Abstract 4359561: Win Ratio Analysis of Low-Voltage Area Ablation in Persistent Atrial Fibrillation: a Sub-Analysis of the SUPPRESS-AF Study

Background: In patients with persistent atrial fibrillation (AF), low-voltage areas (LVAs) in the left atrium are considered potential arrhythmogenic substrates. While additional substrate ablation targeting LVAs may reduce AF recurrence, the impact on broader clinical outcomes remains unclear. Hypothesis: Given the potential procedural risks associated with extensive ablation, comprehensive outcome assessment beyond recurrence is warranted. Aims: This study aimed to compare hierarchical clinical outcomes between pulmonary vein isolation (PVI) alone and PVI plus LVA ablation using a win ratio analysis. Methods: This was a post-hoc sub-analysis of the SUPPRESS-AF trial, a multicenter, randomized controlled study conducted at eight centers. Among 1,364 enrolled patients, 341 with LVAs detected on voltage mapping were randomized 1:1 to undergo either PVI alone (n = 171) or PVI with additional LVA ablation (n = 170). Hierarchical outcomes included all-cause death, symptomatic stroke, AF recurrence, bleeding events, and periprocedural complications. Win ratio analysis was used to compare outcomes in order of clinical importance. Results: Baseline characteristics were well balanced between the two groups. The mean age of the cohort was 74.3 ± 6.5 years, and 49% of the patients were female. Persistent atrial fibrillation lasting more than one year was observed in 20.5% of patients. The average left atrial diameter was 43.8 ± 5.5 mm. The PVI plus LVA ablation group had significantly longer procedure time (192 ± 73 vs. 164 ± 59 minutes, P < 0.001) and greater energy delivery (86 ± 27 vs. 63 ± 20 kJ, P < 0.001). In the hierarchical win ratio analysis, no significant difference was observed between groups (win ratio: 1.01, 95% CI: 0.73-1.39, p = 0.940). Numerically, PVI alone was associated with fewer deaths, strokes, bleeding events, and complications, whereas LVA ablation showed a modest benefit in AF recurrence suppression. Subgroup analyses revealed consistent results regardless of various patient characteristics. Conclusion: In patients with persistent AF and LVAs, the addition of LVA ablation to PVI prolonged procedure time but did not improve hierarchical clinical outcomes. Routine LVA ablation using the current strategy is not supported by these findings. However, the addition of LVA ablation may suppress the recurrence of AF, and new approaches are anticipated in future studies. LVA ablation will continue to be recognized as an important treatment strategy.