Prevalence and prognosis of hyperdynamic left ventricular systolic function in septic patients: a systematic review and meta-analysis.

PURPOSE: The prevalence of hyperdynamic left ventricular (LV) systolic function in septic patients and its impact on mortality remain controversial. In this systematic review and meta-analysis, we investigated the prevalence and association of hyperdynamic LV systolic function with mortality in patients with sepsis. METHODS: We searched MEDLINE, Cochrane Central Register of Controlled Trials, and Embase. Primary outcomes were the prevalence of hyperdynamic LV systolic function in adult septic patients and the associated short-term mortality as compared to normal LV systolic function. Hyperdynamic LV systolic function was defined using LV ejection fraction (LVEF) of 70% as cutoff. Secondary outcomes were heart rate, LV end-diastolic diameter (LVEDD), and E/e' ratio. RESULTS: Four studies were included, and the pooled prevalence of hyperdynamic LV systolic function was 18.2% ([95% confidence interval (CI) 12.5, 25.8]; I2 = 7.0%, P < 0.0001). Hyperdynamic LV systolic function was associated with higher mortality: odds ratio of 2.37 [95%CI 1.47, 3.80]; I2 = 79%, P < 0.01. No difference was found in E/e' (P = 0.43) between normal and hyperdynamic LV systolic function, while higher values of heart rate (mean difference: 6.14 beats/min [95%CI 3.59, 8.69]; I2 = 51%, P < 0.0001) and LVEDD (mean difference: - 0.21 cm [95%CI - 0.33, - 0.09]; I2 = 73%, P < 0.001) were detected in patients with hyperdynamic LV systolic function. CONCLUSION: The prevalence of hyperdynamic LV systolic function is not negligible in septic patients. Such a finding is associated with significantly higher short-term mortality as compared to normal LV systolic function.

The efficacy and safety of cryoballoon atrial fibrillation ablation in patients with heart failure: A systematic review and meta-analysis.

INTRODUCTION: While atrial fibrillation (AF) ablation has proven beneficial for heart failure (HF) patients, most reports were performed with radiofrequency ablation. We aimed to evaluate the efficacy and safety of cryoballoon AF ablation in patients with HFrEF. METHOD: We comprehensively searched the databases of MEDLINE, EMBASE, and Cochrane database from inception to December 2022. Studies that reported the outcomes of freedom from atrial arrhythmia, complications, NYHA functional class (NYHA FC), and left ventricular ejection fraction (LVEF) after Cryoballoon AF ablation in HF patients were included. Data from each study were combined with a random-effects model. RESULT: A total of 9 studies observational studies with 1414 HF patients were included. Five studies had only HF with reduced ejection fraction (HFrEF), 1 study with HF with preserved ejection fraction (HFpEF), and others with mixed HF types. Freedom from AA in HFrEF at 12 months was 64% (95% CI 56-71%, I2 58%). There was a significant improvement of LVEF in these patients with a standard mean difference of 13% (95% CI 8.6-17.5%, I2 99% P < 0.001. The complication rate in HFrEF group was 6% (95% CI 4-10%, I2 0%). The risk of recurrence of atrial arrhythmia was not significantly different between HF and no HF patients (RR 1.34, 95% CI 0.8-2.23, I2 76%). CONCLUSION: Cryoballoon AF ablation is effective in HFrEF patients comparable to radiofrequency ablation. The complication rate was low.

Efficacy and safety between radiofrequency ablation and types of cryoablation catheters for atrioventricular nodal reentrant tachycardia: A Network Meta-analysis and Systematic Review.

