Adjunctive low-voltage zone ablation improves outcomes in select patients with persistent AF

Low-voltage zone ablation, when performed in addition to pulmonary vein isolation, helps improve rhythm outcomes and health-related quality of life in patients with persistent atrial fibrillation (AF) and significant low-voltage zones, according to the IDEAL-AF trial.

IDEAL-AF included 209 persistent AF patients (median age 72 years, 52.2 percent female) who had low-voltage zones of ≥3 cm² and were undergoing first-time ablation. These patients were randomized to either receive individualized adjunctive low-voltage zone ablation (n=102) or no further ablation (n=107) after pulmonary vein isolation.

Freedom from documented atrial arrhythmia without antiarrhythmic drugs at 12 months following one or two ablation procedures within 6 months was the primary outcome. Secondary outcomes included time to first recurrence after a single procedure without antiarrhythmic drugs, health-related quality of life, and safety.

At 12 months, the primary outcome was achieved in a greater percentage of patients in the adjunctive low-voltage zone ablation group than in the pulmonary vein isolation alone group (67.6 percent vs 37.4 percent; odds ratio, 3.5, 95 percent confidence interval [CI], 2.0–6.2; p<0.001).

Result for time to first recurrence after a single ablation procedure without antiarrhythmic drugs also favoured the adjunctive low-voltage zone ablation group (hazard ratio, 0.4, 95 percent CI, 0.3–0.6; p<0.001).

Health-related quality of life improvements were greater in the adjunctive low-voltage zone ablation group than in the pulmonary vein isolation alone group. The incidence of serious adverse events was similar between the two groups.

The findings support a low-voltage zone–guided ablation strategy for persistent AF patients with significant low-voltage zones.