Comparative effectiveness of catheter ablation devices in the treatment of atrial fibrillation: a network meta-analysis

Abstract

Atrial fibrillation (AF) ablation is most commonly performed using radiofrequency (RF) and cryoballoon (CB) catheters. Ablation Index is a novel lesion-quality marker associated with improved outcomes in RF ablation. Due to lack of direct comparative evidence between the latest generations of technologies, there is uncertainty regarding the best treatment option. Aim: To conduct a network meta-analysis to evaluate the comparative effectiveness of RF with Ablation Index to other catheter ablation devices in the treatment of AF. Methods: Searches for randomized and nonrandomized prospective comparative studies of ablation catheters were conducted in multiple databases. The outcome of interest was 12-month freedom from atrial arrhythmias after a single ablation procedure. Studies were grouped as high-, low- and unclear-quality based on study design and balanced baseline patient characteristics. Bayesian hierarchical network meta-analysis was conducted and results presented as relative risk ratios with 95% credible intervals (CrIs). Results: 12 studies evaluating five different catheter ablation devices were included. Radiofrequency ablation with Ablation Index was associated with statistically significantly greater probability of 12-month freedom from atrial arrhythmias than Arctic Front (relative risk: 1.77; 95% CrI: 1.21–2.87), Arctic Front Advance™ (1.41; 1.06–2.47), THERMOCOOL™ (1.34; 1.17–1.48) and THERMOCOOL SMARTTOUCH™ (1.09; 1–1.3). Results were robust in multiple sensitivity analyses. Conclusion: Radiofrequency catheter with Ablation Index is superior to currently available options for 12-month freedom from atrial arrhythmias after AF ablation. This study provides decision-makers with robust, pooled, comparative evidence of the latest ablation technologies.

A systematic review and meta‐analysis comparing second‐generation cryoballoon and contact force radiofrequency ablation for initial ablation of paroxysmal and persistent atrial fibrillation

“…Acute procedural success was also similar between the two groups in our study, with 10 out of 17 studies included in our analysis, not requiring additional RFA touch up to achieve PVI. In the network meta‐analysis by Gupta et al, contact force RFA guided by ablation index demonstrated higher freedom from arrhythmia compared with other modalities of RFA and CBA 35 . However, these results are limited by lack of direct comparison studies between CBA‐2G and RFA‐CF as well as the inclusion of several poor‐quality studies in the network meta‐analysis 35 .…”

“…In the network meta-analysis by Gupta et al, contact force RFA guided by ablation index demonstrated higher freedom from arrhythmia compared with other modalities of RFA and CBA. 35 However, these results are limited by lack of direct comparison studies between CBA-2G and RFA-CF as well as the inclusion of several poor-quality studies in the network meta-analysis. 35 Our analysis is also the largest study to demonstrate that CBA-2G is equally efficacious as RFA-CF for first-time catheter ablation of patients with persistent AF.…”

“…35 However, these results are limited by lack of direct comparison studies between CBA-2G and RFA-CF as well as the inclusion of several poor-quality studies in the network meta-analysis. 35 Our analysis is also the largest study to demonstrate that CBA-2G is equally efficacious as RFA-CF for first-time catheter ablation of patients with persistent AF. These results are particularly important given the common use of CBA for treatment of persistent AF in clinical practice and limitation of data for CBA-2G in patients with persistent AF to single-center, non-RCT.…”

Comparing Efficacy and Safety in Catheter Ablation Strategies for Paroxysmal Atrial Fibrillation: A Network Meta-Analysis of Randomized Controlled Trials

“…Our data, consistent with previous studies, did not detect strong evidence of superiority with regards to efficacy in one technology over the other [ 29 , 33 , 34 ]. However, a recent NMA by Gupta et al [ 14 ] showed that PVI using RF combined with ablation index technology was superior in terms of efficacy compared with other options, such as CBA. This result is in contrast with our results.…”

“…Network meta-analysis (NMA) is a statistical method that provides estimates of the relative effects for all available interventions, allowing comparison between every pair of treatments, even when they have not been compared directly in any trial [ 10 , 11 ]. NMA is an established method and has been applied in the field of cardiovascular medicine [ 12 , 13 ] and provides a powerful tool for the development of decision-making guidelines at different levels [ 14 ]. Thus, by employing the NMA methodology, we sought to compare the efficacy and safety of different CA strategies for the treatment of PAF.…”