INTRODUCTION: Atrioventricular nodal reentrant tachycardia (AVNRT) is the most common supraventricular tachycardia referred for ablation. Periprocedural conduction system damage was a primary concern during AVNRT ablation. This study aimed to assess the incidence of permanent atrioventricular (AV) block and the success rate associated with different types of catheters in slow pathway ablation. METHOD: A literature search was performed to identify studies that compared various techniques, including types of radiofrequency ablation (irrigated and nonirrigated) and different sizes of catheter tip cryoablation (4, 6, and 8-mm), in terms of their outcomes related to permanent atrioventricular block and success rate. To assess and rank the treatments for the different outcomes, a random-effects model of network meta-analysis, along with p-scores, was employed. RESULTS: A total of 27 studies with 5110 patients were included in the analysis. Overall success rates ranged from 89.78% to 100%. Point estimation showed 4-mm cryoablation exhibited an odds ratio of 0.649 (95%CI: 0.202-2.087) when compared to nonirrigated RFA. Similarly, 6-mm cryoablation had an odds ratio of 0.944 (95%CI: 0.307-2.905), 8-mm cryoablation had an odds ratio of 0.848 (95%CI: 0.089-8.107), and irrigated RFA had an odds ratio of 0.424 (95%CI: 0.058-3.121) compared to nonirrigated RFA. CONCLUSION: Our study found no significant difference in the incidence of permanent AV block between the types of catheters. The success rates were consistently high across all groups. These findings emphasize the potential of both RF ablation (irrigated and nonirrigated catheter) and cryoablation as viable options for the treatment of AVNRT, with similar safety and efficacy profile.

Atrial fibrillation catheter ablation in endurance athletes: systematic review and meta-analysis.

BACKGROUND: Atrial fibrillation (AF) management in endurance athletes (EA) is challenging due to the paucity of data, especially on the efficacy and safety of catheter ablation (CA). The hypothesis is that the efficacy and safety of AF CA in EA are comparable to the non-EA. METHODS: Databases from EMBASE, Medline, PubMed, and Cochrane were searched from inception through February 2023. Studies with available information on efficacy and safety profiles were included. Effect estimates from the individual studies were extracted and combined using random effect and generic inverse variance method of DerSimonian and Laird. RESULTS: Nine observational studies with a total of 1129 participants were identified, of whom 51% were EA. Our analysis found that rate of atrial arrhythmia (AA) recurrences following AF CA was not statistically different between EA and non-EA (RR 1.04, I2 = 57.6%, p = 0.54). The AA survival rates after a single ablation in EA was 60.2%, which improved up to 77% after multiple ablations during the follow-up period. Infrequent complication rates ranging from 0 to 7.6% were observed, with no mortality. CONCLUSIONS: Our meta-analysis suggests that AF CA is as effective and safe in EA as in non-EA. In the future, AF CA should be considered as a first-line therapeutic choice in this patient group.

Outcomes of cardiac resynchronization therapy in congenital heart disease: A meta-analysis and systematic review.

INTRODUCTION: Cardiac resynchronization therapy (CRT) is a standard treatment for patients with heart failure with reduced ejection fraction. However, there is still a gap of evidence in congenital heart disease (CHD) patients regarding resynchronization therapy. METHODS: We performed a meta-analysis and systematic review of CHD patients who received CRT implantation. We comprehensively searched the databases of MEDLINE, EMBASE, and Cochrane database from inception to June 2023. Studies that reported response rate to CRT, total mortality rate, change in QRS duration, change in left ventricular ejection fraction, and change in New York Heart Association functional class were included. RESULTS: A total of 14 studies were included in the study. There were 10 studies that reported response rates after implantation. The overall response rate to CRT in CHD patients was 68% (95% confidence interval [CI] 61%-75%, I2 32%). The response rates in patients with systemic right ventricle (RV), systemic left ventricle (LV), and single ventricle were 58% (95% CI 46%-70%, I2 0%), 80% (95% CI 74%-86% I2 14%), and 67% (95% CI 49%-80% I2 0%). Response to CRT in systemic RV was inferior to systemic LV with an odds ratio of 0.38 (95% CI 0.15-0.95, I2 38%). The total mortality rate from seven studies was 12% (95% CI 8%-18%, I2 55%). The parameters which represented ventricular dyssynchrony improved after CRT implantation. CONCLUSION: The overall response rate to CRT in CHD was 68%. Patients with systemic RV had a lower response rate to CRT when compared to patients with systemic LV. The total mortality rate after CRT implantation was 12%.

Sex differences in clinical characteristics, management, and outcomes in patients admitted for ventricular tachycardia: 2016-2018.

