Increased Heart Failure Risk After Low-Voltage-Area Ablation in Patients With Paroxysmal Atrial Fibrillation

BACKGROUND: Extensive atrial ablation may impair atrial function; however, its impact on long-term heart failure (HF) risk remains unclear. OBJECTIVES: This study sought to evaluate the association between low-voltage area (LVA) ablation and HF outcomes after catheter ablation for paroxysmal atrial fibrillation (AF). METHODS: This was a long-term follow-up analysis of the Volatile Coronary Lesion and Obstructive Nodal Atrial Fibrillation trial. A total of 398 patients were followed for up to 7 years and classified into 3 groups: no LVAs (group A), LVAs with LVA ablation (group B), and LVAs without LVA ablation (group C). The primary outcome was HF hospitalization. RESULTS: During a median follow-up of 1,660 (735-2,555) days, HF hospitalization occurred in 21 patients. Sinus rhythm was maintained in 96% of patients, with no differences among groups (P = 0.26). Patients with LVAs had a higher incidence of HF hospitalization than those without (18% vs 3%; P < 0.001). Among patients with LVAs, HF hospitalization occurred more frequently in those undergoing LVA ablation (30% vs 6%; P = 0.01). In a competing-risk analysis accounting for all-cause death, the cumulative incidence of HF hospitalization remained significantly higher in patients undergoing LVA ablation (Gray's test, P = 0.042). Among patients who experienced HF hospitalization, most events occurred during documented sinus rhythm. CONCLUSIONS: Among patients with paroxysmal AF and LVAs, LVA ablation was associated with a higher incidence of HF hospitalization despite a high rate of sinus rhythm maintenance. Given the limited sample size and number of events, these findings should be considered exploratory and hypothesis-generating, and warrant confirmation in larger prospective studies.