- Question
- In patients with persistent atrial fibrillation and significant low-voltage zones, does adding individualized low-voltage zone ablation to pulmonary vein isolation improve rhythm outcomes and quality of life compared with pulmonary vein isolation alone?
- Design
- Multicenter, randomized, single-masked clinical trial at 5 Swedish ablation centers with 12 months of follow-up. Of 936 patients undergoing first-time ablation with voltage mapping, 209 were randomized.
- Population
- Adults with persistent atrial fibrillation undergoing a first ablation and voltage mapping, with low-voltage zones of 3.0 cm2 or greater. Median age was 72 years and 109 (52.2%) were female.
- Intervention
- Pulmonary vein isolation plus individualized ablation of low-voltage zones (n = 102).
- Control
- Pulmonary vein isolation alone, with no further ablation (n = 107).
- Primary outcome
- Freedom from documented atrial arrhythmia without antiarrhythmic drugs at 12 months, after 1 or 2 ablation procedures within the first 6 months.
- Results
- Arrhythmia-free survival was 67.6% (69 patients) with low-voltage zone ablation vs 37.4% (40 patients) with pulmonary vein isolation alone (unadjusted difference 30.3%; 95% CI 17.4%-43.2%; OR 3.5; 95% CI 2.0-6.2; P < .001). Time to first recurrence after a single procedure without antiarrhythmic drugs also favored the added ablation (HR 0.4; 95% CI 0.3-0.6; P < .001).
- Safety
- Rates of serious adverse events were similar between groups.
- Conclusion
- Adding low-voltage zone ablation to pulmonary vein isolation improved rhythm control and quality of life without increasing serious adverse events in this population.
- Why it matters
- It supports a voltage-guided ablation strategy in persistent atrial fibrillation with a significant low-voltage substrate, going beyond pulmonary vein isolation as the foundational approach.
Card generated automatically with AI from the abstract of the original publication and the trial registry; every figure was checked against those sources. It may contain errors: verify the data at the source before using it for clinical decisions.
Generated on October 16, 2026