Impact of low-voltage area burden and topological obstacles on atrial fibrillation recurrence after pulmonary vein antrum isolation

Q: What are the key findings of this study?

Topological obstacle counts were not significantly associated with 1-year AF/AT recurrence after de novo ablation (46.2% in TO=1 and 44.4% in TO≥4 vs 34.4% in TO=3, p=0.433), though TO varied with LVA.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Atrial fibrillation undergoing de novo radiofrequency catheter ablation (n=237). Intervention: Extreme topological obstacle count (TO = 1 or ≥4) and low-voltage area burden vs. Intermediate topological obstacle count (TO = 3 reference group). Primary outcome: 1-year recurrence of atrial fibrillation or atrial tachycardia (≥30 seconds) after a 3-month blanking period (OR 0.46 (TO=1 vs TO=3); OR 1.17 (TO≥4 vs TO=3), 95% CI 0.08-2.72, p=0.433).

Q: What does this research mean for the field?

Topological obstacle counts are not significantly associated with one-year AF/AT recurrence following de novo catheter ablation, despite varying significantly across low-voltage area burden quartiles. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

JungMin Choi; Y. Go; Soonil Kwon; Kyung-Yeon Lee; Hyo‐Jeong Ahn; So-Ryoung Lee; Taehun Kim; Jung Chan Lee; Eue‐Keun Choi; Seil Oh

doi:10.3389/fnetp.2026.1945351

October 21, 2026Frontiers in Network PhysiologyOpen Access

Impact of low-voltage area burden and topological obstacles on atrial fibrillation recurrence after pulmonary vein antrum isolation

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Key result

Topological obstacle counts fail to predict 1-year AF recurrence after catheter ablation.

OR 0.46 (TO=1 vs TO=3); OR 1.17 (TO≥4 vs TO=3)
95% CI 0.08-2.72
P=0.433
n=237

Why the study?

Topological obstacles can provide reentry circuits in the left atrium, and their quantity and relationship with low-voltage area burden may influence recurrent AF after ablation, but this impact remains poorly understood.

Does the quantity of left atrial topological obstacles and low-voltage area burden influence 1-year atrial fibrillation or atrial tachycardia recurrence in patients undergoing de novo pulmonary vein antrum isolation?

Key Points

Investigate the association between topological obstacle count, low-voltage area burden, and post-ablation arrhythmia recurrence in patients undergoing de novo atrial fibrillation ablation.
Analyzed 237 patients (mean age 62.4 ± 8.8 years; 27.0% female; 42.6% paroxysmal AF) undergoing de novo pulmonary vein antrum isolation with a mean follow-up of 1.0 ± 0.1 years.
Categorized patients into topological obstacle groups (counts 1, 2, 3, and ≥4) using pulmonary vein antrum isolation lines and voltage maps, and quantified low-voltage area burden (<0.5 mV) across quartiles.
Assessed one-year atrial fibrillation and atrial tachycardia recurrence, alongside dominant frequency and organization index measurements.
Arrhythmia recurrence occurred in 35.4% of patients overall, with recurrence rates of 46.2% in Group 1, 23.5% in Group 2, 34.4% in Group 3, and 44.4% in Group ≥4, showing no statistically significant difference (p = 0.433).
Topological obstacle counts varied significantly across low-voltage area burden quartiles (p < 0.001), with Group 1 displaying the highest mean low-voltage area burden (36.6% ± 24.8%).
Arrhythmia recurrence increased across low-voltage area burden quartiles (Q1: 20.0%, Q2: 41.7%, Q3: 34.5%, Q4: 45.8%; p = 0.018), while dominant frequency (p = 0.115) and organization index (p = 0.195) showed no significant differences.

Study Design

Type

Cohort (n=237)

Multicenter

No

Structured PICO

Does the quantity of left atrial topological obstacles and low-voltage area burden influence 1-year atrial fibrillation or atrial tachycardia recurrence in patients undergoing de novo pulmonary vein antrum isolation?

P

Population

237 adults (mean age 62.4 years, 27.0% female) with atrial fibrillation (42.6% paroxysmal) undergoing de novo pulmonary vein antrum isolation with complete left atrial voltage mapping, followed for 1 year.

E

Exposure

De novo radiofrequency catheter ablation consisting of pulmonary vein antrum isolation (PVAI) with electroanatomical voltage mapping (CARTO 3) to quantify low-voltage area (LVA) burden (<0.5 mV in sinus rhythm, <0.2 mV in AF) and identify topological obstacles (TOs, minimum threshold 4.5 cm²); adjunctive ablation performed in 34.1% of patients (including cavotricuspid isthmus ablation in 22.8%).

C

Comparator

Comparison across topological obstacle (TO) count groups: Group 1 (TO=1, n=13), Group 2 (TO=2, n=17), Group 3 (TO=3, reference group, n=180), and Group ≥4 (TO≥4, n=27), as well as across LVA burden quartiles (Q1–Q4).

