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CLINICAL RESEARCH: HEART RHYTHM DISORDER

A Randomized Assessment of the Incremental Role of Ablation of Complex Fractionated Atrial Electrograms After Antral Pulmonary Vein Isolation for Long-Lasting Persistent Atrial Fibrillation

Division of Cardiovascular Medicine, Cardiovascular Center, University of Michigan, Ann Arbor, Michigan

Manuscript received July 24, 2008; revised manuscript received September 16, 2008, accepted October 8, 2008.

^_* Reprint requests and correspondence: Dr. Hakan Oral, Cardiovascular Center, SPC 5853, 1500 E. Medical Center Drive, Ann Arbor, Michigan 48109-5853 (Email: oralh{at}umich.edu).

Objectives: This study sought to determine whether ablation of complex fractionated atrial electrograms (CFAEs) after antral pulmonary vein isolation (APVI) further improves the clinical outcome of APVI in patients with long-lasting persistent atrial fibrillation (AF).

Background: Ablation of CFAEs has been reported to eliminate persistent AF. However, residual pulmonary vein arrhythmogenicity is a common mechanism of recurrence.

Methods: In this randomized study, 119 consecutive patients (mean age 60 ± 9 years) with long-lasting persistent AF underwent APVI with an irrigated-tip radiofrequency ablation catheter. Antral pulmonary vein isolation resulted in termination of AF in 19 of 119 patients (Group A, 16%). The remaining 100 patients who still were in AF were randomized to no further ablation and underwent cardioversion (Group B, n = 50) or to ablation of CFAEs in the left atrium or coronary sinus for up to 2 additional hours of procedure duration (Group C, n = 50).

Results: Atrial fibrillation terminated during ablation of CFAEs in 9 of 50 patients (18%) in Group C. At 10 ± 3 months after a single ablation procedure, 18 of 50 (36%) in Group B and 17 of 50 (34%) in Group C were in sinus rhythm without antiarrhythmic drugs (p = 0.84). In Group A, 15 of 19 patients (79%) were in sinus rhythm. A repeat ablation procedure was performed in 34 of 100 randomized patients (for AF in 30 and atrial flutter in 4). At 9 ± 4 months after the final procedure, 34 of 50 (68%) in Group B and 30 of 50 (60%) in Group C were in sinus rhythm without antiarrhythmic drugs (p = 0.40).

Conclusions: Up to 2 h of additional ablation of CFAEs after APVI does not appear to improve clinical outcomes in patients with long-lasting persistent AF.

Key Words: atrial fibrillation • catheter ablation • electrogram

Abbreviations and Acronyms   AF = atrial fibrillation   APVI = antral pulmonary vein isolation   CFAE = complex fractionated atrial electrogram   PV = pulmonary vein

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