Efficacy of Low-Voltage-Area Ablation Is Enhanced in Patients With Advanced Left Atrial Enlargement: A Subanalysis of the SUPPRESS-AF Trial

BACKGROUND: In the randomized controlled SUPPRESS-AF trial, the efficacy of low-voltage-area (LVA) ablation was highly dependent on the degree of atrial remodeling, while the efficacy was not statistically significant in total patients. This subanalysis of the SUPPRESS-AF trial aimed to compare the efficacy of LVA ablation in patient groups classified by left atrial diameter (LAD), which is a commonly used atrial remodeling index. METHODS: The SUPPRESS-AF trial included patients with persistent AF and left atrial LVAs, and compared rhythm outcomes between patients randomized to undergo pulmonary vein isolation (PVI) followed by left atrial LVA ablation group (n=170) or PVI-alone group (n=172). In this post hoc subanalysis, patients in each of the 2 randomly allocated groups were further divided into 2 groups using a median LAD of 44 mm. RESULTS: Atrial fibrillation or atrial tachycardia recurrence–free rates did not differ between patients with LAD>44 mm and ≤44 mm (60.1% versus 53.7%; P =0.261). Among patients with a LAD>44 mm, the LVA ablation group demonstrated a higher atrial fibrillation or atrial tachycardia-recurrence–free rate than the PVI-alone group (62.5% versus 43.4%; P =0.016). In contrast, no difference in atrial fibrillation or atrial tachycardia recurrence–free rate was found between the 2 groups of patients with a LAD≤44 mm (60.8% versus 59.6%; P =0.986). CONCLUSIONS: The efficacy of LVA ablation in addition to PVI for the treatment of persistent AF was more pronounced in patients with a large left atrium. REGISTRATION: URL: https://www.umin.ac.jp/ctr ; Unique identifier: UMIN000035940.