Table 8.
Clinical trials comparing left atrial posterior wall isolation plus PVI vs. PVI alone in AF patients undergoing catheter ablation
| Study | Study design | Number of patients | Ablation strategy | Outcome |
|---|---|---|---|---|
| Wong et al.957 | RCT | 67 persistent AF patients (PVI + PWI: 39, PVI: 28) | PVI vs. PVI + PWI PWI: box with additional ablation lesions within the box as needed |
No difference in atrial arrhythmia recurrence rate between the PVI + PWI and PVI only groups at a median follow-up of 12.4 ± 3.0 months (25.6 vs. 28.6%; P = 0.79) |
| Kistler et al.838 | RCT | 338 symptomatic persistent AF patients (first ablation) (PVI + PWI: 170, PVI: 168) | PVI (wide antral circumferential) plus PWI (roof and floor lines deployment plus ablation of earliest electrograms within the box if needed) or PVI alone | No difference in the primary study endpoint at 12 months, with 52.4% freedom from recurrent atrial arrhythmia after a single ablation procedure without AADs in the PVI + PWI group as compared to 53.6% in the PVI group (P = 0.98) |
| Jiang et al.839 | Pooled analysis of 26 studies (9 RCTs) | 3287 paroxysmal and persistent AF patients receiving PVI + PWI | PWI: both box and non-box ablation lesions | In persistent AF, adjunctive PWI was associated with substantially lower recurrence of all atrial arrhythmias (risk ratio: 0.74; 95% CI: 0.62–0.90, P < 0.001) and AF (risk ratio: 0.67; 95% CI: 0.50–0.91, P = 0.01), particularly when only randomized data were examined PVI + PWI using a non-box lesion was associated with significantly less recurrence of AF (OR: 0.30; 95% CI: 0.22–0.41). |
| Jankelson et al.958 | Consecutive series | 321 paroxysmal AF patients (PVI: 214; PVI + PWI: 107) | PVI vs. PVI + PWI PWI consisted of a roof line connecting the LSPV and RSPV along with a low posterior line connecting the inferior PVs |
Recurrence at 1 year: PVI group: 14% vs. PVI + PWI group: 15% (P = 0.96) |
| Ahn et al.953 | RCT | 100 persistent AF patients undergoing first ablation (PVI only: 50 vs. PVI + PWI: 50) with cryoballoon | PWI: additional cryoballoon ablation lesions at 9–13 different locations on the LAPW. | Atrial tachyarrhythmia recurrence during a mean follow-up of 457.9 ± 61.8 days: PVI only: 46% PVI + PWI: 24%, P = 0.035 |
| Sirico et al.840 | Consecutive series | 73 persistent and long-standing persistent AF patients receiving PWI + PVI | PWI: roof line joining the 2 superior PVs and inferior line linking the 2 inferior PVs | PWI + PVI was able to reduce the mean atrial arrhythmic burden by more than 50% compared with preablation, reporting very low levels (≤5%) over 2 years |
| Tokioka et al.841 | Consecutive series | 181 persistent AF patients (PVI only: 91 vs. PVI + PWI: 90) | PWI: Pentaray was placed at the posterior wall to record electrical potentials Endpoint was defined as the absence of electrical activity and inability to capture outside the posterior wall during pacing with the Pentaray catheter with 5 mA output from the posterior LA |
At a median follow-up of 19 months: AF recurrence: PVI only: 47.3% PVI + PWI: 31.1% (P = 0.35) Persistent AF recurrence: PVI only: 20.9% PVI + PWI: 5.6% (P = 0.002) |
| Pothineni et al.842 | Consecutive series | 196 paroxysmal (61%) and persistent (39%) AF patients undergoing repeat ablation (PVRI: 93; PWI ± PVRI: 103) | PVRI vs. PWI ± PVRI PWI consisted of linear lesions across the LA roof and floor connecting the previous circumferential lesion sets that were used for left and right PVI, with additional lesions at sites of earliest activation within the ‘box’ if needed |
