{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,8]],"date-time":"2026-07-08T20:29:38Z","timestamp":1783542578074,"version":"3.55.0"},"reference-count":32,"publisher":"Wiley","license":[{"start":{"date-parts":[[2026,7,8]],"date-time":"2026-07-08T00:00:00Z","timestamp":1783468800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,7,8]],"date-time":"2026-07-08T00:00:00Z","timestamp":1783468800000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Cardiovasc electrophysiol"],"abstract":"ABSTRACT<\/jats:title>\n \n Background<\/jats:title>\n Multiple randomized controlled trials (RCTs) have compared the efficacy of pulmonary vein isolation adjunct (PVI+) techniques with PVI alone in patients with persistent atrial fibrillation (AF). However, these comparisons have been limited by a small sample size or conflicting results. It remains unclear if there is any benefit offered by these PVI+ techniques.<\/jats:p>\n <\/jats:sec>\n \n Objectives<\/jats:title>\n We conducted a systematic review and meta\u2010analysis of RCTs and compared the efficacy of different PVI+ techniques with PVI alone. We hypothesized that as compared with PVI alone, the PVI+ techniques have a superior efficacy in freedom from atrial arrhythmias.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n A systematic search of MEDLINE and EMBASE was conducted. The outcomes of interest included freedom from atrial arrhythmias, freedom from AF, procedure time, fluoroscopy time, ablation time and procedural complications. For dichotomous outcomes, Mantel\u2010Haenszel risk ratios (RR) with 95% CIs were calculated using random\u2010effects model. For the continuous outcomes standardized mean differences (SMD) were calculated. Subgroup analyses were conducted for various PVI + techniques including posterior wall isolation, linear lines, complex fractionated atrial electrograms, and low voltage area ablation.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n A total of 18 RCTs comprising 3459 patients (PVI\u2009+\u2009=\u20091956, PVI alone=1503) were included. There was no statistically significant difference between the two arms in the freedom from atrial arrhythmias (RR 1.10; 95% CI [1.00\u20131.22];\n p<\/jats:italic>\n \u2009=\u20090.06;\n I<\/jats:italic>\n 2<\/jats:sup>\n \u2009=\u200956%), and freedom from AF (RR 1.12; 95% CI [0.99\u20131.25];\n p<\/jats:italic>\n \u2009=\u20090.06;\n I<\/jats:italic>\n 2<\/jats:sup>\n \u2009=\u200963%). PVI+ techniques were associated with a statistically significant increase in procedure time (SMD 1.46; 95% CI [0.76\u20132.15];\n p<\/jats:italic>\n \u2009<\u20090.0001;\n I<\/jats:italic>\n 2<\/jats:sup>\n \u2009=\u200996%), fluoroscopy time (SMD 0.45; 95% CI [0.06\u20130.84];\n p<\/jats:italic>\n \u2009=\u20090.02;\n I<\/jats:italic>\n 2<\/jats:sup>\n \u2009=\u200991%), and ablation time (SMD 1.32; 95% CI [0.74\u20131.90];\n p<\/jats:italic>\n \u2009<\u20090.00001;\n I<\/jats:italic>\n 2<\/jats:sup>\n \u2009=\u200995%). There was no statistically significant difference in the pooled total complications between PVI + vs. PVI alone (RR 1.61; 95% CI [0.99\u20132.62];\n p<\/jats:italic>\n \u2009=\u20090.05;\n I<\/jats:italic>\n 2<\/jats:sup>\n \u2009=\u200926%).\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n This meta\u2010analysis of 18 RCTs shows that there is no difference in the freedom from atrial arrhythmias with various PVI + techniques vs. PVI alone in patients with persistent AF. Further large RCTs are needed to determine the ideal ablation strategy for these patients.<\/jats:p>\n <\/jats:sec>","DOI":"10.1111\/jce.70437","type":"journal-article","created":{"date-parts":[[2026,7,8]],"date-time":"2026-07-08T20:01:58Z","timestamp":1783540918000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Pulmonary Vein Isolation Plus Adjunct Techniques Versus Pulmonary Vein Isolation Alone for Persistent Atrial Fibrillation: A Systematic Review and Meta\u2010Analysis of Randomized Controlled Trials"],"prefix":"10.1111","author":[{"given":"Zain Ul Abideen","family":"Asad","sequence":"first","affiliation":[{"name":"Department of Medicine University of Oklahoma Health Sciences Center Oklahoma City Oklahoma USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aditi","family":"Bhamare","sequence":"additional","affiliation":[{"name":"Department of Medicine University of Oklahoma Health Sciences Center Oklahoma City Oklahoma USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Usama","family":"Qamar","sequence":"additional","affiliation":[{"name":"Department of Medicine King Edward Medical University Lahore Pakistan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laila","family":"Hashim","sequence":"additional","affiliation":[{"name":"Department of Medicine University of Oklahoma Health Sciences Center Oklahoma City Oklahoma USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Siddharth","family":"Agarwal","sequence":"additional","affiliation":[{"name":"Department of Medicine University of Oklahoma Health Sciences Center Oklahoma City Oklahoma USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jagjit","family":"Khosla","sequence":"additional","affiliation":[{"name":"Department of Medicine University of Oklahoma Health Sciences Center Oklahoma City Oklahoma USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hemanth","family":"Sanjamala","sequence":"additional","affiliation":[{"name":"Department of Medicine University of Oklahoma Health Sciences Center Oklahoma City Oklahoma USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Satyam","family":"Krishan","sequence":"additional","affiliation":[{"name":"Department of Medicine