Long-Term Outcome of Pulmonary Vein Isolation With and Without Focal Impulse and Rotor Modulation Mapping: Insights From a Meta-Analysis

Sanghamitra Mohanty; Prasant Mohanty; Chintan Trivedi; Carola Gianni; Domenico G Della Rocca; Luigi Di Biase; Andrea Natale

doi:10.1161/CIRCEP.117.005789

Long-Term Outcome of Pulmonary Vein Isolation With and Without Focal Impulse and Rotor Modulation Mapping: Insights From a Meta-Analysis

Circ Arrhythm Electrophysiol. 2018 Mar;11(3):e005789. doi: 10.1161/CIRCEP.117.005789.

Authors

Sanghamitra Mohanty¹, Prasant Mohanty¹, Chintan Trivedi¹, Carola Gianni¹, Domenico G Della Rocca¹, Luigi Di Biase¹, Andrea Natale²

Affiliations

¹ From the Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (S.M., P.M., C.T., C.G., D.G.D.R., L.D.B., A.N.); Dell Medical School, Austin, TX (S.M., A.N.); Electrophysiology and Arrhythmia Services, California Pacific Medical Center, San Francisco (A.N.); MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH (A.N.); and Division of Cardiology, Stanford University, CA (A.N.).
² From the Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (S.M., P.M., C.T., C.G., D.G.D.R., L.D.B., A.N.); Dell Medical School, Austin, TX (S.M., A.N.); Electrophysiology and Arrhythmia Services, California Pacific Medical Center, San Francisco (A.N.); MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH (A.N.); and Division of Cardiology, Stanford University, CA (A.N.). [email protected].

PMID: 29545360
DOI: 10.1161/CIRCEP.117.005789

Abstract

Background: This meta-analysis systematically evaluated the outcome of pulmonary vein isolation (PVI) with and without focal impulse and rotor modulation (FIRM) ablation in patients with atrial fibrillation.

Methods and results: Extensive literature search was performed for studies reporting outcomes of PVI alone and PVI+FIRM procedures. For PVI alone, only randomized trials conducted in the past 3 years reporting single-procedure off-antiarrhythmic drugs success rate at ≥12-month follow-up were included. In PVI+FIRM group, all published studies reporting single-procedure off-antiarrhythmic drugs success rate with at least 1-year follow-up were identified. Meta-analytic estimates were derived using DerSimonian and Laird random-effects models, and pooled estimates of success rate (95% confidence interval) were computed. Statistical heterogeneity was assessed using Cochran Q test and I². Study quality was assessed using Newcastle-Ottawa Scale. Fifteen trials were included, 10 with PVI+FIRM (n=511, nonrandomized prospective design), and 5 with PVI-only trials (n=295, randomized trials). All patients in PVI-only trials had 100% nonparoxysmal atrial fibrillation, except 1 study, and no prior ablations. About 24% of PVI+FIRM population had paroxysmal atrial fibrillation. After 15.9±5.5 (median 12) months follow-up, the off-antiarrhythmic drugs pooled success rate was 50% in FIRM+PVI (95% confidence interval, 28%-72%) and 58% in PVI (95% confidence interval, 46%-71%). Difference in effect size between groups was not statistically significant (P=0.21). No significant heterogeneity (total or within group) was observed in this meta-analysis (negative I² values considered equal to zero).

Conclusions: The overall pooled estimate did not show any therapeutic benefit of PVI+FIRM approach over PVI alone, which suggests the need to reevaluate the clinical use of FIRM ablation in atrial fibrillation.

Keywords: atrial fibrillation; catheter ablation; pulmonary vein isolation; rotors.

Publication types

Meta-Analysis
Review

MeSH terms

Atrial Fibrillation / physiopathology
Atrial Fibrillation / surgery*
Body Surface Potential Mapping / methods*
Catheter Ablation / methods*
Follow-Up Studies
Humans
Pulmonary Veins / surgery*
Randomized Controlled Trials as Topic
Time Factors
Treatment Outcome