Low-voltage area substrate modification for atrial fibrillation ablation: a systematic review and meta-analysis of clinical trials

Junarta, Joey; Siddiqui, Muhammad Umer; Riley, Joshua M.; Dikdan, Sean; Patel, Akash; Frisch, Daniel R.

doi:10.1093/europace/euac089

Cited by 25 publications

(25 citation statements)

References 45 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Low-voltage areas are just 1 of a multitude of potential additional ablation targets, which includes linear lesion sets, posterior wall isolation, scar encirclement or homogenization, the ligament of Marshall, complex fractionated electrograms, and focal impulse and rotor modulation . Results of prior studies of LVA ablation have been promising from small trials, but a recent larger trial was disappointing . The investigator group has previously reported the results of the STABLE-SR-II trial, which had a similar design to the present study but evaluated persistent rather than paroxysmal AF .…”

mentioning

confidence: 77%

Gauging the Success of Low-Voltage-Area Ablation

Patton

2023

JAMA Cardiol

View full text Add to dashboard Cite

The treatment of atrial fibrillation (AF) has evolved with the development of catheter ablation techniques. Ablation of paroxysmal AF is now standard of care, with accelerating uptake due to the results of recent high-profile randomized clinical trials showing improved outcomes compared with antiarrhythmic medications. 1 However, despite advances in technique and technology, the long-term durability of rhythm control remains less than desired. Recurrence of any atrial arrhythmia after ablation is commonly 36% to 43% by 1 year after ablation, although symptomatic recurrence rates are far lower at 11% to 13% and are considerably less than with antiarrhythmic medications. 2 Success rates are related to the creation of durable transmural lesions, the type of AF, the extent of concomitant structural heart disease, and the underlying atrial myocardial substrate.Progressive left atrial fibrosis and dilation, remodeling of gap junction proteins, alterations in collagen deposition, inflammation, and changes in ion channel expression all contribute to the risk of AF recurrence after ablation. Fibrosis, the fundamental substrate of a reentry circuit, can be detected during electroanatomic mapping as low-voltage areas (LVAs). 3 Lowvoltage areas are identified in at least 10% of patients with paroxysmal AF and 35% of patients with persistent AF. 4 Using a voltage-guided substrate modification approach to ablate LVA, in addition to circumferential pulmonary vein isolation (CPVI), may improve ablation success. 4 In this issue of JAMA Cardiology, Chen et al 5 report the results of a multicenter randomized clinical trial of AF ablation in 438 patients aged 65 to 80 years with paroxysmal AF to assess the benefit of LVA ablation in addition to CPVI. The trial randomized patients to receive CPVI alone or CPVI with LVA ablation, using a primary outcome of atrial arrhythmia lasting longer than 30 seconds determined by intermittent Holter monitoring, clinic visits, or clinical review due to symptoms. Identified in 40% of patients, LVAs were defined by an amplitude less than 0.5 mV in more than 3 adjacent low-voltage points spatially separated by 0.5 cm using point-by-point mapping with a force-sensing catheter. Individual LVA burden, defined as the proportion of LVA over the surface area of the left atrium, was 7.2%. After 2 years of follow-up, the recurrence

show abstract

mentioning

confidence: 77%

Gauging the Success of Low-Voltage-Area Ablation

Patton

2023

JAMA Cardiol

View full text Add to dashboard Cite

show abstract

“…In our study, freedom from AF after a single DISPERS procedure was high but many patients suffered from AT within the follow‐up period. Similar to other ablation approaches that involve any form of substrate‐based ablation, DISPERS ablation is considered as “stepwise” where long term arrythmia freedom can only be achieved by sequential ablations 15–17 …”

Section: Discussionmentioning

confidence: 99%

“…Similar to other ablation approaches that involve any form of substrate-based ablation, DISPERS ablation is considered as "stepwise" where long term arrythmia freedom can only be achieved by sequential ablations. [15][16][17] A procedural duration of 182.00 ± 57.13 min is still considered long when compared to standard PVI duration in experienced centers using a HPSD ablation approach. 18,19 This is due to a longer mapping time when analyzing DISPERS areas as well as the subsequent additional ablation time.…”

Section: Discussionmentioning

confidence: 99%

First clinical data on artificial intelligence‐guided catheter ablation in long‐standing persistent atrial fibrillation

