Celebrates the IDEAL-AF publication in JAMA as a team achievement
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Low-Voltage Ablation in Persistent Atrial Fibrillation
Astrid Paul NordinEmmanouil CharitakisCarina CarnlöfFinn ÅkerströmOtt SaluveerHenrik AlmrothLars O. KarlssonAnders JönssonCsaba HerczkuJari TapanainenNiklas HöglundEmma SvennbergFrieder BraunschweigTara BourkeJonas SchwielerHamid BastaniSerkan SaygıFahd AsaadYusuf TürkmenMats Jensen‐UrstadNikola Drca
What happened
Adjunctive low-voltage zone ablation boosts 12-month atrial arrhythmia freedom by an absolute ~30% vs PVI alone.
- OR 3.5
- 95% CI 2.0-6.2
- P<.001
- n=209
- 69/102 (67.6%) vs 40/107 (37.4%) at 12 months
Does this change practice?
Where experts agree
Multiple clinicians agree that IDEAL-AF supports a move toward individualized, substrate-guided ablation rather than a uniform PVI-only strategy in persistent AF with low-voltage zones.
What this trial adds
Experts read IDEAL-AF as a strong signal that substrate-guided ablation should replace a one-size-fits-all approach in persistent AF with low-voltage zones, though questions remain about how broadly these results generalize.
Published field read
The reaction to IDEAL-AF is broadly positive, with clinicians framing the result as an important step toward individualized, substrate-guided ablation rather than pulmonary vein isolation alone. One electrophysiologist flags a striking discrepancy between the control-arm recurrence rates in IDEAL-AF and a comparable trial, raising questions about what drove the large treatment effect. The live question is whether these findings will change guidelines and how consistently low-voltage zone mapping can be implemented across centers.
Still open
Questions raised in published commentaryOne clinician highlights that the PVI-alone arm in IDEAL-AF had a much higher recurrence rate than in the comparable SUPPRESS-AF trial, raising the question of whether patient selection or procedural differences inflated the treatment effect.
It also remains unclear whether these results will prompt guideline revisions or how reproducible substrate-guided ablation will be outside specialized trial centers.
Context from published commentary. Source summaries are not a new guideline recommendation.
Who says what
Masato Okada
Endpoint critiqueCompares IDEAL-AF to the SUPPRESS-AF trial and asks why the PVI-alone arm recurrence rate differed so starkly between the two studies.
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Edgardo AlaniaResults readout
Sees the result as a push toward substrate-guided ablation with improved arrhythmia-free survival and quality of life without added serious adverse events.
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Calls the trial an important step toward more individualized, substrate-guided ablation in persistent AF with significant low-voltage zones.
X post ↗Charles Te
ContextPoints to a prior meta-analysis on low-voltage area ablation and notes IDEAL-AF builds on earlier evidence by clarifying where and how to ablate.
X post ↗Diogo Fouto
Results readoutCongratulates the team and highlights the significant benefit of low-voltage zone-guided ablation added to PVI.
X post ↗Full evidence
Why the trial, key points, tables, limitations, PICO, abstract, media & sources
Full evidence
Why the trial, key points, tables, limitations, PICO, abstract, media & sources
Why the trial?
Pulmonary vein isolation alone frequently fails in persistent atrial fibrillation, and trials of additional substrate ablation have conflicted. IDEAL-AF asked whether individualised ablation of low-voltage areas improves outcomes over standard PVI.
Does adjunctive individualized low-voltage zone ablation improve freedom from atrial arrhythmia in adult patients with persistent atrial fibrillation and significant low-voltage zones undergoing first-time ablation?
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Key Points
- To determine whether adding individualized low-voltage zone ablation to pulmonary vein isolation improves arrhythmia freedom and health-related quality of life in persistent atrial fibrillation.
- Multicenter randomized clinical trial conducted at 5 Swedish ablation centers with 12 months of follow-up (ClinicalTrials.gov: NCT04377594).
- Screened 936 adults undergoing first-time ablation and randomized 209 patients with low-voltage zones ≥3.0 cm² to pulmonary vein isolation plus individualized low-voltage zone ablation (n = 102) or isolation alone (n = 107).
