Empiric and Trigger-Guided Superior Vena Cava Isolation in AF Ablation: Systematic Review and Meta-Analysis

Department

Internal Medicine

Document Type

Article

Publication Title

Pacing and Clinical Electrophysiology : PACE

Abstract

Background: Superior vena cava isolation (SVCI) is performed as an adjunct to pulmonary vein isolation (PVI) for atrial fibrillation, yet whether an empiric or trigger-guided strategy is preferable remains uncertain. Prior meta-analyses have been largely restricted to index procedures in paroxysmal AF and have not explicitly stratified by ablation strategy. We sought to address these gaps through a systematic review of available randomized evidence.

Methods: Major databases were searched through November 2025 for RCTs comparing PVI+SVCI versus PVI alone. Trials were stratified by strategy: empiric SVCI (performed irrespective of SVC ectopy) or trigger-guided SVCI (performed only upon demonstrated SVC triggers). The primary outcome was atrial tachyarrhythmia recurrence (≥ 30 s) beyond the blanking period. Random-effects models, pre-specified subgroup analyses, meta-regression, and GRADE certainty assessment were performed.

Results: Eight RCTs (n = 1231) were included; most enrolled paroxysmal AF, while two incorporated non-paroxysmal AF subtypes and one evaluated repeat ablation procedures. Overall, SVCI+PVI significantly reduced recurrence versus PVI alone (97/604 vs. 135/627; RR 0.77, 95% CI 0.61-0.97; p = 0.03; I2 = 0%). On stratified analysis, empiric SVCI demonstrated a significant recurrence reduction (RR 0.70, 95% CI 0.53-0.92; p = 0.01; I2 = 0%), while trigger-guided SVCI did not reach statistical significance (RR 0.80, 95% CI 0.37-1.74; p = 0.57; I2 = 52%). In paroxysmal AF (n = 1038), adjunctive SVCI significantly reduced recurrence compared with PVI alone (RR 0.68, 95% CI 0.52-0.90; p = 0.01; I2 = 0%). Fluoroscopy time was longer with SVCI; total procedure duration was comparable. Major complications were infrequent but numerically higher with SVCI+PVI (15/604 vs. 7/627; RR 1.96, 95% CI 0.87-4.38; p = 0.10). Meta-regression identified no significant effect modifiers. GRADE certainty was high for overall and empiric analyses, and moderate for trigger-guided SVCI.

Conclusions: Empiric SVCI significantly reduced AT/AF recurrence as an adjunct to PVI, while trigger-guided SVCI did not demonstrate a significant benefit. These findings suggest SVC isolation confers benefit independent of prior trigger documentation, supporting the role of empiric SVCI as an adjunct to AF ablation.

First Page

1630

Last Page

1640

DOI

10.1111/pace.70296

Volume

49

Issue

10

Publication Date

10-1-2026

Publisher

Futura Pub. Co.

Medical Subject Headings

Atrial Fibrillation; Humans; Catheter Ablation; Vena Cava, Superior; Pulmonary Veins; Randomized Controlled Trials as Topic

PubMed ID

42154216

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