Comparative Effectiveness of Wide Antral Versus Ostial Pulmonary Vein Isolation

Abstract

Background-For the past decade, electric pulmonary vein isolation (PVI) has become a procedure implemented worldwide for the treatment of atrial fibrillation. Currently, 2 main approaches are used for PVI: ostial isolation of the PVs and wide antral PVI. The aims of this systematic review are to evaluate the relative merits of each technique with a pooled comparative analysis of efficacy and complications. Methods and Results-Studies were identified by searching electronic databases for studies on ostial versus antral PVI.Information was extracted from each included trial. Odds ratio was the primary measure of treatment effect or side effects.The proportion of patients with recurrences of atrial fibrillation or other atrial tachyarrhythmias was evaluated at the end of the follow-up periods in 12 trials, including 1183 patients. The recurrence rate of total supraventricular arrhythmias was significantly lower in wide antral than in segmental PVI group (odds ratio, 0.42; 95% confidence interval, 0.32-0.56; P<0.00001). Atrial fibrillation recurrence was significantly lower in the wide antral group (odds ratio, 0.33; 95% confidence interval, 0.24-0.46; P<0,00001). A trend toward a higher incidence of left atrial tachycardia occurrence in the wide antral circumferential ablation group was detected, which did not reach statistical significance (odds ratio, 1.53; 95% confidence interval, 0.88-2.69; P=0.13). Conclusions-Our primary finding is that PVI performed with a wide antral approach is more effective than ostial PVI in achieving freedom from total atrial tachyarrhythmia recurrence at long-term follow-up. (Circ Arrhythm Electrophysiol. 2014;7:39-45.)

Pulmonary Vein Antrum Isolation in Patients With Paroxysmal Atrial Fibrillation

“…28,29 Also, in a meta-analysis by Proietti et al, wideantral approach encompassing the part of the posterior wall in between the PVs was observed to be more effective than ostial PV isolation in achieving freedom from arrhythmia. 30 For Shah et al, 14 the recurrence rate at 1, 2, 3, 4, and 5 years of follow-up were 8.7%, 5.8%, 8.8%, 13%, and 25.5%. This was a retrospective study of mixed PAF (86%) and non-PAF cohort.…”

Electroanatomic Mapping of the Intercaval Bundle in Atrial Fibrillation

“…Wide area circumferential ablation (WACA) in the antrum has increasingly replaced pulmonary vein (PV) ostial ablation because of a higher success rate and reduced risk of PV stenosis. 1 However, a percentage of patients require a second procedure for AF control. 2,3 At repeat ablation, PV reconnection is a common finding, and occasionally, it is difficult to achieve true entrance and exit block, especially for the right pulmonary veins (RPVs).…”

Catheter Ablation of Paroxysmal Atrial Fibrillation: Have We Achieved Cure with Pulmonary Vein Isolation?

“…On the other hand, the wide antral group had a nonsignificant trend towards a higher incidence of left atrial tachycardias (OR = 1.53, 95% CI 0.88 to 2.69; P = 0.13) (Figure 1). 21 No significant difference between the two ablation techniques were found in terms of periprocedural complications. Based on the results of clinical studies evaluating different PVI techniques, several conclusions can be drawn: (1) empirical isolation of all PVs is necessary to eliminate the majority of AF triggers and improve arrhythmia-free survival; (2) PVI should be verified with a circular mapping catheter; (3) a wide antral PVI empirically encompassing the left atrial posterior wall between the PVs is associated with improved success at follow-up compared to ostial PVI.…”

“…20 To better evaluate the benefit of wide antral PVI compared to ostial PVI, Proietti et al recently performed a systematic review and meta-analysis comparing the effectiveness of the two ablation techniques. 21 A total of 12 studies with 1,183 patients were included in the meta-analysis with a follow-up ranging from 6 to 48 months. Compared to ostial PVI (OR = 0.42, 95% confidence interval [CI] 0.32 to 0.56; P < 0.001), wide antral PVI was associated with a significantly lower rate of arrhythmia recurrence, which was driven by a reduced rate of AF at follow-up (OR = 0.33, 95% CI 0.24 to 0.46; P < 0.001).…”

“…From Proietti et al with permission. 21 houstonmethodist.org/debakey-journal strategy shown to improve the procedural success. In a multicenter trial, Di Biase et al randomized 257 consecutive patients undergoing a first AF ablation procedure to general anesthesia (n = 129) or conscious sedation (n = 128).…”