Complete Low-Voltage Area Ablation in Persistent Atrial Fibrillation　- Post Hoc Subanalysis of the SUPPRESS-AF Trial

Incomplete low-voltage area (LVA) ablation may confound evaluation of its true efficacy in persistent atrial fibrillation (AF). This post hoc subanalysis of the multicenter randomized SUPPRESS-AF trial assessed the impact of complete LVA ablation.

Patients with persistent AF and a left atrial (LA) LVA ≥5 cm²after pulmonary vein isolation were randomized to LVA ablation or no additional ablation. The primary endpoint was freedom from AF or atrial tachycardia recurrence, assessed by 24-h Holter and twice-daily electrocardiogram recordings. Outcomes were compared among 3 groups: no LVA ablation; complete LVA ablation; and incomplete LVA ablation. Among 341 patients, 170 underwent LVA ablation, including 37 with incomplete. LVA size was significantly larger in the incomplete than complete ablation group (22.0 vs. 12.2 cm²; P<0.001). Incomplete LVA ablation was not associated with increased arrhythmia recurrence. Arrhythmia-free survival did not differ significantly between the complete and no LVA ablation groups (hazard ratio [HR] 0.80; 95% confidence interval [CI] 0.56-1.13), including after propensity score matching (HR 0.76; 95% CI 0.51-1.15). However, a trend towards greater benefit of complete LVA ablation was observed with increasing LA diameter (P_interaction=0.099).

Leaving LVA ablation incomplete to avoid complications appears reasonable. Although complete LVA ablation showed no overall superiority, LA enlargement may represent a clinically relevant factor for patient stratification.