INTRODUCTION: The concurrent data on sex disparities in VT management and outcomes have remained unclear. Therefore, our objective was to determine the impact of sex on ventricular tachycardia (VT) management and outcomes in patients admitted with VT, dervied from the US National Inpatient Sample database (NIS). METHODS: We used data from the US NIS to identify hospitalized adult patients who were admitted with VT between 2016 and 2018. Regression analysis was conducted to evaluate the impact of sex on VT management, in-hospital mortality, complications, length of stay, and hospitalization costs. RESULTS: Of the database, a total of 146 070 patients, who were primarily hospitalized for VT, were approximated. Among these, women comprised 25.5%; they were significantly younger and had fewer comorbidities. Of procedural aspects, women were less likely to receive an angiogram, mechanical support, implantable cardioverter-defibrillator implantation, and VT ablation compared to men. Notably, women were associated with higher do-not-resuscitate rates and in-hospital cardiac arrests than men. No differences in in-hospital mortality and cardiogenic shock were observed between men and women (p > .05). Length of stay was significantly longer for women, while no differences in hospital costs were observed in both sexes. CONCLUSION: Significant sex disparities in management and outcomes were observed in admitted patients with VT. Our results reflect the need for further studies to explore factors causing such diversities.

Stroke risk in radial versus femoral approach in coronary intervention: an updated systematic review and meta-analysis.

AIM: Peri-cardiac catheterization (CC) stroke is associated with increased morbidity and mortality. Little is known about any potential difference in stroke risk between transradial (TR) and transfemoral (TF) approaches. We explored this question through a systematic review and meta-analysis. METHODS: MEDLINE, EMBASE, and PubMed were searched from 1980 to June 2022. Randomized trials and observational studies comparing radial versus femoral access CC or intervention that reported stroke events were included. A random-effects model was used for analysis. RESULTS: The total population in our 41 pooled studies comprised 1 112 136 patients - average age 65 years, women averaging 27% in TR and 31% in TF approaches. Primary analysis of 18 randomized-controlled trials (RCTs) that included a total of 45 844 patients showed that there was no statistical significance in stroke outcomes between the TR approach and the TF approach [odds ratio (OR) 0.71, 95% confidence interval (CI) 0.48-1.06, P -value = 0.013, I2 = 47.7%]. Furthermore, meta-regression analysis of RCTs including procedural duration between those two access sites showed no significance in stroke outcomes (OR 1.08, 95% CI 0.86-1.34, P -value = 0.921, I2 = 0.0%). CONCLUSIONS: There was no significant difference in stroke outcomes between the TR approach and the TF approach.

Prevalence and Prognosis of Sepsis-Induced Cardiomyopathy: A Systematic Review and Meta-Analysis.

Purpose: The prevalence and its impact on mortality of sepsis-induced cardiomyopathy (SICM) remain controversial. In this systematic review and meta-analysis, we investigated the prevalence and prognosis of SICM. Materials and Methods: We searched MEDLINE, Cochrane Central Register of Controlled Trials, and Embase. Titles and abstracts were evaluated based on the following criteria: (1) published in English, (2) randomized controlled trials, cohort studies, or cross-sectional studies, (3) ≥ 18 years with sepsis, (4) reporting the prevalence and/or comparison of short-term mortality between those with and without SICM, defined as the new-onset reduction in left ventricular ejection fraction (LVEF) within 72 h on admission or from the diagnosis of sepsis. The random-effect model was used for all analyses. This meta-analysis was registered at PROSPERO (CDR42022332896). Results: Sixteen studies reported the prevalence of SICM and the pooled prevalence of SICM was 20% (95% confidence interval [CI], 16-25%; I2 = 89.9%, P < 0.01). Eleven studies reported short-term mortality and SICM was associated with significantly higher short-term mortality (The pooled odds ratio: 2.30, 95% CI, 1.43-3.69; I2 = 0%, P = 0.001). Conclusion: The prevalence of SICM was 20% in patients with sepsis, and the occurrence of SICM was associated with significantly higher short-term mortality.

Predicting arrhythmic event score in Brugada syndrome: Worldwide pooled analysis with internal and external validation.