- Arrhythmia-free survival at 12 months without antiarrhythmic drugs occurred in 67.6% (69/102) of the combination group versus 37.4% (40/107) of the control group (unadjusted difference 30.3% [95% CI, 17.4%-43.2%]; OR 3.5 [95% CI, 2.0-6.2]; P < .001).
- Time to first arrhythmia recurrence after a single procedure favored the low-voltage ablation group (HR 0.4 [95% CI, 0.3-0.6]; P < .001), with greater improvements in quality of life and similar serious adverse event rates.
Evidence details
What drove the result?
| Outcome | PVI + LVZ | PVI alone |
|---|---|---|
| Freedom from atrial arrhythmia off AADs at 12 months | 69/102 (67.6%) | 40/107 (37.4%) |
| Primary · difference 30.3 pp (95% CI 17.4–43.2); OR 3.5 (2.0–6.2); p<0.001; after 1–2 procedures | ||
| Time to first recurrence after a single procedure | ||
| Secondary · HR 0.4 (95% CI 0.3–0.6; p<0.001) favoring low-voltage-zone ablation | ||
Limitations & tradeoffs
Representation
Applies only to the 22% of screened patients with low-voltage zones ≥3.0 cm² (209 of 936).
Design limitations
The primary endpoint permitted a repeat ablation within 6 months, and serious adverse event rates are described only as similar between groups with no counts reported.
Patient burden
Quality-of-life gains are stated without numeric detail.
Structured PICO
Does adjunctive individualized low-voltage zone ablation improve freedom from atrial arrhythmia in adult patients with persistent atrial fibrillation and significant low-voltage zones undergoing first-time ablation?
P
Population
209 adult patients with persistent atrial fibrillation and low-voltage zones ≥3.0 cm2 undergoing first-time ablation, followed for 12 months.
I
Intervention
Individualized adjunctive low-voltage zone ablation following pulmonary vein isolation (n=102)
C
Comparator
No further ablation following pulmonary vein isolation (n=107)
O
Outcome
Freedom from documented atrial arrhythmia without antiarrhythmic drugs at 12 months after 1 or 2 ablation procedures within 6 monthshard clinical
Main Result
Odds Ratio: 3.5 (95% CI 2–6.2)
Absolute Event Rate: 67.6% vs 37.4%
Absolute Risk Reduction: 30.3%
p-value: p=<.001
Adjunctive low-voltage zone ablation significantly improves 12-month arrhythmia-free survival compared to pulmonary vein isolation alone in patients with persistent atrial fibrillation and significant low-voltage zones.
Discussion
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Expert reaction
What experts said about IDEAL-AF
JAMA · ESC Congress 2026
1 expert quoted, 0 with a clear stance so far. We show the split once 3 have one.
Expert labels are toward IDEAL-AF's result, from named public quotes (n=0). As of Aug 31, 2026.
Where experts stand
Experts read IDEAL-AF as a strong signal that substrate-guided ablation should replace a one-size-fits-all approach in persistent AF with low-voltage zones, though questions remain about how broadly these results generalize.
The reaction to IDEAL-AF is broadly positive, with clinicians framing the result as an important step toward individualized, substrate-guided ablation rather than pulmonary vein isolation alone. One electrophysiologist flags a striking discrepancy between the control-arm recurrence rates in IDEAL-AF and a comparable trial, raising questions about what drove the large treatment effect. The live question is whether these findings will change guidelines and how consistently low-voltage zone mapping can be implemented across centers.
Agreement
Multiple clinicians agree that IDEAL-AF supports a move toward individualized, substrate-guided ablation rather than a uniform PVI-only strategy in persistent AF with low-voltage zones.
2 clinicians say this directly
Still unclear
One clinician highlights that the PVI-alone arm in IDEAL-AF had a much higher recurrence rate than in the comparable SUPPRESS-AF trial, raising the question of whether patient selection or procedural differences inflated the treatment effect. It also remains unclear whether these results will prompt guideline revisions or how reproducible substrate-guided ablation will be outside specialized trial centers.
