Approach to the Catheter Ablation Technique of Paroxysmal and Persistent Atrial Fibrillation: A Meta‐Analysis of the Randomized Controlled Trials

Journal of Cardiovascular Electrophysiology (Impact Factor: 3.48). 06/2011; 22(7):729 - 738. DOI: 10.1111/j.1540-8167.2011.02010.x

ABSTRACT Review of the Catheter Ablation Technique in AF. Background: Several randomized controlled trials (RCTs) have been published to investigate the optimal techniques for atrial fibrillation (AF) ablation. Many of these are small in number and include both paroxysmal and persistent AF; however, the techniques for each of these types of AF may differ.Method and Results: We searched MEDLINE, EMBASE, and the Cochrane Controlled Trials Register for RCTs evaluating AF ablation for either paroxysmal or persistent AF. The primary endpoint was freedom from AF after a single procedure. A total of 35 unique randomized controlled trials were found to fulfill the criteria. A significant degree of heterogeneity was present given the differing sample sizes, populations studied, and outcomes. Radiofrequency ablation (RFA) was found to be favorable in prevention of AF over antiarrhythmic drugs (AADs) in either paroxysmal (5 studies, RR 2.26; 95% CI 1.74, 2.94) or persistent AF (5 studies, RR 3.20; 95% CI 1.29, 8.41). When comparing specific techniques, wide-area PVI appeared to offer the most benefit for both paroxysmal (6 studies, RR 0.78; 95% CI 0.63, 0.97) and persistent AF (3 studies, RR 0.64; 95% CI 0.43, 0.94). CFE ablation provided only benefit for persistent AF when combined with antral PVI (4 studies, RR 0.55; 95% CI 0.34, 0.87).Conclusions: Despite significant methodological limitations, it appears that additional ablations beyond PVI are necessary for persistent AF but not proven for paroxysmal AF. The optimal technique for persistent AF, however, deserves a further study, in the setting of a large, randomized controlled trial. (J Cardiovasc Electrophysiol, Vol. 22, pp. 729-738, July 2011)

  • [Show abstract] [Hide abstract]
    ABSTRACT: Background-Catheter ablation (CA) is commonly performed for persistent atrial fibrillation, but few high-quality randomized controlled trials (RCTs) exist, leading to funding restrictions being proposed in several countries. We performed a random-effects meta-analysis of RCTs and non-RCTs to assess the efficacy of CA for persistent atrial fibrillation. Methods and Results-We systematically searched PubMed, EMBASE, CENTRAL, OpenGrey, and for RCTs and non-RCTs reporting clinical outcomes after CA for persistent atrial fibrillation. Forty-six eligible studies were identified containing 3819 patients. After a single procedure, CA significantly reduced the risk of recurrent atrial fibrillation compared with medical therapy (odds ratio [OR], 0.32; 95% confidence interval [CI], 0.20-0.53; P<0.001). Outcomes were better if the pulmonary veins were encircled (OR, 0.26; 95% CI, 0.09-0.74; P=0.01), and electrical isolation reduced AF recurrence compared with purely anatomic encirclement (OR, 0.33; 95% CI, 0.13-0.86; P=0.02). Linear ablation within the left atrium (OR, 0.22; 95% CI, 0.10-0.49; P<0.001), but not complex fractionated atrial electrogram ablation (OR, 0.64; 95% CI, 0.35-1.18; P=0.15), significantly reduced AF recurrence. Results were not improved by performing more extensive linear lesion sets (OR, 0.77; 95% CI, 0.41- 1.43; P=0.40) or from biatrial ablation (OR, 0.62; 95% CI, 0.31-1.24; P=0.17). Where data were available, the relative benefits seen held true both after a single or multiple procedure(s). Sensitivity analyses showed that inclusion of non-RCTs increased statistical power without biasing the calculated effect sizes. Conclusions-For patients with persistent atrial fibrillation, CA achieves significantly greater freedom from recurrent atrial fibrillation compared with medical therapy. The most efficacious strategy is likely to combine isolation of the pulmonary veins with limited linear ablation within the left atrium.
    Circulation Arrhythmia and Electrophysiology 08/2014; 7(5). DOI:10.1161/CIRCEP.114.001759 · 5.95 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Durable isolation of the pulmonary veins (PVs) remains the cornerstone of treatment for paroxysmal atrial fibrillation (PAF) and is also used in the treatment of some patients with persistent atrial fibrillation. Visually guided laser ablation (VGLA) has been proven to be safe and effective as a treatment for atrial fibrillation (AF). It has shown high levels of durable PV isolation (PVI), even in the hands of less experienced users. This paper presents the long-term clinical outcomes of all patients treated with VGLA over the course of 4 years in the world's most experienced centre: from early product feasibility work treating only PAF patients to our work using the commercially available product, when we also treated persistent AF patients.
    Europace 07/2014; 16(12). DOI:10.1093/europace/euu168 · 3.05 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The efficacy and safety of catheter ablation for the management of atrial fibrillation (AF) has been improved in recent years. Radiofrequency (RF) catheter ablation for maintaining sinus rhythm is superior to the current antiarrhythmic drug therapy in selected patients. Pulmonary vein isolation (PVI) is the cornerstone of various catheter ablation strategies. It is well recognized that pulmonary vein (PV) antrum contributes to the AF initiation and/or perpetuation. Since PV stenosis is a complication of ablation within a PV, the ablation site for PVI has shifted to the junction between the left atrium and the PV rather than the ostium of the PV. However, PV reconnection after ablation is the major cause of recurrence of AF. The recovery of PV conduction could be caused by anatomical variations such as the failure to produce complete transmural lesion or gaps at the ablation line due to the transient electrophysiologic effects from the RF ablation. In this review, we discussed several factors to be considered for the achievement of the best PVI, including clinical aspects and technical aspects.
    Korean Circulation Journal 09/2014; 44(5):291-300. DOI:10.4070/kcj.2014.44.5.291