BACKGROUND: Brugada syndrome is an inherited arrhythmic disease associated with major arrhythmic events (MAE). Risk predictive scores were previously developed with various performances. OBJECTIVE: The purpose of this study was to create a novel score-Predicting Arrhythmic evenT (PAT)-with internal and external validation. METHODS: A systematic review was performed to identify risk factors for MAE. The odds ratios (ORs) of each factor were pooled across studies. The PAT scoring scheme was developed based on pooled ORs. The PAT score was internally validated with published 105 Asian patients (follow-up 8.0 ± 4.1 [SD] years) and externally validated with unpublished 164 multiracial patients (82.3% White, 14.6% Asian, 3.2% Black; mean follow-up 8.0 ± 6.9 years) with Brugada syndrome. Performances were assessed and compared with previous scores using receiver operating characteristic curve (ROC) analysis. RESULTS: Sixty-seven studies published between 2002 and 2022 from 26 countries (7358 patients) were included. Pooled ORs were estimated, indicating that 15 of 23 risk factors were significant. The PAT score was then developed accordingly. The PAT score had significantly better discrimination (ROC 0.9671) than the BRUGADA-RISK score (ROC 0.7210; P = .006), Shanghai Score System (ROC 0.7079; P = .003), and Sieira et al score (ROC 0.8174; P = .026) in an external validation cohort. PAT score ≥ 10 predicted the first MAE with 95.5% sensitivity and 89.1% specificity (ROC 0.9460) and the recurrent MAE (ROC 0.7061) with 15.4% sensitivity and 93.3% specificity. CONCLUSION: The PAT score was shown to be useful in predicting MAE for primary prevention in patients with Brugada syndrome.

Type of syncope and outcome in Brugada syndrome: A systematic review and meta-analysis.

Introduction: Brugada syndrome is an inherited arrhythmic disease associated with major arrhythmic events (MAE). The importance of primary prevention of sudden cardiac death (SCD) in Brugada syndrome is well recognized; however, ventricular arrhythmia risk stratification remains challenging and controversial. We aimed to assess the association of type of syncope with MAE via systematic review and meta-analysis. Methods: We comprehensively searched the databases of MEDLINE and EMBASE from inception to December 2021. Included studies were cohort (prospective or retrospective) studies that reported the types of syncope (cardiac, unexplained, vasovagal, and undifferentiated) and MAE. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate the odds ratio (OR) and 95% confidence intervals (CIs). Results: Seventeen studies from 2005 to 2019 were included in this meta-analysis involving 4355 Brugada syndrome patients. Overall, syncope was significantly associated with an increased risk of MAE in Brugada syndrome (OR = 3.90, 95% CI: 2.22-6.85, p < .001, I 2 = 76.0%). By syncope type, cardiac (OR = 4.48, 95% CI: 2.87-7.01, p < .001, I 2 = 0.0%) and unexplained (OR = 4.71, 95% CI: 1.34-16.57, p = .016, I 2 = 37.3%) syncope was significantly associated with increased risk of MAE in Brugada syndrome. Vasovagal (OR = 2.90, 95% CI: 0.09-98.45, p = .554, I 2 = 70.9%) and undifferentiated syncope (OR = 2.01, 95% CI: 1.00-4.03, p = .050, I 2 = 64.6%, respectively) were not. Conclusion: Our study demonstrated that cardiac and unexplained syncope was associated with MAE risk in Brugada syndrome populations but not in vasovagal syncope and undifferentiated syncope. Unexplained syncope is associated with a similar increased risk of MAE compared to cardiac syncope.

Reverse of left ventricular remodeling in heart failure patients with left bundle branch area pacing: Systematic review and meta-analysis.

BACKGROUND: Left bundle branch area pacing (LBBAP) has recently become a promising option for the near-natural restoration of electrical activation. However, the clinical relevance of therapeutic effects in individuals with heart failure with reduced ejection fraction (HFrEF) and dyssynchrony remains unknown. METHODS: MEDLINE, EMBASE, and Cochrane databases were searched from inception until June 2022. Data from each study was combined using a random-effects model, the generic inverse variance method of DerSimonian and Laird, to calculate standard mean differences and pooled incidence ratio, with 95% confidence intervals (CIs). RESULTS: A total of 772 HFrEF patients were analyzed from 15 observational studies per protocol. The success rate of LBBAP implantation was 94.8% (95% CI 89.9-99.6, I2 = 79.4%), which was strongly correlated with shortening QRS duration after LBBAP implantation, with a mean difference of -48.10 ms (95% CI -60.16 to -36.05, I2 = 96.7%). Over a period of 6-12 months of follow-up, pacing parameters were stable over time. There were significant improvements in left ventricular ejection fraction (LVEF), left ventricular end-systolic volume (LVESV), left ventricular end-diastolic diameter (LVEDD), and left ventricular end-diastolic volume (LVEDV) with mean difference of 16.38% (95% CI 13.13-19.63, I2 = 90.2%), -46.23 ml (95% CI -63.17 to -29.29, I2 = 86.82%), -7.21 mm (95% CI -9.71 to -4.71, I2 = 84.6%), and -44.52 ml (95% CI -64.40 to -24.64, I2 = 85.9%), respectively. CONCLUSIONS: LBBAP was associated with improvements in both cardiac function and electrical synchrony. The benefits of LBBAP in individuals with HFrEF and dyssynchrony should be further validated by randomized studies.

