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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:Introduction Catheter ablation for atrial fibrillation (AF) is the most frequently performed cardiac ablation procedure worldwide. The majority of ablations can now be performed safely with minimal radiation exposure or even without the use of fluoroscopy, thanks to advances in 3-dimensional electroanatomical mapping systems and/or intracardiac echocardiography. The aim of this study was to conduct a meta-analysis to compare the effectiveness of zero fluoroscopy (ZF) versus non-zero fluoroscopy (NZF) strategies for AF ablation procedures. Methods Electronic databases were searched and systematically reviewed for studies comparing procedural parameters and outcomes of ZF vs. NZF approaches in patients undergoing catheter ablation for AF. We used a random-effects model to derive the mean difference (MD) and risk ratios (RR) with a 95% confidence interval (CI). Results Our meta-analysis included seven studies comprising 1,593 patients. The ZF approach was found to be feasible in 95.1% of patients. Compared to the NZF approach, the ZF approach significantly reduced procedure time [mean difference (MD): −9.11 min (95% CI: −12.93 to −5.30 min; p < 0.01)], fluoroscopy time [MD: −5.21 min (95% CI: −5.51 to −4.91 min; p < 0.01)], and fluoroscopy dose [MD: −3.96 mGy (95% CI: −4.27 to −3.64; p < 0.01)]. However, there was no significant difference between the two groups in terms of total ablation time [MD: −104.26 s (95% CI: −183.37 to −25.14; p = 0.12)]. Furthermore, there was no significant difference in the acute [risk ratio (RR): 1.01, 95% CI: 1.00–1.02; p = 0.72] and long-term success rates (RR: 0.96, 95% CI: 0.90–1.03; p = 0.56) between the ZF and NZF methods. The complication rate was 2.76% in the entire study population and did not differ between the groups (RR: 0.94, 95% CI: 0.41–2.15; p = 0.89). Conclusion The ZF approach is a feasible method for AF ablation procedures. It significantly reduces procedure time and radiation exposure without compromising the acute and long-term success rates or complication rates.

Project description:BackgroundAtrial fibrillation (AF) is a risk factor for cognitive dysfunction. Although catheter ablation (CA) is one of the main treatments for AF, whether it can improve cognitive function in patients with AF remains unclear. We conducted a systematic review and meta-analysis to evaluate the cognitive outcome post-CA procedure.MethodsTwo investigators independently searched the PubMed, EMBASE, Web of Science, CNKI, WanFang, and VIP databases from inception to September 2021 for all the potentially eligible studies. The outcomes of interest included dementia or cognitive disorder through scoring or recognized classification criteria. Heterogeneity was determined by using Cochrane's Q test and calculating the I 2. A random-effects model was used to incorporate the potential effects of heterogeneity. The Newcastle-Ottawa Scale (NOS) was used to assess the methodological quality of each included study, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method was adopted to evaluate the quality of evidence.ResultThirteen studies including 40,868 patients were included, among which 12,086 patients received AF ablation. Meta-analysis indicated that patients with AF ablation had a lower risk of dementia incidence in comparison to patients with AF without ablation [hazard ratio (HR): 0.60, 95% CI: 0.43 to 0.84, p = 0.003 I 2 = 40%]. Significant differences were observed in the incidence of new-onset dementia [risk ratio (RR): 0.43, 95% CI: 0.28 to 0.65, p < 0.0001 I 2 = 84%]; the changes in the Montreal Cognitive Assessment (MoCA) score [weighted mean difference (WMD): 1.00, 95% CI: 0.36 to 1.64, p < 0.005 I 2 = 0%] and Mini-Mental State Examination (MMSE) score (WMD: 0.98, 95% CI: 0.69 to 1.26, p < 0.00001 I 2 = 0%]. However, in subgroup analysis, we did not observe significant changes in MoCA score at < 3 months (WMD: 1.20, 95% CI: -0.19 to 2.58, p = 0.09 I 2 = 50%) and changes in cognitive function scores between the radiofrequency group and cryoballoon group [standard mean difference (SMD): 0.39, 95% CI: -0.47 to 1.24, p = 0.38 I 2 = 87%]. The NOS indicated that included studies were moderate to high quality, while the quality of evidence assessed by GRADE was low in 2 and very low in 2.ConclusionWe analyzed the related cognitive outcomes after AF ablation. In the overall population, AF ablation had a positive trend for improving cognitive function at >3 months post-procedure. However, AF ablation might not be related to the improvement of cognitive function at < 3 months.Systematic review registrationhttps://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42021285198.

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:IntroductionAtrial Fibrillation (AF) is a common tachyarrhythmia affecting 33 million people worldwide. Hybrid AF ablation utilises a surgical (epicardial) ablation followed by an endocardial catheter-based ablation. The aim of this systematic review and meta-analysis is to summarize the literature reporting mid-term freedom from AF following hybrid ablation.MethodsAn electronic search of databases was performed to identify all relevant studies providing mid-term (2 year) outcomes following hybrid ablation for AF. The primary study outcome was to assess the mid-term freedom from AF following hybrid ablation, utilising the metaprop function on Stata® (Version 17.0, StataCorp, Texas, USA). Subgroup analysis was performed to assess the impact of various operative characteristics on mid-term freedom from AF. The secondary outcomes assessed mortality and procedural complication rate.ResultsThe search strategy identified 16 studies qualifying for inclusion in this meta-analysis, with 1242 patients in total. The majority of papers were retrospective cohort studies (15) and one study was a randomized control trial (RCT). The mean follow up was 31.5 ± 8.4 months. Following hybrid ablation, the overall mid-term freedom from AF was 74.6% and 65.4% for patients off antiarrhythmic drugs (AAD). Actuarial freedom from AF was 78.2%, 74.2% and 73.6% at 1, 2 and 3 years respectively. No significant differences in mid-term freedom from AF based epicardial lesion set (box vs pulmonary vein isolation) or Left atrial appendage/Ganglionated Plexus/Ligament of Marshall ablation or staged vs concomitant procedures. There were 12 deaths overall following the hybrid procedure with a pooled complication rate of 5.53%.ConclusionHybrid AF ablation offers promising mid-term freedom from AF reported at a mean follow-up of 31.5 months. The overall complication rate remains low. Further analysis of high-quality studies with randomized data and long-term follow up will help verify these results.

Dataset Information

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

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

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