Key result
Adding low-voltage area ablation to PVI linked to ~47% lower AF/AT recurrence at 18 months.
Why the study?
The optimal catheter ablation strategy for persistent AF is unknown, prompting evaluation of pulmonary vein isolation plus low-voltage area ablation guided by contemporary high-density mapping.
Does pulmonary vein isolation plus low-voltage area ablation guided by high-density mapping improve freedom from atrial tachycardia/atrial fibrillation compared to pulmonary vein isolation alone in patients with persistent atrial fibrillation?
Cohort (n=145)
Does pulmonary vein isolation plus low-voltage area ablation guided by high-density mapping improve freedom from atrial tachycardia/atrial fibrillation compared to pulmonary vein isolation alone in patients with persistent atrial fibrillation?
In patients with persistent AF, adding high-density mapping-guided low-voltage area ablation to PVI is associated with significantly higher 18-month freedom from atrial arrhythmias without compromising safety, though shorter procedure times were actually observed in the PVI + LVA group.
Answers are grounded in this paper and cite their sources.
Supports high-density mapping-guided substrate modification in persistent AF but should not yet change practice; leaves open whether randomized trials will confirm this recurrence benefit.
Background Several approaches have been proposed to address the challenge of catheter ablation of persistent atrial fibrillation (AF). However, the optimal ablation strategy is unknown. We sought to evaluate the efficacy of pulmonary vein isolation (PVI) plus low-voltage area (LVA) ablation using contemporary high-density mapping to identify LVA in patients with persistent AF. Methods Consecutive patients accepted for AF catheter ablation were studied. High-density bipolar voltage mapping data were acquired in sinus rhythm using multipolar catheters to detect LVA (defined as bipolar voltage < 0.5 mV). Semiautomated impedance-based software was used to ensure catheter contact during data collection. Patients underwent PVI + LVA ablation (if LVA present). Results A total of 145 patients were studied; 95 patients undergoing PVI + LVA ablation were compared with 50 controls treated with PVI only. Average age was 61 ± 10 years, and 80% were male. Baseline characteristics were comparable. Freedom from atrial tachycardia/AF at 18 months was 72% after PVI + LVA ablation vs 58% in controls (P = 0.022). Median procedure duration (273 [240, 342] vs 305 [262, 360] minutes; P = 0.019) and radiofrequency delivery (50 [43, 63] vs 55 [35, 68] minutes; P = 0.39) were longer in the PVI + LVA ablation group. Multivariable analysis showed that the ablation strategy (PVI + LVA) was the only independent predictor of freedom from atrial tachycardia/AF (hazard ratio, 0.53; 95% confidence interval, 0.29-0.96; P = 0.036). There were no adverse safety outcomes associated with LVA ablation. Conclusions An individualized strategy of high-density mapping to assess the atrial substrate followed by PVI combined with LVA ablation is associated with improved outcomes. Adequately powered randomized clinical trials are needed to determine the role of PVI + LVA ablation for persistent AF.
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Nery et al. (2020) conducted a cohort in Persistent atrial fibrillation (n=145). Pulmonary vein isolation (PVI) plus low-voltage area (LVA) ablation using high-density bipolar voltage mapping vs. Pulmonary vein isolation (PVI) only was evaluated on Freedom from atrial tachycardia/atrial fibrillation at 18 months (HR 0.53, 95% CI 0.29-0.96, p=0.022). PVI plus low-voltage area ablation improved 18-month freedom from atrial tachycardia/AF compared with PVI alone (72% vs 58%, P=0.022; adjusted HR 0.53, 95% CI 0.29-0.96).
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