Key result
Adjunctive low-voltage area ablation plus PVI cuts recurrent atrial tachyarrhythmia ~33% vs. PVI alone.
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Why the study?
Randomized controlled trials evaluating adjunctive low-voltage area ablation in persistent atrial fibrillation have yielded inconsistent findings regarding its efficacy.
Does adjunctive low-voltage area ablation in addition to pulmonary vein isolation reduce recurrent atrial tachyarrhythmia in patients with persistent atrial fibrillation?
Meta-Analysis (n=1,487)
Does adjunctive low-voltage area ablation in addition to pulmonary vein isolation reduce recurrent atrial tachyarrhythmia in patients with persistent atrial fibrillation?
Hazard Ratio: 0.67 (95% CI 0.5–0.88)
p-value: p=0.004
Adjunctive low-voltage area ablation significantly reduces the recurrence of atrial arrhythmias at 1 year compared to PVI alone in patients with persistent atrial fibrillation, without an increase in procedural complications.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“In our multicentre trial, the addition of further ablation targeting low-voltage areas that trigger rhythm abnormalities did not reduce the recurrence of AF at one year in the overall cohort, but showed promising results in an important sub-group with advanced left atrial enlargement, which affects around half of patients with persistent AF.”
“I think that's the biggest issue that we have—personalizing our treatments for persistent atrial fibrillation to know who should have a posterior wall isolation or who should have a vein of Marshall ablation with alcohol or who should have linear ablation. I think that's where the biggest bang for the buck is going to be moving forward.”
Supports adjunctive low-voltage area ablation with PVI in persistent AF; confirms benefit across prior inconsistent RCTs.
BACKGROUND Adjunctive low-voltage area ablation (LVAA) has been proposed as a substrate modification strategy to improve outcomes of catheter ablation in persistent atrial fibrillation (AF); however, randomized controlled trials (RCTs) evaluating LVAA have yielded inconsistent findings. OBJECTIVES This meta-analysis sought to evaluate the efficacy of LVAA in addition to pulmonary vein isolation (PVI) compared with PVI alone in patients with persistent AF. METHODS Electronic databases were searched from inception to September 2026 for eligible RCTs. The primary endpoint was recurrent AF/atrial tachyarrhythmia ≥12 months after index ablation. Secondary endpoints included major periprocedural complications and procedural durations. Meta-analyses were performed using random-effects models. Trial sequential analysis was performed to assess the robustness of cumulative evidence. RESULTS Seven RCTs comprising 1,487 participants (weighted mean age 68 years, 60% male) were included. Compared with PVI alone, PVI + LVAA was associated with significantly lower recurrence of AF/atrial tachyarrhythmia (HR: 0.67; 95% CI: 0.50-0.88; I2 = 55%; P = 0.004). Trial sequential analysis demonstrated that the cumulative Z-curve crossed the monitoring boundary for benefit, supporting the robustness of the observed treatment effect. Adjunctive LVAA increased total procedure duration (mean difference: 30.5 minutes; 95% CI: 5.8-55.2; P = 0.02) and radiofrequency ablation duration (mean difference: 12.3 minutes; 95% CI: 5.4-19.1; P < 0.001) without increasing fluoroscopy time or major periprocedural complications (relative risk: 1.12; 95% CI: 0.60-2.10; P = 0.7). CONCLUSIONS Among patients with persistent AF, adjunctive LVAA in addition to PVI significantly reduces recurrent atrial tachyarrhythmia compared with PVI alone. These findings support electroanatomically guided substrate modification as a promising individualized ablation strategy in persistent AF.
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Virk et al. (2026) conducted a meta-analysis in Persistent atrial fibrillation (n=1,487). Adjunctive low-voltage area ablation (LVAA) in addition to pulmonary vein isolation (PVI) vs. Pulmonary vein isolation (PVI) alone was evaluated on Recurrent AF/atrial tachyarrhythmia ≥12 months after index ablation (HR 0.67, 95% CI 0.50-0.88, p=0.004). Adjunctive low-voltage area ablation plus PVI significantly reduced recurrent atrial tachyarrhythmia compared with PVI alone (HR 0.67; 95% CI 0.50-0.88; P=0.004).
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