Pulmonary vein isolation with posterior wall isolation versus pulmonary vein isolation alone for patients with persistent atrial fibrillation: a systematic review and meta-analysis

Abstract

Abstract Background Pulmonary vein isolation (PVI) is considered the cornerstone of atrial fibrillation (AF) ablation, with a better success rate in paroxysmal AF vs. persistent AF. Although recent evidence suggests that additional ablation targets such as the left atrial posterior wall (LAPW) may play a role in improving the efficacy of AF ablation, the effectiveness of PVI combined with posterior wall isolation (PWI) remains unclear in patients with persistent AF. Purpose We aimed to perform a systematic review and meta-analysis of PVI with vs. without PWI in patients with persistent AF. Methods We systematically searched PubMed, EMBASE, Cochrane and ClinicalTrials databases for randomised controlled trials (RCTs) comparing PVI alone and PVI with PWI. The systematic review and meta-analysis followed Cochrane and PRISMA recommendations. Review Manager 5.1 was used for statistical analysis. Heterogeneity was examined with I2 statistics. Random-effect models were used if I² > 25%. Results We included 10 RCTs with a total of 1,415 patients, of whom 702 (49.6%) were assigned to the PVI alone group. Freedom from AF recurrence did not differ significantly between groups (OR 1.40; 95% CI 0.95-2.05; p=0.09; Figure 1A), nor did freedom from all recurrence of any atrial arrhythmia (OR 1.33; 95% CI 0.80-2.21; p=0.28; Figure 1B). No significant differences were found between the two groups in terms of left ventricular ejection fraction (p=0.24) or left atrial diameter (p=0.71). There was also no significant difference found in adverse events, including phrenic nerve injury (p=0.73), pericarditis (p=0.71), and cardiac tamponade (p=0.59). Total procedure time (MD 22.7 minutes; 95% CI 15.6-29.9; p<0.01; Figure 2A) and ablation time (MD 13.56 minutes; 95% CI 8;06-19.07; p<0.01; Figure 2B) were significantly lower in the PVI group. Conclusion Our findings suggest that freedom from recurrence of AF, freedom from recurrence of atrial arrhythmias, and adverse events is not significantly different between patients who undergo PVI for persistent AF with or without PWI. As expected, adding PWI to PVI was associated with a longer procedure and ablation time.Figure 1Figure 2