Li Zhaofeng, Gao Tingwen, Li Wei, Wang Xue, Xie Xinxing
Department of cardiology, Rizhao Heart Hospital Qingdao University, Rizhao, China.
Cardiology. 2025;150(4):427-436. doi: 10.1159/000542368. Epub 2024 Dec 6.
The clinical outcomes of adjunctive posterior wall isolation (PWI) beyond pulmonary vein isolation (PVI) for non-paroxysmal atrial fibrillation (AF) remain unclear. This meta-analysis was conducted to evaluate the role of PWI in non-paroxysmal AF by pooled analysis of most updated randomized controlled trials (RCTs).
A literature search in PubMed, Embase, and the Cochrane Library was performed to identify RCTs comparing the outcomes of PVI with and without PWI in non-paroxysmal AF patients. The primary outcomes were recurrence rates of all atrial arrhythmias, AF, and atrial tachycardia/flutter (AT/AFL). The secondary outcomes included total procedure time, ablation time, fluoroscopy time and procedure-related complications. Estimated risk ratios (RRs) and 95% confidence intervals (CIs) were evaluated.
Nine RCTs with a total of 1,243 non-paroxysmal AF patients were included in our analysis. There were no significant differences in all atrial arrhythmias recurrence (RR: 0.86, 95% CI: 0.66-1.11, p = 0.24, I2 = 49%) and AF recurrence (RR: 0.74, 95% CI: 0.51-1.08, p = 0.12, I2 = 62%) between stand-alone PVI group and PVI plus PWI group. Adjunctive PWI increased the AT/AFL recurrence rate (RR: 1.62 95% CI: 1.08-2.42, p = 0.02, I2 = 0%). In the subgroup analysis, PWI using cryoballoon ablation was associated with a significantly lower recurrence rate of all atrial arrhythmias (p = 0.01) and AF (p = 0.02) recurrence and similar recurrence rate of AT/AFL (p = 0.15). Additional PWI was associated with an increased AT/AFL recurrence (p = 0.03) in patients with left atrial diameter (LAD) <44 mm. Adjunctive PWI needed longer ablation time, fluoroscopy time, and total procedure time. The incidence of procedural adverse events was low and similar between both groups.
Adjunctive PWI beyond PVI did not improve the freedom from all atrial arrhythmias and AF with an increased recurrence rate of AT/AFL in non-paroxysmal AF patients. The ablation energy and LAD might affect the clinical outcome of PWI. However, larger more RCTs were needed to verify our findings.
对于非阵发性心房颤动（房颤），在肺静脉隔离（PVI）基础上进行附加后壁隔离（PWI）的临床结局仍不明确。本荟萃分析旨在通过对最新随机对照试验（RCT）的汇总分析，评估PWI在非阵发性房颤中的作用。
在PubMed、Embase和Cochrane图书馆进行文献检索，以确定比较非阵发性房颤患者单纯PVI与PVI联合PWI结局的RCT。主要结局为所有房性心律失常、房颤以及房性心动过速/扑动（AT/AFL）的复发率。次要结局包括总手术时间、消融时间、透视时间和手术相关并发症。评估估计风险比（RR）和95%置信区间（CI）。
我们的分析纳入了9项RCT，共1243例非阵发性房颤患者。单纯PVI组与PVI加PWI组在所有房性心律失常复发率（RR：0.86，95%CI：0.66 - 1.11，p = 0.24，I² = 49%）和房颤复发率（RR：0.74，95%CI：0.51 - 1.08，p = 0.12，I² = 62%）方面无显著差异。附加PWI增加了AT/AFL复发率（RR：1.62，95%CI：1.08 - 2.42，p = 0.02，I² = 0%）。在亚组分析中，使用冷冻球囊消融的PWI与所有房性心律失常复发率显著降低（p = 0.01）以及房颤复发率降低（p = 0.02）相关，且AT/AFL复发率相似（p = 0.15）。在左心房直径（LAD）<44 mm的患者中，附加PWI与AT/AFL复发增加相关（p = 0.03）。附加PWI需要更长的消融时间、透视时间和总手术时间。两组手术不良事件发生率均较低且相似。
在非阵发性房颤患者中，PVI基础上的附加PWI并未提高无所有房性心律失常和房颤的发生率，反而增加了AT/AFL复发率。消融能量和LAD可能影响PWI的临床结局。然而，需要更多更大规模的RCT来验证我们的发现。
