Abstract 15716: Meta-Analysis of Randomized Controlled Trials Comparing Ablation Targets Beyond Pulmonary Vein Isolation versus Pulmonary Vein Isolation Alone in Patients With Persistent Atrial Fibrillation

Abstract

Introduction: Catheter ablation for persistent atrial fibrillation (PeAF) is challenging and pulmonary vein isolation(PVI) alone has limited success. Adjunctive ablation strategies like posterior wall isolation (PWI), linear ablation, substrate modification utilizing complex fractionated atrial electrograms (CFAE) or MRI guided fibrosis ablations have demonstrated variable results beyond PVI alone. We performed a meta analysis of randomized controlled trials (RCTs) comparing efficacy, safety and procedural outcomes of PVI plus adjunctive ablation strategies versus PVI alone. Methods: We performed a comprehensive search of electronic databases from inception to April 2023 searching RCTs comparing PVI alone versus PVI+adjunctive strategies(linear ablations, CFAE, PWI, low voltage area ablation and MRI-guided atrial fibrosis ablation). Primary efficacy outcome was recurrence of atrial arrhythmias > 30s after a single ablation procedure, with or without antiarrhythmics. Secondary safety outcome was composite of access site complications, tamponade, hemopericardium, pericardial effusion, pericarditis, stroke/TIA, pulmonary vein stenosis, atrioesophageal fistula or phrenic nerve palsy. Procedural characteristics included mean procedural time and mean ablation time. Pooled risk ratio (RR), mean difference (MD) and 95% confidence interval (CI) were calculated. Statistical analysis was performed using RevMan5.4.1 Results: 10 RCTs with a total of 3042 patients (PVI plus adjunctive n= 1717; PVI alone n= 1325) were included. The mean age was 61.6 ± 0.14 years. The mean follow-up was 16.5 months. There was no significant difference in primary efficacy outcome (RR: 0.99; CI: 0.88-1.12; p> 0.05; I2 = 28%) or secondary safety outcome (RR: 1.46; CI: 0.97-2.18; p> 0.05; I2 = 16%), between two groups. Procedural characteristics including mean procedural time in minutes (MD: 31.84; CI: 4.92-58.75; p< 0.05; I2 = 95%) and mean ablation time in minutes (MD: 20.30; CI: 8.16-32.43; p< 0.05; I2 = 95%) were significantly shorter for PVI alone group. Conclusions: Adjunctive ablation strategies provide no additional benefit over PVI alone in PeAF, but are associated with significantly longer procedural and ablation time.