Pulmonary Vein Isolation Plus Adjunct Techniques Versus Pulmonary Vein Isolation Alone for Persistent Atrial...

Multiple randomized controlled trials (RCTs) have compared the efficacy of pulmonary vein isolation adjunct (PVI+) techniques with PVI alone in patients with persistent atrial fibrillation (AF). However, these comparisons have been limited by a small sample size or conflicting results. It remains unclear if there is any benefit offered by these PVI+ techniques.

We conducted a systematic review and meta-analysis of RCTs and compared the efficacy of different PVI+ techniques with PVI alone. We hypothesized that as compared with PVI alone, the PVI+ techniques have a superior efficacy in freedom from atrial arrhythmias.

A systematic search of MEDLINE and EMBASE was conducted. The outcomes of interest included freedom from atrial arrhythmias, freedom from AF, procedure time, fluoroscopy time, ablation time and procedural complications. For dichotomous outcomes, Mantel-Haenszel risk ratios (RR) with 95% CIs were calculated using random-effects model. For the continuous outcomes standardized mean differences (SMD) were calculated. Subgroup analyses were conducted for various PVI + techniques including posterior wall isolation, linear lines, complex fractionated atrial electrograms, and low voltage area ablation.

A total of 18 RCTs comprising 3459 patients (PVI + = 1956, PVI alone=1503) were included. There was no statistically significant difference between the two arms in the freedom from atrial arrhythmias (RR 1.10; 95% CI [1.00-1.22]; p = 0.06; I² = 56%), and freedom from AF (RR 1.12; 95% CI [0.99-1.25]; p = 0.06; I² = 63%). PVI+ techniques were associated with a statistically significant increase in procedure time (SMD 1.46; 95% CI [0.76-2.15]; p < 0.0001; I² = 96%), fluoroscopy time (SMD 0.45; 95% CI [0.06-0.84]; p = 0.02; I² = 91%), and ablation time (SMD 1.32; 95% CI [0.74-1.90]; p < 0.00001; I² = 95%). There was no statistically significant difference in the pooled total complications between PVI + vs. PVI alone (RR 1.61; 95% CI [0.99-2.62]; p = 0.05; I² = 26%).

This meta-analysis of 18 RCTs shows that there is no difference in the freedom from atrial arrhythmias with various PVI + techniques vs. PVI alone in patients with persistent AF. Further large RCTs are needed to determine the ideal ablation strategy for these patients.