O

Outcome

Development of atrial fibrillation (AF) or atrial tachycardia (AT) lasting ≥30 seconds documented by 12-lead ECG or Holter monitoring during the 12-month follow-up period after a 3-month post-ablation blanking period.surrogate

Main Result

Odds Ratio: 0.46 (95% CI 0.08–2.72)

Absolute Event Rate: 46.2% vs 34.4%

p-value: p=0.433

In patients undergoing de novo pulmonary vein antrum isolation for atrial fibrillation, left atrial topological obstacle counts varied significantly with low-voltage area burden, and while extreme obstacle counts (1 or ≥4) showed a numerically higher 1-year arrhythmia recurrence rate than intermediate counts, this association did not reach statistical significance.

Limitations

Retrospective, single-center design with potential selection bias and unmeasured confounders
Small sample size in Group 1 (n = 13, 5.5%), limiting statistical power and generalizability
Reliance on low-voltage areas (LVA) as a surrogate marker for atrial scar tissue
Voltage measurements via multipolar catheters were susceptible to variations in underlying rhythm (70% sinus/paced vs 30% AF), wavefront directionality, and electrode configuration
Use of fixed, literature-derived action potential duration and conduction velocity approximations to define the 4.5 cm2 topological obstacle threshold
Assumption of circular obstacle geometry, which may under-count small, irregularly shaped low-voltage areas
Retrospective study design
Small sample sizes within extreme topological obstacle subgroups, limiting statistical power
Exploratory, hypothesis-generating nature requiring confirmation in larger, adequately powered cohorts

Implication

Topological obstacle counts should not guide recurrence risk stratification or ablation decisions; leaves open their mechanistic interaction with low-voltage areas in prospective cohorts.

Abstract

Background Topological obstacles (TOs), electrically isolated regions such as the mitral annulus and atrial scars, can provide reentry circuits in the left atrium. Their quantity and relationship with low-voltage area (LVA) burden may influence recurrent atrial fibrillation (AF), but this impact remains poorly understood. We aimed to investigate the association between TO count, LVA burden, and post-ablation AF recurrence in patients undergoing de novo AF ablation. Methods Patients were categorized by TO counts, identified using pulmonary vein antrum isolation lines and voltage maps. LVA burden (<0.5 mV) was quantified and grouped into quartiles. One-year AF/atrial tachycardia (AT) recurrence was evaluated across groups. Results Among 237 patients (mean age 62.4 ± 8.8 years; 27.0% female, paroxysmal AF 42.6%, follow-up 1.0 ± 0. years), the majority had an intermediate TO count (TO = 3, 75.9%). Patients with the lowest TO count (TO = 1, 5.5%) were significantly older, had higher CHA 2 DS 2 -VASc scores, worse echocardiographic parameters, and the highest mean LVA burden (36.6% ± 24.8%). AF/AT recurrence occurred in 35.4% of patients. Although recurrence rates were numerically higher in patients with extreme TO counts (TO = 1 or ≥4) and lower in those with intermediate counts (TO = 2 or 3), these differences were not statistically significant ( p = 0.433), and the TO group remained non-significantly associated with recurrence after multivariable adjustment for age, AF clinical type, left atrial diameter, left ventricular ejection fraction, CHA 2 DS 2 -VASc score, and LVA burden. TO counts differed significantly across LVA burden quartiles ( p < 0.001), with the greatest variation observed in the group with the highest LVA burden. Dominant frequency and organization index showed no significant intergroup differences. Conclusion Patients with extreme TO counts (TO = 1 or ≥4) showed a numerically higher, although not statistically significant, trend toward post-ablation recurrence compared with those with intermediate counts. TO quantity varied significantly with LVA burden, suggesting that atrial substrate heterogeneity may influence AF recurrence patterns.

Discussion

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Cite This Study

Choi et al. (2026) conducted a cohort in Atrial fibrillation undergoing de novo radiofrequency catheter ablation (n=237). Extreme topological obstacle count (TO = 1 or ≥4) and low-voltage area burden vs. Intermediate topological obstacle count (TO = 3 reference group) was evaluated on 1-year recurrence of atrial fibrillation or atrial tachycardia (≥30 seconds) after a 3-month blanking period (OR 0.46 (TO=1 vs TO=3); OR 1.17 (TO≥4 vs TO=3), 95% CI 0.08-2.72, p=0.433). Topological obstacle counts were not significantly associated with 1-year AF/AT recurrence after de novo ablation (46.2% in TO=1 and 44.4% in TO≥4 vs 34.4% in TO=3, p=0.433), though TO varied with LVA.

synapsesocial.com/papers/6adc966ca704d151585a5dfb https://doi.org/10.3389/fnetp.2026.1945351

Topics

Atrial fibrillation

Persistent AF management

AF ablation outcomes

Anticoagulation in AF

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Impact of low-voltage area burden and topological obstacles on atrial fibrillation recurrence after pulmonary vein antrum isolation

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Topics

Impact of low-voltage area burden and topological obstacles on atrial fibrillation recurrence after pulmonary vein antrum isolation

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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