Pulmonary vein isolation and low-voltage area ablation in sinus rhythm for persistent atrial fibrillation: The...

Targeting low-voltage areas (LVAs) in addition to pulmonary vein isolation (PVI) can improve ablation outcome in persistent atrial fibrillation (AF).

SCAR-AF was a multicenter, prospective, randomized trial, evaluating LVA ablation plus PVI for persistent AF.

Patients with de novo persistent AF were recruited (9 referral centers in France) into the SCAR-AF study (September 2019 to August 2021). Patients without LVA were treated with PVI alone (PVI-), and those with LVA were randomized to either PVI alone (PVI+) or PVI plus LVA ablation (PVI + LVA). The primary outcome was freedom from atrial arrhythmias (AF/atrial tachycardia) after a single procedure.

A total of 211 patients (73.5% men, mean ± standard deviation age 63.8 ± 9.3 years, CHA₂DS₂-VASc score 2.1, long-standing AF 44.5%) were included. At 18-month follow-up, the incidence of atrial-arrhythmia-free survival did not differ between groups (79.0% in PVI-, 75.7% in PVI+, and 73.1% in PVI + LVA; PVI- vs PVI+, hazard ratio (HR) 1.28, 95% confidence interval [CI] 0.64-2.55, P = .48; PVI+ vs PVI + LVA, HR 1.28; 95% CI 0.67-2.45, P = .45). On multivariable analysis, presence of LVA was associated with advancing age (HR 1.11, 95% CI 1.06-1.16, P < .001) and was inversely correlated with body mass index (HR 0.93, 95% CI 0.87-0.99, P = .029) and smoking.

In this randomized trial, PVI plus LVA ablation did not improve outcomes in patients with persistent AF. LVA may represent a marker of atrial cardiomyopathy, but its presence does not seem to be an effective target in persistent AF.