What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: Atrial fibrillation (n=1613). Intervention: Adjunctive ganglionated plexi (GP) ablation vs. Pulmonary vein isolation (PVI) alone. Primary outcome: Freedom from atrial tachyarrhythmia at short-term follow-up (OR 1.72, 95% CI 1.21-2.45, p=0.003).

What does this research mean for the field?

Adding ganglionated plexi (GP) ablation to pulmonary vein isolation (PVI) significantly increases freedom from atrial tachyarrhythmia in patients with atrial fibrillation, whereas adjunctive complex fractionated atrial electrogram (CFAE) ablation does not provide this benefit. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.NEUTRAL.

October 20, 2016Open Access

Atrial Substrate Modification in Atrial Fibrillation: Targeting GP or CFAE? Evidence from Meta-Analysis of Clinical Trials

MQMu QinShanghai Jiao Tong University XLXu LiuHebei Medical University SWShaohui WuShanghai Jiao Tong University

Key Result

Addition of ganglionated plexi ablation to pulmonary vein isolation significantly increased freedom from atrial tachyarrhythmia at short-term follow-up (OR 1.72) compared to PVI alone, whereas adjunctive CFAE ablation did not.

Study Design

Type

Meta-Analysis (n=1,613)

Structured PICO

Does adjunctive GP or CFAE ablation improve freedom from atrial tachyarrhythmia in patients with atrial fibrillation compared to PVI alone?

Population

1,613 patients with atrial fibrillation (AF) pooled from 14 randomized and non-randomized controlled trials

Intervention

Adjunctive cardiac ganglionated plexi (GP) or complex fractionated atrial electrograms (CFAE) ablation added to pulmonary vein isolation (PVI)

Comparator

Pulmonary vein isolation (PVI) alone

Outcome

Freedom from atrial tachyarrhythmia in short- and long-term follow-up

In patients with AF, adjunctive GP ablation, but not CFAE ablation, significantly improves sinus rhythm maintenance when added to PVI alone.

Main Result

Effect estimate: OR 1.72 (95% CI 1.21-2.45)

p-value: p=0.003

Limitations

Distinctly different AF populations across studies and lack of access to original patient-level data
Some patients receiving repeat procedures did not follow initial randomization assignment
A small percentage of patients remained on anti-arrhythmic drugs at follow-up
Relatively low number of trials for the subgroup analysis of GP ablation

Abstract

Several clinically relevant outcomes post atrial substrate modification in patients with atrial fibrillation (AF) have not been systematically analyzed among published studies on adjunctive cardiac ganglionated plexi (GP) or complex fractionated atrial electograms (CFAE) ablation vs. pulmonary vein isolation (PVI) alone. Out of 176 reports identified, the present meta-analysis included 14 randomized and non-randomized controlled trials (1613 patients) meeting inclusion criteria. Addition of GP ablation to PVI significantly increased freedom from atrial tachyarrhythmia in short- (OR: 1.72; P = 0.003) and long-term (OR: 2.0, P = 0.0006) follow-up, while adjunctive CFAE ablation did not after one or repeat procedure (P<0.05). The percentage of atrial tachycardia or atrial flutter (AT/AFL) after one procedure was higher for CFAE than GP ablation. In sub-analysis of non-paroxysmal AF, relative to PVI alone, adjunctive GP but not CFAE ablation significantly increased sinus rhythm maintenance (OR: 1.88, P = 0.01; and OR:1.24, P = 0.18, respectively). Meta regression analysis of the 14 studies indicated that sample size was significant source of heterogeneity either in outcomes after one or repeat procedure. In conclusion, in patients with AF, adjunctive GP but not CFAE ablation appeared to significantly add to the beneficial effects on sinus rhythm maintenance of PVI ablation alone; and CFAE ablation was associated with higher incidence of subsequent AT/AFL.

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