Three Ablation Techniques for Atrial Fibrillation during Concomitant Cardiac Surgery: A Systematic Review and Network Meta-Analysis

Dudy Arman Hanafy, Wahyu Prima Erdianto, Theresia Feline Husen, Ilona Nathania, Ananda Pipphali Vidya, Ruth Angelica, Widya Trianita Suwatri, Pasati Lintangella, Priscillia Prasetyo, Sugisman

Research output: Contribution to journalReview articlepeer-review


Atrial fibrillation (AF) ablation is a frequent procedure used in concomitant cardiac surgery. However, uncertainty still exists concerning the optimal extent of lesion sets. Hence, the objective of this study was to assess the results of various ablation techniques, aiming to offer a reference for clinical decision making. This review is listed in the prospective register of systematic reviews (PROSPERO) under ID CRD42023412785. A comprehensive search was conducted across eight databases (Scopus, Google Scholar, EBSCOHost, PubMed, Medline, Wiley, ProQuest, and Embase) up to 18 April 2023. Studies were critically appraised using the Cochrane Risk of Bias 2.0 for randomized control trials (RCTs) and the Newcastle Ottawa Scale adapted by the Agency for Healthcare Research and Quality (AHRQ) for cohort studies. Forest plots of pooled effect estimates and surface under the cumulative ranking (SUCRA) were used for the analysis. Our analysis included 39 studies and a total of 7207 patients. Both bi-atrial ablation (BAA) and left atrial ablation (LAA) showed similar efficacy in restoring sinus rhythm (SR; BAA (77.9%) > LAA (76.2%) > pulmonary vein isolation (PVI; 66.5%); LAA: OR = 1.08 (CI 0.94–1.23); PVI: OR = 1.36 (CI 1.08–1.70)). However, BAA had higher pacemaker implantation (LAA: OR = 0.51 (CI 0.37–0.71); PVI: OR = 0.52 (CI 0.31–0.86)) and reoperation rates (LAA: OR = 0.71 (CI 0.28–1.45); PVI: OR = 0.31 (CI 0.1–0.64)). PVI had the lowest efficacy in restoring SR and a similar complication rate to LAA, but had the shortest procedure time (Cross-clamp (Xc): PVI (93.38) > LAA (37.36) > BAA (13.89)); Cardiopulmonary bypass (CPB): PVI (93.93) > LAA (56.04) > BAA (0.03)). We suggest that LAA is the best surgical technique for AF ablation due to its comparable effectiveness in restoring SR, its lower rate of pacemaker requirement, and its lower reoperation rate compared to BAA. Furthermore, LAA ranks as the second-fastest procedure after PVI, with a similar CPB time.

Original languageEnglish
Article number5716
JournalJournal of Clinical Medicine
Issue number17
Publication statusPublished - Sept 2023


  • atrial fibrillation
  • bi-atrial ablation
  • left atrial ablation
  • pulmonary vein isolation


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