Work

The efficacy of additional atrial driver ablation in persistent and long-standing persistent atrial fibrillation: a systematic review and meta-analysis of randomized controlled trials

Year: 2026

Type: review

Study designs: Systematic Review, Meta-Analysis

Abstract: OBJECTIVE: Pulmonary vein isolation (PVI) remains the primary ablation strategy for atrial fibrillation (AF), yet its success in persistent (PeAF) and long-standing persistent AF (LS-PeAF) is suboptimal. Adjunctive ablation targeting atrial drivers has been proposed to enhance outcomes. This systematic review and meta-analysis compared PVI alone with PVI plus atrial driver ablation in PeAF and LS-PeAF. METHODS: Comprehensive searches of PubMed, Scopus, Europe PMC, and Cochrane Library identified randomized controlled trials (RCTs) enrolling adults with PeAF or LS-PeAF undergoing first-time ablation. Eligible studies compared PVI alone versus PVI plus driver ablation and trials utilizing other adjunctive ablations were excluded. Outcomes included recurrence of AF and any atrial tachyarrhythmia (ATA) beyond the blanking period, procedural parameters, and complications. Pooled analyses employed random-effects models to measure risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs). RESULTS: Seven RCTs met inclusion criteria. Adjunctive driver ablation modestly improved freedom from AF (RR 1.16; 95% CI, [1.03, 1.31]; p = 0.01; I²=61%). However, this finding was accompanied by substantial heterogeneity and was not robust to leave-one-out sensitivity analysis. Driver ablation failed to elevate freedom from any ATA (RR 1.09; 95% CI, [0.98, 1.20]; p = 0.11; I²=47%). Procedure duration (MD 37.81 min; 95% CI, [4.42, 71.20]; p = 0.03; I²=96%), fluoroscopy time (MD 4.25 min; 95% CI, [2.83, 5.67]; p < 0.00001; I²=0%), and ablation time (MD 10.01 min; 95% CI, [0.25, 19.77]; p = 0.04; I²=95%) were significantly longer with adjunctive driver ablation. Procedural complication rates were comparable among both groups (RR 1.65; 95% CI, [0.80, 3.43]; p = 0.18; I²=20%). CONCLUSION: Additional atrial driver ablation modestly improves freedom from AF but does not reduce ATA recurrence, prolonging procedure time without increasing complications.

Source: The Egyptian Heart Journal

DOI: 10.1186/s43044-026-00792-x