Dr. Burak Kardeşler

Study Title: 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 (SUPPRESS-AF Trial)

Conference: ESC 2024

Introduction: Pulmonary vein isolation (PVI) is the standard approach for eliminating ectopic triggers in patients with paroxysmal atrial fibrillation (AF). In patients with persistent AF, additional ablation beyond PVI is often considered necessary because persistent AF is typically associated with more complex triggers and a more extensive arrhythmogenic substrate. However, the efficacy and necessity of additional substrate modifications beyond PVI in patients with persistent AF remain controversial. AF recurrence rates are higher in patients with low-voltage areas (LVA) in the left atrium compared to those without.

Objective: This multicenter, randomized study aims to determine whether LVA-guided ablation in addition to PVI is superior to PVI alone in maintaining sinus rhythm in patients with persistent AF, given an adequate sample size. This study compares the efficacy of LVA-guided ablation plus PVI to PVI alone in patients with persistent AF and LVA.

Methods: The SUPPRESS-AF study investigates whether LVA-guided ablation in addition to PVI is superior to PVI alone in terms of recurrence of AF, documented by electrocardiography during a 1-year follow-up period after the ablation procedure. SUPPRESS-AF is a prospective, multicenter, randomized, open-label study involving patients with persistent AF undergoing catheter ablation. After obtaining informed consent from each patient, if operators confirm the presence of LVA(s) ? 5 cm² during the procedure, patients are randomized to receive LVA-guided ablation in addition to PVI or PVI alone. Patients undergoing their first ablation procedure for persistent atrial fibrillation were included. Patients with LA diameter >55 mm, valvular AF, those on dialysis, pregnant patients, and those who had suffered a stroke, TIA, or systemic embolism in the past 6 months were excluded.

Results: Before ablation, patients underwent assessment of medication history, blood parameters, transthoracic echocardiography, and 12-lead ECG. Patients were followed up at 3, 6, and 12 months post-ablation. The primary endpoint of the study was AF recurrence during the 1-year follow-up period, as documented by planned or symptom-driven ECG tests. In the PVI-only group, the freedom from AF/atrial tachycardia (AT) without antiarrhythmic drugs at 1 year was achieved in 50% of patients, compared to 61% in the LVA ablation group after PVI. There was no statistically significant difference between these two groups. The freedom from AF/AT with antiarrhythmic drugs at 1 year was observed in 55% of patients in the PVI group and 63% in the LVA ablation group after PVI. No statistically significant difference was noted between these two groups.

Conclusion: Adding low-voltage area (LVA) ablation targeting diseased myocardium to pulmonary vein isolation (PVI) for treating persistent atrial fibrillation (AF) does not significantly reduce AF recurrence at 1 year.

Commentary: The SUPPRESS-AF study indicates that routine LVA ablation in addition to PVI may be unnecessary for most patients, except for those at high risk. For patients with a low risk of recurrence, PVI alone appears to be sufficient.