Benefits and risks of additional ablation of complex fractionated atrial electrograms for patients with atrial fibrillation: a systematic review and meta-analysis

Abstract

Background: The benefits and risks of additional complex fractionated atrial electrograms (CFAE) ablation in patients with atrial fibrillation (AF) remain unclear.

Methods: Trials were identified in PubMed, Embase, Web of Science, and Cochrane Database, reviews, and reference lists of relevant papers. The primary end point was the recurrence of atrial arrhythmias after a single ablation.

Results: We meta-analyzed 11 studies (total, n=983) using random-effects model to compare PVI (n=478) with PVI plus CFAE ablation (PVI+CFAE) (n=505). Additional CFAE ablation reduced recurrence of atrial tachyarrhythmia after a single procedure (pooled RR 0.73; 95% CI 0.61, 0.88; P=0.0007) at ≥ 3-month follow-up. There was no evidence of heterogeneity among studies (I(2)=33%). Subgroup analysis demonstrated that additional CFAE ablation reduced rates of recurrence in nonparoxysmal AF (RR 0.68; 95% CI 0.47, 0.99; P=0.05), whereas had no effect on patients with paroxysmal AF (RR 0.79; 95% CI 0.59, 1.06; P=0.12). Eight studies reported results of post-procedure ATs. The addition of CFAE ablation increased the rate of post-procedure ATs (RR 1.77; 95% CI 1.02, 3.07; P=0.04). Additional CFAE ablation significantly increased mean procedural times (245.4+75.7 vs. 189.5+62.3 min, P<0.001), mean fluoroscopy (72.1+25.6 vs. 59.5+19.3 min, P<0.001), and mean RF energy application times (75.3+38.6 vs. 53.2+27.5 min, P<0.001).

Conclusions: The adjunctive CFAE ablation could provide additional benefit in terms of reducing recurrence of atrial tachyarrhythmia for patients with nonparoxysmal AF but not for patients with paroxysmal AF after a single procedure with or without antiarrhythmic drugs (AADs). The main risk of adjunctive CFAE ablation is the increasing rate of untraceable postablation ATs.

Keywords: AADs; AF; ATs; Antiarrhythmic drugs; Atrial fibrillation; CFAE; Catheter ablation; Complex fractionated atrial electrograms; DF; Dominant frequency; LA; Left atria; Meta-analysis; Organized atrial tachyarrhythmias; PVI; Pulmonary vein isolation; RCT; RF; Radiofrequency; Randomized controlled trials.