Clinical outcomes of adjunctive posterior wall isolation in persistent atrial fibrillation: A meta‐analysis

Abstract

Background: Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation but the recurrence rate remains relatively high in persistent patients with AF. Therefore, posterior wall isolation (PWI) in addition to PVI has been proposed to increase freedom from AF.Objective: To evaluate the success of adjunctive PWI in persistent AF. Methods:We searched electronic database using specific terms. The primary outcomes are recurrence rate of AF and recurrence of atrial arrhythmias. The secondary outcomes were atrial flutter/tachycardia (AFL/AT), procedure time, fluoroscopy time, and procedure related complications. Estimated risk ratios (RRs) and 95% confidence intervals (CIs) were evaluated.Results: Six studies were included (1334 patients with persistent AF). Adjunctive PWI resulted in a significant reduction in the recurrence rate of AF compared with patients who had PVI only (19.8% vs 29.1%; RR, 0.64; 95% CI, 0.42-0.97; P < .04; I 2 = 76%). There was a significant reduction in the recurrence rate of all atrial arrhythmia (30.8% vs 41.1%; RR, 0.75; 95% CI, 0.60-0.94; P < .01; I 2 = 60%). Compared with PVI only, adjunctive PWI did not increase the rate of AFL or AT (11.6% vs 13.9%; RR, 0.85; 95% CI, 0.54-1.32; P < .46; I 2 = 47%) or the rate of procedure related complications (4.6% vs 3.6%; RR, 1.25; 95% CI, 0.72-2.17; P < .44; I 2 = 0%). Conclusion:In patients with persistent AF, adjunctive PWI was associated with decreased recurrence of AF and atrial arrhythmias compared with PVI alone without an increased risk of AFL or AT or procedure related complications. K E Y W O R D Satrial fibrillation, atrial flutter, meta-analysis, posterior wall isolation, pulmonary vein isolation 1 | BACKGROUND Atrial fibrillation (AF) is the most common arrhythmia, with a prevalence of 0.5% to 1% of the population, 1 and is expected to rise even more over the next decades. 2 Historically management of AF has been geared toward rate control, or rhythm control with antiarrhythmic drugs. Over the last two decades, catheter ablation has emerged as an alternative for rhythm control with medications and is now a recognized first line therapy for the treatment of AF in select populations. This is emphasized for instance in the recent American College of Cardiology updated guidelines, which states that catheter ablation may be used in selected patients with symptomatic AF and heart failure with low ejection fraction based on data to support reduced hospitalization and potentially even reduce mortality. 3

Repeat procedures for recurrent persistent atrial fibrillation: A propensity‐matched score comparison between left atrial linear ablation with radiofrequency and posterior wall isolation with the cryoballoon

“…Consistent with preclinical data, a recent meta‐analysis 18 reported that adjunctive LAPWI in PersAF resulted in a significant reduction in the recurrence rate of ATas, without an increased risk of atrial flutter, compared to patients who had PVI only. Noticeably, only in one of the included studies PVI and LAPWI were performed with a second‐generation CB‐A and few studies focusing on LAPWI with CB‐A have been published so far.…”

Persistent Atrial Fibrillation: The Role of Left Atrial Posterior Wall Isolation and Ablation Strategies

“…The majority of these studies included only patients with PersAF and LSPersAF, which is in line with current guideline recommendations when considering posterior wall isolation in conjunction with PVI [ 1 ]. Meta-analyses of a few randomised and observational comparison studies have suggested an overall benefit of endocardial posterior wall ablation compared to pulmonary vein isolation alone in PersAF [ 35 , 36 ], but results of the individual studies, including the randomised clinical trials [ 37 , 38 , 39 ], are mixed ( Table 1 ). This may, in part, be due to the lack of a standardised approach to posterior wall isolation, which is evidenced by the various lesion sets used in published studies.…”

Residual potential at the epicardial left atrium after conventional left atrial posterior wall isolation for persistent atrial fibrillation: A case report

“…Pulmonary vein isolation (PVI) has become the standard treatment for atrial fibrillation (AF) and some studies have reported the benefits of additional posterior wall isolation (PWI) after PVI for persistent AF, which they had confirmed by meta-analysis. 1 However, a previous study reported that PWI in addition to PVI did not improve the recurrence of AF. 2 Furthermore, PWI with additional ablation within the box lesion from 41% to 55% after roof and inferior line ablation has been reported.…”