Various Radiofrequency Catheter Ablation Techniques For Treatment Of Atrial Fibrillation:A Network Meta-analysis

Objective:Percutaneous catheter ablation is the first-line treatment for paroxysmal atrial fibrillation,particularly in cases that are refractory to antiarrthymic medications.However,catheter ablation is less successful for persistent atrial fibrillation.Guidelines suggest that adjuvant substrate modification in addition to pulmonary-vein isolation is required in persistent atrial fibrillation,but the comparative efficacy and safety of these radiofrequency ablation techniques is still unknown.We aim to compare and rank radiofrequency catheter ablation techniques for treatment of atrial fibrillation and provide evidence-based medical evidence for clinicians.Methods:For this network meta-analysis,randomised controlled trials comparing different radiofrequency catheter ablation techniques with any type of catheter ablation currently approved in the USA were identified through Pubmed,Embase,Cochrane databases,and proceedings of international meetings.Information about study design,inclusion and exclusion criteria,sample characteristics,and clinical outcomes was extracte.Primary outcome is freedom from atrial fibrillation or atrial tachycardia after 12 months.Second outcome is procedure-related complication rates.We did random-effects network meta-analysis to obtain estimates for primary and secondary outcomes and we presented these estimates as odds ratios with 95%CIs.We ranked the effects and safety of all radiofrequency ablation with surface under the cumulative ranking(SUCRA)probabilities.Results:34 studies comparising 5930 patients,with follow-up ranging from 10 months to 36months after the index intervention,were included in the network meta-analysis.Network meta-analysis showed:No radiofrequency ablation was more effective than pulmonary-vein isolation(PVI)for the primary outcome.On the contrary,compared with pulmonary-vein isolation,the outcome of freedom from atrial fibrillation or atrial tachycardia was significantly less likely after the ablation of focal impulse and rotor modulation(FIRM)[OR=0.10,95%CI(0.02-0.63)]and the ablation of complex fractionated atrial electrograms(CFAE)[OR=0.10,95%CI(0.04-0.27)].On the other side,there were also no significant differences among different catheter ablations for the outcome of complication rates.Conclusion:(1)Among patients with atrial fibrillation,the ablation of pulmonary-vein isolation was noinferior to adjuvant substrate modification in addition to pulmonary-vein isolation.(2)PVI+no-PV trigger had clear curative effect on the treatment of atrial fibrillation,and in principle,should be taken into consideration firstly.However,because of the insufficient number of trials,the positive effects should be illustrated cautiously.(3)Ablations of CFAE and FIRM have low complicaction rates,but these techniques have poor outcome of freedom from atrial fibrillation or atrial arrthymia.Clinicians should avoid to using these techniques for treatment in patient with atrial fibrillation.