Adjunctive Low-Voltage Area Ablation and Atrial Tachycardia Inducibility in Persistent Atrial Fibrillation: Insights from the SUPPRESS-AF Trial

Background Although low-voltage area (LVA) ablation has been proposed as a substrate-modification strategy, it may also facilitate atrial tachycardia (AT), making it difficult to distinguish the effects of underlying substrate from those of adjunctive ablation. Objective To evaluate whether adjunctive LVA ablation is associated with post-protocol AT inducibility and whether inducibility is associated with clinical AT recurrence in a randomized cohort. Methods This post hoc analysis included patients from the SUPPRESS-AF randomized trial comparing pulmonary vein isolation (PVI) alone with PVI plus LVA ablation (PVI+LVA-ABL) in persistent atrial fibrillation with LVAs ≥5 cm 2 . After completion of the assigned ablation strategy, AT inducibility was assessed by atrial burst pacing. The primary analysis compared post-protocol AT inducibility between groups, and induced AT characteristics were compared descriptively. A secondary analysis examined the association between AT inducibility and clinical AT recurrence. Results Among 341 patients, AT was inducible in 38 (11%). AT inducibility was more frequent after PVI+LVA-ABL than after PVI alone (16% vs 6%, P=0.005). Reentrant AT was the predominant pattern, with a numerically higher frequency after PVI+LVA-ABL. During 1-year follow-up, clinical AT recurrence occurred in 35 patients. Despite a 79% acute procedural success rate for induced AT ablation, AT inducibility was associated with AT recurrence in multivariable competing-risk analysis (subdistribution hazard ratio 2.23, 95% confidence interval 1.02–4.91). Conclusion In this randomized cohort with comparable LVA burden, adjunctive LVA ablation was associated with more frequent induced ATs compared with PVI alone. Post-protocol AT inducibility was associated with clinical AT recurrence.