Low‐Voltage Area Ablation for Persistent Atrial Fibrillation: Meta‐Analysis and Trial Sequential Analysis of RCTs

BACKGROUND: Pulmonary vein isolation (PVI) often yields suboptimal success, particularly in persistent atrial fibrillation (AF). This systematic review, frequentist meta-analysis, and Bayesian hierarchical meta-analysis evaluated whether adjunctive low-voltage area (LVA) ablation improves atrial tachyarrhythmia (ATa) outcomes, while assessing safety and potential effect modifiers. METHODS: PubMed, SCOPUS, and ScienceDirect were systematically searched for randomized controlled trials comparing PVI with versus without adjunctive LVA ablation. The primary outcome was ATa recurrence. Frequentist and Bayesian random-effects models, meta-regression, trial sequential analysis (TSA), and sensitivity analyses were performed. RESULTS: = 3.2%). Bayesian hierarchical meta-analysis demonstrated concordant findings (posterior pooled RR 0.768, 95% credible interval [CrI] 0.655-0.898) with minimal between-study heterogeneity (τ = 0.077, 95% CrI 0.004-0.241). Bayesian inference showed a 99.9% posterior probability of treatment benefit (RR<1.0), a 97.6% probability of ≥10% relative risk reduction, and a 90.8% probability of ≥15% reduction. Posterior predictive analysis yielded a 97.6% probability of benefit in a future trial. Leave-one-out and prior sensitivity analyses confirmed robust, data-driven results. Meta-regression identified no significant effect modifiers. Procedure and ablation times were not significantly prolonged, and serious complications were comparable between groups (RR 1.52, 95% CI 0.84-2.74; p = 0.169). TSA showed that 47% of the required information size had been accrued. Evidence certainty was moderate by GRADE. CONCLUSIONS: Adjunctive LVA ablation was associated with reduced ATa recurrence compared with PVI without adjunctive LVA ablation, with consistent findings across frequentist and Bayesian analyses, without increasing serious complications.