What happened
Adjunctive low-voltage area ablation fails to reduce arrhythmia recurrence over PVI alone in persistent AF.
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Why the trial, key points, tables, limitations, PICO, abstract, media & sources
Pulmonary vein isolation (PVI) for persistent atrial fibrillation (AF) has demonstrated modest success rates, and while ablation of atrial low-voltage areas (LVA) has shown potential, more data are required. The COAST-AF trial was conducted to determine whether PVI plus LVA ablation is superior to PVI alone in reducing atrial arrhythmia recurrence in patients with persistent AF.
Does pulmonary vein isolation plus low-voltage area ablation reduce atrial arrhythmia recurrence compared with pulmonary vein isolation alone in adults with persistent atrial fibrillation?
Does pulmonary vein isolation plus low-voltage area ablation reduce atrial arrhythmia recurrence compared with pulmonary vein isolation alone in adults with persistent atrial fibrillation?
Routine adjunctive low-voltage area ablation added to PVI did not significantly reduce arrhythmia recurrence in the overall persistent AF population over 21 months, though a prespecified subgroup analysis suggested benefit among the 54% of patients who actually had low-voltage areas.
Adjunctive LVA ablation should not be added to PVI in persistent AF; challenges observational support for routine substrate modification.
Importance Pulmonary vein isolation (PVI) for persistent atrial fibrillation (AF) has demonstrated modest success rates. Ablation of atrial low-voltage areas (LVA) has shown potential results, but more data are required. Objective To determine whether PVI plus LVA ablation is superior to PVI alone in reducing atrial arrhythmia recurrence in patients with AF. Design, Setting, and Participants Single-blind randomized clinical trial in 14 AF ablation centers in Canada. Adults with persistent AF of more than 3 months were enrolled between August 2018 and September 2024 and followed up for 18 to 36 months through April 2026. Intervention Patients were randomized to PVI plus LVA ablation or PVI alone. Main Outcomes and Measures The primary outcome was atrial arrhythmia recurrence beyond 90 days after a single catheter ablation procedure. Secondary outcomes included repeat ablation for AF, atrial flutter, or atrial tachycardia, emergency visits or hospitalization, arrhythmia recurrence over 18 months, procedure duration, total ablation delivery time, AF burden, and safety outcomes. The primary efficacy analysis was based on the modified intention-to-treat principle for patients who received the intervention. Results Among 508 enrolled patients, 253 were randomized to PVI plus LVA ablation and 255 to PVI alone. Mean (SD) age was 65.2 (9.0) years, 386 (76%) were male and 268 (54%) had LVA. After a mean (SD) follow-up of 21 (15) months, 124 (49.4%) randomized to PVI plus LVA and 146 (57.5%) randomized to PVI reached the primary outcome (hazard ratio [HR], 0.82; 95% CI, 0.65-1.04; P = .11). In the prespecified principal subgroup analysis of 268 patients with LVA, arrhythmia recurrence occurred in 68 of 138 patients (49.3%) following PVI plus LVA ablation compared with 90 of 130 patients (69.2%) following PVI alone (HR, 0.77; 95% CI, 0.66-0.91; P = .002). Arrhythmia recurrence over 18 months (37.0% vs 56.2%; HR, 0.77; 95% CI, 0.64-0.92) and AF burden were lower after PVI plus LVA ablation in this group. Among patients without LVA, recurrence was similar between ablation groups (56 of 113 [49.6%] vs 51 of 113 [45.1%]; HR, 1.09; 95% CI, 0.90-1.32). Procedure duration and ablation delivery time were longer in the PVI plus LVA ablation group. Safety outcomes were similar between groups. Conclusions and Relevance In this study, among patients with persistent AF, adjunctive LVA ablation did not significantly reduce atrial arrhythmia recurrence in the overall population over a mean 21-month follow-up. A prespecified principal subgroup analysis of patients with LVA suggested that adjunctive LVA ablation was consistent with reduced recurrence of atrial arrhythmias in this group. Trial Registration ClinicalTrials.gov, Identifier: NCT03347227
Nery et al. (2026) conducted an RCT in Persistent atrial fibrillation (n=508). Pulmonary vein isolation (PVI) plus low-voltage area (LVA) ablation vs. Pulmonary vein isolation (PVI) alone was evaluated on Atrial arrhythmia recurrence beyond 90 days after a single catheter ablation procedure (HR 0.82, 95% CI 0.65-1.04, p=0.11). PVI plus LVA ablation did not significantly reduce atrial arrhythmia recurrence vs PVI alone in persistent AF (49.4% vs 57.5%; HR 0.82; 95% CI 0.65-1.04; P=0.11).
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