Key result
PVI plus LVA ablation reduces AF recurrence ~47% versus PVI alone in females, but not males.
Why the study?
Female sex is a known risk factor for low-voltage areas and post-ablation recurrence in AF, but sex differences in recurrence after PVI versus PVI plus LVA ablation were not established.
Does pulmonary vein isolation plus low-voltage area ablation reduce atrial arrhythmia recurrence compared to pulmonary vein isolation alone in patients with atrial fibrillation and low-voltage areas?
Does pulmonary vein isolation plus low-voltage area ablation reduce atrial arrhythmia recurrence compared to pulmonary vein isolation alone in patients with atrial fibrillation and low-voltage areas?
Low-voltage area ablation in addition to pulmonary vein isolation significantly reduces atrial arrhythmia recurrence beyond the blanking period in female patients, but not in male patients.
Supports adjunctive LVA ablation in females with LVAs; extends evidence for sex-specific AF ablation responses.
Background Female sex is a known risk factor for the presence of low-voltage areas (LVAs) and post-ablation recurrence in patients with atrial fibrillation (AF). Purpose This study aimed to evaluate sex differences in AF recurrence after pulmonary vein isolation (PVI-alone) versus PVI plus LVA ablation (PVI+LVA-ABL). Methods An analysis was performed from the SUPPRESS-AF trial, a randomized controlled trial evaluating the efficacy of LVA ablation. LVAs were defined as areas where bipolar peak-to-peak voltage was <0.50 mV, and patients with an LVA area ≥5 cm² were included in this study. The primary endpoint was any atrial arrhythmia lasting for >30 seconds without antiarrhythmic drugs (AADs). Arrhythmia episodes identified during the 3-month blanking period are not considered AF recurrences. Results Among 339 study patients, 165 (48.7%) were females. Females were older than males (76 [IQR, 69–78] vs. 74 years [IQR, 72–79], p=0.014) and had larger LVA areas (16.4 cm² [IQR, 10.0–28.6] vs. 11.7 cm² [IQR, 8.1–19.7], p<0.001). At one year post-ablation, recurrence rates were similar between the PVI-alone and PVI+LVA-ABL groups in males (42.5% vs. 42.4%, log-rank p=0.92). In females, the PVI+LVA-ABL group exhibited a trend toward lower recurrence compared to the PVI-alone group (42.7% vs. 30.1%, log-rank p=0.10, P for interaction=0.17). Excluding patients with persistent AF recurrence or AAD use at 3 month, a landmark analysis beyond the blanking period demonstrated that the recurrence rates remained compatible in males (33.3% vs. 32.4%, log-rank p=0.91). However, in females, the recurrence rate was significantly lower in the PVI+LVA-ABL group compared to the PVI-alone group (43.8% vs. 23.3%, log-rank p=0.013), with a P for interaction of 0.080. Conclusion The efficacy of LVA ablation in addition to PVI was compatible between sexes. However, in females, LVA ablation was associated with a significantly lower recurrence rate beyond the blanking period, suggesting its potential efficacy as a substrate modification strategy in female patients.
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Miyazaki et al. (2025) studied this question. In females with LVAs, PVI plus LVA ablation reduced AF recurrence beyond blanking period to 23.3% vs 43.8% with PVI alone (p=0.013), with no difference in males.
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