Empirical Superior Vena Cava Isolation Added to Pulmonary Vein Isolation in Atrial Fibrillation: A Systematic Review and Meta-Analysis.

BACKGROUND: Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation for atrial fibrillation (AF), yet recurrence remains common due to non–pulmonary vein triggers, particularly the superior vena cava (SVC). Empiric superior vena cava isolation (SVCI) has been proposed as an adjunct to improve outcomes, but its clinical benefit remains uncertain. METHODS: This systematic review and meta-analysis was conducted according to the Cochrane Handbook and PRISMA 2020 guidelines. PubMed, Embase, Cochrane Library, and clinical trial registries were searched from inception through December 10, 2025. Randomized controlled trials and observational cohort studies comparing PVI plus empiric SVCI with PVI alone in adults with atrial fibrillation were included. Outcomes assessed included AF recurrence, event-free survival, procedural success, procedural metrics, and complications. Risk of bias was assessed using RoB 2.0 and the Robins-I. Pooled estimates were calculated using random-effects models. RESULTS: Ten studies comprising 1,055 patients (PVI: 531; PVI + SVCI: 524) were included. There was no statistically significant difference in AF recurrence between PVI + SVCI and PVI alone (OR 1.32; 95% CI 0.95–1.84). Event-free survival (OR 0.73; 95% CI 0.53–1.00) and procedural success rates also did not differ significantly. Procedural time, ablation duration, and fluoroscopy time were comparable between strategies. Notably, PVI + SVCI was associated with a significantly lower risk of phrenic nerve injury (OR 0.20; 95% CI 0.10–0.41), while other complications, including pericardial effusion, pseudo-aneurysm, and deep venous thrombosis, were similar between groups. CONCLUSIONS: Empiric SVC isolation added to pulmonary vein isolation does not significantly improve rhythm outcomes in unselected AF populations but appears safe and may reduce phrenic nerve injury without increasing procedural burden.