title: The impact of adjunctive complex fractionated atrial electrogram ablation and linear lesions on outcomes in persistent atrial fibrillation: a meta-analysis.
abstract: OBJECTIVE
  In persistent atrial fibrillation (PsAF), success rates for pulmonary vein isolation (PVI) alone are limited and additional substrate modification is often performed. The two most widely used substrate-based strategies are the ablation of complex fractionated atrial electrograms (CFAE) and left atrial linear ablation (LALA) at the roof and mitral isthmus. However, it is unclear whether adjunctive CFAE ablation or LALA add significant benefit to PVI alone. We performed a meta-analysis to better gauge the benefit of adjunctive CFAE ablation and LALA in PsAF.
  
  
  RESULTS
  Electronic databases were systematically searched. We included studies that examined the impact of CFAE ablation or LALA in addition to a PVI-based strategy on clinical outcomes in PsAF. We included both randomized and non-randomized studies. Totally 10 studies (n = 1821) were included: 6 evaluating CFAE ablation, 3 LALA, and 1 both approaches. In comparison with PVI alone, the addition of CFAE ablation [RR 0.86; 95% confidence intervals (CI) 0.64, 1.16; P = 0.32] or LALA (RR 0.64; 95% CI 0.37, 1.09; P = 0.10) offered no significant improvement in arrhythmia-free survival. However, adjunctive CFAE ablation was associated with significant increases (P < 0.05) and LALA non-significant increases in procedure and fluoroscopy times.
  
  
  CONCLUSIONS
  In PsAF, the addition of CFAE ablation or LALA, in comparison with PVI alone, offers no significant improvement in arrhythmia-free survival. Furthermore, they are associated with increases in both procedural and fluoroscopy times. The optimal ablation strategy for PsAF is currently unclear and needs further refinement.
authors.affiliation: Department of Cardiology, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK paul.andrew.scott@btinternet.com.
authors.forename: Paul A
authors.initials: PA
authors.lastname: Scott
authors.affiliation: Department of Cardiology, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK.
authors.forename: John
authors.initials: J
authors.lastname: Silberbauer
authors.affiliation: Department of Cardiology, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK.
authors.forename: Francis D
authors.initials: FD
authors.lastname: Murgatroyd
mesh_terms: D000200:Action Potentials; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D017115:Catheter Ablation / Q000009:adverse effects / Q000379:methods*; D016009:Chi-Square Distribution; D018572:Disease-Free Survival; D022062:Electrophysiologic Techniques, Cardiac; D005471:Fluoroscopy; D006339:Heart Rate; D006801:Humans; D016017:Odds Ratio; D061646:Operative Time; D011237:Predictive Value of Tests; D011667:Pulmonary Veins / Q000503:physiopathology / Q000601:surgery*; D011829:Radiation Dosage; D000069079:Radiation Exposure; D012307:Risk Factors; D016896:Treatment Outcome
keywords: Atrial fibrillation; Catheter ablation; Complex fractionated atrial electrograms; Meta-analysis; Pulmonary vein isolation