The Impact of the Presence of Left Atrial Low Voltage Areas on Outcomes from Pulmonary Vein Isolation

Background: AF ablation (AFA) with pulmonary vein isolation (PVI) is highly successful for paroxysmal atrial fibrillation (PAF). However, success rates for persistent AF (PsAF) are significantly lower. In this study we evaluate the impact of left atrial (LA) low voltage areas (LVA) on response to AFA.

Methods: Consecutive patients undergoing first-time radiofrequency AFA were included (n = 160, 53% PAF). PVI was performed followed by LA voltage mapping during sinus rhythm. Patients were categorized as having LVA based on the presence of LVA (0.2-0.5 mV) in the LA assessed visually by the operator intra-procedurally. Further adjunctive LA ablation was performed at the operators' discretion. The end-point was recurrence of any sustained atrial arrhythmia (atrial fibrillation/tachycardia/flutter) during 12 months follow-up.

Results: All patients had PVI and 23 (14%) had adjunctive LA ablation. LVA were found in 49 (31%) patients and were an independent predictor of arrhythmia recurrence. Patients with LVA compared to those without had significantly lower 12-month arrhythmia-free survival in both PAF (38% vs 76%;  = 0.002) and PsAF (27% vs 61%;  = 0.015). PsAF patients without LVA (93% had PVI alone) had similar arrhythmia-free survival to patients with PAF (61% vs 67%, respectively;  = 0.42). Recurrence in patients with LVA compared to those without was more likely to be an organized atrial arrhythmia rather than AF (16/30 recurrences vs 2/26,  < 0.001).

Conclusions: The presence of LVA predicts AFA success as well as the type of arrhythmia recurrence. The absence of LVA identifies PsAF patients that respond well to a PVI-based ablation strategy.