The efficacy of circumferential pulmonary vein combined with additional ablation in reducing recurrence of atrial fibrillation after radiofrequency ablation: a meta-analysis
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摘要: 目的 探究相比于单纯环肺静脉消融(CPVI)，CPVI联合额外部位消融(包括二尖瓣环峡部、三尖瓣环峡部、上腔静脉、左心房顶部、左心房后壁、Marshall静脉、复杂碎裂电位、神经节)是否降低消融术后房颤(AF)的复发率。方法 计算机检索中国知网、万方、维普、中国生物医学文献数据库、PubMed、Embase、Cochrane Library等数据库，筛选出近10年符合标准的随机对照研究，应用Stata软件进行meta分析，比较单纯CPVI与CPVI联合额外部位消融策略在消融后AF复发中的差异。结果 共纳入21篇文献。meta分析结果表明，与单纯CPVI相比，CPVI联合额外部位消融未降低AF复发率。根据额外消融部位、AF类型、左心房内径、AF持续时间进行亚组分析，发现只在较小的左心房内径亚组中，CPVI联合额外部位消融进一步降低AF的复发率(OR=0.68，95%CI：0.47~0.98，P=0.040)，在其他亚组中未发现上述现象。结论 相比于单纯CPVI，CPVI联合额外部位的消融策略未降低消融后AF的复发率。Abstract: Objective To investigate whether circumferential pulmonary vein isolation(CPVI) combined with additional ablation(mitral isthmus, tricuspid isthmus, superior vena cava, left atrial roof, left atrial posterior wall, the vein of marshall, complex fractionated atrial electrograms, ganglionated plexi) reduces the recurrence rate of atrial fibrillation(AF) compared with CPVI alone.Methods A literature search was conducted using the databases CNKI, WanFang, VIP, CBM, PubMed, Embase, Cochrane Library. Randomized controlled studies that met the standards in the past ten years were screened out, and the relevant literature contents were meta-analyzed by Stata software. The content about comparing CPVI alone with CPVI combined with the additional ablation strategies in the recurrence of AF was summarized.Results A total of 21 papers were included. Meta-analysis showed that no significant difference between CPVI alone and CPVI combined ablation strategies in reducing AF recurrence. Subgroup analysis based on additional ablation site, AF type, left atrial diameter, AF diagnosis time, and outcome indicators showed that only in the small left atrial diameter subgroup, CPVI combined with additional ablation further reduced the recurrence rate of AF(OR=0.68, 95%CI: 0.47-0.98, P=0.040), which was not found in other subgroups.Conclusion The ablation strategy of CPVI combined with additional sites does not reduce the recurrence rate of AF compared with CPVI alone.
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图 2 CPVI联合额外部位与单纯CPVI消融复发率的森林图
Figure 2. The forest plot of the recurrence rate of CPVI combined with ablation and CPVI alone
图 3 根据消融部位分析CPVI联合额外部位消融复发率的森林图
Figure 3. The forest plot of the recurrence rate of CPVI combined with different ablation sites
图 4 根据AF类型分析CPVI联合额外部位消融复发率的森林图
Figure 4. The forest plot of the recurrence rate of CPVI combined with ablation according to AF type
图 5 根据LAD分析CPVI联合额外部位消融复发率的森林图
Figure 5. The forest plot of the recurrence rate CPVI combined with ablation according to LAD
图 6 根据 AF 持续时间分析 CPVI 联合额外部位消融复发率的森林图
Figure 6. The forest plot of the recurrence rate CPVI combined with ablation according to AF duration
表 1 纳入研究的基线特征
Table 1. General characteristics of included studies
X±S, M(P25, P75) 第1作者
(发表年份)研究
类型额外消融
部位AF类型 年龄/岁 男性/% LAD/mm AF持续时间/月 随访时
间/月Jadad
评分对照组 试验组 对照组 试验组 对照组 试验组 对照组 试验组 Da Costa
