No Benefit OF Complex Fractionated Atrial Electrogram (CFAE) Ablation in Addition to Circumferential Pulmonary Vein Ablation and Linear Ablation: BOCA Study

Background —The optimal ablation strategy for persistent atrial fibrillation (AF) remains unclear. Methods and Results —This multicentre randomized study compared circumferential pulmonary vein ablation (CPVA) + linear ablation (control arm) versus CPVA + linear ablation + Complex Fractionated Atrial Electrogram (CFAE) ablation (CFAE arm) in patients with persistent AF. CPVA was performed followed by roof and mitral isthmus ablation, before CFAE ablation in the CFAE arm. Ablation strategy was maintained at the first redo-procedure. 65 patients were recruited in each arm. Mean age was 61±10 years, 75% were male, median AF duration was 2 years, 42% had long-lasting persistent AF, 68% had associated cardiovascular disease, mean left atrial dimension was 46±6 mm and median CHA2DS2-VASc score was 2. Ablation and procedure times were significantly longer in the CFAE arm (70±20 vs. 55±17; 201±35 vs. 152±45 mins, p<0.005). After a mean follow up of 35±5 months, single procedural success off anti-arrhythmic drugs at 12 months (CFAE: 30/65 [46%] vs. control: 37/65 [57%], p=0.29) and multiple-procedure success (CFAE: 51/65 [78%] vs. control: 52/65 [80%], p=1.0) were not significantly different. At the first redo-procedure, patients in the CFAE arm had a higher incidence of organized atrial tachycardia/flutter (24/33[73%] vs. 11/31[35%], p=0.005) and gap-related macroreentrant flutter (8/33[24%] vs. 1/31[3%], p=0.03). Early recurrence of atrial arrhythmia was an independent predictor of late recurrence. Conclusions —CFAE ablation did not confer incremental benefit when performed in addition to CPVA and linear ablation. It was associated with a higher incidence of gap-related flutter Clinical Trial Registration —www.ClinicalTrials.gov; Unique Identifier: [NCT01711047][1]. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT01711047&atom=%2Fcircae%2Fearly%2F2015%2F08%2F17%2FCIRCEP.114.002504.atom