Adjunctive Low-Voltage Area Ablation Reduces Atrial Fibrillation Recurrence in Persistent Atrial Fibrillation: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis
In brief
Low-voltage area ablation cuts recurrence by 33% in persistent atrial fibrillation
Across seven randomized trials involving 1,487 patients, adding low-voltage area ablation to pulmonary vein isolation was associated with about one-third fewer recurrences of atrial fibrillation or related rhythm problems. The added treatment extended procedures by about 30 minutes, without a detected increase in major complications; moderate variation between trials leaves questions about which patients benefit most.
- Journal
- JACC. Clinical electrophysiology (Q1)
- Published
- 26 September 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Sohaib A Virk, Vincenzo Somma, Peter M Kistler, Jonathan M Kalman
- PMID
- 42848330
- DOI
- 10.1016/j.jacep.2026.08.023
Why clinicians should know about it
- Picked for Cardiology and Cardiovascular Medicine (paper of the day, 11 October 2026): LVAA + PVI reduces AF recurrence meta‑analysis
Abstract
BACKGROUND: Adjunctive low-voltage area ablation (LVAA) has been proposed as a substrate modification strategy to improve outcomes of catheter ablation in persistent atrial fibrillation (AF); however, randomized controlled trials (RCTs) evaluating LVAA have yielded inconsistent findings. OBJECTIVES: This meta-analysis sought to evaluate the efficacy of LVAA in addition to pulmonary vein isolation (PVI) compared with PVI alone in patients with persistent AF. METHODS: Electronic databases were searched from inception to September 2026 for eligible RCTs. The primary endpoint was recurrent AF/atrial tachyarrhythmia ≥12 months after index ablation. Secondary endpoints included major periprocedural complications and procedural durations. Meta-analyses were performed using random-effects models. Trial sequential analysis was performed to assess the robustness of cumulative evidence. RESULTS: Seven RCTs comprising 1,487 participants (weighted mean age 68 years, 60% male) were included. Compared with PVI alone, PVI + LVAA was associated with significantly lower recurrence of AF/atrial tachyarrhythmia (HR: 0.67; 95% CI: 0.50-0.88; I2 = 55%; P = 0.004). Trial sequential analysis demonstrated that the cumulative Z-curve crossed the monitoring boundary for benefit, supporting the robustness of the observed treatment effect. Adjunctive LVAA increased total procedure duration (mean difference: 30.5 minutes; 95% CI: 5.8-55.2; P = 0.02) and radiofrequency ablation duration (mean difference: 12.3 minutes; 95% CI: 5.4-19.1; P < 0.001) without increasing fluoroscopy time or major periprocedural complications (relative risk: 1.12; 95% CI: 0.60-2.10; P = 0.7). CONCLUSIONS: Among patients with persistent AF, adjunctive LVAA in addition to PVI significantly reduces recurrent atrial tachyarrhythmia compared with PVI alone. These findings support electroanatomically guided substrate modification as a promising individualized ablation strategy in persistent AF.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.