Low-voltage area ablation added to pulmonary vein isolation reduced AF recurrence in nondiabetic patients (35% vs 49%, P=0.018) but not in diabetic patients (P for interaction=0.041).
RCT (n=343)
randomized
Yes
Does PVI + LVA ablation reduce AF/atrial tachycardia recurrence compared to PVI alone in patients with persistent AF, and does diabetes status modify this efficacy?
LVA ablation in addition to PVI may reduce arrhythmia recurrence in patients with persistent AF without diabetes, but appears to offer no benefit in those with diabetes.
p-value: p=0.041
Background The potential value of low‐voltage area (LVA) ablation for persistent atrial fibrillation (AF) has been suggested. However, its efficacy determinants remain unclear. We investigated the impact of diabetes on the outcomes of LVA ablation in patients with persistent AF. Methods This post hoc subanalysis of the multicenter randomized controlled trial SUPPRESS‐AF (Efficacy and Safety of Low‐Voltage‐Guided Ablation for Recurrence Prevention Compared With Pulmonary Vein Isolation Alone in Patients With Persistent Atrial Fibrillation) included patients with persistent AF undergoing initial ablation. Following pulmonary vein isolation (PVI), patients with LVAs were randomized to PVI+LVA‐ablation or PVI alone. We compared recurrence‐free survival between patients with and without diabetes. The primary end point was freedom from AF/atrial tachycardia recurrence. Results Of 1347 patients with persistent AF, 343 (25.5%) had left atrial LVAs. The nondiabetic group comprised 264 patients (136 and 128 in the PVI‐alone and PVI+LVA‐ablation arms, respectively), and the diabetic group comprised 77 patients (35 and 42 in each arm, respectively). No significant difference was observed in LVA extent between the groups. Overall recurrence rates were also similar (44% versus 42%; P =0.658). In the nondiabetic group, the PVI+LVA‐ablation arm showed significantly lower recurrence rates compared with the PVI‐alone arm (35% versus 49%; P =0.018). Conversely, patients with diabetes exhibited higher recurrence rates in the PVI+LVA‐ablation arm compared with those in the PVI‐alone arm (48% versus 40%; P =0.290). A significant interaction was observed between diabetes status and LVA ablation efficacy ( P for interaction=0.041). Conclusions In this exploratory post hoc analysis, LVA ablation may benefit patients without diabetes, whereas no clear benefit, and a possible signal of futility, was observed in patients with diabetes.
Ozaki et al. (2026) conducted an RCT in persistent atrial fibrillation (n=343). Low-voltage area (LVA) ablation plus pulmonary vein isolation (PVI) vs. Pulmonary vein isolation (PVI) alone was evaluated on freedom from AF/atrial tachycardia recurrence (p=0.041). Low-voltage area ablation added to pulmonary vein isolation reduced AF recurrence in nondiabetic patients (35% vs 49%, P=0.018) but not in diabetic patients (P for interaction=0.041).