Do specific catheter ablation techniques improve freedom from AF compared to antiarrhythmic drugs or other ablation strategies in patients with paroxysmal or persistent atrial fibrillation?
Wide-area PVI offers benefit for both paroxysmal and persistent AF, while additional ablations beyond PVI (such as CFE ablation) appear necessary and beneficial only for persistent 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.
Parkash et al. (Fri,) studied this question.