Left atrial posterior wall isolation in addition to pulmonary vein isolation using a pentaspline catheter in pulsed-field ablation for atrial fibrillation: A systematic review and meta-analysis

Background Persistent atrial fibrillation (AF) may require extensive ablation strategies. Left atrial posterior wall isolation (LAPWI) might address potential substrates for recurrence during pulsed-field ablation (PFA). Objective This meta-analysis aimed to investigate the feasibility and effectiveness of LAPWI in addition to pulmonary vein isolation (PVI) using a pentaspline catheter in PFA for AF. Methods Comprehensive search was conducted using PubMed, SCOPUS, ScienceDirect, and EuropePMC for studies reporting LAPWI+PVI using a pentaspline catheter in PFA ablation for AF. The primary outcome was atrial tachyarrhythmia (ATa) recurrence, defined as AF/atrial flutter/atrial tachycardia after blanking period. Results There were 882 patients from 7 studies. The success rate of LAPWI was 100% using mean/median of 16 to 20 added PFA applications with no reported acute left atrial posterior wall reconnection and esophageal complications. In mean follow-up of 240 +/- 91 days, ATa recurrence was 21% (95% CI 13%-29%; I-2 = 84.8%) in the LAPWI+PVI group. Meta-regression analysis showed that age, left ventricular ejection fraction, and repeat procedure did not significantly influence ATa recurrence (P > .05). Each 1-mm increase in left atrial diameter, increases the chance of ATa recurrence by 6% (R-2 = 100%, P < .001, I-2 = 0%). Meta-analysis showed no difference in terms of ATa recurrence among LAPWI+PVI patients compared with those without LAPWI (odds ratio 0.78, 95% confidence interval 0.50-1.21, P = .27; I-2 = 0%, P = .86). Procedure time and fluoroscopy time did not significantly differ (P > .05). Conclusion LAPWI using a pentaspline catheter during PFA was feasible and did not prolong the procedure/fluoroscopy but did not reduce ATa recurrence. LAPWI may be considered during PFA, although the benefit is uncertain.