Key result
Low-voltage area modification added to CPVI fails to improve arrhythmia-free survival in persistent AF.
Why the study?
The benefits of adjunctive ablation strategies beyond circumferential pulmonary vein isolation (CPVI), such as low-voltage area (LVA) modification, were uncertain in patients with persistent atrial fibrillation (PeAF).
Does circumferential pulmonary vein isolation plus low-voltage area modification improve freedom from documented atrial arrhythmias compared to circumferential pulmonary vein isolation alone in patients with persistent atrial fibrillation?
RCT (n=300)
Prospective 1:1 randomization
Does circumferential pulmonary vein isolation plus low-voltage area modification improve freedom from documented atrial arrhythmias compared to circumferential pulmonary vein isolation alone in patients with persistent atrial fibrillation?
Additional low-voltage area ablation during sinus rhythm did not improve arrhythmia-free survival at 18 months compared to circumferential pulmonary vein isolation alone in patients with persistent atrial fibrillation.
Answers are grounded in this paper and cite their sources.
May support low-voltage modification adjunct to PVI in persistent AF; leaves open efficacy without randomized confirmation.
Background Benefits of adjunctive ablation strategies beyond circumferential pulmonary vein isolation (CPVI) are uncertain in patients with persistent atrial fibrillation (PeAF). Objectives This study sought to compare clinical outcomes of CPVI plus low-voltage area (LVA) modification during STABLE-SR (SubsTrate ABlation in the LEft Atrium during Sinus Rhythm) vs circumferential pulmonary vein isolation (CPVI) alone in patients with PeAF. Methods From March 2018 to August 2019, 300 patients with PeAF who underwent de novo ablation were recruited and prospectively randomized to either STABLE-SR group (n = 150) or CPVI alone (n = 150) group. In the STABLE-SR group, after CPVI, high-density voltage mapping of left atrium (LA) was performed during sinus rhythm, and additive ablation targeted LVA and complex electrograms, if any were present. All the ablations were titrated by ablation index. The primary endpoint was freedom from documented atrial arrhythmias lasting for ≥30 s without the use of antiarrhythmic drugs, after a single ablation procedure and blanking period of 3 months. Results After 18 months, atrial-arrhythmia-free survival did not differ significantly between STABLE-SR group and CPVI alone group (67.2% vs 67.4%; HR: 0.89; 95% CI: 0.55-1.36; P = 0.52). Only around one-half of the patients (50.2%) had abnormal LA substrate with a medium LVA burden of 4.6% (2.1%-9.5%). However, the success rate differs dramatically between patients with normal vs abnormal LA substrate (84.8% vs 60.9%; P < 0.001). Conclusions Additional LVA ablation did not improve successful rates of CPVI in this PeAF cohort, of whom one-half had normal LA substrate. Voltage map could identify patients with PeAF with normal LA substrate who can achieve excellent rhythm control with CPVI alone. (CPVI Alone Versus CPVI Plus Electrophysiological Substrate Ablation in the LA During SR for the Treatment of Non-PAF [STABLE-SR_II]; NCT03448562).
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Yang et al. (2022) conducted an RCT in Persistent atrial fibrillation (PeAF) (n=300). Circumferential pulmonary vein isolation (CPVI) plus low-voltage area (LVA) modification during sinus rhythm (STABLE-SR) vs. Circumferential pulmonary vein isolation (CPVI) alone was evaluated on Freedom from documented atrial arrhythmias lasting for ≥30 s without antiarrhythmic drugs after a single ablation procedure and a 3-month blanking period (HR 0.89, 95% CI 0.55-1.36, p=0.52). CPVI plus low-voltage area modification did not significantly improve 18-month atrial arrhythmia-free survival vs CPVI alone in persistent AF (67.2% vs 67.4%; HR 0.89; 95% CI 0.55-1.36; P=0.52).
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