Impact of renal function on the efficacy of low-voltage area ablation after pulmonary vein isolation: A sub-analysis of the SUPPRESS-AF trial

Abstract Background and Aims The SUPPRESS-AF trial showed that pulmonary vein isolation (PVI) plus low-voltage area (LVA) ablation may reduce atrial fibrillation (AF) recurrence in some subgroups. Renal dysfunction is a cause of LVAs due to atrial cardiomyopathy and is also a risk factor for AF recurrence after catheter ablation. The aim of this study was to investigate the efficacy of LVA ablation after PVI stratified by renal function. Methods This study was a sub-analysis of the SUPPRESS-AF trial, a multicenter, prospective, randomized, open-label trial. A total of 341 consecutive patients who underwent initial radiofrequency catheter ablation for persistent AF and whose LVAs were ≥5 cm2 were analyzed. Patients were randomized to PVI alone (PVI-alone group) or LVA ablation after PVI (PVI+LVA-ABL group). Primary outcome was defined as the recurrence of atrial tachyarrhythmias during the 12 months following ablation. Estimated glomerular filtration rate (eGFR) was assessed before ablation, and patients were stratified by chronic kidney disease (CKD) stage. Results Mean eGFR was 60 ± 16 mL/min/1.73 m2, and 146 (43%) patients developed the primary outcome. In patients with CKD G1-2 (eGFR ≥60 mL/min/1.73 m2), freedom from the primary outcome was similar between the PVI+LVA-ABL and PVI-alone groups (53.1% vs. 55.3%, p=0.59). In contrast, in patients with CKD G3a-5 (eGFR 60 mL/min/1.73 m2), freedom from the primary outcome was significantly higher in the PVI+LVA-ABL group than in the PVI-alone group (69.1% vs. 43.3%, p=0.004). Conclusions In patients with renal dysfunction, LVA ablation after PVI reduced AF recurrence after radiofrequency catheter ablation for persistent AF.