Adjunctive posterior wall isolation for patients with persistent atrial fibrillation: A systematic review and meta-analysis.

Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. Its effectiveness for persistent atrial fibrillation (PeAF) is limited, and the benefits of adjunctive posterior wall ablation are uncertain. The purpose of this study was to perform a systematic review and meta-analysis of PVI with/without adjunctive PWI in patients with PeAF. We systematically searched PubMed, Embase, Cochrane, and ClinicalTrials.gov databases for randomized controlled trials (RCTs) comparing PVI with/without PWI in patients with PeAF. Random-effects model was used for the meta-analysis. Atrial tachyarrhythmia (ATA) was a composite of AF, atrial flutter, or atrial tachycardia. Our meta-analysis included eight RCTs with 1104 patients (546 PVI, 558 PVI plus PWI). Compared with PVI alone, adjunctive PWI significantly increased freedom from ATA recurrence (relative risk [RR] 1.13, 95% confidence interval [CI] 1.01-1.27, P = .036). A subanalysis of patients with long-standing PeAF showed a greater effect of PWI (RR 1.76, 95% CI 1.02-3.04, P = .04). A subgroup analysis of PWI techniques indicated no significant difference for ATA recurrence with box isolation alone (RR 1.13, 95% CI 0.97-1.33, P = .12), whereas a pooled analysis using only studies with direct posterior wall ablation favored the adjunctive PWI group (RR 1.39, 95% CI 1.11-1.74, P <.01). Adverse events did not significantly differ between groups. Our findings support that adjunctive PWI to PVI is an effective strategy compared with PVI alone for reducing ATA recurrence in patients with PeAF without compromising safety. Notably, patients with long-standing PeAF may benefit more from PWI.