Affiliation:
1. Department of Medicine Stanford University School of Medicine Stanford CA
2. Veterans Affairs Palo Alto Health Care System Palo Alto CA
3. Center for Digital Health Stanford University School of Medicine Stanford CA
Abstract
Background
The objective was to explore the efficacy of ablation lesion sets in addition to pulmonary vein isolation (
PVI
) for paroxysmal atrial fibrillation. The optimal strategy for catheter ablation of paroxysmal atrial fibrillation is debated.
Methods and Results
The SMASH‐AF (Systematic Review and Meta‐analysis of Ablation Strategy Heterogeneity in Atrial Fibrillation) study cohort includes trials and observational studies identified in PubMed, Scopus, and Cochrane databases from January 1 1990, to August 1, 2016. We included studies reporting single procedure paroxysmal atrial fibrillation ablation success rates. Exclusion criteria included insufficient reporting of outcomes, ablation strategies that were not prespecified and uniform, and a sample size of fewer than 40 patients. We analyzed lesion sets performed in addition to
PVI
(
PVI
plus) using multivariable random‐effects meta‐regression to control for patient, study, and procedure characteristics. The analysis included 145 total studies with 23 263 patients (
PVI‐
only cohort: 115 studies, 148 treatment arms, 16 500 patients;
PVI
plus cohort: 39 studies; 46 treatment arms, 6763 patients).
PVI
plus studies, as compared with
PVI
‐only studies, included younger patients (56.7 years versus 58.8 years,
P
=0.001), fewer women (27.2% versus 32.0% women,
P
=0.002), and were more methodologically rigorous with longer follow‐up (29.5 versus 17.1 months,
P
0.004) and more randomization (19.4% versus 11.8%,
P
<0.001). In multivariable meta‐regression,
PVI
plus studies were associated with improved success (7.6% absolute improvement [95% CI, 2.6–12.5%];
P
<0.01,
I
2
=88%), specifically superior vena cava isolation (4 studies, 4 treatment arms, 1392 patients; 15.1% absolute improvement [95% CI, 2.3–27.9%];
P
0.02,
I
2
=87%). However, residual heterogeneity was large.
Conclusions
Across the paroxysmal atrial fibrillation ablation literature,
PVI
plus ablation strategies were associated with incremental improvements in success rate. However, large residual heterogeneity complicates evidence synthesis.
Publisher
Ovid Technologies (Wolters Kluwer Health)
Subject
Cardiology and Cardiovascular Medicine