SUPPRESS-AF: What is the value of adding LVA ablation to PVI in AF?

Low-voltage-area (LVA) ablation plus pulmonary vein isolation (PVI) was not superior to PVI alone in patients with persistent atrial fibrillation (AF) with respect to recurrence of AF. However, patients with advanced left atrial remodelling did appear to benefit from adding LVA ablation to PVI.

“PVI is a standard ablation procedure for persistent AF,” said Dr Masaharu Masuda (Kansai Rosai Hospital, Japan) [1,2]. However, the efficacy of this procedure is suboptimal. “And no additional ablation procedure has shown consistent benefits.” In the SUPPRESS-AF trial, participants with persistent AF and left atrial LVA >5 cm² undergoing a first ablation (n=341) were randomised 1:1 to PVI plus LVA ablation or PVI alone. The primary endpoint was 1-year freedom from AF/atrial tachycardia (AT) recurrence after initial ablation.

At 1 year, freedom from AF/AT recurrence was reported in 61% of the participants in the additional LVA ablation group and 50% of those in the PVI-alone group, a non-significant difference (HR 0.79; 95% CI 0.56–1.08; P_log-rank=0.13; see Figure). “A subgroup analysis showed that the efficacy of LVA ablation may be more pronounced in patients with advanced atrial remodelling,” mentioned Dr Masuda. Participants with a CHA₂DS₂VA score of 4 or higher, those with an NYHA class of II or higher, a left atrial diameter ≥45 mm, or an LVA size ≥20 cm² appeared to have a larger benefit from the additional LVA ablation procedure than participants without these characteristics.  Finally, there was no substantial difference between the 2 arms in terms of safety.

Figure: Freedom from AF/AT recurrence after initial ablation [2]



LVA-ABL, low-voltage-area ablation; PVI, pulmonary vein isolation.

“LVA ablation in addition to PVI is not recommended as a routine procedure for persistent AF,” concluded Dr Masuda. “However, if the patient has left atrial remodelling, LVA ablation could be a therapeutic option.”

1. 
   
   1. Hindricks G, et al. Eur Heart J. 2021;42:373-498
   2. Masuda M, et al. The efficacy of low-voltage-area ablation in patients with persistent atrial fibrillation: results from a SUPPRESS-AF trial. HOTLINE 10, ESC Congress 2024, 30 Aug–02 Sept, London, UK.

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Posted on 7 November 20247 November 2024