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Meta-Analysis
. 2018 May;11(5):e006119.
doi: 10.1161/CIRCEP.117.006119.

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

Tina Baykaner  1 , Albert J Rogers  1 , Gabriela L Meckler  1 , Junaid Zaman  1 , Rachita Navara  1 , Miguel Rodrigo  1 , Mahmood Alhusseini  1 , Christopher A B Kowalewski  1 , Mohan N Viswanathan  1 , Sanjiv M Narayan  1 , Paul Clopton  1 , Paul J Wang  2 , Paul A Heidenreich  1
Affiliations
Meta-Analysis

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

Tina Baykaner et al. Circ Arrhythm Electrophysiol. 2018 May.

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.

Keywords: ablation, catheter; arrhythmia; atrial fibrillation; cohort studies; freedom; meta-analysis; odds ratio.

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Conflict of interest statement

The other authors report no conflicts.

Figures

Figure 1.
Figure 1.. Flowchart illustrating study selection methodology.
AF indicates atrial fibrillation; and PVI, pulmonary vein isolation.
Figure 2.
Figure 2.. Meta-analysis of studies with control groups.
Top, Table demonstrates pooled odds ratio (OR) for freedom from atrial fibrillation (AF). Bottom, Table demonstrates pooled OR for freedom from AF/atrial tachycardia (AT) of 3 studies with driver ablation with pulmonary vein isolation (PVI) and 2 studies with driver-only ablation, compared with PVI. The study by Atienza et al is represented in 2 rows to reflect driver ablation with PVI and driver-only ablation cohorts. CI indicates confidence interval.
Figure 3.
Figure 3.. Forest plot diagrams showing pooled outcomes for long-term freedom from atrial fibrillation (AF; left) and freedom from all arrhythmias (right) in 15 studies that performed AF driver ablation with pulmonary vein isolation.
AT indicates atrial tachycardia; and CI, confidence interval.
Figure 4.
Figure 4.. Forest plot diagrams demonstrating acute termination rates of atrial fibrillation (AF) in 15 studies that performed AF driver ablation with pulmonary vein isolation.
CI indicates confidence interval.
See this image and copyright information in PMC

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