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Clinical Implications of Ablation of Drivers for Atrial Fibrillation: A Systematic Review and Meta-Analysis.

ABSTRACT: BACKGROUND:The outcomes from pulmonary vein isolation (PVI) for atrial fibrillation (AF) are suboptimal, but the benefits of additional lesion sets remain unproven. Recent studies propose ablation of AF drivers improves outcomes over PVI, yet with conflicting reports in the literature. We undertook a systematic literature review and meta-analysis to determine outcomes from ablation of AF drivers in addition to PVI or as a stand-alone procedure. METHODS:Database search was done using the terms atrial fibrillation and ablation or catheter ablation and driver or rotor or focal impulse or FIRM (Focal Impulse and Rotor Modulation). We pooled data using random effects model and assessed heterogeneity with I2 statistic. RESULTS:Seventeen studies met inclusion criteria, in a cohort size of 3294 patients. Adding AF driver ablation to PVI reported freedom from AF of 72.5% (confidence interval [CI], 62.1%-81.8%; P<0.01) and from all arrhythmias of 57.8% (CI, 47.5%-67.7%; P<0.01). AF driver ablation when added to PVI or as stand-alone procedure compared with controls produced an odds ratio of 3.1 (CI, 1.3-7.7; P=0.02) for freedom from AF and an odds ratio of 1.8 (CI, 1.2-2.7; P<0.01) for freedom from all arrhythmias in 4 controlled studies. AF termination rate was 40.5% (CI, 30.6%-50.9%) and predicted favorable outcome from ablation(P<0.05). CONCLUSIONS:In controlled studies, the addition of AF driver ablation to PVI supports the possible benefit of a combined approach of AF driver ablation and PVI in improving single-procedure freedom from all arrhythmias. However, most studies are uncontrolled and are limited by substantial heterogeneity in outcomes. Large multicenter randomized trials are needed to precisely define the benefits of adding driver ablation to PVI.

SUBMITTER: Baykaner T

PROVIDER: S-EPMC6474343 | biostudies-literature | 2018 May

REPOSITORIES: biostudies-literature

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Clinical Implications of Ablation of Drivers for Atrial Fibrillation: A Systematic Review and Meta-Analysis.

Baykaner Tina T Rogers Albert J AJ Meckler Gabriela L GL Zaman Junaid J Navara Rachita R Rodrigo Miguel M Alhusseini Mahmood M Kowalewski Christopher A B CAB Viswanathan Mohan N MN Narayan Sanjiv M SM Clopton Paul P Wang Paul J PJ Heidenreich Paul A PA

Circulation. Arrhythmia and electrophysiology 20180501 5

<h4>Background</h4>The outcomes from pulmonary vein isolation (PVI) for atrial fibrillation (AF) are suboptimal, but the benefits of additional lesion sets remain unproven. Recent studies propose ablation of AF drivers improves outcomes over PVI, yet with conflicting reports in the literature. We undertook a systematic literature review and meta-analysis to determine outcomes from ablation of AF drivers in addition to PVI or as a stand-alone procedure.<h4>Methods</h4>Database search was done usi ...[more]

PMID: 29743170

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Project description:Abstract Introduction Catheter placement and stability are well‐known challenges in atrial fibrillation (AF) ablation. As a result, steerable sheaths (SS) were developed to improve catheter stabilization and maintain proper catheter–tissue contact. The purpose of this systematic review and meta‐analysis is to see if employing a SS influences procedure outcome. Method We performed a comprehensive literature search for studies that evaluated the efficacy and safety of SS compared to nonsteerable sheaths (NSS) in AF ablation. The primary outcome was the rate of atrial arrhythmia (AA) freedom by the time of the last follow‐up. The secondary outcomes were the procedure‐related complications and procedural characteristics. Risk ratio (RR) or the mean difference (MD) and corresponding 95% confidence intervals (CIs) were calculated using the random‐effects model. Results A total of 10 studies, including 967 AF patients (mean age: 59.2 ± 11.1 years, 516 patients managed with SS vs. 454 with NSS), were included. SS group showed a higher rate of freedom of AA compared to NSS (RR: 1.19; 95% CI 1.09–1.29; p < .001). Both techniques had similar rate for procedural‐related complication (RR: 1.09, 95% CI 0.50–2.39; p = .83). The SS strategy had a shorter procedure time (MD −10.6 [min], 95% CI −20.97, −0.20; p = .05) but comparable fluoroscopic and radiofrequency application times to the NSS group. Conclusions The SS for AF catheter ablation not only reduced the total procedure time but also significantly increased the rate of successful ablation while maintaining a similar safety profile when compared to the traditional NSS. This meta‐analysis reveals that the use of a steerable sheath for atrial fibrillation ablation resulted in a better success rate and a lower risk of late atrial arrhythmia recurrence. However, this should be weighed against the possibility of an increase in periprocedural complications and procedure costs.

Project description:Background: Balloon-based catheter ablations, including hot balloon ablation (HBA) and cryoballoon ablation (CBA), have rapidly emerged as alternative modalities to conventional catheter atrial fibrillation (AF) ablation owing to their impressive procedural advantages and better clinical outcomes and safety. However, the differences in characteristics, effectiveness, safety, and efficacy between HBA and CBA remain undetermined. This study compares the characteristic and prognosis differences between HBA and CBA. Methods: Electronic search was conducted in six databases (PubMed, Embase, Cochrane Library, Web of Science, ClinicalTrial.gov, and medRxiv) with specific search strategies. Eligible studies were selected based on specific criteria; all records were identified up to June 1, 2021. The mean difference, odds ratios (ORs), and 95% confidence intervals (CIs) were calculated to evaluate the clinical outcomes. Heterogeneity and risk of bias were assessed using predefined criteria. Results: Seven studies were included in the final meta-analysis. Compared with CBA, more patients in the HBA group had residual conduction and required a higher incidence of touch-up ablation (TUA) [OR (95% CI) = 2.76 (2.02-3.77), P = 0.000]. The most frequent sites of TUA were the left superior pulmonary veins (PVs) in the HBA group vs. the right inferior PVs in the CBA group. During HBA surgery, the left and right superior PVs were more likely to have a higher fluid injection volume. Furthermore, the procedure time was longer in the HBA group than in the CBA group [weighted mean difference (95% CI) = 14.24 (4.39-24.09), P = 0.005]. Patients in the CBA group could have an increased risk of AF occurrence, and accepted more antiarrhythmic drug therapy; however, the result was insignificant. Conclusions: HBA and CBA are practical ablation approaches for AF treatment. Patients who received HBA had a higher incidence of TUA and longer procedure time. Clinical outcomes during the mid-term follow-up between HBA and CBA were comparable. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=259487, identifier: CRD42021259487.

Dataset Information

Clinical Implications of Ablation of Drivers for Atrial Fibrillation: A Systematic Review and Meta-Analysis.

Publications

Clinical Implications of Ablation of Drivers for Atrial Fibrillation: A Systematic Review and Meta-Analysis.

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