Candidate for the Lee B. Lusted Student Prize Competition
Purpose: To evaluate the comparative effectiveness of pulmonary vein isolation (PVI) versus PVI plus adjuvant atrial ablations (PVI+) in patients with atrial fibrillation (AF).
Method: A systematic review of literature, published before October 2010, was undertaken to include randomized and non-randomized controlled trials evaluating clinical efficacy, effectiveness, or safety of ablation procedures in adult patients with AF.
Result: Of 2,726 potential citations identified by the original search 17 randomized controlled trials and 3 non-randomized trials were included. Our meta-analysis revealed that at 12 months, AF patients who underwent PVI+ strategies had a significantly higher rate of maintaining sinus rhythm than those who underwent PVI alone (RR 1.09, 95% CI 1.01, 1.16). However, subgroup analysis was significant for only PVI+ left atrial (LA) linear ablations (RR 1.18, 95% CI 1.05, 1.32). Overall, the pooled success rates were higher in PVI+ group in both subgroups of paroxysmal (RR 1.14, 95% CI 1.05, 1.24) and persistent/permanent AF (RR 1.70, 95% CI 1.16, 2.49). The effect of PVI+ LA ablation was greater in persistent/permanent AF patients than those with paroxysmal AF. Technical approaches used for PVI (segmental or circumferential) did not make any difference in the superiority of PVI+ LA linear ablations to PVI alone. The summary estimates of effect were 1.17 (1.05, 1.31) and 1.08 (1.02, 1.14) for segmental and circumferential PVI groups, respectively. Our review found insufficient data to evaluate the impact of study interventions on stroke, heart failure, procedural complications and mortality.
Conclusion: PVI+ strategies appear to result in significantly higher success rates than PVI alone in the first year after the procedure. Studies of longer duration are needed to evaluate the long-term benefits and safety of different adjunctive ablation approaches for rhythm control in AF patients.