Additional left atrial posterior wall ablation using pulsed field ablation for atrial fibrillation: a meta-analysis

Abstract Background The posterior wall of the left atrium represents a potential target for ablation in patients with recurrent atrial fibrillation, particularly when pulmonary vein isolation is insufficient. Pulsed field ablation (PFA) stands out as a promising technique, providing an efficient and safe approach. However, the available data regarding its specific application in this area remains limited. Purpose We conducted a meta-analysis to evaluate the role of additional posterior wall ablation (PWA) with PFA in patients with AF. Methods PubMed, Embase, and Cochrane database were analyzed. Binary single-arm outcomes were pooled with the inverse method and Arcsine transformation. Pairwise comparisons used risk ratios (RR) with 95% confidence intervals. A random effects model was applied to all endpoints. P ≤ .05 is considered as statistically significant. Analyses were done in R (version 4.3.2). Heterogeneity was assessed with I2 statistics. Results We included 1,193 patients from 6 observational studies (in our pairwise analysis, we included 832 patients from 3 studies). 1,132 (95%) patients were persistent or long-standing persistent AF. The prevalence of freedom from atrial arrhythmias, major and minor adverse events in additional PWA with PFA was 68.65%, 0.46% and 3.53%, respectively. There was not difference between groups regarding freedom from atrial arrhythmias (RR 0.98; 95% CI 0.88-1.09; P = 0.724; I2 = 6%), minor adverse events (RR 1.86; 95% CI 0.86-4.05; P = 0.114; I2 = 0%), coronary spasm (RR 2.77; 95% CI 0.25-30.15; P = 0.402; I2 = 12%) and groin AV fistula (RR 0.93; 95% CI 0.09-8.82; P = 0.954; I2 = 0%). Conclusion In this meta-analysis, additional PWA with PFA was not different from isolated PVI ablation in terms of freedom from atrial arrhythmias, minor adverse events, coronary spasm and groin AV fistula.