What does this research mean for the field?

Adding low-voltage area ablation to pulmonary vein isolation in persistent atrial fibrillation does not improve clinical outcomes but prolongs procedures. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

What question did this study set out to answer?

To investigate the effects of low-voltage area ablation added to pulmonary vein isolation on clinical outcomes in persistent atrial fibrillation.

February 22, 2026Open Access

Win Ratio Analysis of Low-Voltage Area Ablation in Persistent Atrial Fibrillation: Sub-Analysis of SUPPRESS-AF

Key Result

Adding low-voltage area ablation to pulmonary vein isolation in persistent AF did not improve clinical outcomes (win ratio 1.01, p=0.940) but prolonged procedures.

Key Points

To investigate the effects of low-voltage area ablation added to pulmonary vein isolation on clinical outcomes in persistent atrial fibrillation.
Post-hoc sub-analysis of the SUPPRESS-AF trial involving 341 patients with LVAs.
Comparison of outcomes between pulmonary vein isolation alone and with LVA ablation.
Hierarchical analysis of clinical outcomes using win ratio.
Assessment of procedural times and adverse events.
No significant difference in win ratio between PVI alone and PVI with LVA ablation (1.01, p = 0.940).
PVI plus LVA ablation group had longer procedure times and higher energy delivery.
PVI alone showed numerically fewer adverse events compared to LVA ablation.
LVA ablation group indicated a numerical reduction in AF recurrence, but not statistically significant.

Structured PICO

Does adding low-voltage area (LVA) ablation to pulmonary vein isolation (PVI) improve hierarchical clinical outcomes in patients with persistent atrial fibrillation and LVAs?

Population

341 patients with persistent atrial fibrillation and low-voltage areas (LVAs) in the left atrium (a sub-cohort of the 1,364 patients randomized in the SUPPRESS-AF trial).

Intervention

Pulmonary vein isolation (PVI) plus low-voltage area (LVA) ablation (n=170)

Comparator

Pulmonary vein isolation (PVI) alone (n=171)

Outcome

Hierarchical clinical outcomes analyzed by win ratio (all-cause death, symptomatic stroke, AF recurrence, bleeding, and periprocedural complications)composite

Adding low-voltage area ablation to pulmonary vein isolation in patients with persistent atrial fibrillation does not improve overall hierarchical clinical outcomes and prolongs procedure times.

Main Result

Absolute Event Rate: 0% vs 0%

Abstract

Abstract Background and Aims In persistent atrial fibrillation (AF), low-voltage areas (LVAs) in the left atrium are considered arrhythmogenic. Although substrate ablation targeting LVAs may reduce AF recurrence, its effect on broader clinical outcomes remains unclear, and procedural risks must be considered. To compare hierarchical clinical outcomes between pulmonary vein isolation (PVI) alone and PVI plus LVA ablation in patients with persistent AF and LVAs using a win ratio analysis. Methods This was a post-hoc sub-analysis of the SUPPRESS-AF trial, including 341 patients with LVAs out of 1,364 randomized. Patients received either PVI alone (n = 171) or PVI with LVA ablation (n = 170). Hierarchical outcomes were analyzed in order of clinical importance: all-cause death, symptomatic stroke, AF recurrence, bleeding, and periprocedural complications. Win ratio analysis was used for comparison. Results Baseline characteristics were balanced between groups. The PVI plus LVA group had longer procedure times and higher energy delivery. The win ratio analysis showed no significant difference between groups (win ratio: 1.01, 95% CI: 0.73–1.39, p = 0.940). The PVI-alone group had numerically fewer adverse events, while the LVA ablation group showed a numerical reduction in AF recurrence. Subgroup analyses showed consistent findings. Conclusion In patients with persistent AF and LVAs, LVA ablation added to PVI did not improve hierarchical clinical outcomes and prolonged procedures. Routine use of current LVA ablation strategies is not supported, though targeted substrate modification may warrant further research.