Selective Complex Fractionated Atrial Electrograms (CFAE) Targeting for Atrial Fibrillation

Study Overview
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Brief Summary
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This study will be a multicenter, open, prospective, randomized trial. Patients with either paroxysmal or persistent atrial fibrillation will be considered for the study. (For US, only paroxysmal atrial fibrillation will be considered.) Eligible subjects will be randomized into one of two arms in the study: (1) targeted CFAE ablation or (2) generalized CFAE ablation. Both techniques will then be followed by PVAI (pulmonary vein antral isolation) as part of a hybrid ablation strategy. The nature of the ablation procedures does not allow physicians to be blinded to the randomization.

Detailed Description
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The purpose of this study is to compare a strategy of targeted CFAE ablation, focusing on regions of continuous electrical activity versus a strategy of generalized CFAE ablation in terms of (1) acute effects on AFCL (atrial fibrillation cycle length), AF regularization, and AF termination; (2) number and distribution of lesion sets delivered; and (3) long term effects on procedural outcome when combined with PVAI as a hybrid strategy.

Official Title
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Selective CFAE Targeting for Atrial Fibrillation (SELECT-AF)

Conditions
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Atrial Fibrillation

Intervention / Treatment
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* Procedure: CFAE ablation


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Candidates for this study must meet ALL of the following criteria: Age ≥ 18 years old First-time ablation procedure for AF Symptomatic AF which has been refractory to at least one antiarrhythmic medication (AAD). Symptomatic patients are those who have been aware of their AF anytime within the last 5 years. Symptoms may include, but are not restricted to, palpitations, shortness of breath, chest pain, fatigue, or other symptoms, or any combination of the above One of the following must apply: AF must either be PERSISTENT AF (non-US sites only) or HIGH BURDEN PAROXYSMAL AF - High burden paroxysmal AF is defined as episodes that terminate within 30 days and meet any ONE of the following criteria: More than 1 episode of AF per month in the preceding 6 months with at least 1 episode lasting >24 hours by symptoms, LA size of >/= 48 mm in the PLAX (parasternal long axis) view on echocardiography LA volume >/= 100 cc Total AF history >/= 10 years At least one episode of AF must have been documented by ECG, Holter, TTM, or telemetry strip within 24 months of inclusion in the study. Patients must be able and willing to provide written informed consent to participate in the study. Able and willing to comply with all pre-, post- and follow-up testing and requirements. Exclusion Criteria: Candidates will be excluded from the study if any of the following conditions apply: Patients with long-standing persistent AF >1 year for which cardioversion (pharmacologic or electrical) has failed or will never be attempted. Patients with AF felt to be secondary to an obvious reversible cause. Patients with contraindications to systemic anticoagulation with heparin or Coumadin. Patients who have previously undergone atrial fibrillation ablation. Patients who are pregnant (by history of menses or pregnancy test if history is considered unreliable. Left atrial size ≥55 mm (PLAX view on echocardiography).

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: (1) targeted CFAE ablation<br> | Procedure: CFAE ablation<br>* CFAE ablation (targeted vs. generalized)<br>* Other names: CARTO mapping system;|
| Active Comparator: (2) generalized CFAE ablation<br> | Procedure: CFAE ablation<br>* CFAE ablation (targeted vs. generalized)<br>* Other names: CARTO mapping system;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Proportion of Subjects Who Were Free From Atrial Arrhythmia at One Year. | Proportion of subjects who were free from atrial arrhythmia (no recurrence of atrial fibrillation, atrial flutter, and atrial tachycardia (AF/AFL/AT)) between Day 91 and Day 365 post first ablation procedure. | From day 91 to day 365 post first ablation procedure | 
| Total Radio-frequency (RF) Delivery Time During CFAE | Total RF delivery time (minutes) is defined as the duration of the RF delivered per ablation site and totaled for each procedure. | Duration of an Atrial Fibrillation RF ablation procedure (up to about 5 hours) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Duration of Ablation Procedure | Duration of ablation procedure includes three components: Access time - Time from first stick to tracking of the NAVISTAR catheter to the chamber of interest; Mapping time - Creation of first workable map; Ablation and verification time - Creation and verification of all ablation points including pulmonary vein isolation and complex fractionated electrograms. | Duration of ablation procedure (up to about 5 hours) | 
| Fluoroscopy Time | Fluoroscopy time is divided into: Fluoroscopy time for access - Time to track the NAVISTAR catheter to the chamber of interest; Fluoroscopy time to map - Creation of first workable map, ablation, and verification time; Fluoroscopy to create and verify all ablation points including pulmonary vein isolation and complex fractionated electrograms. Fluoroscopy time for access is independent of the strategies and will not be included in comparative analysis. | Duration of an Atrial Fibrillation RF ablation procedure (up to about 5 hours) | 
| Change in Atrial Fibrillation Cycle Length From Baseline to the End of the Ablation Procedure for Each Target | Change in atrial fibrillation cycle length from baseline to the end of the ablation procedure for each target | Duration of an Atrial Fibrillation RF ablation procedure (up to 5 hours) | 
| Incidence of Atrial Fibrillation (AF) Termination/Regularization | Incidence of Atrial Fibrillation (AF) termination/regularization is defined as AF terminates during a complex fractionated atrial electrograms (CFAE) procedure. | Duration of an Atrial Fibrillation RF ablation procedure (up to about 5 hours) | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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paroxysmal, persistent, targeted, generalized, CFAE