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Strategy-Specific Effects of Low-Voltage Area-Targeted Ablation Added to Pulmonary Vein Isolation: A Meta-Analysis of
Akihiro Sunaga1, Daisuke Sakamoto1, Daisaku Nakatani1
1Department of Cardiovascular Medicine The University of Osaka Graduate School of Medicine Suita Japan.
Background:
Left atrial low-voltage areas (LVAs) represent an arrhythmogenic substrate in atrial fibrillation (AF). LVA-targeted ablation is increasingly used as an adjunct to pulmonary vein isolation (PVI), yet outcomes vary across randomized trials, potentially due to differences in ablation strategy. We performed a meta-analysis to evaluate the effectiveness of LVA-targeted ablation added to PVI and to assess whether treatment effects differ between LVA isolation and LVA homogenization strategies.
Methods:
Following PRISMA, we systematically searched PubMed and CENTRAL for randomized controlled trials (RCTs). Eligible studies enrolled patients with any AF type undergoing voltage mapping and compared PVI plus LVA-targeted ablation (PVI + LVA) with PVI alone. The primary outcome was AF/atrial tachyarrhythmia recurrence during follow-up, as defined in each trial. Odds ratios (ORs) with 95% confidence intervals (CIs) were pooled using a random-effects model. Subgroup analyses were performed according to the predominant LVA strategy (isolation vs. homogenization).
Results:
Six RCTs involving 1565 patients (PVI + LVA, n = 780; PVI alone, n = 785) were included. Overall, PVI + LVA reduced recurrence compared with PVI alone (OR 0.72; 95% CI 0.54-0.96). In strategy-specific analyses, LVA isolation was associated with a significant reduction in recurrence (OR 0.57; 95% CI 0.38-0.87), whereas LVA homogenization showed a smaller and non-significant effect (OR 0.85; 95% CI 0.59-1.24). Between-strategy heterogeneity was substantial (I 2 = 90.4%).
Conclusions:
In RCTs of AF ablation, adding LVA-targeted ablation to PVI reduced arrhythmia recurrence. The treatment effect appeared more pronounced with LVA isolation than with homogenization; however, these strategy-specific findings should be considered exploratory and require confirmation in future randomized studies.
