom (J.R.P., M.S., R.B.); and Department of Cardiology, Changi General Hospital, Singapore, Singapore (K.C.K.W.).
Yaver
Y
Bashir
From the Department of Cardiology, Oxford University Hospitals NHS Trust, Oxford, United Kingdom (K.C.K.W., M.J., N.Q., C.R.H., M.R.G., K.R., Y.B., T.R.B.); Department of Cardiology, Royal Bournemouth and Christchurch Hospitals NHS Trust, Dorset, United Kingdom (J.R.P., M.S., R.B.); and Department of Cardiology, Changi General Hospital, Singapore, Singapore (K.C.K.W.). ep.doctors@ouh.nhs.uk.
Timothy R
TR
Betts
D000200:Action Potentials; D000368:Aged; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D001282:Atrial Flutter / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000628:therapy; D017115:Catheter Ablation / Q000009:adverse effects / Q000379:methods*; D022062:Electrophysiologic Techniques, Cardiac; D004739:England; D005260:Female; D006339:Heart Rate / Q000187:drug effects; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000503:physiopathology / Q000601:surgery*; D011237:Predictive Value of Tests; D011446:Prospective Studies; D011667:Pulmonary Veins / Q000503:physiopathology / Q000601:surgery*; D012008:Recurrence; D012086:Reoperation; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
D000889:Anti-Arrhythmia Agents
anti-arrhythmia agents; atrial fibrillation; catheter ablation; heart atria; pulmonary veins