Complex Fractionated Electrogram Distribution and Temporal Stability in Patients Undergoing Atrial Fibrillation Ablation

Roux, Jean François; Gojraty, Sattar; Bala, Rupa; Liu, Christopher F.; Hutchinson, Mathew D.; Dixit, Sanjay; Callans, David J.; Marchlinski, Francis E.; Gerstenfeld, Edward P.

doi:10.1111/j.1540-8167.2008.01133.x

Cited by 52 publications

(72 citation statements)

References 31 publications

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“…9,10 All subjects with drug-refractory AF undergoing their first ablation procedure that fulfilled American College of Cardiology, European Society of Cardiology, American Heart Association, and Heart Rhythm Society defined criteria for persistent or longlasting persistent AF 4 were eligible to participate in the study. The exclusion criteria included aged Ͻ30 years, inability to provide informed consent, and any contraindication to undergoing AF ablation.…”

Section: Methodsmentioning

confidence: 99%

Randomized Ablation Strategies for the Treatment of Persistent Atrial Fibrillation

Dixit

Marchlinski

Lin

et al. 2012

Circ: Arrhythmia and Electrophysiology

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237

168

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Background-The single-procedure efficacy of pulmonary vein isolation (PVI) is less than optimal in patients with persistent atrial fibrillation (AF). Adjunctive techniques have been developed to enhance single-procedure efficacy in these patients. We conducted a study to compare 3 ablation strategies in patients with persistent AF. Methods and Results-Subjects were randomized as follows: arm 1, PVI ϩ ablation of non-PV triggers identified using a stimulation protocol (standard approach); arm 2, standard approach ϩ empirical ablation at common non-PV AF trigger sites (mitral annulus, fossa ovalis, eustachian ridge, crista terminalis, and superior vena cava); or arm 3, standard approach ϩ ablation of left atrial complex fractionated electrogram sites. Patients were seen at 6 weeks, 6 months, and 1 year; transtelephonic monitoring was performed at each visit. Antiarrhythmic drugs were discontinued at 3 to 6 months. The primary study end point was freedom from atrial arrhythmias off antiarrhythmic drugs at 1 year after a single-ablation procedure. A total of 156 patients (aged 59Ϯ9 years; 136 males; AF duration, 47Ϯ50 months) participated (arm 1, 55 patients; arm 2, 50 patients; arm 3, 51 patients). Procedural outcomes (procedure, fluoroscopy, and PVI times) were comparable between the 3 arms. More lesions were required to target non-PV trigger sites than a complex fractionated electrogram (33Ϯ9 versus 22Ϯ9; PϽ0.001). The primary end point was achieved in 71 patients and was worse in arm 3 (29%) compared with arm 1 (49%; Pϭ0.04) and arm 2 (58%; Pϭ0.004). Conclusions-These

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Section: Methodsmentioning

confidence: 99%

Randomized Ablation Strategies for the Treatment of Persistent Atrial Fibrillation

Dixit

Marchlinski

Lin

et al. 2012

Circ: Arrhythmia and Electrophysiology

Self Cite

237

168

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“…88,89 Although PVI can reduce the amount of substrate required for atrial re-entry, persistent AF seems to be less dependent on the PV antral region for arrhythmia initiation and perpetuation, relying more on perpetuating regions outside the PV-LA junction. It has been postulated that these CFAEs (local signals during AF that are either at a very short cycle length, or are fractionated with two or more components and/or a continuous perturbation of the baseline) represent areas of slow conduction, conduction block or 'pivot' points for AF perpetuating re-entry.…”

