Comparing efficacy and safety in catheter ablation strategies for atrial fibrillation: a network meta-analysis

Abstract

Background: There is no consensus on the most efficient catheter ablation (CA) strategy for patients with atrial fibrillation (AF). The objective of this study was to compare the efficacy and safety of different CA strategies for AF ablation through network meta-analysis (NMA).

Methods: A systematic search of PubMed, Web of Science, and CENTRAL was performed up to October 5th, 2020. Randomized controlled trials (RCT) comparing different CA approaches were included. Efficacy was defined as arrhythmia recurrence after CA and safety as any reported complication related to the procedure during a minimum follow-up time of 6 months.

Results: In total, 67 RCTs (n = 9871) comparing 19 different CA strategies were included. The risk of recurrence was significantly decreased compared to pulmonary vein isolation (PVI) alone for PVI with renal denervation (RR: 0.60, CI: 0.38-0.94), PVI with ganglia-plexi ablation (RR: 0.62, CI: 0.41-0.94), PVI with additional ablation lines (RR: 0.8, CI: 0.68-0.95) and PVI in combination with bi-atrial modification (RR: 0.32, CI: 0.11-0.88). Strategies including PVI appeared superior to non-PVI strategies such as electrogram-based approaches. No significant differences in safety were observed.

Conclusions: This NMA showed that PVI in combination with additional CA strategies, such as autonomic modulation and additional lines, seem to increase the efficacy of PVI alone. These strategies can be considered in treating patients with AF, since, additionally, no differences in safety were observed. This study provides decision-makers with comprehensive and comparative evidence about the efficacy and safety of different CA strategies.

Systematic review registration: PROSPERO registry number: CRD42020169494 .

Keywords: Antiarrhythmic drugs; Atrial fibrillation; Catheter ablation; Efficacy; Network meta-analysis; Safety.

Fig. 1

PRISMA flow chart diagram

Fig. 2

Network plots for efficacy (A), safety (B), and procedural time (C). Each treatment is represented as a node and an edge exists between two nodes if direct trial evidence is available. The size of each node is proportional to the number of patients involved in each treatment across all trials, while the size of the edges is proportional to the number of studies available in the corresponding comparison. Abbreviations: Bi, bi-atrial; comb, combination; EGM, electrocardiogram; GP, ganglia plexi; mod. modification; LAA, left atrial appendage; PVI, pulmonary vein isolation; RDN, renal denervation; RR, risk ratio; step, stepwise ablation; sub, substrate; SVC, superior vena cava; trig, trigger

Fig. 3

Forest plots for efficacy (A), safety (B), and procedural time (C) compared with PVI showing the network meta-analysis RRs with their 95% CIs. Abbreviations: Bi, bi-atrial; comb, combination; EGM, electrocardiogram; GP, ganglia plexi; mod, modification; LAA, left atrial appendage; PVI, pulmonary vein isolation; RDN, renal denervation; RR, risk ratio; step, stepwise ablation; sub, substrate; SVC, superior vena cava; trig, trigger

Fig. 4

RRs for efficacy (lower triangle) and safety (upper triangle) with their 95% CIs derived from network meta-analysis of 19 AF strategies in the full network colored by certainty of evidence assessed for each comparison with CINeMA and classified in high (in green), moderate (in blue), low (in yellow) and very low (in red). Empty cells correspond to comparisons not available for the safety outcome. RRs lower than 1 favor the treatment in the column for both outcomes. Abbreviations: Bi, bi-atrial; comb, combination; EGM, electrocardiogram; GP, ganglia plexi; mod, modification; LAA, left atrial appendage; RDN, renal denervation; RR, risk ratio; step, stepwise ablation; sub, substrate; SVC, superior vena cava; trig, trigger