Empiric superior vena cava isolation during first-time catheter ablation for paroxysmal atrial fibrillation: a systematic review and meta-analysis of randomized trials.

BACKGROUND

Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation for paroxysmal atrial fibrillation, yet recurrences related to non-pulmonary vein triggers such as the superior vena cava are common. Whether empiric SVC isolation (SVCI) during first-time ablation improves outcomes in paroxysmal AF remains uncertain.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials comparing PVI plus empiric SVCI versus PVI alone in patients undergoing first-time catheter ablation for paroxysmal atrial fibrillation. Databases were searched through September 15, 2025.

RESULTS

Four randomized trials comprising 608 patients (304 PVI+SVCI, 304 PVI alone; mean age 61 years; 38% female) were included. Compared with PVI alone, empiric SVCI did not significantly reduce atrial arrhythmia recurrence (RR 0.70 [0.49–1.01], p = 0.06; I² = 0%), with recurrence occurring in 13.8% of patients in the PVI + SVCI group versus 19.7% in the PVI alone group. Procedural complication rates and total procedure duration were similar between groups, while fluoroscopy time was modestly longer with SVCI. Notably, phrenic nerve injury occurred exclusively in the SVCI group (3 patients).

CONCLUSIONS

In randomized trials limited to first-time ablation for paroxysmal atrial fibrillation, empiric SVC isolation did not reduce atrial arrhythmia recurrence and was associated with phrenic nerve injury. In randomized trials limited to first-time ablation for paroxysmal atrial fibrillation, empiric superior vena cava isolation did not reduce atrial arrhythmia recurrence compared with pulmonary vein isolation alone and was associated with phrenic nerve injury.