Long-Term Outcome of Pulmonary Vein Isolation With and Without Focal Impulse and Rotor Modulation Mapping: Insights From a Meta-Analysis

This meta-analysis systematically evaluated the outcome of pulmonary vein isolation (PVI) with and without focal impulse and rotor modulation (FIRM) ablation in patients with atrial fibrillation.

Extensive literature search was performed for studies reporting outcomes of PVI alone and PVI+FIRM procedures. For PVI alone, only randomized trials conducted in the past 3 years reporting single-procedure off-antiarrhythmic drugs success rate at ≥12-month follow-up were included. In PVI+FIRM group, all published studies reporting single-procedure off-antiarrhythmic drugs success rate with at least 1-year follow-up were identified. Meta-analytic estimates were derived using DerSimonian and Laird random-effects models, and pooled estimates of success rate (95% confidence interval) were computed. Statistical heterogeneity was assessed using Cochran Q test and I². Study quality was assessed using Newcastle-Ottawa Scale. Fifteen trials were included, 10 with PVI+FIRM (n=511, nonrandomized prospective design), and 5 with PVI-only trials (n=295, randomized trials). All patients in PVI-only trials had 100% nonparoxysmal atrial fibrillation, except 1 study, and no prior ablations. About 24% of PVI+FIRM population had paroxysmal atrial fibrillation. After 15.9±5.5 (median 12) months follow-up, the off-antiarrhythmic drugs pooled success rate was 50% in FIRM+PVI (95% confidence interval, 28%-72%) and 58% in PVI (95% confidence interval, 46%-71%). Difference in effect size between groups was not statistically significant (P=0.21). No significant heterogeneity (total or within group) was observed in this meta-analysis (negative I² values considered equal to zero).

The overall pooled estimate did not show any therapeutic benefit of PVI+FIRM approach over PVI alone, which suggests the need to reevaluate the clinical use of FIRM ablation in atrial fibrillation.