Key result
Adding LVA ablation to PVI fails to improve arrhythmia-free survival in persistent AF.
Why the study?
Targeting low-voltage areas (LVA) in addition to pulmonary vein isolation (PVI) can improve ablation outcome in persistent AF, motivating a randomized evaluation of LVA ablation plus PVI in de-novo persistent AF.
Does adding low-voltage area (LVA) ablation in sinus rhythm to pulmonary vein isolation (PVI) improve freedom from atrial arrhythmias at 18 months compared with PVI alone in patients with de-novo persistent atrial fibrillation and LVA?
RCT (n=211)
Patients with low-voltage areas (LVA) were randomized to either PVI alone (PVI+) or PVI plus LVA ablation (PVI+LVA)
Yes
Does adding low-voltage area (LVA) ablation in sinus rhythm to pulmonary vein isolation (PVI) improve freedom from atrial arrhythmias at 18 months compared with PVI alone in patients with de-novo persistent atrial fibrillation and LVA?
Adding low-voltage area ablation in sinus rhythm to pulmonary vein isolation does not improve 18-month arrhythmia-free survival in patients with de-novo persistent atrial fibrillation, suggesting LVA is a marker of atrial cardiomyopathy rather than an effective ablation target.
Answers are grounded in this paper and cite their sources.
Discourages routine low-voltage area ablation beyond PVI in de-novo persistent AF; challenges substrate-guided ablation strategies by framing low voltage as a disease marker rather than a modifiable target.
BACKGROUND Targeting low-voltage areas (LVA) in addition to pulmonary vein isolation (PVI) can improve ablation outcome in persistent atrial fibrillation (AF). OBJECTIVE SCAR-AF was a multicenter, prospective, randomized trial, evaluating LVA ablation plus PVI for persistent AF. METHODS Patients with de-novo persistent AF were recruited (9 referral centers in France) into the SCAR-AF study (September 2019 to August 2021). Patients without LVA were treated with PVI alone (PVI-) and those with LVA were randomized to either PVI alone (PVI+) or PVI plus LVA ablation (PVI+LVA). The primary outcome was freedom from atrial arrhythmias (AF/atrial tachycardia) after a single procedure. RESULTS A total of 211 patients (73.5% male, mean±SD age 63.8±9.3 years, CHA2DS2-VASc score 2.1, long-standing AF 44.5%) were included. At 18-month follow-up, the incidence of atrial-arrhythmia-free survival did not differ between groups (79.0% in PVI-, 75.7% in PVI+, and 73.1% in PVI+LVA; PVI- vs PVI+: hazard ratio (HR) 1.28; 95% confidence interval [CI] 0.64-2.55, P=.48; PVI+ vs PVI+LVA: HR 1.28; 95% CI 0.67-2.45; P=.45). On multivariable analysis, presence of LVA was associated with advancing age (HR 1.11, CI 1.06-1.16; P<.001) and was inversely correlated with body mass index (HR 0.93, CI 0.87-0.99; P=.029) and smoking. CONCLUSION In this randomized trial, PVI plus LVA ablation did not improve outcomes in patients with persistent AF. LVA may represent a marker of atrial cardiomyopathy, but its presence does not appear to be an effective target in persistent AF.
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Lepillier et al. (2025) conducted an RCT in De-novo persistent atrial fibrillation (n=211). Pulmonary vein isolation (PVI) plus low-voltage area (LVA) ablation in sinus rhythm vs. PVI alone in patients with LVA (PVI+); patients without LVA also received PVI alone (PVI-) was evaluated on Freedom from atrial arrhythmias (AF/atrial tachycardia) after a single procedure at 18-month follow-up (HR 1.28, 95% CI 0.67-2.45, p=0.45). PVI plus LVA ablation did not improve 18-month atrial-arrhythmia-free survival compared with PVI alone in persistent AF with LVA (73.1% vs 75.7%; HR 1.28; 95% CI 0.67-2.45; P=0.45).
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