Network meta-analysis and systematic review comparing efficacy and safety between very high power short duration, high power short duration, and conventional radiofrequency ablation of atrial fibrillation.

BACKGROUND: High-power short-duration (HPSD) atrial fibrillation (AF) ablation with a power of 40-50 W was proved to be safe and effective. Very high-power short-duration (vHPSD) AF ablation is a novel method using >50 W to obtain more durable AF ablation. This study aimed to evaluate the efficacy and safety of vHPSD ablation compared with HPSD ablation and conventional power ablation. METHODS: A literature search for studies that reported AF ablation outcomes, including short-term freedom from atrial arrhythmia, first-pass isolation (FPI) rate, procedure time, and major complications, was conducted utilizing MEDLINE, EMBASE, and Cochrane databases. All relevant studies were included in this analysis. A random-effects model of network meta-analysis and surface under cumulative ranking curve (SUCRA) were used to rank the treatment for all outcomes. RESULTS: A total of 29 studies with 9721 patients were included in the analysis. According to the SUCRA analysis, HPSD ablation had the highest probability of maintaining sinus rhythm. Point estimation showed an odds ratio of 1.5 (95% confidence interval [CI]: 1.2-1.9) between HPSD ablation and conventional power ablation and an odds ratio of 1.3 (95% CI: 0.78-2.2) between vHPSD ablation and conventional power ablation. While the odds ratio of FPI between HPSD ablation and conventional power ablation was 3.6 (95% CI: 1.5-8.9), the odds ratio between vHPSD ablation and conventional power ablation was 2.2 (95% CI: 0.61-8.6). The procedure times of vHPSD and HPSD ablations were comparable and, therefore, shorter than that of conventional power ablation. Major complications were low in all techniques. CONCLUSION: vHPSD ablation did not yield higher efficacy than HPSD ablation and conventional power ablation. With the safety concern, vHPSD ablation outcomes were comparable with those of other techniques.

Comparison of Bivalirudin Versus Heparin for Anticoagulation During Extracorporeal Membrane Oxygenation.

The effect and safety of bivalirudin compared with heparin in patients undergoing extracorporeal membrane oxygenation (ECMO) remains unclear. Therefore, we conducted a systematic review and meta-analysis to compare the effectiveness and safety of heparin and bivalirudin in patients who underwent ECMO. We searched Embase, the Cochrane Central Register of Controlled Trials, and MEDLINE. Inclusion criteria included patients (1) undergoing ECMO and (2) receiving bivalirudin or heparin. We excluded studies where the majority of patients switched heparin to bivalirudin or vice versa during the clinical course. The primary outcome was short-term mortality. We presented the results of all analyses with the use of random-effects models. Eleven studies reported short-term mortality. The use of bivalirudin was associated with significantly lower short-term mortality, compared with heparin (odds ratio: 0.71, 95% confidence interval, 0.55-0.92; p = 0.01, I2 = 7%). In this meta-analysis of observational studies, the use of bivalirudin was associated with significantly lower short-term mortality, compared with heparin. Further prospective studies are warranted to clarify this finding.

Machine Learning-Based Predictive Model of Aortic Valve Replacement Modality Selection in Severe Aortic Stenosis Patients.

The current recommendation for bioprosthetic valve replacement in severe aortic stenosis (AS) is either surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR). We evaluated the performance of a machine learning-based predictive model using existing periprocedural variables for valve replacement modality selection. We analyzed 415 patients in a retrospective longitudinal cohort of adult patients undergoing aortic valve replacement for aortic stenosis. A total of 72 clinical variables including demographic data, patient comorbidities, and preoperative investigation characteristics were collected on each patient. We fit models using LASSO (least absolute shrinkage and selection operator) and decision tree techniques. The accuracy of the prediction on confusion matrix was used to assess model performance. The most predictive independent variable for valve selection by LASSO regression was frailty score. Variables that predict SAVR consisted of low frailty score (value at or below 2) and complex coronary artery diseases (DVD/TVD). Variables that predicted TAVR consisted of high frailty score (at or greater than 6), history of coronary artery bypass surgery (CABG), calcified aorta, and chronic kidney disease (CKD). The LASSO-generated predictive model achieved 98% accuracy on valve replacement modality selection from testing data. The decision tree model consisted of fewer important parameters, namely frailty score, CKD, STS score, age, and history of PCI. The most predictive factor for valve replacement selection was frailty score. The predictive models using different statistical learning methods achieved an excellent concordance predictive accuracy rate of between 93% and 98%.

