What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: Persistent Atrial Fibrillation (n=1119). Intervention: Pulmonary Vein Isolation (PVI) plus Posterior Wall Isolation (PWI) vs. Pulmonary Vein Isolation (PVI) alone. Primary outcome: Recurrence of Atrial Fibrillation (RR 0.66, 95% CI 0.44-0.98, p=0.04).

January 1, 2025Open Access

Efficacy and Safety of Adjunctive Posterior Wall Isolation in Patients with Persistent Atrial Fibrillation: A Systematic Review and Meta-Analysis

Key Result

Adjunctive posterior wall isolation significantly reduced the recurrence of atrial fibrillation (RR 0.66) compared to pulmonary vein isolation alone in patients with persistent atrial fibrillation.

Study Design

Type

Meta-Analysis (n=1,119)

Structured PICO

Does the addition of posterior wall isolation to pulmonary vein isolation reduce AF recurrence in patients with persistent atrial fibrillation?

Population

1119 patients with persistent atrial fibrillation from 8 randomized trials

Intervention

Pulmonary vein isolation (PVI) plus posterior wall isolation (PWI)

Comparator

Pulmonary vein isolation (PVI) alone

Outcome

Atrial fibrillation (AF) recurrence at 12-24 months follow-uphard clinical

In patients with persistent AF, adding posterior wall isolation to pulmonary vein isolation reduces AF recurrence but increases procedure time without increasing major complications.

Main Result

Effect estimate: RR 0.66 (95% CI 0.44-0.98)

Absolute Event Rate: 28.1% vs 36.2%

p-value: p=0.04

Limitations

Variability in rhythm monitoring approaches (intermittent Holter monitors vs. continuous implantable devices)
Lack of blinding for outcome assessors in some of the included studies
Heterogeneity in ablation techniques (cryoablation vs. radiofrequency) and operator experience
Presence of high or unclear risk of bias in some included studies

Abstract

Abstract Background In patients with persistent atrial fibrillation (AF), addition of posterior wall isolation (PWI) to pulmonary vein isolation (PVI) is controversial. Objective Compare PVI plus PWI versus PVI alone in patients with persistent AF. Methods We searched PubMed (by MEDLINE), Embase, LILACS, CENTRAL (by Cochrane Library), and Clinicaltrials.gov databases for randomized trials comparing PVI + PWI and PVI alone in persistent AF. The outcomes were: (i) AF recurrence; (ii) composite of recurrent atrial arrhythmias (i.e., AF, atrial tachycardia, or atrial flutter); (iii) major clinical complications (i.e., pericardial effusion or tamponade, sinus node dysfunction, or atrioesophageal fistula); (iv) mean ablation time. Risk of bias and quality of evidence were evaluated using the Cochrane Risk of Bias 2.0 tool and GRADE, respectively. Statistical significance was set at 5%, and subgroup and sensitivity analyses were performed. Results We included eight studies and 1119 patients, of which 561 underwent PVI + PWI. During follow-up (12 – 24 months), recurrence of AF was significantly reduced with adjunctive PWI (RR 0.66, 95% CI 0.44-0.98). Composite of recurrent atrial arrhythmias did not differ significantly (RR 0.83, 95% CI 0.65-1.06). Major clinical complications (RR 0.81, 95% CI 0.42-1.58) were similar, with PVI alone having a shorter mean procedure time (mean difference -23.37 minutes, 95% CI -30.23, -16.50). Conclusion Adjunctive PWI appears to be effective in improving recurrent AF, but not recurrence of all atrial arrhythmias. Procedure time was longer with PVI + PWI without significant change in overall safety. Further studies should focus on long-term benefit.

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