tion and regularization of AF during CFAE ablation are the regions of

the PV ostia, the interatrial septum, and the LA anterior wall close to
the roof of the LAA.
After ablation of CFAEs in the LA, those in the CS and RA are
targeted. RA ablation aimed at termination of AF can potentially offer
a clinical benefit in patients with longstanding persistent AF, but it does
not seem to improve outcome in patients with persistent AF of shorter
durations.218
Ablation Technique
The ablation typically begins at sites at which CFAEs have the shortest
interval and preferably also have a high ICL. RF energy is applied using
an 8-mm-tip or, preferably, an irrigated-tip catheter. Lower power output
is applied in the CS and along the LA posterior wall. RF application is
typically continued for 30 to 60 seconds at each site, aiming to eliminate
or organize local electrograms.196
The typical response of CFAE ablation procedures for persistent AF
is a progressive increase in CL, and AF organizes into AFL or AT. It is
rare for persistent AF to convert to NSR without changing to AT or
AFL first.218
Once AF organizes into AFL or AT, residual CFAEs around the tagged
or previously ablated areas are sought and ablated. When the areas with
CFAEs are completely eliminated, the focus or reentry circuit underlying
the AT is mapped and specifically targeted by ablation. Administration
of IV ibutilide can help lengthen the tachycardia cycle length (TCL),
reduce residual fibrillatory conduction, and unmask the primary
arrhythmia.
If the arrhythmias are not successfully terminated by ablation or
ibutilide, external cardioversion is performed.218
When CFAE ablation is combined with PV isolation, some investigators
recommend that CFAE ablation be performed before PV isolation,
since the PV antra commonly harbor target CFAE. Others, however,
recommend targeting CFAEs after, rather than before, PV isolation
because that latter strategy can itself reduce the burden of CFAEs and
minimize the consequent need for extensive LA ablation.196,218
Endpoints of Ablation
The ablation endpoints when targeting CFAEs are uncertain. In most
studies, the primary endpoints were complete elimination of the areas
 with CFAEs or organization and slowing of local electrograms,
conversion
of AF to NSR (either directly or first to an AT) for patients with
persistent AF, or noninducibility of AF (with isoproterenol and atrial
pacing) for patients with paroxysmal AF. When areas with CFAEs are
completely eliminated, but arrhythmias continue as organized AFL or
AT, those arrhythmias are mapped and ablated.30
AF termination (conversion to AT or NSR) in patients with persistent
AF can potentially be a challenging endpoint to achieve and generally
requires very long procedure times. Reports demonstrated the limited
ability of CFAE ablation to terminate persistent AF. Furthermore,
although AF termination during ablation can potentially predict the
mode of recurrence (AT vs. AF), its correlation with long-term success
is still controversial. AF recurrence rates of more than 50% were
observed
even in patients in whom AF was terminated during CFAE ablation.
Thus ablation of all areas displaying the electrogram of interest in the
LA and CS can be a reasonable alternative endpoint when ablation fails
to terminate AF.
Preliminary reports suggested the clinical utility of monitoring
dominant frequency in real time to guide catheter ablation of AF. A
critical decrease (11% or higher, measured in lead V1 and the CS) of
dominant frequency following CFAE ablation can potentially indicate
adequate elimination of drivers of AF and is associated with clinical
efficacy that is as high as when AF is terminated by ablation. However,
these findings require validation in prospective studies.
and