Premorbid angiotensin converting enzyme inhibitors or angiotensin II receptor blockers in patients with sepsis.

OBJECTIVE: The aim of this study was to conduct a systematic review and meta-analysis to investigate the effect of the premorbid use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (ACEI/ARB) on short-term mortality in patients with sepsis. DATA SOURCES: Embase, the Cochrane Central Register of Controlled Trials, and MEDLINE were searched for studies based on the below eligibility criteria. The protocol was registered at the PROSPERO (CRD42022309129). STUDY SELECTION: Eligibility criteria were as follows: (1) randomized controlled trials, cohort studies, cross-sectional studies, (2) patients with sepsis aged ≥16 years, and (3) received premorbid ACEI/ARB, or not. DATA EXTRACTION: The patient and study characteristics and outcomes were extracted. All analyses were presented with the use of random-effects models. The primary outcome was short-term mortality defined as ≤30-day, in-hospital, or intensive care unit (ICU)- mortality. The secondary outcome was acute kidney injury (AKI). DATA SYNTHESIS: Fifteen studies (N = 96,159) met the eligibility criteria. Of these, eleven studies (N = 40,360) reported unadjusted short-term mortalities. The pooled odds ratio (OR) of short-term mortality with the premorbid use of ACEI/ARB was as follows: OR, 0.86; 95% confidence interval (CI), 0.67 to 1.11; P = 0.24, I2 = 88%. Five studies reported an adjusted OR of short-term mortality with the premorbid use of ACEI/ARB as follows: OR, 0.74; 95%CI, 0.59 to 0.93; P < 0.01, I2 = 93%. Seven studies reported the pooled adjusted OR of AKI with the premorbid use of ACEI/ARB as follows: OR: 1.57, 95%CI: 1.26-1.96, p < 0.01, I2 = 69%. CONCLUSION: In this meta-analysis, the premorbid ACEI/ARB was associated with significantly lower short-term mortality in patients with sepsis despite the significantly higher risk of AKI.

The efficacy of posterior wall isolation in atrial fibrillation ablation: A systematic review and meta-analysis of randomized controlled trials.

Background: Posterior wall isolation (PWI) is an emerging approach in atrial fibrillation (AF) ablation, yet its efficacy remains controversial. This is the first meta-analysis of randomized controlled trials (RCT) to evaluate the efficacy of PWI in AF ablation. Objective: To assess the efficacy of PWI in reducing atrial arrhythmia recurrence following initial AF ablation at long-term follow-ups when compared to conventional methods. Methods: We conducted a literature search from inception through September 2021 in EMBASE and MEDLINE databases. We included RCTs that compared outcomes in PWI and conventional approaches of AF ablation. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate odds ratio (OR), and 95% confidence interval (CI). Results: Eight RCT from 2009 to 2020, including 1024 AF patients, were included. PWI did not decrease overall atrial arrhythmias recurrence (RR 0.96, 95% CI:0.88-1.05, I 2 = 31.6%, p-value 0.393). However, the pooled analysis showed a significant decrease in AF recurrence in PWI compared to controlled approaches (RR 0.88, 95% CI:0.81-0.96, I 2 = 48.2%, p-value .004). In the subgroup analysis, PWI significantly decreased AF recurrence in the studies that included only persistent AF (RR = 0.89, 95% CI:0.80-0.98, I 2 = 65.2%, p-value .014). PWI significantly decreased AF recurrence when compared to PVI with roof line (RR 0.84, 95% CI 0.74-0.95, I 2 0.00%, p-value .008). Conclusion: Our study suggests that adding PWI significantly decreased AF recurrence in patients with persistent AF compared to controlled approaches. It highlights the importance of considering PWI during the initial procedure in this patient population.