Key expert perspectives
AJACC Journal Scan
“IDEAL-AF, with its stricter trial design, shifts support toward atrial mapping and individualized adjunctive low-voltage zone ablation, present in a minority of patients.”
Celebrates the IDEAL-AF publication in JAMA as a team achievement
As an electrophysiologist connected to the trial team, Drca highlights the IDEAL-AF publication in JAMA and credits the group behind the work.
Distilled from their postX post
MO
Masato Okada · Aug 31 Endpoint critique Compares IDEAL-AF to the SUPPRESS-AF trial and asks why the PVI-alone arm recurrence rate differed so starkly between the two studies. X post
Implication
Supports adjunctive low-voltage ablation in persistent AF with significant zones; extends randomized evidence beyond pulmonary vein isolation alone.
Abstract
Importance Pulmonary vein isolation remains the foundational ablation approach for atrial fibrillation (AF), yet outcomes in persistent AF remain suboptimal. Targeting low-voltage zones identified by electroanatomical mapping offers a promising strategy for enhancing ablation success. Objective To determine whether adjunctive individualized low-voltage zone ablation improves arrhythmia outcomes and health-related quality of life beyond pulmonary vein isolation alone in patients with persistent AF and significant low-voltage zones. Design, Setting, and Participants Multicenter randomized clinical trial with 12 months of follow-up conducted at 5 Swedish ablation centers between May 18, 2020, and April 9, 2026. Of 936 adult patients undergoing first-time ablation and voltage mapping for persistent AF, 209 with low-voltage zones of 3.0 cm 2 or greater were randomized. Interventions Following pulmonary vein isolation, patients with significant low-voltage zones were randomized to either receive individualized adjunctive low-voltage zone ablation (n = 102) or receive no further ablation (n = 107). Main Outcomes and Measures The primary outcome was freedom from documented atrial arrhythmia without antiarrhythmic drugs at 12 months after 1 or 2 ablation procedures within 6 months. Secondary outcomes were time to first recurrence after a single procedure without antiarrhythmic drugs, health-related quality of life, and safety. Results Among the 209 randomized patients (median age, 72 years; 109 females [52.2%]), the primary outcome was achieved more frequently in the pulmonary vein isolation plus low-voltage zone ablation group than in the pulmonary vein isolation alone group. Arrhythmia-free survival was achieved in 69 patients (67.6%) vs 40 patients (37.4%), respectively (unadjusted difference, 30.3% [95% CI, 17.4%-43.2%]; odds ratio, 3.5 [95% CI, 2.0-6.2]; P < .001). Time to first recurrence after a single ablation procedure without antiarrhythmic drugs also favored low-voltage zone ablation (hazard ratio, 0.4; 95% CI, 0.3-0.6; P < .001). Improvements in health-related quality of life were greater in the low-voltage zone ablation group, whereas rates of serious adverse events were similar between groups. Conclusions and Relevance Adjunctive low-voltage zone ablation added to pulmonary vein isolation improved rhythm outcomes and health-related quality of life without increasing serious adverse events in patients with persistent AF and significant low-voltage zones. These findings support a low-voltage zone–guided ablation strategy in this population. Trial Registration ClinicalTrials.gov Identifier: NCT04377594
Coverage & sources
Journal, society, and media accounts. Useful signal, not independent expert judgment.
Cite This Study
Nordin et al. (2026) conducted an RCT in Persistent atrial fibrillation (n=209). Individualized adjunctive low-voltage zone ablation vs. No further ablation (pulmonary vein isolation alone) was evaluated on Freedom from documented atrial arrhythmia without antiarrhythmic drugs at 12 months after 1 or 2 ablation procedures within 6 months (OR 3.5, 95% CI 2.0-6.2, p=<.001). Adjunctive low-voltage zone ablation added to pulmonary vein isolation improved freedom from atrial arrhythmia compared to isolation alone (67.6% vs 37.4%; OR 3.5; 95% CI 2.0-6.2; P<.001).