Bahlke,

Englert,

Popa

et al. 2024

Cardiovasc electrophysiol

View full text Add to dashboard Cite

IntroductionDespite advanced ablation strategies and major technological improvements, treatment of persistent atrial fibrillation (AF) remains challenging and the underlying pathophysiology is not fully understood. This study analyzed the multiple procedure outcome and safety of catheter ablation of spatiotemporal dispersions (DISPERS) detected by artificial intelligence (AI)‐guided software in patients with long‐standing persistent AF.Methods and ResultsThe Volta VX1 software was used for 50 consecutive patients undergoing catheter ablation for persistent AF. First, high‐density mapping (78% biatrial) with a multipolar mapping catheter was performed. In addition to pulmonary vein isolation (PVI), ablation of DISPERS was performed aiming at homogenizing, dissecting, isolating, or connecting DISPERS areas to nonconducting anatomical structures. Follow‐up contained regular visits at our outpatient clinic at 1, 3, 6, and 12 months including 7‐day Holter electrocardiograms. Patients were mainly suffering from long‐standing persistent AF (mean AF duration 50.30 ± 54.28 months). Following PVI, ablation of left atrial and right atrial DISPERS areas led to AF cycle length prolongation (mean of 162.0 ± 16.6 to 202.2 ± 21.6 ms after) and AF termination to atrial tachycardia (AT) or sinus rhythm (SR) in 12 patients (24%). No stroke or pericardial effusion occurred; major groin complications (pseudoaneurysm n = 1, atrioventricular fistula n = 1) were detected in two patients. After a blanking period of 6 weeks, recurrence of any atrial arrhythmia was documented in 26 patients (52%). The majority of patients presented with organized AT (n = 15) while AF was present in n = 9 patients and AT/AF was observed in n = 2 patients. Twenty‐two patients underwent reablation. During a mean follow‐up of 363.14 ± 187.42 days and after an average of 1.46 ± 0.68 procedures, 82% of patients remained in stable SR.ConclusionDISPERS‐guided ablation using machine learning software (the Volta VX1 software) in addition to PVI in long‐standing persistent AF ablation resulted in high long‐term success rates regarding AF and AT elimination. Most arrhythmia recurrences were reentrant AT. After a total of 1.46 ± 0.68 procedures, freedom from AF/AT was 82%. Despite prolonged procedure times complication rates were low. Randomized studies are necessary to evaluate long‐term efficacy of dispersion‐guided ablation using AI.

show abstract

“…A recent meta-analysis ( 35 ) showed that LVAs modification strategy was superior to traditional ablation strategy, but it was not further explored whether LVAs modification had the same benefit in AF patients with LVAs. Our study further verified that LVAs modification in AF patients with LVAs can further reduce arrhythmia recurrence.…”

Section: Discussionmentioning

confidence: 99%

A systematic review and meta-analysis of the safety and efficacy of left atrial substrate modification in atrial fibrillation patients with low voltage areas

Mao

Fan²,

Wang³

et al. 2022

Front. Cardiovasc. Med.

View full text Add to dashboard Cite

BackgroundThe left atrial low-voltage areas (LVAs) are associated with atrial fibrosis; however, it is not clear how the left atrial LVAs affect the recurrence of arrhythmias after catheter ablation, and the efficacy and safety of the left atrial substrate modification based on LVAs as a strategy for catheter ablation of atrial fibrillation (AF) are not evident for AF patients with LVAs.MethodsWe performed a systematic search to compare the arrhythmia recurrence in AF patients with and without LVAs after conventional ablation and arrhythmia recurrence in LVAs patients after conventional ablation with and without substrate modification based on LVAs.ResultA total of 6 studies were included, involving 1,175 patients. The arrhythmia recurrence was higher in LVA patients after conventional ablation (OR: 5.14, 95% CI: [3.11, 8.49]; P < 0.00001). Additional LVAs substrate modification could improve the freedom of arrhythmia in LVAs patients after the first procedure (OR: 0.30, 95% CI: [0.15, 0.62]; P = 0.0009). However, there was no significant difference after multiple procedures (P = 0.19). The procedure time (MD: 26.61, 95% CI [15.79, 37.42]; P < 0.00001) and fluoroscopy time (MD: 6.90, 95% CI [4.34, 9.47]; P < 0.00001) in LVAs patients with additional LVAs substrate modification were significantly increased compared to LVAs patients’ without substrate modification. Nevertheless, there were no higher LVAs substrate modification-related complications (P = 0.93) between LVAs patients with and without additional LVAs substrate modification. In the subgroup analysis, the additional LVAs substrate modification reduced the risk of arrhythmia recurrence in LVAs patients during the follow-up time, which was 12 months (OR: 0.32, 95% CI (0.17, 0.58); P = 0.002), and box isolation (OR: 0.37, 95% CI (0.20, 0.69); P = 0.002) subgroups, but the type of AF, follow up >12 months and homogenization subgroups were not statistically significant. Trial sequential analysis shows conclusive evidence for the LVAs ablation.ConclusionThis study has shown that LVAs could improve the risk of arrhythmia recurrence in AF patients after conventional ablation. And additional LVAs substrate modification after conventional ablation could increase the freedom of arrhythmia recurrence in LVAs patients. Interestingly, the box isolation approach appeared more promising.Systematic review registration[http://www.crd.york.ac.uk/prospero], identifier [CRD42021239277].

show abstract

Low-voltage area substrate modification for atrial fibrillation ablation: a systematic review and meta-analysis of clinical trials

Cited by 25 publications

References 45 publications

Gauging the Success of Low-Voltage-Area Ablation

Gauging the Success of Low-Voltage-Area Ablation

First clinical data on artificial intelligence‐guided catheter ablation in long‐standing persistent atrial fibrillation

A systematic review and meta-analysis of the safety and efficacy of left atrial substrate modification in atrial fibrillation patients with low voltage areas

Contact Info

Product

Resources

About