Key result
Adjunctive LVA ablation is linked to ~52% lower recurrence only in high ALID score patients.
Why the study?
In persistent AF, the incremental benefit of adjunctive low-voltage area ablation beyond pulmonary vein isolation remains inconsistent.
Does adjunctive low-voltage area ablation beyond pulmonary vein isolation reduce recurrence in specific subgroups of patients with persistent atrial fibrillation as identified by the ALID score?
Does adjunctive low-voltage area ablation beyond pulmonary vein isolation reduce recurrence in specific subgroups of patients with persistent atrial fibrillation as identified by the ALID score?
The ALID score identifies treatment-effect heterogeneity in persistent atrial fibrillation, suggesting that adjunctive low-voltage area ablation reduces recurrence in high-score patients but may increase recurrence in low-score patients.
ALID score may identify persistent AF patients for selective LVA ablation; hypothesis-generating pending randomized confirmation.
BACKGROUND: In persistent atrial fibrillation (AF), the incremental benefit of adjunctive low-voltage area (LVA) ablation beyond pulmonary vein isolation (PVI) remains inconsistent. OBJECTIVE: and to perform an exploratory supportive analysis in an independent randomized cohort. Patients were stratified into low (0-1), intermediate (2), and high (3-4) score groups. Because EARNEST-PVI did not use LVA-guided ablation or select patients based on mapped LVA, it was analyzed as an exploratory supportive cohort rather than as an external validation cohort. RESULTS: In SUPPRESS-AF (n = 336), a significant treatment-by-score interaction was observed (P < 0.001). Adjunctive LVA ablation was associated with increased recurrence in the low-score stratum (HR 3.92; 95% CI 1.50-10.20) and reduced recurrence in the high-score stratum (HR 0.48; 95% CI 0.26-0.86). In EARNEST-PVI (n = 494), a qualitatively similar interaction pattern was observed for additional ablation beyond PVI (interaction P = 0.029), although the ablation strategy differed from LVA-guided ablation. These hypothesis-generating findings require prospective validation before clinical implementation.
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Egami et al. (2026) studied Persistent atrial fibrillation (n=830). Adjunctive low-voltage area (LVA) ablation vs. Pulmonary vein isolation (PVI) alone was evaluated on Recurrence (HR 0.48, 95% CI 0.26-0.86, p=<0.001). Adjunctive LVA ablation increased recurrence in low ALID score patients (HR 3.92) but reduced recurrence in high score patients (HR 0.48; 95% CI 0.26-0.86; interaction P<0.001).
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