Pulsed field ablation for superior vena cava isolation during atrial fibrillation ablation: a systematic review and meta-analysis of acute success and complications
O Makdah, M Bistriceanu, A Khebbaiz, A Anghel, E Gales, A Musat, A Florescu, C Ursu, S Bogdan, D MusatAbstract
Background/Introduction
The superior vena cava (SVC) has been identified as a non-pulmonary vein trigger in atrial fibrillation (AF) and SVC isolation has been suggested for improvement of long-term outcomes. Thermal ablation techniques for SVC isolation have been limited by the risk of sinus node and phrenic nerve injury. Pulsed field ablation (PFA), with myocardial selectivity, may provide a safer alternative. However, evidence remains fragmented across individual studies.
Purpose
To evaluate the safety and short-term efficacy of PFA for SVC isolation in patients undergoing catheter ablation for AF.
Methods
A systematic search of PubMed, Embase, and Cochrane databases identified seven studies (four prospective, two retrospective, and one case series) evaluating SVC isolation in addition to pulmonary vein isolation using PFA for atrial fibrillation. A single-arm meta-analysis was conducted to assess acute procedural success and related complications, including sinus node dysfunction and phrenic nerve injury.
Results
The cohort included 878 patients (36% paroxysmal AF, age 65 ± 11 years) who underwent SVC isolation for AF treatment. Acute SVC isolation was achieved in all patients (100%). No cases of symptomatic bradycardia were reported (95% CI 0.00 to 100.00; I² = 0%) (Figure 1). Transient sinus node dysfunction occurred in 1.67% (95% CI 0.12 to 18.80; I² = 78.6%), and transient phrenic nerve stunning in 12.77% (95% CI 0.41 to 84.00; I² = 97%). Importantly, no permanent sinus node dysfunction (95% CI 0.00 to 100.00; I² = 0%) and no persistent phrenic nerve palsy (95% CI 0.00 to 100.00; I² = 0%) were observed (Figure 1). No major procedural or vascular complications were reported across studies. During a follow up of 158 ± 24 days AF recurred in 11.7% of patients (95% CI 0.065 to 0.203; I² = 23.6 %) (Figure 2).
Conclusion
Our data demonstrate that PFA is safe for SVC isolation with excellent acute and short-term efficacy and no lasting sinus node dysfunction or phrenic nerve injury. Larger prospective trials are warranted to confirm long-term outcomes.