Although pulmonary vein isolation (PVI) is a well-established treatment of paroxysmal atrial fibrillation (AF), early studies of PVI only in patients with persistent AF (PeAF) reported suboptimal success rates. This led to the development of novel strategies to target atrial substrate, including linear lesion creation, ablation of complex fractionated atrial electrograms (CFAEs) and non-PV triggers, and more recently rotor ablation. However, data from STAR AF II indicated that addition of linear lesions or CFAE ablation did not improve outcomes over PVI alone.1 Similarly, evidence for rotor ablation efficacy is observational and has not been widely reproduced. In this context, and with the advent of more advanced technologies (including contact force-sensing catheters and the second-generation cryoballoon [CB2]), a number of recent studies have revisited the approach of PVI only for management of PeAF. The focus of this systematic review was to examine these recently reported success rates for “PVI only” in PeAF using the latest technology iterations and to identify predictors of success.
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We performed a comprehensive literature search of MEDLINE, Embase, Web of Science, PubMed, and the Cochrane-controlled Trials Register in August 2016. The search was restricted to studies involving humans that were published in English. In addition, the reference lists of all relevant trials and reviews were hand searched. Key search terms were “persistent atrial fibrillation,” “catheter ablation,” “pulmonary vein isolation,” and “second generation cryoballoon.” With respect to trials involving
From the 2218 citations first screened, 84 full-text articles were reviewed, and 14 met inclusion criteria for analysis of the primary outcome (Figure 1). Baseline patient characteristics and single-procedure 12-month arrhythmia-free survival rates of the included studies are given in Table 1, Table 2, respectively. Of the 956 patients with PeAF undergoing PVI only included in the analysis, 419 (45.2%) underwent PVI alone with RF, whereas 509 (54.8%) underwent cryoballoon PVI. Seven studies
Based on results from recent studies using the latest technology, we observed a 66.7% single-procedure 12-month arrhythmia-free survival using PVI only in a PeAF population with a low prevalence of structural heart disease. This result is comparable to data reported in an earlier (2011) meta-analysis of PVI in paroxysmal AF, which observed a 12-month success rate of 66.6%.2 However, for PVI alone in PeAF, the same meta-analysis observed a 12-month success rate of just 51.9%. Improved success
In patients with PeAF and minimal structural heart disease, PVI alone yields a 1-year single-procedure arrhythmia-free survival of 66.7% and is a legitimate strategy. These medium-term outcomes in lower-risk patients are now comparable to results in the paroxysmal AF population, with very low complication rates. Ongoing technologic advances, earlier referral in the disease process, and addition of risk factor modification may further improve outcomes.
Dr. Voskoboinik is supported by a co-funded National Health and Medical Research Council of Australia (NHMRC)/National Heart Foundation of Australia (NHF) postgraduate scholarship and Baker IDI Bright Sparks scholarship. Profs. Kistler, Sanders, and Kalman are supported by practitioner fellowships from the NHMRC. Prof. Sanders is also supported by a practitioner fellowship from the NHF. This research is supported in part by the Victorian Government’s Operational Infrastructure Funding. Prof. Kalman sits on the advisory board of Biosense Webster and Boston Scientific; and receives research and fellowship support from Biosense Webster, Boston Scientific, St. Jude Medical, and Medtronic. Prof. Sanders has served on the advisory board of Biosense Webster, Medtronic, and St. Jude Medical; has received lecture fees from Biosense Webster, Medtronic, St. Jude Medical, Boston Scientific, and Merck; and has received research funding from Medtronic, St. Jude Medical, Boston Scientific, Biotronik, and Sorin.
