Ablation of Complex Fractionated Atrial Electrograms for Atrial Fibrillation Rhythm Control: A Systematic Review and Meta-analysis

Background: Pulmonary vein isolation (PVI) has become an increasingly important therapy in the management of atrial fibrillation (AF), however, the best procedural techniques to ensure success have not been determined. We assessed the incremental benefit of complex fractionated atrial electrograms (CFAEs) ablation for AF rhythm control. Methods: PubMed, Embase, CENTRAL, and Clinicaltrials. gov databases were searched up until May 7, 2015. Included were randomized controlled trials that compared PVI with PVI and CFAEs ablation (PVI+) with a minimum of 3 months' follow-up. Statistical analysis was performed with Review Manager version 5.3 (Cochrane Collaboration, Oxford, United Kingdom). Categorical and continuous outcomes were reported as summary risk differences and mean differences (MDs), respectively. P < 0.05 was considered statistically significant for all analyses. Results: Ten randomized controlled trials randomized patients to PVI+ (n = 635) and PVI (n = 427) with follow-up ranging from 3 to 23 months. There was no significant difference in freedom from atrial tachyarrhythmias without antiarrhythmic agents after a single ablation between PVI+ and PVI (313 of 635 vs 230 of 427; risk difference, 0.01 [95% confidence interval (CI) -0.08 to 0.10]; P = 0.78; I-2 = 52%). Findings were not different for any prespecified subgroup analyses, including paroxysmal vs nonparoxysmal AF, automated vs manual detection of CFAEs, and left atrial vs biatrial ablation. PVI+ led to significantly increased procedure time (MD, 49.81 minutes [95% CI 42.86-56.76]; P < 0.001), fluoroscopy time (MD, 11.55 minutes [95% CI 8.02-15.07]; P < 0.001), and radiofrequency energy application time (MD, 19.16 minutes [95% CI 6.61-31.70]; P = 0.003) compared with PVI. Conclusions: Ablation of CFAEs in addition to PVI did not increase freedom from atrial tachyarrhythmias but procedural times were increased.