and repetitive CFAE and, hence, higher ICL.

The CARTO software

can
also measure CFAE by either the “shortest complex interval” (which
is
the shortest interval found in milliseconds out of all the intervals
identified
between consecutive CFAE complexes) or the “average complex
interval” (which is the average of all the intervals identified between
consecutive CFAE complexes for each 2.5-second electrogram).
CFAE
areas are displayed on the whole-chamber map in a color-coded
manner
according to the degree of fractionated signals and their CLs for
easier
identification (eFig. 15.21).215–217
The algorithm embedded in the EnSite mapping system uses a
different
principle, the “CFAE mean.” The CFAE mean is defined as the
average time interval between consecutive deflections (−dV/dt) in a
local AF intracardiac bipolar electrogram recorded over a specified
length of time (5 to 8 seconds). The mean interdeflection time
interval
(i.e., the mean CL) is then projected onto the LA anatomic shell as a
color-coded display. The shorter the mean CL, the more rapid and
fractionated the local electrogram. Regions with mean CLs shorter
than
120 milliseconds are considered to correspond to CFAE. To
optimize
algorithm accuracy, bipolar recordings are filtered at 30 to 500 Hz
(to
avoid sensing noise), electrogram width is set at less than 10 to 20
milliseconds (to avoid detecting far-field signals), and electrogram
“refractory” period is set at 30 to 50 milliseconds (less than 30
milliseconds
is regarded as nonphysiological). In addition, the baseline signal
 noise level is determined, and the peak-to-peak electrogram
amplitude
detection limit is set just higher than the noise level (typically, 0.03
to
0.05 mV) to minimize noise detection while allowing detection of
CFAEs,
which are typically of very low amplitude (less than 0.5 mV). This
algorithm is probably most analogous to the “average complex
interval”
map from the CARTO software. Advantages of the EnSite system
include
an adjustable duration of recording from 1 to 8 seconds and the
ability
to record electrograms from multiple poles of several catheters
simultaneously,
which can potentially occupy a significant proportion of
local AF CL.196,215–217
Importantly, assessment of fractionated electrograms during AF
requires a recording duration of at least 5 seconds at each site to
obtain
a consistent fractionation and accurate analysis. A small mapping
catheter
tip (4 mm), good atrial contact, and stable mapping catheter position
for several seconds while mapping at each location are important to
obtain high-quality recordings.
In general, CFAEs can be identified in most (80%) areas of the LA,
but they appear to be predominantly located in the interatrial
septum,
LA roof, posterior wall, mitral annulus, and PV ostia. Less
commonly,
CFAEs are located in the RA, involving the septal region, crista
terminalis,
and CTI, as well as the CS os. Notably, patients with paroxysmal
AF appear to have more CFAE sites identified around the PV ostia,
whereas CFAEs detected in patients with persistent AF appear to be
 more evenly distributed over all areas of the LA. However, these
findings
have not been consistent across studies using different CFAE
detection
methods.
Target of Ablation
Atrial ablation is performed at atrial sites that harbor CFAEs
characterized
by the following: (1) low-voltage (range 0.04 to 0.25 mV) signals
that have multiple potentials with continuous deflection of a
prolonged
activation complex; (2) stationary CFAEs that have temporal and
spatial
stability; and (3) short CL (less than 120 milliseconds) electrograms
that occur repeatedly with a relatively stable frequency with or
without
multiple potentials as CFAEs. CFAE sites that are fleeting, have
high
amplitude, or have a relatively long CL (greater than 150
milliseconds)
are not targeted by ablation.218
The atrial septum, followed by the regions of the PVs, is the most
common site for CFAEs. The most common localizations for
termina