The impact of posterior wall ablation in conjunction with pulmonary vein isolation in patients with persistent atrial fibrillation: a meta-analysis comparing cryoballoon vs. radiofrequency energy

FUNDING ACKNOWLEDGEMENTS: Type of funding sources: None. BACKGROUND: Pulmonary vein isolation (PVI) remains the cornerstone of atrial fibrillation (AF) ablation. In patients with persistent AF (PeAF), additional posterior wall ablation (PWA) has been proposed to improve outcomes. Individual small series have included patients ablated with a cryoballoon (CB) and radiofrequency (RF) energy and have yielded controversial results. We conducted a meta-analysis of available data to assess the incremental impact of PWA based on type of energy used for ablation. OBJECTIVE: To evaluate whether PVI + PWA is a more effective approach for treatment of PeAF than PVI alone based on ablation energy used. METHODS: The online databases (Pubmed, Medline, Embase) were searched using the terms "pulmonary vein isolation", "posterior wall isolation", or "posterior wall ablation". Out of 1917 studies, eight met our strict criteria (Table). Specifically, patients were undergoing de novo ablation for treatment of PeAF using either CB or RF. Patients had PVI alone vs PVI + PWA; studies that delivered additional ablations (except for cavotricuspid isthmus) were excluded. The primary outcome was recurrence of any atrial tachyarrhythmia (AT). RESULTS: The cohort consisted of 1607 patients (66 ± 17 years, 75% male); 830 (52%) patients were ablated CB and 777 (48%) patients were ablated with RF (Table). In the CB group, AT recurrence was significantly higher in patients who underwent PVI alone as compared to those who also had additional PWA (OR 2.55, 95% CI [1.89, 3.42], P < 0.0001, Figure). In contrast, in the RF group, outcome between the 2 groups (OR 1.40, 95% CI [0.81, 2.42], P = 0.22, Figure) was similar. CONCLUSIONS: Addition of CB based PWA to PVI in patients with PeAF undergoing ablation was associated with improved long-term ablation success. However, RF based PVA did not appear to confer the same benefit. Additional randomized studies are needed to determine the impact of ablation energy in patients undergoing PWA during ablation of PeAF. [Figure: see text] [Figure: see text]