Efficacy and safety of driver-guided catheter ablation for atrial fibrillation: A systematic review and meta-analysis

Introduction Targeting localized drivers (electrical rotors or focal impulses) during catheter ablation for atrial fibrillation (AF) has been proposed as a strategy to improve procedural success. However, the strength and quality of the evidence to support this approach is unclear. Methods and results Clinical studies reporting efficacy or safety outcomes of driver-guided ablation for AF were identified in Medline, Embase, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, Pubmed, and conference abstracts from major scientific meetings. Random-effects meta-analysis of efficacy outcomes from controlled studies was performed. Thirty-one reports from 30 studies were included: two randomized controlled trials, five nonrandomized controlled studies, and 23 uncontrolled studies. In controlled studies, driver-guided ablation has been associated with higher rates of acute AF termination (RR 2.08, 95% CI 1.43–3.05; P < 0.001) and increased freedom from AF/atrial tachycardia (AT) at ≥1 year (RR 1.34, 95% CI 1.05–1.70; P = 0.02). Similar rates of procedural complications have been reported between ablation strategies. Overall, current data on driver-guided ablation are predominantly from nonrandomized studies with considerable heterogeneity in mapping and ablation strategies used and in clinical outcomes reported. Conclusion Pooled data on the efficacy of AF driver-guided catheter ablation suggest increased freedom from AF/AT relative to conventional strategies. However, most studies are nonrandomized and of moderate quality. Though promising data exist, there remains no conclusive evidence for the efficacy of AF driver ablation. Robust data from randomized trials are needed.