Atrial Substrate Modification in Atrial Fibrillation: Targeting GP or CFAE? Evidence from Meta-Analysis of Clinical Trials

<div><p>Several clinically relevant outcomes post atrial substrate modification in patients with atrial fibrillation (AF) have not been systematically analyzed among published studies on adjunctive cardiac ganglionated plexi (GP) or complex fractionated atrial electograms (CFAE) ablation vs. pulmonary vein isolation (PVI) alone. Out of 176 reports identified, the present meta-analysis included 14 randomized and non-randomized controlled trials (1613 patients) meeting inclusion criteria. Addition of GP ablation to PVI significantly increased freedom from atrial tachyarrhythmia in short- (OR: 1.72; P = 0.003) and long-term (OR: 2.0, P = 0.0006) follow-up, while adjunctive CFAE ablation did not after one or repeat procedure (P<0.05). The percentage of atrial tachycardia or atrial flutter (AT/AFL) after one procedure was higher for CFAE than GP ablation. In sub-analysis of non-paroxysmal AF, relative to PVI alone, adjunctive GP but not CFAE ablation significantly increased sinus rhythm maintenance (OR: 1.88, P = 0.01; and OR:1.24, P = 0.18, respectively). Meta regression analysis of the 14 studies indicated that sample size was significant source of heterogeneity either in outcomes after one or repeat procedure. In conclusion, in patients with AF, adjunctive GP but not CFAE ablation appeared to significantly add to the beneficial effects on sinus rhythm maintenance of PVI ablation alone; and CFAE ablation was associated with higher incidence of subsequent AT/AFL.</p></div

Effects of additional GP/CFAE ablation on long-term sinus rhythm maintenance after one procedure.

<p>Effects of additional GP/CFAE ablation on long-term sinus rhythm maintenance after one procedure.</p

Effects of additional GP/CFAE ablation on short-term sinus rhythm maintenance in patients with non-paroxysmal AF.

<p>Effects of additional GP/CFAE ablation on short-term sinus rhythm maintenance in patients with non-paroxysmal AF.</p

Effects of additional GP/CFAE ablation on sinus rhythm maintenance after repeat procedure.

<p>Effects of additional GP/CFAE ablation on sinus rhythm maintenance after repeat procedure.</p

Results of literature search for the meta-analysis

<p>Results of literature search for the meta-analysis</p

Funnel plot (with pseudo-95% confidence intervals) of studies in the meta-analysis.

<p>Funnel plot (with pseudo-95% confidence intervals) of studies in the meta-analysis.</p

Atrial tachyarrhythmia recurrence in each ablation strategy.

<p>Atrial tachyarrhythmia recurrence in each ablation strategy.</p

Characteristics of patients in each ablation strategy.

<p>Characteristics of patients in each ablation strategy.</p

Detailed procedures of included trials.

<p>Detailed procedures of included trials.</p

Kinetics of I_to and I_Kur channels.

<p>Kinetics of I_to and I_Kur channels.</p