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Pulmonary vein (PV) isolation is a generally accepted endpoint in catheter ablation of patients with paroxysmal atrial fibrillation (AF). In long-standing persistent AF or in the presence of advanced structural heart disease, atrial substrate modification on top of PV isolation may be required.1 This may consist of deployment of additional linear lesions, adjunctive ablation of areas exhibiting complex fractionated atrial electrograms (CFAEs), or even a stepwise ablation strategy until conversion.2In recent years, several randomized controlled, single- and multicentre trials have been performed comparing a strategy of PV ablation only vs. PV ablation followed by additional defractionation. These studies revealed divergent results even between very experienced centres. Kong et al .3 performed a meta-analysis of six prospective randomized studies evaluating the additional value of defractionation beyond PV ablation including both patients with paroxysmal AF and long-standing persistent AF.4–9 This meta-analysis reveals a distinct benefit of additional defractionation on top of PV ablation with a significant overall increase in freedom of AF from 48 to 66% and a twice as high likelihood of being in sinus rhythm (odds ratio 1.98; …

A meta-analysis on adjunctive complex fractionated atrial electrogram ablation: comparing the incomparable?