Comparative efficacy and safety of different catheter ablation strategies for persistent atrial fibrillation: a network meta-analysis of randomized clinical trials

Abstract Aims Whereas pulmonary vein isolation (PVI) is the universally agreed target in catheter ablation of paroxysmal atrial fibrillation (AF), an ideal ablation set in persistent AF remains questioned. Aim of this study is to conduct a network meta-analysis (NMA) of randomized clinical trials (RCTs) comparing different ablation strategies in persistent AF patients. Methods and results Network meta-analysis was performed in a frequentist framework with the different ablation strategies constituting the competitive arms of interest. Primary efficacy endpoint was recurrences of atrial tachyarrhythmia (AF, atrial flutter, and/or organized atrial tachycardia). Secondary endpoints included major peri-procedural complications, procedure, and fluoroscopy duration. PubMED/MEDLINE and EMBASE databases were searched through June 2020. 2548 records were screened and 57 full-text articles assessed. Eventually 24 RCTs were included, encompassing 3245 patients (median follow-up 15 months, IQR 12–18). Compared to PVI alone, PVI plus linear lesions in the left atrium and elimination of extra-PV sources was the only strategy associated with a reduced risk of arrhythmia recurrence (RR 0.49, 95%CI 0.27–0.88). Most treatment arms were associated with longer procedural time compared with PVI; however, major peri-procedural complications and fluoroscopy time did not differ. Conclusion A comprehensive strategy including PVI, linear lesions in the left atrium, and elimination of extra-PV sources (constrained by a heterogeneous definition across studies) was associated with reduced risk of recurrent atrial tachyarrhythmias compared to PVI alone. All investigated treatment arms yielded similar safety profiles. Further research should rely on enhanced substrate-based approach definitions to solve one of the most evident knowledge gaps in interventional electrophysiology.

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Evaluation of proarrythmogenic effects after different techniques of radiofrequency catheter ablation of atrial fibrillation

Patologiya krovoobrashcheniya i kardiokhirurgiya ◽

10.21688/1681-3472-2013-1-33-37 ◽

2015 ◽

Vol 17 (1) ◽

pp. 33 ◽

Cited By ~ 1

Author(s):

S. N. Artemenko ◽

A. B. Romanov ◽

V. V. Shabanov ◽

I. G. Stenin ◽

D. A. Yelesin ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Left Atrium ◽

Radiofrequency Catheter Ablation ◽

Persistent Atrial Fibrillation ◽

Linear Lesions ◽

Group I ◽

Significant Difference ◽

Group Ii

To assess proarrythmogenic effects after different techniques of radiofrequency catheter ablation, 427 patients with paroxysmal, persistent, and long-standing persistent atrial fibrillation (AF) were examined. The patients were randomized into four groups: antral pulmonary vein isolation (PVI) (Group I), PVI plus roof line and mitral isthmus ablation (Group II), anatomic ablation of ganglionated plexuses (GP) of the left atrium (Group III) and GP plus PVI (Group IV). At the end of follow up (34,43,2 months) the largest number of proarrythmogenic effects was observed in Group II, 24,8% (26 patients). In the remaining groups the percentage of proarrythmogenic effects did not exceed 11%, neither was there any significant difference among Groups I, III and IV. Thus, the creation of additional linear lesions in the left atrium is a predictor of proarrythmogenic effects during follow up.

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Catheter Ablation vs. Anti-Arrhythmic Drugs as First-Line Treatment in Symptomatic Paroxysmal Atrial Fibrillation: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Frontiers in Cardiovascular Medicine ◽

10.3389/fcvm.2021.664647 ◽

2021 ◽

Vol 8 ◽

Author(s):

Andrea Saglietto ◽

Fiorenzo Gaita ◽

Roberto De Ponti ◽

Gaetano Maria De Ferrari ◽

Matteo Anselmino

Keyword(s):

Atrial Fibrillation ◽

Systematic Review ◽

Clinical Trials ◽

Catheter Ablation ◽

Randomized Clinical Trials ◽

Meta Analysis ◽

Rhythm Control ◽

First Line ◽

Atrial Tachyarrhythmias

Background: Catheter ablation has become a well-established indication for long-term rhythm control in atrial fibrillation (AF) patients refractory to anti-arrhythmic drugs (AADs). Efficacy and safety of AF catheter ablation (AFCA) before AADs failure are, instead, questioned.Objective: The aim of the study was to perform a systematic review and meta-analysis of randomized clinical trials (RCTs) comparing first-line AFCA with AADs in symptomatic patients with paroxysmal AF.Methods: We performed a random-effects meta-analysis of binary outcome events comparing AFCA with AADs in rhythm control-naïve patients. The primary outcomes, also stratified by the type of ablation energy (radiofrequency or cryoenergy), were (1) recurrence of atrial tachyarrhythmias and (2) recurrence of symptomatic atrial tachyarrhythmias. The secondary outcomes included adverse events.Results: Six RCTs were included in the analysis. AFCA was associated with lower recurrences of atrial tachyarrhythmias [relative risk (RR) 0.58, 95% confidence interval (CI) 0.46–0.72], consistent across the two types of ablation energy (radiofrequency, RR 0.50, 95% CI 0.28–0.89; cryoenergy, RR 0.60, 95% CI 0.50–0.72; p-value for subgroup differences: 0.55). Similarly, AFCA was related to less symptomatic arrhythmic recurrences (RR 0.46, 95% CI 0.27–0.79). Overall, adverse events did not differ. A trend toward increased periprocedural cardiac tamponade or phrenic nerve palsy was observed in the AFCA group, while more atrial flutter episodes with 1:1 atrioventricular conduction and syncopal events were reported in the AAD group.Conclusions: First-line rhythm control therapy with AFCA, independent from the adopted energy source (radiofrequency or cryoenergy), reduces long-term arrhythmic recurrences in patients with symptomatic paroxysmal AF compared with AADs.

