Key result
In a meta-regression of 58 studies, left atrial appendage isolation increased freedom from AF by 39.5% (95% CI 9.1-78.4, P=0.008), while increased left atrial diameter reduced freedom from AF.
Why the study?
Ablation of persistent AF has been performed with varying success rates, which may be influenced by ablation techniques, patient demographics, comorbidities, and trial design.
Do specific ablation lesion sets (such as CFAE, LAA isolation, or PWI) and patient factors predict freedom from atrial fibrillation in patients undergoing persistent AF ablation?
Meta-Analysis (n=6,767)
Do specific ablation lesion sets (such as CFAE, LAA isolation, or PWI) and patient factors predict freedom from atrial fibrillation in patients undergoing persistent AF ablation?
In persistent AF ablation, posterior wall isolation and left atrial appendage isolation are associated with improved freedom from AF, whereas CFAE ablation may reduce success, and increased left atrial size strongly predicts recurrence.
LAA isolation may improve persistent AF ablation success; extends meta-regression evidence for lesion optimization while underscoring LA size as recurrence predictor.
AIMS: Ablation of persistent atrial fibrillation (PsAF) has been performed by many techniques with varying success rates. This may be due to ablation techniques, patient demographics, comorbidities, and trial design. We conducted a meta-regression of studies of PsAF ablation to elucidate the factors affecting atrial fibrillation (AF) recurrence. METHODS AND RESULTS: Databases were searched for prospective studies of PsAF ablation. A meta-regression was performed. Fifty-eight studies (6767 patients) were included. Complex fractionated atrial electrogram (CFAE) ablation reduced freedom from AF by 8.9% [95% confidence interval (CI) -15 to -2.3, P = 0.009). Left atrial appendage [LAA isolation (three study arms)] increased freedom from AF by 39.5% (95% CI 9.1-78.4, P = 0.008). Posterior wall isolation (PWI) (eight study arms) increased freedom from AF by 19.4% (95% CI 3.3-38.1, P = 0.017). Linear ablation or ganglionated plexi ablation resulted in no significant effect on freedom from AF. More extensive ablation increased intraprocedural AF termination; however, intraprocedural AF termination was not associated with improved outcomes. Increased left atrial diameter was associated with a reduction in freedom from AF by 4% (95% CI -6.8% to -1.1%, P = 0.007) for every 1 mm increase in diameter. CONCLUSION: Linear ablation, PWI, and CFAE ablation improves intraprocedural AF termination, but such termination does not predict better long-term outcomes. Study arms including PWI or LAA isolation in the lesion set were associated with improved outcomes in terms of freedom from AF; however, further randomized trials are required before these can be routinely recommended. Left atrial size is the most important marker of AF chronicity influencing outcomes.
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Sau et al. (2019) conducted a meta-analysis in persistent atrial fibrillation (PsAF) (n=6,767). Left atrial appendage (LAA) isolation was evaluated on freedom from AF (39.5% increase, 95% CI 9.1-78.4, p=0.008). In a meta-regression of 58 studies, left atrial appendage isolation increased freedom from AF by 39.5% (95% CI 9.1-78.4, P=0.008), while increased left atrial diameter reduced freedom from AF.
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