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. 2019 Apr 18;1(5):206-211.
doi: 10.1253/circrep.CR-19-0002.

Efficacy of Complex Fractionated Atrial Electrogram-Guided Extensive Encircling Pulmonary Vein Isolation for Persistent Atrial Fibrillation

Akihiro Yoshida  1 , Kaoru Takami  1 , Shinichiro Yamada  1 , Kohei Yamawaki  1 , Toru Tagashira  1 , Mana Hiraishi  1 , Daisuke Terashita  1 , Shigeyasu Tsuda  1 , Koichi Nakamura  1 , Ayaka Fujita  1 , Shota Naniwa  1 , Kojiro Awano  1 , Kunihiko Kiuchi  2 , Koji Fukuzawa  2 , Ken-Ichi Hirata  2
Affiliations

Efficacy of Complex Fractionated Atrial Electrogram-Guided Extensive Encircling Pulmonary Vein Isolation for Persistent Atrial Fibrillation

Akihiro Yoshida et al. Circ Rep. .

Abstract

Background: In persistent AF, the effect of adjunctive ablation in addition to PV isolation (PVI) is controversial. We considered a new modified PVI including complex fractionated atrial electrogram (CFAE) area. Methods and Results: In 57 patients with persistent AF undergoing first ablation, CFAE were mapped before ablation and CFAE-guided extensive encircling PVI (CFAE-guided EEPVI) was performed. The PVI line was designed to include the CFAE area near PV or to cross the minimum cycle length points of the CFAE area near PV (CFAE-guided EEPVI group). The outcome was compared with conventional PVI in 34 patients with persistent AF (conventional PVI group). During a mean follow-up of 365±230 days after the first procedure, AF in 13 and atrial tachycardia (AT) in 9 patients recurred in the CFAE-guided EEPVI group, while only AF in 17 patients recurred in the conventional PVI group. Eight of 9 AT in the CFAE-guided EEPVI group were successfully ablated at second procedure. After first and second procedures, the recurrence of atrial tachyarrhythmia in the CFAE-guided EEPVI group was significantly reduced compared with the conventional PVI group (8 patients, 14% vs. 11 patients, 32%, respectively; P<0.01, log-rank test). Conclusions: CFAE-guided EEPVI was more effective for persistent AF compared with conventional PVI after first and second procedures, because recurring AT as well as re-conduction of PV was successfully ablated.

Keywords: Atrial tachycardia; Complex fractionated atrial electrogram; Persistent atrial fibrillation; Pulmonary vein isolation; Radiofrequency catheter ablation.

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Conflict of interest statement

The authors declare no conflicts of interest.

Figures

Figure 1.
Figure 1.
Example of complex fractionated atrial electrogram (CFAE) mapping during atrial fibrillation before ablation. (A) Distribution of CFAE on high-density cycle length map (color bar, 50–120 ms). CFAE area was extended in the anterior wall next to the right pulmonary vein (PV), and a shorter cycle length area (red zone) exists in the antero-septum. (B) Roof of the right PV does not include the CFAE area, although the roof of the left PV next to the left appendage includes the CFAE area. The extended line of PV isolation was set cross the shortest CFAE area. AP, anteroposterior; PA, posteroanterior; RAO, right anterior oblique.
Figure 2.
Figure 2.
Freedom from any atrial tachyarrhythmia between complex fractionated atrial electrogram-guided extensive encircling pulmonary vein isolation (CFAE) group and conventional pulmonary vein isolation (C) group (A) after the single procedure and (B) after the second procedure.
Figure 3.
Figure 3.
Case of second ablation for recurring atrial tachycardia (AT) after complex fractionated atrial electrogram-guided extensive encircling pulmonary vein isolation (CFAE-guided EEPVI). (A) Electro-anatomical mapping shows that the earliest site of AT originates from the roof of the left atrium (LA) near the right superior PV and propagates centrifugally. (B) AT was terminated by the ablation of the earliest site. Note that the potential of the superior right PV (RPV), which shows 2:1 conduction following LA potential during AT, continues in sinus rhythm after AT termination. (C) Ablation of the gap in the previous PVI line at the distal site of ablated AT origin eliminates PV potential. AP, anteroposterior; PA, posteroanterior.
See this image and copyright information in PMC

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