Key result
Adjunctive atrial driver ablation yields ~16% higher freedom from AF vs. PVI alone.
Why the study?
Pulmonary vein isolation has suboptimal success in persistent and long-standing persistent AF, and adjunctive ablation targeting atrial drivers has been proposed to enhance outcomes.
Does pulmonary vein isolation plus adjunctive atrial driver ablation improve freedom from atrial fibrillation and atrial tachyarrhythmia compared to pulmonary vein isolation alone in adults with persistent or long-standing persistent atrial fibrillation?
Meta-Analysis (n=1,359)
Randomized controlled trials
Yes
Does pulmonary vein isolation plus adjunctive atrial driver ablation improve freedom from atrial fibrillation and atrial tachyarrhythmia compared to pulmonary vein isolation alone in adults with persistent or long-standing persistent atrial fibrillation?
Adding atrial driver ablation to PVI in persistent AF modestly improves freedom from AF (though not robust to sensitivity analysis) without reducing overall atrial tachyarrhythmia recurrence, while significantly prolonging procedure, ablation, and fluoroscopy times.
Answers are grounded in this paper and cite their sources.
Should not change practice for persistent AF ablation; challenges assumptions of incremental benefit from driver ablation beyond PVI.
Objective Pulmonary vein isolation (PVI) remains the primary ablation strategy for atrial fibrillation (AF), yet its success in persistent (PeAF) and long-standing persistent AF (LS-PeAF) is suboptimal. Adjunctive ablation targeting atrial drivers has been proposed to enhance outcomes. This systematic review and meta-analysis compared PVI alone with PVI plus atrial driver ablation in PeAF and LS-PeAF. Methods Comprehensive searches of PubMed, Scopus, Europe PMC, and Cochrane Library identified randomized controlled trials (RCTs) enrolling adults with PeAF or LS-PeAF undergoing first-time ablation. Eligible studies compared PVI alone versus PVI plus driver ablation and trials utilizing other adjunctive ablations were excluded. Outcomes included recurrence of AF and any atrial tachyarrhythmia (ATA) beyond the blanking period, procedural parameters, and complications. Pooled analyses employed random-effects models to measure risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs). Results Seven RCTs met inclusion criteria. Adjunctive driver ablation modestly improved freedom from AF (RR 1.16; 95% CI, [1.03, 1.31]; p = 0.01; I²=61%). However, this finding was accompanied by substantial heterogeneity and was not robust to leave-one-out sensitivity analysis. Driver ablation failed to elevate freedom from any ATA (RR 1.09; 95% CI, [0.98, 1.20]; p = 0.11; I²=47%). Procedure duration (MD 37.81 min; 95% CI, [4.42, 71.20]; p = 0.03; I²=96%), fluoroscopy time (MD 4.25 min; 95% CI, [2.83, 5.67]; p < 0.00001; I²=0%), and ablation time (MD 10.01 min; 95% CI, [0.25, 19.77]; p = 0.04; I²=95%) were significantly longer with adjunctive driver ablation. Procedural complication rates were comparable among both groups (RR 1.65; 95% CI, [0.80, 3.43]; p = 0.18; I²=20%). Conclusion Additional atrial driver ablation modestly improves freedom from AF but does not reduce ATA recurrence, prolonging procedure time without increasing complications.
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Bramantyo et al. (2026) conducted a meta-analysis in Persistent and long-standing persistent atrial fibrillation (n=1,359). Pulmonary vein isolation (PVI) plus adjunctive atrial driver ablation vs. Pulmonary vein isolation (PVI) alone was evaluated on Freedom from atrial fibrillation beyond the blanking period (RR 1.16, 95% CI 1.03-1.31, p=0.01). Adjunctive atrial driver ablation plus PVI modestly improved freedom from AF compared to PVI alone (RR 1.16, 95% CI 1.03-1.31, p=0.01) without significantly reducing overall ATA recurrence.
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