A meta analysis of pulmonary vein isolation compared with additional ablation strategies for atrial fibrillation

Pulmonary Vein Isolation (PVI) is considered to be the primary strategy for atrial fibrillation (AF) ablation. However, recurrence of AF and atrial tachycardia was observed to occur often after PVI, which led to the proposition of performing additional ablations such as linear lesions, left atrial (LA) posterior wall isolation, substrate modification, and electrocardiogram (EGM)-based approaches as add-ons to PVI or alternative strategies. While numerous randomized controlled trials have been conducted in this regard, the efficacy of these strategies compared with PVI alone has been ambiguous, with some trials showing significant improvement and others showing no superiority over PVI alone. Thus, a systematic review and meta-analysis were conducted to address this ambiguity and assess the efficacy of additional or alternative ablation strategies as compared with Pulmonary Vein Isolation alone.

To assess whether additional or alternative ablation strategies lead to better outcomes as compared with PVI alone.

We included only Randomized Controlled trials comparing Pulmonary Vein Isolation alone with Pulmonary Vein Isolation along with additional ablations or alternative ablation strategies in adults with persistent or paroxysmal Atrial Fibrillation. A thorough literature search was performed, and data were extracted in a tabulated form. A random-effects meta-analysis was performed, and afterwards, subgroup analyses were done to individually assess the efficacy of the most commonly used additional ablation strategies.

A total of 65 studies with 10,760 participants were included. The mean age was 57 years, with approximately 68% male participants. The Additional Ablation group was associated with a significantly lower Risk Ratio (0.76, 95% CI: 0.70,0.82. P < 0.00001) of the composite primary outcome compared with PVI alone.

While additional ablation strategies beyond pulmonary vein isolation (PVI) have been associated with a trend towards improved outcomes, current evidence does not conclusively demonstrate superior efficacy over PVI alone. Further research is needed to clarify the potential benefits of adjunctive ablation approaches and to determine whether individualized strategies may improve outcomes in selected patient populations.