Strategy‐Specific Effects of Low‐Voltage Area–Targeted Ablation Added to Pulmonary Vein Isolation: A Meta‐Analysis of Randomized Controlled Trials

ABSTRACT 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.