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Faculty Opinions recommendation of The impact of adjunctive complex fractionated atrial electrogram ablation and linear lesions on outcomes in persistent atrial fibrillation: a meta-analysis.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.725932128.793537245 ◽

2017 ◽

Author(s):

Brian Olshansky

Keyword(s):

Atrial Fibrillation ◽

Meta Analysis ◽

Persistent Atrial Fibrillation ◽

Linear Lesions ◽

Atrial Electrogram ◽

The Impact ◽

Complex Fractionated Atrial Electrogram

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Pre-Procedural Prediction of Termination of Persistent Atrial Fibrillation by Catheter Ablation as an Indicator of Reverse Remodeling of the Left Atrium

Circulation Journal ◽

10.1253/circj.cj-12-0934 ◽

2013 ◽

Vol 77 (6) ◽

pp. 1416-1423 ◽

Cited By ~ 9

Author(s):

Koji Kumagai ◽

Tamotsu Sakamoto ◽

Keijiro Nakamura ◽

Mamoru Hayano ◽

Eiji Yamashita ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Left Atrium ◽

Persistent Atrial Fibrillation ◽

Reverse Remodeling

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Meta-Analysis of Randomized Clinical Trials Comparing the Impact of Implantable Loop Recorder Versus Usual Care After Ischemic Stroke for Detection of Atrial Fibrillation and Stroke Risk

The American Journal of Cardiology ◽

10.1016/j.amjcard.2021.09.013 ◽

2021 ◽

Author(s):

Darae Ko ◽

Qiying Dai ◽

David B. Flynn ◽

Nicholas A. Bosch ◽

Robert H. Helm ◽

...

Keyword(s):

Atrial Fibrillation ◽

Clinical Trials ◽

Ischemic Stroke ◽

Usual Care ◽

Stroke Risk ◽

Randomized Clinical Trials ◽

Meta Analysis ◽

Implantable Loop Recorder ◽

Loop Recorder ◽

The Impact

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Abstract 14648: Gender Differences in Procedural Complications Associated With Atrial Fibrillation Catheter Ablation: A Systematic Review and Meta-analysis of 244,353 Patients

Circulation ◽

10.1161/circ.142.suppl_3.14648 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Martin L Campbell ◽

John Larson ◽

Talha Farid ◽

Stacy Westerman ◽

Michael S Lloyd ◽

...

Keyword(s):

Atrial Fibrillation ◽

Systematic Review ◽

Catheter Ablation ◽

Gender Gap ◽

Major Bleeding ◽

Fixed Effects ◽

Meta Analysis ◽

Vascular Complications ◽

Increased Risk ◽

Procedural Complications

Introduction: Women undergoing atrial fibrillation catheter ablation (AFCA) have higher rates of vascular complications and major bleeding. However, studies have been underpowered to detect differences in rare complications such as stroke/transient ischemic attack (TIA) and procedural mortality. Methods: We performed a systematic review of databases (PubMed, World of Science, Embase) to identify studies published since 2010 reporting AFCA complications by gender. Six complications of interest were: 1) vascular/groin complications; 2) pericardial effusion/tamponade; 3) stroke/TIA; 4) permanent phrenic nerve injury; 5) major bleeding & 6) procedural mortality. For meta-analysis, random effects models were used when heterogeneity between studies was ≥ 50% (vascular complications, major bleeding) and fixed effects models for other endpoints. Results: Of 5716 citations, 19 studies met inclusion criteria, comprising 244,353 patients undergoing AFCA, of whom 33% were women. Women were older (65.3 ± 11.2 vs. 60.4 ± 13.2 years), more likely hypertensive (60.6 vs. 55.5%) and diabetic (18.3 vs. 16.5%) and had higher CHA 2 DS 2 -VASc scores (3.0 ± 1.8 vs. 1.4 ± 1.4) (p<0.0001 for all comparisons). The rates of all 6 complications were significantly higher in women (Table). However, despite statistically significant differences, the overall incidences of major complications were very low in both genders: stroke/TIA (women 0.51 vs. men 0.39%) and procedural mortality (women 0.25 vs. men 0.18%). Conclusion: Women experience significantly higher rates of AFCA complications. However, the incidence of major procedural complications is very low in both genders. The higher rate of complications in women may be partially attributable to older age and a higher prevalence of comorbidities at the time of ablation. More detailed studies are needed to better define the mechanisms of increased risk in women and to identify strategies for closing the gender gap.

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