The quality of evidence is downgraded by inconsistency (variability in results).
A Cochrane review[Abstract] 1 included 3 studies with a total of 261 subjects (mean age 60 years). The aim of the review was to determine the efficacy and safety of ablation (catheter and surgical) in people with non-paroxysmal (persistent or long-standing persistent) atrial fibrillation compared to antiarrhythmic drugs. All studies included participants that had not responded to antiarrhythmic drug therapy. Radiofrequency catheter ablation (RFCA) increased the proportion of patients achieving freedom from atrial arrhythmias (RR 1.84, 95% CI 1.17 to 2.88; 3 studies, n=261), reduced the need for cardioversion (RR 0.62, 95% CI 0.47 to 0.82; 3 studies, n=261), and reduced cardiac-related hospitalisation (RR 0.27, 95% CI 0.10 to 0.72; 2 studies, n=216) at 12 months follow-up compared to antiarrhythmic drugs. There was substantial uncertainty on the effect of RFCA regarding significant bradycardia (or need for a pacemaker) (RR 0.20, 95% CI 0.02 to 1.63; 3 studies, n=261), periprocedural complications, and other safety outcomes (RR 0.94, 95% CI 0.16 to 5.68, statistical heterogeneity I2 =54%; 3 studies, n=261).
Another Cochrane review[Abstract] 2 included 32 studies with a total of 3 560 subjects with paroxysmal or persistent AF. Catheter ablation (CA) compared with medical therapies had a better effect in inhibiting recurrence of AF (RR 0.27, 95% CI 0.18 to 0.41; 7 studies, n=760) but there was significant heterogeneity (I2 =72%). There was limited evidence to suggest that sinus rhythm was restored during CA (RR 0.28, 95% CI 0.20 to 0.40; 1 study, n=198), and at the end of follow-up (RR 1.87, 95% CI 1.31 to 2.67; I2 =83%; 4 studies, n=526). There were no differences in mortality (RR 0.50, 95% CI 0.04 to 5.65; 1 study, n=137), fatal and non-fatal embolic complication (RR 1.01, 95% CI 0.18 to 5.68; 2 studies, n=167) or death from thrombo-embolic events (RR 3.04, 95% CI 0.13 to 73.43; 1 study, n=137). 25 studies compared CA of various kinds. Circumferential pulmonary vein ablation was better than segmental pulmonary vein ablation in improving symptoms of AF (p<=0.01) and in reducing the recurrence of AF (p<0.01). There was limited evidence to suggest which ablation method was the best.
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