Duration of Rhythm Monitoring and Arrhythmia Recurrence After Pulmonary Vein Isolation for Atrial Fibrillation: A Systematic Review and Meta-Regression Study

Introduction: The effect of the rhythm monitoring strategy after catheter ablation for atrial fibrillation (AF) on reported atrial arrhythmia (AA) recurrence is not well characterized. We aimed to determine whether continuous rhythm monitoring after AF ablation detects more AA recurrence than intermittent rhythm monitoring, and whether the total duration of intermittent rhythm monitoring predicts reported AA recurrence. Methods: EMBASE, MEDLINE, and CENTRAL databases were systematically searched for randomized controlled trials (RCT) of adult patients undergoing first catheter ablation for AF from 2007 to 2019. Studies with a minimum of 12 months follow-up were included. We selected trial arms of patients undergoing first-time ablation for AF using pulmonary vein isolation alone, without additional left-sided ablation lesion sets. Studies of surgical and hybrid ablation, or those without full rhythm monitoring details were excluded. Duration of rhythm monitoring was extracted and summed in duplicate. Meta-regression with random effects and mixed-effects models was used to identify any association between duration of monitoring and single-procedure AA recurrence. Analyses were performed separately on arms of patients with paroxysmal AF, and persistent AF (PeAF) or combined PAF/PeAF. Results: The search strategy and study selection yielded 47 trial arms from 46 RCTs comprising 4236 patients: 30 arms of patients with PAF and 17 arms of patients with PeAF or both PAF/PeAF. There was less AA recurrence in arms undergoing intermittent monitoring than continuous monitoring in PAF arms (31.1% vs. 44.4%, p < 0.01), but not in PeAF/ PAF-PeAF combined arms (47.1% vs. 63.6%, p=0.22). There was no significant relationship between the duration of intermittent rhythm monitoring and AA recurrence in both PAF (p=0.87) and PeAF/ PAF-PeAF combined arms (p=0.14). Conclusions: In RCTs of catheter ablation for PAF, continuous rhythm monitoring detected higher AA recurrence rates than intermittent rhythm monitoring. The duration of intermittent rhythm monitoring did not influence reported AA recurrence. These findings have important implications to the care of patients with AF and to researchers studying AF ablation.