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Comparative efficacy and safety of different catheter ablation strategies for persistent atrial fibrillation: a network meta-analysis of randomized clinical trials.

AIMS
Whereas pulmonary vein isolation (PVI) is the universally agreed target in catheter ablation of paroxysmal AF, an ideal ablation set in persistent AF remains questioned. Aim of this study is to conduct a network meta-analysis (NMA) of randomized controlled clinical trials (RCTs) comparing different ablation strategies in persistent AF patients.


METHODS AND RESULTS
NMA was performed in a frequentist framework with the different ablation strategies constituting the competitive arms of interest. Primary efficacy endpoint was recurrences of atrial tachyarrhythmia (AF, atrial flutter and/or organized atrial tachycardia). Secondary endpoints included major peri-procedural complications, procedure and fluoroscopy duration. PubMED/MEDLINE and EMBASE databases were searched through June 2020. 2548 records were screened and 57 full-text articles assessed. Eventually 24 RCTs were included, encompassing 3,245 patients (median follow-up 15 months, IQR 12-18). Compared to PVI alone, PVI plus linear lesions in the left atrium and elimination of extra-PV sources was the only strategy associated with a reduced risk of arrhythmia recurrence (RR 0.49, 95%CI 0.27-0.88). Most treatment arms were associated with longer procedural time compared with PVI, however, major peri-procedural complications and fluoroscopy time did not differ.


CONCLUSION
A comprehensive strategy including PVI, linear lesions in the left atrium and elimination of extra-PV sources (constrained by a heterogeneous definition across studies) was associated with reduced risk of recurrent atrial tachyarrhythmias compared to PVI alone. All investigated treatments arms yielded similar safety profiles. Further research should rely on enhanced substrate-based approach definitions to solve one of the most evident knowledge gaps in interventional electrophysiology.