Section: Mechanism Of Actionmentioning

confidence: 99%

Pharmacological Tests in Atrial Fibrillation Ablation

Gourraud

Andrade

Macle

et al. 2016

Arrhythmia &Amp; Electrophysiology Review

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Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia observed in clinical practice, occurring in approximately 2 % of the general population.1-3 A progressive increase in both the prevalence and incidence of AF has been demonstrated in recent years, defining AF as a major economic and public health issue. 1 The identification of sites of AF initiation and/or maintenance within the pulmonary veins (PVs) has led to the development of percutaneous procedures to electrically isolate the PVs from the left atrium (LA). 4 Large observational studies and multiple randomised-controlled trials have demonstrated that catheter ablation is universally superior to anti-arrhythmic drugs (AADs) for the maintenance of sinus rhythm (66-89 % versus 9-58 %, respectively) and results in a greater improvement in arrhythmia-related symptoms, exercise capacity and quality of life.1,2,5-8 As a result, catheter ablation has become the 'standard of care' for the maintenance of sinus rhythm in symptomatic patients in whom drugs are ineffective or poorly tolerated.While the results of ablation are unequivocally superior to medical therapy, they are unfortunately not flawless: approximately 30 % of paroxysmal AF patients will experience arrhythmia recurrence after a single ablation procedure.8 As most recurrences are in association with PV reconnection or as a result of non-PV triggers, several pharmacological challenges have been proposed to improve outcomes. [9][10][11][12] This article reviews the pathophysiological background and evidence for the use of pharmacological challenges during catheter ablation procedures. Pathophysiology of Atrial Fibrillation and Atrial Fibrillation Catheter AblationDespite decades of progress, there is no comprehensive pathophysiological explanation of AF. Early hypotheses postulated that AF resulted from the co-existence of multiple independent wavelets propagating randomly throughout the left and right atria (the 'multiple wavelet hypothesis'). 13,14 This hypothesis suggested that as long as the atria had a sufficient electrical mass, and an adequately short refractory period, AF could be initiated and indefinitely perpetuated. 15 Based on this theory, the early surgical interventions for AF were designed to reduce the excitable mass of atrial tissue by compartmentalising the atria into smaller regions incapable of sustaining a critical number of circulating wavelets. 16 Unfortunately this strategy has proved to be of limited efficacy and has been associated with a substantial risk of major complications. 17In the late 1990s, Haïssaguerre and colleagues demonstrated that AF is a triggered arrhythmia initiated by rapid repetitive discharges, predominantly from the proximal aspect of the PVs. 4 This discovery led to the development of percutaneous procedures to directly eliminate spontaneous focal ectopic activity within the PVs. However, early AF recurrences from the targeted and other nontargeted PVs led to modification of the ablation strategy to electrically isolate all of the PV...

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“…The points on the LA roof (region 5), and 10 points in the inferior LA (including the endocardial aspect of the CS, region 6). Our division of the LA into six areas is comparable with partitions used in previous studies (22,45). For the reconstruction of CFAE maps, we applied the following settings: voltage threshold within 0.05-0.15 mV (before displaying the CFAE map, the level of noise was reconfirmed to stay below the level of 0.05 mV) and electrograms with cycle lengths between 50 and 120 ms were counted as CFAE.…”

Section: *Parasternal Left Atrial Diametermentioning

confidence: 99%

“…For the reconstruction of CFAE maps, we applied the following settings: voltage threshold within 0.05-0.15 mV (before displaying the CFAE map, the level of noise was reconfirmed to stay below the level of 0.05 mV) and electrograms with cycle lengths between 50 and 120 ms were counted as CFAE. Our settings were similar to the settings used by other investigators (22,45,46). We applied the ICL to define the level of repetitiveness of the CFAE signals.…”

Section: *Parasternal Left Atrial Diametermentioning

confidence: 99%

“…In previous animal and human studies, a high level of spatial and temporal stability of CFAEs was verified (45,49,50,51). We hypothesized that CFAE sites acquired during 3D mapping before ablation are stable without any shifting after PVI, and this would be applicable also for CFAE points outside the PVI antrum without need for a further and time-consuming CFAE remap.…”

Section: Acute Effects Of Cfae Ablationmentioning

confidence: 99%

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New aspects of ablation treatment for atrial fibrillation

Bencsik¹

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Complex Fractionated Electrogram Distribution and Temporal Stability in Patients Undergoing Atrial Fibrillation Ablation

Abstract: During persistent AF, most CFE regions are found in the vicinity of the PVs. There is a significant correlation between two CFE maps constructed 31 minutes apart, with 78% concordance of CFE sites.

Cited by 52 publications

References 31 publications

Randomized Ablation Strategies for the Treatment of Persistent Atrial Fibrillation

Randomized Ablation Strategies for the Treatment of Persistent Atrial Fibrillation

Pharmacological Tests in Atrial Fibrillation Ablation

New aspects of ablation treatment for atrial fibrillation

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