Efficacy of Low‐Voltage Area Ablation Across Substrate Size in Persistent Atrial Fibrillation: A Post Hoc Analysis of the SUPPRESS‐AF Randomized Trial

Figures

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  Figure 1. Distribution of LVA size. The distribution of left atrial LVA size was nonnormal (Shapiro–Wilk P<0.001) and right skewed, with a median of 13.3 cm2 (interquartile range, 8.7–23.2 cm2). LVA indicates low‐voltage area.

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  Figure 2. Incidence rate of AF/AT recurrence across LVA size. Association between LVA size and arrhythmia recurrence during follow‐up, evaluated using a Cox regression model with restricted cubic splines. The horizontal axis represents LVA size on a logarithmic scale, labeled with the corresponding absolute values (cm2); the vertical axis shows the adjusted incidence rate of AF/AT recurrence per 100 patient‐years. The incidence increased progressively with greater LVA burden. AF indicates atrial fibrillation; AT, atrial tachycardia; and LVA, low‐voltage area.

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  Figure 3. AF/AT‐recurrence‐free rate across LVA size categories. Kaplan–Meier curves showing freedom from AF/AT recurrence after a single procedure without antiarrhythmic drug use, stratified by LVA size category and treatment group. Adjunctive LVA ablation significantly reduced recurrence in patients with extensive LVAs but not in those with small or moderate substrate burden. AF indicates atrial fibrillation; AT, atrial tachycardia; HR, hazard ratio; LVA, low‐voltage area; PVI, pulmonary vein isolation; and PVI+LVA‐ABL, pulmonary vein isolation followed by low‐voltage area ablation.

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  Figure 4. Treatment effect of LVA‐ABL compared with PVI alone across the spectrum of LVA size. Treatment effect of adjunctive LVA ablation across the continuous spectrum of LVA size, evaluated with a Cox regression model using restricted cubic splines. The horizontal axis represents LVA size on a logarithmic scale labeled with absolute values (cm2), and the vertical axis shows the estimated HR with 95% CIs (shaded area) for AF/AT recurrence. HR <1.0 indicates a favorable treatment effect of adjunctive LVA ablation compared with PVI alone. AF indicates atrial fibrillation; AT, atrial tachycardia; HR, hazard ratio; LVA, low‐voltage area; PVI, pulmonary vein isolation; and PVI+LVA‐ABL, pulmonary vein isolation followed by low‐voltage area ablation.

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  Figure 5. Type of arrhythmia recurrence across LVA size and treatment group. A, Proportions of patients with AF recurrence across treatment groups. B, Proportions of patients with AT recurrence across treatment groups. Because separate AF and AT recurrence dates were unavailable, recurrence type was defined by the first documented event after the blanking period. Event proportions during the 1‐y study period were compared between treatment groups within each LVA size category. AF indicates atrial fibrillation; AT, atrial tachycardia; LVA, low‐voltage area; PVI, pulmonary vein isolation; and PVI+LVA‐ABL, pulmonary vein isolation followed by low‐voltage area ablation.

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  Figure 6. Treatment effect of PVI+LVA‐ABL compared with PVI alone across LVA size categories. Forest plot showing the treatment effect of adjunctive LVA ablation compared with PVI alone on 4 distinct end points: AF/AT recurrence without AADs, AF/AT recurrence, AF recurrence, and AT recurrence. Analyses were stratified by LVA size category (small, moderate, extensive), with HRs and 95% CIs displayed for each end point. AAD indicates antiarrhythmic drug; AF, atrial fibrillation; AT, atrial tachycardia; HR, hazard ratio; LVA, low‐voltage area; PVI, pulmonary vein isolation; and PVI+LVA‐ABL, pulmonary vein isolation followed by low‐voltage area ablation.