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Circumferential PVI With vs. Without Additional Low-Voltage-Area Ablation
Quick Takes
- In this randomized clinical trial of patients aged 65-80 years with paroxysmal AF, additional low-voltage-area ablation was associated with a significant reduction in recurrence of atrial arrhythmias compared with circumferential pulmonary vein isolation (CPVI) alone at 23 months.
- Among older patients with paroxysmal AF, additional low-voltage-area ablation beyond CPVI might decrease the recurrence of atrial tachyarrhythmia in older patients with paroxysmal AF compared with CPVI alone.
Study Questions:
Is there an incremental benefit of low-voltage-area ablation after circumferential pulmonary vein isolation (CPVI) in older patients with paroxysmal atrial fibrillation (AF)?
Methods:
Patients with paroxysmal AF who were aged 65-80 years were randomized (1:1) to undergo CPVI plus low-voltage-area ablation or CPVI alone. Low-voltage areas were defined as areas with amplitude <0.5 mV in >3 adjacent points. If low-voltage areas existed, additional substrate ablation was performed in the CPVI plus group but not the CPVI alone group.
Results:
There were 438 randomized patients. After a median follow-up of 23 months, the recurrence rate of atrial tachyarrhythmia was significantly lower in the CPVI plus group (31/209 patients, 15%) compared with the CPVI alone group (49/205, 24%; hazard ratio [HR], 0.61; 95% confidence interval [CI], 0.38-0.95; p = 0.03). In subgroup analyses, among all patients with low-voltage area, CPVI plus substrate modification was associated with a 51% decreased risk of atrial tachyarrhythmia recurrence compared with CPVI alone (HR, 0.49; 95% CI, 0.25-0.94).
Conclusions:
The authors concluded that additional low-voltage-area ablation beyond CPVI decreased the atrial tachyarrhythmia recurrence in older patients with paroxysmal AF compared with CPVI alone.
Perspective:
The authors conducted a randomized clinical trial of patients with paroxysmal AF aged 65-80 years to assess whether low-voltage ablation brings benefits of reducing recurrent atrial tachyarrhythmia compared with performing CPVI alone. Prior studies regarding the benefit of additional low-voltage-area ablation beyond CPVI have had frustratingly inconsistent results. The hypothesis driving this and other studies of this type is that low-voltage areas, which indicate underlying atrial fibrosis, are a strong predictor of AF recurrence.
In the present study, using point-by-point mapping, the authors identified low-voltage areas in about 40% of patients, and their average low-voltage-area burden was about 7% of the left atrial area. The authors observed a 51% decreased risk of atrial tachyarrhythmia recurrence compared with CPVI alone. It is unclear how generalizable this study is to other patient populations with increased low-voltage area such as obesity or sleep apnea. Because of the inconsistent results in the studies of the benefit of low-voltage-area ablation, much additional evidence should emerge before incorporating this strategy in patients with paroxysmal AF.
Clinical Topics: Arrhythmias and Clinical EP, Cardiovascular Care Team, Geriatric Cardiology, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias
Keywords: Ablation Techniques, Arrhythmias, Cardiac, Atrial Fibrillation, Catheter Ablation, Fibrosis, Geriatrics, Pulmonary Veins, Radiofrequency Ablation, Recurrence, Tachycardia
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