Key result
Adding PWI to PFA-based PVI shows no benefit over PVI alone for persistent AF recurrence.
Why the study?
Pulsed field ablation-guided PVI has limited efficacy in persistent AF, and the efficacy of combining PVI with left atrial posterior wall isolation remains controversial.
Does pulsed field ablation-based pulmonary vein isolation combined with posterior wall isolation reduce atrial tachyarrhythmia recurrence compared to pulmonary vein isolation alone in patients with persistent atrial fibrillation?
Meta-Analysis (n=1,983)
Yes
Does pulsed field ablation-based pulmonary vein isolation combined with posterior wall isolation reduce atrial tachyarrhythmia recurrence compared to pulmonary vein isolation alone in patients with persistent atrial fibrillation?
Effect estimate: RR 1.10 (95% CI 0.78-1.57)
p-value: p=0.59
Adding posterior wall isolation to pulsed field ablation-based pulmonary vein isolation for persistent atrial fibrillation does not improve efficacy but significantly prolongs procedure time.
PVI + PWI should not yet change practice for AF ablation; leaves open its efficacy pending dedicated randomized trials despite added procedural burden.
Pulsed field ablation (PFA)-guided pulmonary vein isolation (PVI) has limited efficacy in treating persistent atrial fibrillation (AF) and requires additional substrate modification, but the efficacy of PVI combined with left atrial posterior wall isolation (PWI) under PFA remains controversial. This systematic review and meta-analysis aimed to compare the efficacy and safety of PFA-based PVI alone versus PVI + PWI in such patients. A systematic literature search was conducted up to March 11, 2026, with key endpoints of atrial tachyarrhythmia recurrence and procedural complications analyzed via a random-effects model. Thirteen studies (6 cohort, 7 single-arm) encompassing 1983 patients from diverse clinical centers were included. Cohort study analysis showed no significant recurrence reduction with PVI + PWI (RR = 1.10, 95%CI 0.78-1.57, P = 0.59, I² = 41%). PVI + PWI required more 3D electroanatomic mapping (RR = 1.47, P = 0.03, I² = 95%) and prolonged procedure time by 16.22 min (95%CI 0.35-32.08, P = 0.05, I² = 88%). Conclusion: PVI + PWI provides no significant efficacy benefit over PVI alone in PFA for persistent AF. It prolongs procedure duration and does not increase complication risk.
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Wan et al. (2026) conducted a meta-analysis in persistent atrial fibrillation (n=1,983). Pulmonary vein isolation (PVI) + posterior wall isolation (PWI) under PFA vs. PVI alone under PFA was evaluated on atrial tachyarrhythmia recurrence (RR 1.10, 95% CI 0.78-1.57, p=0.59). PFA-based PVI combined with PWI provided no significant reduction in atrial tachyarrhythmia recurrence compared to PVI alone for persistent AF (RR 1.10; 95% CI 0.78-1.57; P=0.59).
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