Role of adjunctive posterior wall isolation in patients undergoing atrial fibrillation ablation: a systematic review and meta-analysis

Background: The posterior wall of the left atrium may promote atrial fibrillation (AF) due to its propensity for fibrosis, in addition to a high prevalence of non-pulmonary vein triggers. Multiple smaller studies have assessed the incremental value of posterior wall isolation (PWI) in addition to standard atrial fibrillation. Similarly, this method has shown promise as an ablation strategy for patients with persistent AF, when PVI alone has shown only modest efficacy. Methods: We performed an extensive literature search and systematic review of studies that compared AF ablation plus PWI versus control. We separately assessed the recurrence rates of all atrial arrhythmias (AF/AFL/AT), as well as separate recurrence rates of AF and atrial tachycardia/atrial flutter (AT/AFL) after ablation. Risk ratio (RR) 95% confidence intervals were measured using the Mantel-Haenszel method. The random effects model was used due to heterogeneity (I²) > 25%. Results: Seven studies with a total of 1151 patients were included. Patients who underwent concomitant PWI experienced less recurrence of all atrial arrhythmias post ablation (RR 0.77; 95% CI 0.62–0.96, p = 0.02) and less recurrence of AF (RR 0.55; 95% CI 0.39–0.77, p < 0.01). There was no difference in onset of AT/AFL (RR 0.96; 95% CI 0.62–1.48, p = 0.85) after ablation. These results were replicated in subgroup analysis of patients with persistent AF. Conclusions: Based on the results of this meta-analysis, concomitant PWI is associated with less recurrence of AF and all atrial arrhythmias after ablation, without an increase in the risk for post-ablation AFL/AT.