Adjunctive Low-Voltage Area Ablation Reduces Atrial Fibrillation Recurrence in Persistent Atrial Fibrillation: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis.

Background

Adjunctive low-voltage area ablation (LVAA) has been proposed as a substrate modification strategy to improve outcomes of catheter ablation in persistent atrial fibrillation (AF); however, randomized controlled trials (RCTs) evaluating LVAA have yielded inconsistent findings.

Objectives

This meta-analysis sought to evaluate the efficacy of LVAA in addition to pulmonary vein isolation (PVI) compared with PVI alone in patients with persistent AF.

Methods

Electronic databases were searched from inception to September 2026 for eligible RCTs. The primary endpoint was recurrent AF/atrial tachyarrhythmia ≥12 months after index ablation. Secondary endpoints included major periprocedural complications and procedural durations. Meta-analyses were performed using random-effects models. Trial sequential analysis was performed to assess the robustness of cumulative evidence.

Results

Seven RCTs comprising 1,487 participants (weighted mean age 68 years, 60% male) were included. Compared with PVI alone, PVI + LVAA was associated with significantly lower recurrence of AF/atrial tachyarrhythmia (HR: 0.67; 95% CI: 0.50-0.88; I2 = 55%; P = 0.004). Trial sequential analysis demonstrated that the cumulative Z-curve crossed the monitoring boundary for benefit, supporting the robustness of the observed treatment effect. Adjunctive LVAA increased total procedure duration (mean difference: 30.5 minutes; 95% CI: 5.8-55.2; P = 0.02) and radiofrequency ablation duration (mean difference: 12.3 minutes; 95% CI: 5.4-19.1; P < 0.001) without increasing fluoroscopy time or major periprocedural complications (relative risk: 1.12; 95% CI: 0.60-2.10; P = 0.7).

Conclusions

Among patients with persistent AF, adjunctive LVAA in addition to PVI significantly reduces recurrent atrial tachyarrhythmia compared with PVI alone. These findings support electroanatomically guided substrate modification as a promising individualized ablation strategy in persistent AF.