(2014)[3]随机
双盲SVC pAF 58.0±
9.055.0±
10.079.6 78.4 39.0±
6.042.0±
7.050±
4447.5±
3015±
83 Dong
(2024)[4]随机
非盲SVC pAF 57.1±
9.959.1±
8.974.0 70.0 37.4±
2.938.3±
4.324
(6，72)24
(11，60)12 3 Driessen
(2016)[5]随机
非盲GP perAF和
pAF60.2±
8.259.5±
8.274.0 72.0 42.3±
5.542.1±
5.660
(24，120)48
(24，72)12 4 Ammar-
Busch
(2017)[6]随机
非盲LR+
LAAWperAF 65.0±
8.064.0±
9.082.0 76.0 48.0±
6.049.0±
7.039±
4443±
4812 3 Arbelo
(2014)[7]随机
非盲LR pAF 55.0±
12.055.0±
11.068.9 71.2 41.0±
6.041.0±
6.060±
5659±
5915±
103 Yao(2020)[8] 随机
非盲LAAW perAF 58.0±
9.556.6±
10.780.8 83.7 42.6±
4.541.8±
4.552.7±
5.155.3±
5.424 4 Pak(2020)[9] 随机
单盲BOX pAF 61.6±
7.858.6±
11.470.2 73.7 42.7±
6.141.4±
6.121
(9，71)24
(12，60)23.8±
10.24 Fink
(2017)[10]随机
非盲CFAE perAF 62.1±
9.960.9±
9.669.0 74.0 47.3±
4.546.7±
4.312
(7，24)12
(7，24)12 3 Hwang
(2021)[11]随机
非盲CFAE perAF 57.9±
9.858.8±
9.392.0 80.0 50.0±
6.049.0±
4.027.1±
19.221.4±
26.224.0±
23.14 Yu(2017)[12] 随机
非盲BOX+
LAAWpAF 61.4±
11.159.3±
8.975.0 76.0 42.6±
5.342.7±
5.743.7±
50.841.7±
36.718.6±
11.43 Bassiouny
(2016)[13]随机
非盲CFAE perAF 62.2±
9.464.6±
9.474.0 75.0 45.0±
8.842.0±
9.837
(16，92)45
(17，81)12 4 Verma
(2015)[14]随机
单盲CFAE perAF 58.0±
10.060.0±
9.078.0 81.0 44.0±
6.044.0±
6.051.6±
75.650.4±
6018 5 Lee(2019)[15] 随机
双盲BOX+
LAAWperAF 58.6±
11.058.9±
10.580.0 86.3 44.5±
6.745.0±
5.333.1±
31.444.0±
44.616.2±
8.86 Kistler
(2023)[16]随机
单盲BOX perAF 65.5
(57.8，
71.7)65.7
(58.7，
71.1)76.2 77.1 44.0±
7.046.0±
6.05(2，8) 5(2，8) 12 5 Wynn
(2016)[17]随机
双盲LR+MI+
TIperAF和
pAF61.8±
9.761.9±
11.473.0 62.0 43.0±
6.043.0±
6.05.5±
4.25.5±
3.912 5 Kang
(2014)[18]随机
非盲SVC pAF 55.65±
11.8757.89±
11.4674.0 75.0 39.5±
6.240.1±
5.7- - 12.2±
5.33 Valderrábano
(2020)[19]随机
单盲VOM perAF 66.4±
9.966.6±9.6 78.0 74.0 47.0±
7.544.8±
7.9- - 12 6 Katritsis
(2013)[20]随机
单盲GP pAF 56.0±
7.656.0±
8.568.0 70.0 48.0±
7.048.0±
6.0- - 24 5 Aryana
(2021)[21]随机
双盲BOX perAF 70.0±
9.067.0±
8.060.0 64.0 44.0±
5.044.0±
4.0- - 12 5 Kim
(2014)[22]随机
非盲BOX perAF 58.3±
9.656.2±
11.968.3 76.7 42.1±
5.142.3±
6.4- - 12 4 Kim
(2015)[23]随机
非盲BOX+
LAAWpAF 55.32±
12.4257.72±
10.2280.0 70.0 39.1±
5.941.0±
6.8- - 16.34±
4.004 LAAW：左心房前壁线性消融；BOX：后壁盒式消融；pAF：阵发性房颤；perAF：持续性房颤；-：原文未提供相关数据。 
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表 2 纳入临床研究的研究结果
Table 2. Findings included in clinical studies
例 第1作者(发表年
份)对照组 试验组 RR 复发 总例数 复发 总例数 Costa(2014)[3] 9 49 5 51 0.53 Dong(2024)[4] 10 50 6 50 0.60 Driessen(2016)[5] 39 123 34 117 0.92 Ammar-Busch
(2017)[6]9 45 12 45 1.33 Arbelo(2014)[7] 13 61 16 59 1.27 Yao(2020)[8] 45 105 38 104 0.85 Pak(2020)[9] 18 57 16 57 0.89 Fink(2017)[10] 27 61 14 57 0.55 Hwang(2021)[11] 14 25 4 25 0.29 Yu(2017)[12] 9 59 8 54 0.97 Bassiouny
(2016)[13]30 46 31 44 1.08 Verma(2015)[14] 25 61 125 244 1.25 Lee(2019)[15] 25 105 27 102 1.11 Kistler(2023)[16] 78 168 81 170 1.03 Wynn(2016)[17] 19 64 24 66 1.22 Kang(2014)[18] 27 100 6 100 0.22 Valderrábano
(2020)[19]98 158 94 185 0.82 Katritsis(2013)[20] 34 78 21 82 0.59 Aryana(2021)[21] 25 55 14 55 0.56 Kim(2014)[22] 22 60 10 60 0.45 Kim(2015)[23] 6 50 8 50 1.33
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