Persistent Atrial Fibrillation with Left Atrial Low-Voltage Area: Who Benefit from Additional Modification?

Abstract Background The presence of low-voltage areas (LVAs) is associated with increased recurrence rate following ablation of persistent atrial fibrillation (PeAF). However, the benefit of additional LVA modification remains controversial. Aims This substudy of the STABLE-SR-II trial aims to explore the factors that influence the benefit of additional LVA ablation for PeAF patients with LVAs. Methods In the STABLE-SR-II trial, PeAF patients with de novo ablation were randomized to receive either circumferential pulmonary vein isolation (CPVI, CPVI-alone group) or CPVI plus LVA ablation (CPVI-plus group). Patients with LVAs were included and analyzed in this substudy. The primary outcome was freedom from atrial arrhythmias 18 months after a single ablation procedure. Results LVAs were detected in 133 out of 276 PeAF patients (48%). Age and LVA burden were potential factors influencing the relative success of additional LVA ablation compared to CPVI alone in the univariable analysis. In multi-adjusted models, significant benefit from additional LVA ablation was found in patients aged ≥65 years (n=50, hazard ratio [HR] 0.14, 95% confidence interval [CI] 0.02–0.83) or with LVA burden ≥ 15% (n=18, HR 0.01, 95% CI 0–0.44). LVA burden ≥15% was observed in 10 of 50 patients aged ≥65 years (20%) and in 8 of 83 patients aged <65 years (10%). Combined subgroup analysis demonstrated that LVA ablation was particularly beneficial for patients aged ≥65 years, regardless of LVA burden. Conclusion LVA ablation following CPVI may provide additional benefits for older PeAF patients (≥65 years) in the first procedure. Clinical Trial Registration NCT03448562 (CPVI Alone Versus CPVI Plus Electrophysiological Substrate Ablation in the LA During SR for the Treatment of Non-PAF [STABLE-SR_II])