Long‐Term Outcome of Left Atrial Voltage‐Guided Substrate Ablation During Atrial Fibrillation: A Novel Adjunctive Ablation Strategy

Voltage‐Guided Atrial Fibrillation Substrate Ablation Introduction Left atrium (LA) low voltage area (LVA) on 3‐D electroanatomic bipolar voltage mapping (EAVM), as a surrogate for scar, is associated with poor AF ablation outcome. We evaluated the long‐term outcome of an LVA‐guided atrial fibrillation (AF) substrate modification strategy as an adjunct to pulmonary vein isolation (PVI). Methods and Results Two hundred and one consecutive patients with AF (82% persistent/Non‐PAF, age 65 years), who underwent EAVM during AF prior to PVI, were divided into 2 groups according to the presence or absence of LVA outside the PV antra, defined as bipolar voltage of <0.5 mV. LVA‐guided substrate modification was performed after PVI in patients with LVA. LVA was found in 159 patients (79%). Non‐PAF (OR 3.851, P = 0.002) and CHA 2 DS 2 ‐VAS c score (OR 1.815, P < 0.001) were independent predictors for the LVA. After the index procedure, 144 patients (72%) were free from AF at 12 months. With multiple procedures, 148 patients (74%) during a median follow‐up of 3.1 years were free from the recurrence. There was no difference in the recurrence (log‐rank P = 0.746), and complications (0% vs. 7%, P = 0.125) between the groups. Neither LVA nor Non‐PAF was an independent predictor for the recurrence in a multivariate analysis. Conclusions Patients with LVA had an equally favorable long‐term ablation outcome compared to those without. As an adjunct to PVI, voltage‐guided substrate modification may be an important ablation strategy in patients with LA structural remodeling.