Characteristics of Low-Voltage Zones in Patients With Heart Failure With Preserved Ejection Fraction

Atrial fibrillation (AF) frequently coexists with heart failure with preserved ejection fraction (HFpEF), and low-voltage zones (LVZs) in the atria represent atrial remodeling. However, the impact of HFpEF on the extent and distribution of LVZs and ablation outcomes remains unknown.

To characterize LVZs in patients with HFpEF undergoing AF ablation and evaluate their association with arrhythmia recurrence.

A total of 128 consecutive patients (66±12 years) who underwent AF ablation for the first time were retrospectively analyzed. HFpEF was defined as a left ventricular ejection fraction >50% with a history of heart failure treatment or an HFA-PEFF score ≥5. Meanwhile, LVZs were defined as bipolar voltage <0.5 mV and quantified across five left atrial regions.

Forty-seven patients (36.7%) were diagnosed with HFpEF. LVZs were significantly more extensive in the overall left atrium in the HFpEF group (16.3±13.5 vs. 8.2±7.6 cm², p < 0.001), with the greatest difference being observed in the anterior wall (5.6±5.4 vs. 2.3±2.8 cm², p < 0.001). During 9±4 months, arrhythmia recurrence rates did not differ significantly between HFpEF and non-HFpEF groups (12.8% vs. 13.6%, p = 0.310). Posterior wall isolation was more frequently performed in the HFpEF group (27.6% vs. 4.9%, p < 0.001). In multivariable analysis, HFpEF, age, and persistent AF were independent determinants of LVZ extent.

AF patients with HFpEF exhibit more extensive LVZs, indicating advanced atrial remodeling. Despite differences in atrial substrate and ablation strategy, arrhythmia recurrence rates were comparable between patients with and without HFpEF.