The efficacy and safety of left atrial low‐voltage area guided ablation for recurrence prevention compared to pulmonary vein isolation alone in patients with persistent atrial fibrillation trial: Design and rationale

Abstract

Recurrence rates of atrial fibrillation (AF) after pulmonary vein isolation (PVI) are higher in patients with a left atrial low‐voltage area (LVA) than those without. However, the efficacy of LVA guided ablation is still unknown. The purpose of this study—the Efficacy and Safety of Left Atrial Low‐voltage Area Guided Ablation for Recurrence Prevention Compared to Pulmonary Vein Isolation Alone in Patients with Persistent Atrial Fibrillation trial (SUPPRESS‐AF trial)—is to elucidate whether LVA guided ablation in addition to PVI is superior to PVI alone in patients with persistent AF. The Osaka Cardiovascular Conference will conduct a multicenter, randomized, open‐label trial aiming to examine whether LVA guided ablation in addition to PVI is superior to PVI alone in patients with persistent AF and LVAs. The primary outcome is the recurrence of AF documented by scheduled or symptom‐driven electrocardiography (ECG) during the 1 year follow‐up period after the index ablation. The key secondary endpoints include all‐cause death, symptomatic stroke, bleeding events, and other complications related to the procedure. A total of 340 patients with an LVA will be enrolled and followed up to 1 year. The SUPPRESS‐AF trial is a randomized controlled trial designed to assess whether LVA guided ablation in addition to PVI is superior to PVI alone for patients with persistent AF and LVAs detected while undergoing their first catheter ablation.

Pulmonary vein isolation alone versus pulmonary vein isolation with additional extensive ablation for paroxysmal and persistent atrial fibrillation

“…Indeed, alternative strategies beyond the ablation of CFAEs and lines have been investigated. This includes ablation of low‐voltage areas (LVAs), 13–16 isolation of the left atrial appendage (LAA), 17,18 vein of Marshall ethanol infusion, 19 and alternative energy sources such as pulsed field ablation (PFA) 20 …”

“…Preliminary results have shown no difference in outcomes comparing PVI alone versus PVI with fibrosis‐guided ablation. The SUPPRESS‐AF trial will be a multicenter RCT comparing PVI alone versus PVI with LVA ablation in 340 patients 16 …”

“…This includes ablation of low-voltage areas (LVAs), [13][14][15][16] isolation of the left atrial appendage (LAA), 17,18 vein of Marshall ethanol infusion, 19 and alternative energy sources such as pulsed field ablation (PFA). and correlates with reduced electrogram amplitudes in endocardial voltage maps.…”

“…The SUPPRESS-AF trial will be a multicenter RCT comparing PVI alone versus PVI with LVA ablation in 340 patients. 16…”

Sex differences in atrial myocardial fibrosis and degeneration: evaluation using left atrial low-voltage areas during catheter ablation of atrial fibrillation

“…The presence of LVAs was determined when the size of total areas with a bipolar peak-to-peak voltage < 0.50 mV was ≥ 5 cm 2 . 10 Follow-up Patients were followed every 4-8 weeks at the dedicated arrhythmia clinic of our institution for a minimum of 2 years. Routine ECGs were obtained at each outpatient visit, and 24-h ambulatory Holter monitoring was performed at 6 and 12 months post-ablation.…”