Key result
Adjunctive PWI improves atrial tachyarrhythmia-free survival by ~14% vs PVI alone.
Why the study?
It remained unclear whether electrical silence of the left atrial posterior wall offers additional clinical benefits over pulmonary vein isolation alone in patients undergoing catheter ablation for AF.
Does adjunctive posterior wall isolation (PWI) to pulmonary vein isolation (PVI) improve atrial tachyarrhythmia-free survival in patients undergoing catheter ablation for atrial fibrillation?
Systematic Review (n=3,143)
Does adjunctive posterior wall isolation (PWI) to pulmonary vein isolation (PVI) improve atrial tachyarrhythmia-free survival in patients undergoing catheter ablation for atrial fibrillation?
Relative Risk: 1.14 (95% CI 1.04–1.25)
p-value: p=0.004
Adding posterior wall isolation to pulmonary vein isolation improves atrial tachyarrhythmia-free survival in patients with atrial fibrillation, particularly those with persistent AF, without increasing complications.
Adjunctive posterior wall isolation merits consideration in atrial fibrillation ablation; reinforces pooled randomized evidence for better arrhythmia-free survival.
The posterior left atrium (LAPW) is an important substrate for initiation and maintenance of atrial fibrillation (AF). While it has been proposed as a potential target for preventing recurrence of atrial tachyarrhythmias, it remains unclear whether electrical silence of LAPW offers additional benefits over pulmonary vein isolation (PVI) alone. We conducted a systematic review of PubMed, Medline, Embase, and Cochrane databases and identified 21 eligible studies, encompassing 1514 patients assigned to PVI + posterior wall isolation (PWI) group and 1629 patients assigned to PVI group. Over a median follow-up of 12 months, adjunctive PWI significantly improved the atrial tachyarrhythmia-free survival by 14 % in comparison to PVI alone [relative risk (RR): 1.14, 95 % confidence interval (CI): 1.04 to 1.25, p = 0.004]. This improvement was mainly attributed to a pronounced benefit for patients with persistent AF. In addition, patients undergoing PVI + PWI had a longer procedure time [weighted mean difference (WMD): 23.85, 95 % CI: 12.68 to 35.01, p < 0.001], ablation time (WMD: 9.27, 95 % CI: 5.19 to 13.54, p < 0.001), and a nearly negligible increase in fluoroscopic exposure (WMD: 2.69, 95 % CI: -0.23 to 5.62, p = 0.071). There was no increased risk of procedure-related complications between these approaches (RR: 1.06, 95 % CI: 0.71 to 1.57, p = 0.787). Compared with PVI alone, PWI adjunctive to PVI exhibited a higher procedure success of sinus rhythm maintenance in persistent AF during an index catheter ablation. Meanwhile, elongated procedure time and ablation time did not compromise the safety of extensive ablation strategy with additional PWI.
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Song et al. (2024) conducted a systematic review in Atrial fibrillation (n=3,143). Pulmonary vein isolation (PVI) + posterior wall isolation (PWI) vs. PVI alone was evaluated on Atrial tachyarrhythmia-free survival (RR 1.14, 95% CI 1.04 to 1.25, p=0.004). Adjunctive posterior wall isolation significantly improved atrial tachyarrhythmia-free survival compared to pulmonary vein isolation alone (RR 1.14; 95% CI 1.04-1.25; p=0.004).
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