Key result
Adding LVA ablation to PVI reduces AF recurrence ~18 percentage points in high ALDAS-score patients.
Why the study?
Low-voltage area (LVA) in AF reflects arrhythmogenic substrate and may affect ablation outcomes, but its quantification requires electroanatomical mapping and may not be comparable across catheters and 3D systems. A simple clinical score to estimate LVA burden and test for differential treatment effects was needed.
Does pulmonary vein isolation plus low-voltage area ablation reduce atrial fibrillation recurrence compared with pulmonary vein isolation alone in persistent atrial fibrillation patients stratified by ALDAS score?
RCT (n=337)
Randomized (post-hoc subanalysis of the SUPPRESS-AF trial)
Does pulmonary vein isolation plus low-voltage area ablation reduce atrial fibrillation recurrence compared with pulmonary vein isolation alone in persistent atrial fibrillation patients stratified by ALDAS score?
The clinical ALDAS score estimates low-voltage area burden without mapping and identifies persistent AF patients (score ≥6) who derive a significant reduction in AF recurrence from adding LVA ablation to PVI.
Supports ALDAS-guided selection for adjunctive LVA ablation in persistent AF; extends SUPPRESS-AF by validating a mapping-free substrate estimator.
Background Low-voltage area (LVA) in atrial fibrillation (AF) reflects arrhythmogenic substrate and may affect outcomes after ablation. However, LVA quantification requires electroanatomical mapping and may not be comparable across catheters and 3D systems. We developed a simple clinical score to estimate LVA burden and tested whether treatment effects differ by score-estimated substrate burden. Methods This post-hoc subanalysis used the SUPPRESS-AF randomized trial (persistent AF, first ablation, LVA ≥5 cm²) comparing PVI alone versus PVI plus LVA ablation. Continuous LVA was modeled by gamma regression with a log link, and an additive score was derived from prespecified cutoffs of age, left atrial diameter (LAD), AF duration, hemoglobin (Hb), and history of stroke/TIA/systemic embolism. Patients were dichotomized into low vs high score (≤5 vs ≥6). AF recurrence was assessed by Kaplan–Meier curves and log-rank tests to evaluate effect modification. Results Regression coefficients were converted into integer points to construct the ALDAS score: age <70=0, ≥70=+2; LAD <35=0, 35–40=+1, ≥40=+4; AF duration <4=0, 4–10=+1, ≥10=+5; Hb <12=+4, 12–14=+1, ≥14=0; stroke/TIA/systemic embolism history yes=+2, no=0. (Figure) Higher scores were associated with larger observed LVA (Figure). In the low-score group (≤5, n=111), recurrence was 35.1% with PVI alone and 42.6% with PVI+LVA (p=0.417). In the high-score group (≥6, n=226), recurrence was 54.0% and 36.3%, respectively (p=0.0075). The logistic interaction term was significant (p=0.0286). Kaplan–Meier curves showed no separation in ≤5 (log-rank p=0.547) but significant separation in ≥6 (log-rank p=0.0177) (Figure). Conclusion The ALDAS score, based on age, LAD, AF duration, Hb, and stroke/TIA/systemic embolism history, provides a practical estimate of LVA burden and identifies patients in whom PVI plus LVA ablation may reduce AF recurrence compared with PVI alone. External validation is warranted.
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Sunaga et al. (2026) conducted an RCT in Persistent atrial fibrillation (n=337). Pulmonary vein isolation (PVI) plus low-voltage area (LVA) ablation vs. Pulmonary vein isolation (PVI) alone was evaluated on Atrial fibrillation recurrence in the high ALDAS score group (≥6) (p=0.0075 (log-rank p=0.0177; interaction p=0.0286)). PVI plus LVA ablation reduced AF recurrence vs PVI alone in high ALDAS score (≥6) patients (36.3% vs 54.0%, p=0.0075), but not in low score (≤5) patients (42.6% vs 35.1%, p=0.417; p-int=0.0286).
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