University of Oklahoma Health Sciences Center Oklahoma City Oklahoma USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-7210-8498","authenticated-orcid":false,"given":"Muhammad Salman","family":"Khan","sequence":"additional","affiliation":[{"name":"Department of Medicine University of Oklahoma Health Sciences Center Oklahoma City Oklahoma USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shari","family":"Clifton","sequence":"additional","affiliation":[{"name":"Robert M Bird Health Sciences Library University of Oklahoma Health Sciences Center Oklahoma City Oklahoma USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4611-3687","authenticated-orcid":false,"given":"Rakesh","family":"Gopinathannair","sequence":"additional","affiliation":[{"name":"Electrophysiology Section, Kansas City Heart Rhythm Institute Overland Park Kansas USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Warren M.","family":"Jackman","sequence":"additional","affiliation":[{"name":"Department of Medicine University of Oklahoma Health Sciences Center Oklahoma City Oklahoma USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stavros","family":"Stavrakis","sequence":"additional","affiliation":[{"name":"Department of Medicine University of Oklahoma Health Sciences Center Oklahoma City Oklahoma USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Atul","family":"Verma","sequence":"additional","affiliation":[{"name":"Department of Medicine, Faculty of Medicine and Health Sciences McGill University"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3803-8429","authenticated-orcid":false,"given":"Prashanthan","family":"Sanders","sequence":"additional","affiliation":[{"name":"University of Adelaide and Royal Adelaide Hospital Adelaide Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sunny","family":"Po","sequence":"additional","affiliation":[{"name":"Department of Medicine University of Oklahoma Health Sciences Center Oklahoma City Oklahoma USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sana M.","family":"Al\u2010Khatib","sequence":"additional","affiliation":[{"name":"Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center Durham North Carolina USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,7,8]]},"reference":[{"key":"e_1_2_11_2_1","article-title":"Catheter Ablation Versus Medical Therapy for Atrial Fibrillation","volume":"12","author":"Asad Z. 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P. T.","year":"2011","journal-title":"BMJ"},{"key":"e_1_2_11_10_1","doi-asserted-by":"crossref","first-page":"105","DOI":"10.1016\/j.cct.2006.04.004","article-title":"Random\u2010Effects Model for Meta\u2010Analysis of Clinical Trials: An Update","volume":"28","author":"DerSimonian R.","year":"2007","journal-title":"Contemporary Clinical Trials"},{"key":"e_1_2_11_11_1","first-page":"1253","article-title":"The Electrical Isolation of the Left Atrial Posterior Wall in Catheter Ablation of Persistent Atrial Fibrillation","volume":"5","author":"Lee J. M.","year":"2019","journal-title":"JACC: Clinical Electrophysiology"},{"key":"e_1_2_11_12_1","doi-asserted-by":"crossref","first-page":"2871","DOI":"10.1093\/eurheartj\/ehl093","article-title":"Substrate Modification Combined With Pulmonary Vein Isolation Improves Outcome of Catheter Ablation in Patients With Persistent Atrial Fibrillation: A Prospective Randomized Comparison","volume":"27","author":"Willems S.","year":"2006","journal-title":"European Heart Journal"},{"key":"e_1_2_11_13_1","doi-asserted-by":"crossref","DOI":"10.1161\/CIRCEP.117.005114","article-title":"Stand\u2010Alone Pulmonary Vein Isolation Versus Pulmonary Vein Isolation With Additional Substrate Modification as Index Ablation Procedures in Patients With Persistent and Long\u2010Standing Persistent Atrial Fibrillation: The Randomized Alster\u2010Lost\u2010AF Trial (Ablation at St. Georg Hospital for Long\u2010Standing Persistent Atrial Fibrillation)","volume":"10","author":"Fink T.","year":"2017","journal-title":"Circulation. 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F.","year":"2022","journal-title":"Journal of the American Medical Association"},{"key":"e_1_2_11_21_1","doi-asserted-by":"crossref","first-page":"127","DOI":"10.1001\/jama.2022.23722","article-title":"Effect of Catheter Ablation Using Pulmonary Vein Isolation With vs Without Posterior Left Atrial Wall Isolation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation: The CAPLA Randomized Clinical Trial","volume":"329","author":"Kistler P. M.","year":"2023","journal-title":"Journal of the American Medical Association"},{"key":"e_1_2_11_22_1","doi-asserted-by":"crossref","first-page":"1093","DOI":"10.1093\/europace\/euac005","article-title":"Does Isolation of the Left Atrial Posterior Wall Using Cryoballoon Ablation Improve Clinical Outcomes in Patients With Persistent Atrial Fibrillation? 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A.","year":"2019","journal-title":"Circulation: Arrhythmia and Electrophysiology"},{"key":"e_1_2_11_33_1","first-page":"632","article-title":"2012 HRS\/EHRA\/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Patient Selection, Procedural Techniques, Patient Management and Follow\u2010Up, Definitions, Endpoints, and Research Trial Design: A Report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Developed in Partnership With the European Heart Rhythm Association (EHRA), a Registered Branch of the European Society of Cardiology (ESC) and the European Cardiac Arrhythmia Society (ECAS); and in Collaboration With the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). 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