BACKGROUND Ablation for persistent atrial fibrillation (PsAF) has been performed for over 20 years, although success rates have remained modest. Several adjunctive lesion sets have been studied but none have become standard of practice. We sought to describe how the efficacy of ablation for PsAF has evolved in this time period with a focus on the effect of adjunctive ablation strategies. METHODS Databases were searched for prospective studies of PsAF ablation. We performed meta-regression and trial sequential analysis. RESULTS A total of 99 studies (15 424 patients) were included. Ablation for PsAF achieved the primary outcome (freedom of atrial fibrillation/atrial tachycardia rate at 12 months follow-up) in 48.2% (5% CI, 44.0-52.3). Meta-regression showed freedom from atrial arrhythmia at 12 months has improved over time, while procedure time and fluoroscopy time have significantly reduced. Through the use of cumulative meta-analyses and trial sequential analysis, we show that some ablation strategies may initially seem promising, but after several randomized controlled trials may be found to be ineffective. Trial sequential analysis showed that complex fractionated atrial electrogram ablation is ineffective and further study of this treatment would be futile, while posterior wall isolation currently does not have sufficient evidence for routine use in PsAF ablation. CONCLUSIONS Overall success rates from PsAF ablation and procedure/fluoroscopy times have improved over time. However, no adjunctive lesion set, in addition to pulmonary vein isolation, has been conclusively demonstrated to be beneficial. Through the use of trial sequential analysis, we highlight the importance of adequately powered randomized controlled trials, to avoid reaching premature conclusions, before widespread adoption of novel therapies.

中文翻译：

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持续性心房颤动消融的时间趋势和病变组：试验序贯分析和荟萃回归的荟萃分析。

背景 持续性心房颤动 (PsAF) 的消融治疗已经进行了 20 多年，但成功率仍然较低。已经研究了几种辅助病变组，但没有一个成为实践标准。我们试图描述这段时间内 PsAF 消融的疗效如何演变，重点关注辅助消融策略的效果。方法 检索数据库以查找 PsAF 消融的前瞻性研究。我们进行了荟萃回归和试验序贯分析。结果 总共纳入 99 项研究（15 424 名患者）。PsAF 消融达到主要结局（随访 12 个月时房颤消失/房性心动过速发生率）为 48.2%（5% CI，44.0-52.3）。荟萃回归显示，随着时间的推移，12 个月时无房性心律失常的情况有所改善，而手术时间和透视时间也显着减少。通过使用累积荟萃分析和试验序贯分析，我们表明一些消融策略最初看起来可能很有希望，但经过几次随机对照试验后可能发现是无效的。试验序贯分析表明，复杂分割心房电图消融无效，对该治疗的进一步研究将是徒劳的，而后壁隔离目前没有足够的证据可常规用于 PsAF 消融。结论 随着时间的推移，PsAF 消融和手术/透视检查时间的总体成功率有所提高。然而，除了肺静脉隔离之外，没有任何辅助损伤装置被最终证明是有益的。通过使用试验序贯分析，我们强调了充分有力的随机对照试验的重要性，以避免在广泛采用新疗法之前得出过早的结论。