Doubling down on atrial fibrillation: is superior vena cava isolation the missing piece in pulmonary vein ablation? A meta-analysis

Atrial fibrillation (AF) is the most prevalent arrhythmia, often leading to significant morbidity and mortality. Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation for AF; however, the efficacy of adding superior vena cava isolation (SVCI) as an adjunct remains uncertain.

This systematic review and meta-analysis aim to evaluate the impact of SVCI on atrial tachyarrhythmias (AT) recurrence, procedural complications, and overall procedural efficacy when combined with PVI.

A comprehensive literature search was conducted across PubMed, Embase, and Cochrane Library, to identify randomised controlled trials (RCTs) that assessed the effects of SVCI in addition to PVI. Data were analysed using random-effects models to pool risk ratios (RRs) and mean differences (MDs) with their 95% confidence intervals (CIs). All statistical analyses were performed using R verson 4.4.2. Heterogeneity was assessed using the I² statistics.

A total of 5 RCTs comprising 698 patients were included in the analysis. Mean age ranged from 56 to 66 years, and 335 (47.9%) patients were randomised to PVI + SVCI. The addition of SVCI did not significantly reduce AT recurrence (RR 0.77; 95% CI: 0.51–1.17; P=0.22). Moreover, there were also no significant differences in the risk of clinical complications (RR 1.94; 95% CI 0.83–4.51; P=0.12) and in total procedure time (MD 2.83 min; 95% CI: -8.94 min to 14.59 min; P=0.64). However, performing SVCI in addition to PVI significantly increased fluorosocopy time (MD 3.89 min; 95% CI: 0.20 min to 7.58 min; P=0.04).

This meta-analysis indicates that adding SVCI to PVI does not lead to a significant reduction in AT recurrence, nor does it increase the risk of complications or total procedure time. However, fluoroscopy procedure time was significantly increased in the SVCI + PVI group when compared to PVI alone. These findings suggest that routine SVCI may not be warranted in standard AF ablation procedures. Further research is needed to explore the long-term implications of SVCI and to identify specific patient populations that may benefit from this approachFigure 1