Complex Fractionated Atrial Electrogram or Linear Ablation in Patients with Persistent Atrial Fibrillation—A Prospective Randomized Study HEIDI L. ESTNER, M.D.,* GABRIELE HESSLING, M.D.,* ROMAN BIEGLER,* JUERGEN SCHREIECK, M.D.,† STEPHANIE FICHTNER, M.D.,* JINJIN WU, M.D.,* CLEMENS JILEK, M.D.,* BERNHARD ZRENNER, M.D.,‡ GJIN NDREPEPA, M.D.,* CLAUS SCHMITT, M.D.,§ and ISABEL DEISENHOFER, M.D.* From the *Deutsches Herzzentrum M ¨ unchen and 1. Medizinische Klinik, Klinikum rechts der Isar, Technische Universit¨ at M ¨ unchen, Munich, Germany; †Universitaetsklinikum T ¨ ubingen, T ¨ ubingen, Germany; ‡Krankenhaus Landshut-Achdorf, Landshut, Germany; and §Staedtisches Klinikum Karlsruhe, Karlsruhe, Germany Background: Catheter ablation of complex fractionated atrial electrograms (CFAE) for persistent atrial fibrillation (AF) is a promising treatment strategy. We tested the hypothesis that CFAE ablation is superior to linear ablation in patients with persistent or long-standing persistent AF. Methods: In this study, 116 patients with persistent AF were randomly assigned to undergo circumferential PVI plus additional lines (linear ablation group; 59 patients) or CFAE ablation plus ostial pulmonary vein isolation (PVI) (spot ablation group; 57 patients). Primary endpoint was freedom from atrial tachyarrhythmia after a single ablation procedure (clinical and repeat 7-day Holter), 12 months after ablation without antiarrhythmic medication. Results: The primary endpoint was reached in 22 of 59 (37%) patients of the linear ablation group and in 22 of 57 (39%) patients of the spot ablation group (P = 0.9). Freedom from atrial tachyarrhythmias, including reablations, was achieved in 54% of patients (linear ablation group) versus 56% of patients (spot ablation group; P = 0.8). The incidence of recurrent persistent AF was higher after linear ablation than after spot ablation (21/37 vs 11/35 patients; P = 0.03); atrial tachycardia (AT) was seen more often after spot ablation (10/35 vs 4/37 patients; P = 0.03). Conclusion: In patients with persistent AF, CFAE ablation plus PVI reaches the same results as circumferential PVI plus lines, in terms of freedom from symptomatic atrial tachyarrhythmias within the first year after a single ablation procedure. Arrhythmia recurrences in patients after spot ablation were caused more often by AT, whereas recurrent persistent AF was more prevalent after the linear ablation approach. (PACE 2011; 34:939–948) atrial fibrillation, ablation, CFAE, circumferential PV isolation Introduction A variety of ablation strategies have been proposed for patients with persistent atrial fib- rillation (AF) based on the concept of multiple mechanisms contributing to AF initiation and perpetuation. Systematic empirical ostial isolation of all pulmonary veins (PVs) has been performed based on the concept that arrhythmogenic foci within the PV initiate and perpetuate AF. However, PV isolation (PVI) alone achieves only moderate success in patients with (long-standing) Disclosures: There are no potential conflicts of interest to state. This study was presented in parts at the American Heart Association Scientific Session 2009 in Orlando, FL, USA. Address for reprints: Heidi L. Estner, M.D., Deutsches Herzzen- trum M¨ unchen, Lazarettstrasse 36, D – 80636 M¨ unchen, Germany. Fax: 49-89-12184593; e-mail: estner@dhm.mhn.de Received October 25, 2010; revised January 29, 2011; accepted February 12, 2011. doi: 10.1111/j.1540-8159.2011.03100.x persistent AF. 1–3 In contrast to ostial PVI alone, a more extended circumferential PVI technique has been shown to improve outcome in patients with persistent AF, especially if enhanced by additional left atrial linear lesions. This may involve an additional substrate modification effect produced by the long linear lesions. 4 Nademanee et al. 5,6 reported on a different ablation strategy targeting atrial areas with com- plex fractionated atrial electrograms (CFAE). They showed that CFAE ablation leads to progressive regularization and finally termination of AF and hypothesized that CFAE represent substrates for AF maintenance. 7–10 In contrast to circumferential linear ablation, this new approach targets CFAE “spots” in both atria. There are no studies prospectively comparing the clinical outcome of CFAE ablation plus PVI versus circumferential PVI plus additional lines in patients with long-standing persistent AF. We hypothesized that spot ablation (CFAE+ ostial PVI) is superior compared to a linear ablation C 2011, The Authors. Journal compilation C 2011 Wiley Periodicals, Inc. PACE, Vol. 34 August 2011 939