Panoramic vs. empiric mapping in the diagnosis and treatment of persistent atrial fibrillation - meta analysis

Background

Atrial fibrillation (AF) is the most common arrhythmia and is associated with increased risks of stroke and heart failure. Pulmonary vein isolation (PVI) is effective for paroxysmal AF but yields suboptimal outcomes in persistent AF. Panoramic/source-mapping–guided ablation techniques have been proposed to improve arrhythmia control by identifying and targeting non-pulmonary-vein sources.

Objective

To compare the efficacy of empiric (PVI ± empiric substrate/linear/extra PV targets) versus source mapping–guided ablation strategies for persistent AF through a systematic review of studies reporting ≥12 month follow up.

Methods

We searched major databases and identified 1,504 records; after initial filtering 741 remained. Title/abstract screening for PVI-relevant studies reduced this to 373 records (298 empiric, 75 source-mapping). Applying inclusion criteria (publication 2015–2025, ≥12 months follow-up, clear description of ablation/mapping technique, and reported success rates) and exclusion criteria (surgical cases, case reports <10 patients, terminated/no-result trials, retracted or inaccessible articles). This systematic review and meta-analysis included 116 studies evaluating empiric versus source-mapping guided ablation for persistent atrial fibrillation: 16 randomized controlled trials (RCTs) providing direct comparative evidence and 100 non-randomized single-arm studies (16 source-mapping arms, 84 empiric arms) providing contextual event-rates.

Data were manually extracted and tabulated.

Results

Randomized trials (16 RCTs; random-effects, risk ratio): pooled RR = 1.265 (95% CI 1.082–1.479); Z = 2.955, p = 0.003, indicating a statistically significant improvement with source-mapping–based versus empiric-based ablation at α = 0.05. Heterogeneity: Q(15) = 58.696, p < 0.001; I2 = 74%; τ2 = 0.066 (log units); τ = 0.257 (log units). 95% prediction interval for RR = 0.711 to 2.251. Source-mapping single-arm studies (16 studies; random-effects, logit event rate): pooled logit = 0.906 (95% CI 0.419–1.392) → event probability ≈ 71% (95% CI ≈ 60%–80%). Heterogeneity: Q(15) = 121.335, p < 0.001; I2 = 88%; τ2 = 0.837; τ = 0.915. 95% prediction interval (logit) = −1.128 to 2.939 → event probability (freedom from AF) ≈ 24% to 95%. Empiric single-arm studies (84 studies; random-effects, logit event rate): pooled logit = 0.818 (95% CI 0.687–0.950) → event probability ≈ 69% (95% CI ≈ 66%–72%). Heterogeneity: Q(83) = 656.625, p < 0.001; I2 = 87%; τ2 = 0.299; τ = 0.547. 95% prediction interval (logit) = −0.278 to 1.915 → event probability (freedom from AF) ≈ 43% to 87%.

Conclusion

Pooled randomized evidence supports a statistically significant advantage of source-mapping–based ablation over empiric-based ablation.