Catheter ablation for treatment of bradycardia–tachycardia syndrome: is it time to consider it the therapy of choice? A systematic review and meta-analysis

Abstract

BackgroundAtrial fibrillation catheter ablation (AFCA) should be considered as a strategy to avoid pacemaker (PM) implantation for patients with bradycardia–tachycardia syndrome (BTS), but lack of evidence is remarkable.MethodsOur aim was to conduct a random-effects model meta-analysis on safety and efficacy data from controlled trials and observational studies. We compared atrial fibrillation (AF) recurrence, AF progression, procedural complication, additional procedure, cardiovascular death, cardiovascular hospitalization, heart failure and stroke in patients undergoing AFCA vs. PM implantation.ResultsPubMed/MEDLINE, Cochrane Database and Google Scholar were screened, and four retrospective studies were selected. A total of 776 patients (371 in the AFCA group, 405 in the PM group) were included. After a median follow-up of 67.5 months, lower AF recurrence [odds ratio (OR) 0.06, confidence interval (CI) 0.02–0.18, I2 = 82.42%, P < 0.001], AF progression (OR 0.12, CI 0.06–0.26, I2 = 0%, P < 0.001), heart failure (OR 0.12, CI 0.04–0.34, I2 = 0%, P < 0.001), and stroke (OR 0.30, CI 0.15–0.61, I2 = 0%, P = 0.001) were observed in the AFCA group. No differences were observed in cardiovascular death and hospitalization (OR 0.48, CI 0.10–2.28, I2 = 0%, P = 0.358 and OR 0.43, CI 0.14–1.29, I2 = 87.52%, P = 0.134, respectively). Higher need for additional procedures in the AFCA group was highlighted (OR 3.65, CI 1.51–8.84, I2 = 53.75%, P < 0.001). PM implantation was avoided in 91% of BTS patients undergoing AFCA.ConclusionsAFCA in BTS patients seems to be more effective than PM implantation in reducing AF recurrence and PM implantation may be waived in most BTS patients treated by AFCA. Need for additional procedures in AFCA patients is balanced by long-term benefit in clinical end points.

Comparison between catheter ablation versus permanent pacemaker implantation as an initial treatment for tachycardia–bradycardia syndrome patients: a prospective, randomized trial

“…During the 3-year follow-up period, there were no differences in rehospitalizations or deaths (20.5% vs. 20.0%, P = 0.646), but CA was superior in its capacity to reduce the AF/AT recurrence (64.7% vs. 25.7%, P < 0.001). More importantly, the crossover was only 7.4% in the CA arm during the study period, thus suggesting that CA could be an effective alternative for the PM [21]. However, our and other previously published studies had inherent selection biases from observational studies, as CA patients were usually rhythm control-eligible patients at younger ages associated with lower rates of comorbidities.…”

Atrial fibrillation ablation compared to pacemaker therapy in patients with tachycardia–bradycardia syndrome: A systematic review and updated meta-analysis

“…The aforementioned situation is largely in line with findings from previous meta-analyses. [11] Fourth, catheter ablation was shown to reduce the risk of all-cause mortality and thromboembolism compared to pacemaker implantation. There was no significant difference in procedural complications between AF ablation and pacemaker implantation.…”

“…These findings differ from those of previous meta-analyses. [11] Sinus node dysfunction (SND) encompasses several arrhythmias that disrupt the normal pacing function of the heart, such as sinus bradycardia, sinus arrest, sinoatrial block, and alternating episodes of tachycardia (TBS). TBS, a specific subtype of SND, often occurs due to the termination of atrial fibrillation, atrial flutter, or atrial tachycardia.…”

“…[10] However, there is controversy regarding whether the long-term prognosis of AF ablation is superior to pacemaker implantation. In a previous meta-analysis, Magnano et al [11] observed that AFCA in TBS patients seems to be more effective than pacemaker implantation in reducing AF recurrence and pacemaker implantation may be waived in most TBS patients treated by AFCA. Since then, several articles have been published in this field, rendering necessary an update.…”