Systematic review and meta-analysis shows adjunctive SVCI reduces AF recurrence but increases minor complications in AF ablation.

BACKGROUND: Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. Nonpulmonary vein triggers, particularly from the superior vena cava, contribute to arrhythmogenesis in a subset of patients. The benefit of adjunctive superior vena cava isolation (SVCI) in addition to PVI remains uncertain. OBJECTIVE: This study aimed to assess the efficacy and safety of adjunctive SVCI in AF ablation. METHODS: We systematically searched PubMed, Embase, and ClinicalTrials.gov for randomized controlled trials comparing adjunctive SVCI plus PVI with PVI alone in adults undergoing first-time AF ablation. The main outcome was atrial tachyarrhythmia recurrence. Additional outcomes included procedure time, fluoroscopy time, and major and minor complications. Pooled odds ratios (ORs), hazard ratios, and 95% confidence intervals (CIs) were calculated using fixed- and random-effects models, with subgroup analyses by AF type and ablation modality. RESULTS: 7 randomized controlled trials involving 1149 patients were included. Adjunctive SVCI to PVI compared with PVI alone was associated with reduced atrial tachyarrhythmia recurrence (OR 0.71; 95% CI 0.53-0.96; I = 0%), confirmed by time-to-event analysis (hazard ratio 0.71; 95% CI 0.50-0.99). The effect was more pronounced in paroxysmal AF (OR 0.63; 95% CI 0.44-0.88) and with radiofrequency ablation (OR 0.66; 95% CI 0.47-0.93). SVCI plus PVI increased minor complications (13.7% vs 2.7%; OR 4.44; 95% CI 1.95-11.16), mainly transient phrenic nerve injury (6.8% vs 1.4%) and sinus node injury (1.6% vs 0%). Major complications were comparable (1.8% vs 1.0%). CONCLUSION: Adjunctive SVCI to PVI vs PVI alone was associated with reduced atrial tachyarrhythmia recurrence but increased minor complications in AF ablation.