Left Atrial Substrate Modification Targeting Low‐Voltage Areas for Catheter Ablation of Atrial Fibrillation: A Systematic Review and Meta‐Analysis

Background This meta‐analysis aims to assess the impact of a voltage‐guided substrate modification by targeting low‐voltage area (LVA) in addition to pulmonary vein isolation (PVI) in patients undergoing catheter ablation for atrial fibrillation (AF). Methods MEDLINE/PubMed, Cochrane Library, and references reporting AF ablation and “voltage* OR substrate* OR fibrosis OR fibrotic area*” were screened and studies included if matching inclusion and exclusion criteria. Results Six studies were included. Patients enrolled were 885 (517 in the study group and 368 in the control group). Median age was 60 years; 92% had nonparoxysmal AF. At a mean follow‐up of 17 months, 70% of patients in the study group vs. 43% in the control group were free from AF/atrial tachycardia (AT) recurrences (odds ratio [OR] = 3.41, 95% confidence interval [CI] 2.22–5.24). LVA ablation in addition to PVI was more effective than PVI alone and PVI + conventional wide empirical ablation (70% vs. 43%, OR = 3.41, 95% CI 2.22–5.24), without increasing the adverse event rate (2.5% vs. 6%, OR = 0.43, 95% CI 0.15–1.26). Compared to PVI + conventional wide empirical ablation, LVA ablation reduced the occurrence of postablation AT (14% vs. 46%, OR = 0.16, 95% CI 0.07–0.37), procedure time (176 min vs. 220 min, OR = 0.36, 95% CI 0.24–0.56), fluoroscopy time (25 min vs. 31 min, OR = 0.22, 95% CI 0.12–0.39), and radiofrequency time (55 min vs. 90 min, OR = 0.49, 95% CI 0.27–0.90). Conclusions A voltage‐guided substrate modification by targeting LVA in addition to PVI is more effective, safer, and holds a lower proarrhythmic potential than conventional ablation approaches. Further randomized studies are necessary to confirm these findings.