Key result
PVI with low-voltage substrate modification fails to improve arrhythmia freedom over empirical ablation.
Why the study?
Effective therapy for persistent AF beyond pulmonary vein isolation remains unsatisfactory. This study investigated the efficacy and safety of targeting endocardial low-voltage areas for substrate modification compared with PVI plus additional linear ablations.
Does pulmonary vein isolation with low-voltage area-guided substrate modification improve single-procedure arrhythmia-free survival compared to PVI with empirical linear/non-PV trigger ablation in patients with persistent atrial fibrillation?
RCT (n=100)
1:1 ratio
Does pulmonary vein isolation with low-voltage area-guided substrate modification improve single-procedure arrhythmia-free survival compared to PVI with empirical linear/non-PV trigger ablation in patients with persistent atrial fibrillation?
In patients undergoing de-novo ablation for persistent AF, a majority lack low-voltage areas and achieve 70% arrhythmia-free survival with PVI alone, suggesting extensive empirical ablation beyond PVI can be avoided.
Answers are grounded in this paper and cite their sources.
May support limiting ablation to PVI alone in persistent AF without low-voltage areas; challenges routine empirical linear or substrate modification.
Background An effective therapy of persistent atrial fibrillation beyond pulmonary vein isolation remains unsatisfactory. Targeting endocardial low-voltage areas represents an approach of substrate modification. This prospective, randomized study investigated the efficacy of ablation of low-voltage areas versus PVI and additional linear ablations in patients with persistent atrial fibrillation in terms of single-procedure arrhythmia-free outcome and safety. Methods and results A total number of 100 patients undergoing de-novo catheter ablation for persistent AF were randomized in a 1:1 ratio into two different treatment arms: group A: pulmonary vein isolation (PVI) and, if low-voltage areas were present, a substrate modification. Group B: PVI and, if atrial fibrillation persisted, additional ablations, such as linear ablation and/or ablation of non-PV triggers. A total of 50 patients were randomized into each group without significant differences in baseline characteristics. During a mean follow-up of 17.64 ± 4.5 months after a single procedure, 34 (68%) patients of group A were free of arrhythmia recurrence versus 28 (56%) patients in group B (p = ns). In group A, 30 (60%) patients did not show endocardial fibrosis and received solely PVI. Both procedures were performed with a low number of complications; no pericardial effusion or stroke were seen in either group. Conclusions A significant proportion of patients with persistent atrial fibrillation do not show low-voltage areas. A total of 70% of the patients receiving solely PVI did not show any recurrence of atrial fibrillation, and therefore, extensive additional ablation should be avoided in de-novo patients.
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Kaiser et al. (2023) conducted an RCT in Persistent atrial fibrillation (n=100). Pulmonary vein isolation (PVI) plus substrate modification of endocardial low-voltage areas (if present) vs. PVI plus additional ablations (linear ablation and/or non-PV triggers) if AF persisted was evaluated on Single-procedure freedom from arrhythmia recurrence (p=ns). PVI with low-voltage area substrate modification achieved 68% arrhythmia-free survival vs 56% with PVI plus empirical linear/trigger ablation (p=ns).
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