Progressive remodeling of left atrial posterior wall (LAPW) plays an important role in the pathology of persistent/ long-standing persistent atrial fibrillation. The role of pulmonary veins isolation (PVI) and adjunctive LAPW isolation using cryothermal energy in non-paroxysmal atrial fibrillation is yet to be established. The databases of Pubmed, EMBASE and Cochrane Central databases were searched from inception to April 2022. Relevant randomized trials and observational studies comparing de novo cryoballoon PVI only versus PVI+LAPWI in patients with non paroxysmal AF were identified and a meta-analysis was performed using the random effect model. The efficacy endpoints of interest were recurrence of AF, recurrence of non-AF and all atrial arrhythmias at 1-year post ablation. The safety endpoint of interest was all adverse events between the two groups. A total of 6 studies (3 prospective trials and 3 observational studies) with 1037 patients were included. A significant reduction in AF recurrence at 1-year was observed in PVI+LAPWI group (OR 0.36 (17% vs 39%), 95% CI 0.26-0.49, P < 0.001). Also, lower incidence of overall atrial arrhythmias was found in PVI+LAPWI (OR 0.37 (23% vs 47%),95% CI 0.28-0.49, P < 0.001). For safety endpoints, the overall adverse event rate was low without the significant difference between the groups (OR: 0.86, (3% vs 3.5%) 95% CI 0.36-2.07, P = 0.74). Cryoballoon LAPWI plus PVI provides a significant reduction in recurrence of all atrial arrhythmias and AF at 1-year compared with PVI alone in non paroxysmal AF population without increase in adverse events rate.
