EGM (CFAE)-guided ablation for AF
The original CFAE ablation study, reported by Nademanee et al.,
demonstrated high acute AF termination rates of 82% and arrhythmia-free
survival in three quarters of patients at one-year
follow-up.7 Haissaguerre et al. subsequently proposed
EGM-guided ablation targeting fractionated, rapid and gradient signals
in addition to linear ablation, an approach associated with a high acute
AF termination rate.8 The concept of EGM or
CFAE-guided ablation involves targeting AF driver sources represented by
pivot points of wavelets, continuous re-entry of fibrillation waves with
relatively short cycle lengths, and heterogenous temporal and special
distribution.30 Of note however, identification of
CFAE signals is quite subjective (e.g. definition of fractionated
electrograms) and therefore this strategy was not consistent and not
formally established, even with the use of automatic analysis algorithms
incorporated into 3D-EAM systems.21,31 A recent large
meta-analysis did not demonstrate an incremental beneficial effect of
CFAE ablation in addition to PVI compared with PVI alone in PsAF
patients.9 It is possible that in addition to critical
AF drivers CFAEs represent also passive activations, such as signal
artifact, double potential, slow conduction and
wavebreak.15,32 In the present study, EGM-guided
ablation, using the Bordeaux approach,8 was performed
by visual and manual inspection by one sufficiently experienced
operator. However, methodological differences might be associated with
lower AF termination rate (40%) and poor clinical outcome (AF/AT-free
survival of 38% /1.5 years). An important point to consider when
comparing outcomes of CFAE ablation is the inter-operator variability
CFAE identification.