Freedom from atrial arrhythmias off AADs at 1 year: PVRI: 69.9% vs. PWI ± PVRI: 43.7% (P = 0.5) |
| Salih et al.843 | Metaanalysis of 6 studies | 1334 persistent AF patients (PVI: 663; PVI + PWI: 671) | PVI vs. PVI + PWI | At 21.6 ± 13 months: AF recurrence rate: PVI only: 29.1% PVI + PWI: 19.8%, risk ratio: 0.64; 95% CI: 0.42–0.97, P < 0.04 Atrial arrhythmia recurrence rate: PVI only: 41.1% PVI + PWI: 30.8%, risk ratio: 0.75; 95% CI: 0.60–0.94, P < 0.01 |
| Sutter et al.844 | Retrospective study | 558 persistent AF patients undergoing initial and repeat ablation (PVI: 255, PVI + PWI: 78, PVI + lines: 225) | PVI vs. PVI + PWI vs. PVI + lines PWI: linear ablation along the LA roof to connect LSPV and RSPV and linear ablation along the LA floor to connect inferior PVs Lines: one or more of the following: mitral isthmus, LA roof, or cavotricuspid isthmus line |
Sinus rhythm at 6 months: PVI: 73.9% vs. PVI + lines: 72.2% vs. PVI + PWI: 57.7% |
| Yamaji et al.845 | RCT | Persistent AF patients without LA low-voltage area Electrophysiological test subgroup: 57 (+PWI: 24; −PWI: 33) |
+PWI: PVI + PWI + SVCI + CTIA −PWI: PVI + SVCI + CTIA PWI: roof line joining the two superior PVs and inferior line connecting the two inferior PVs |
AF/AT recurrence at median 62.7 weeks: +PWI: 25% vs. −PWI: 15% (P = 0.311) |
| Lee et al.837 | RCT | 207 persistent AF patients (PVI: 105; PVI + PWI: 102) | PVI vs. PVI + PWI PWI: roof line joining the two superior PVs and inferior line connecting the two inferior PVs with touch-up ablation at the PW if needed to achieve exit block (additional anterior line at the physician's discretion) |
Freedom from atrial arrhythmia without AAD at 1 year: PVI: 50.5% vs. PVI + PWI: 55.9% (P = 0.522) |
| McLellan et al.846 | Consecutive series | 161 persistent AF patients undergoing circumferential PVI followed by PWI (no-adenosine challenge: 107, adenosine challenge: 54)a | PWI: roof and inferior wall lines with the endpoint of bidirectional block | Adenosine-induced reconnection of the PW was demonstrated in 17% Freedom from recurrent atrial arrhythmia at 19 ± 8 months: adenosine challenge: 65% vs. no-adenosine challenge: 40% (P < 0.01) |
| Bai et al.836 | Prospective non-randomized trial | 52 persistent AF patients (PVI only: 20; PVI + PWI: 32) All patients underwent a second procedure 3 months after the first procedure |
PWI: PVI was extended to the CS and to the left side of the interatrial septum, along with extensive ablations on the LAPW At 3 months, electrophysiology study was performed in all patients to confirm durability of the PWI and PVI |
Freedom from atrial arrhythmia without AADs at 1, 2, and 3 year follow-ups: PVI: 20, 15, and 10%, respectively PVI + PWI: 65, 50, and 40%, respectively, P < 0.001 |
| Kim et al.847 | RCT | 120 persistent AF patients (PVI + lines: 60 vs. PVI + lines + PWI: 60) | Roof, anterior perimitral and CTI lines with conduction block were performed in all patients PWI: additional posterior inferior line connecting inferior PVs |
Recurrence at 1 year: PVI + lines: 36.7% vs. PVI + lines + PWI: 16.7%, P = 0.02 |
AAD, antiarrhythmic drug; AF, atrial fibrillation; CI, confidence interval; CS, coronary sinus; CTIA, cavotricuspid isthmus ablation; LA, left atrium; LAPW, left atrial posterior wall; LSPV, left superior pulmonary vein; OR, odds ratio; PV, pulmonary vein; PVI, pulmonary vein isolation; PVRI, pulmonary vein reisolation; PWI, posterior wall isolation; RCTs, randomized controlled trials; RSPV, right superior pulmonary vein; SVCI, superior vena cava isolation.
aAdenosine challenge to assess dormant conduction in the PVs and PW.