LVA ablation following the PVI strategy showed better outcomes in diabetic patients with wide LVA compared to narrow LVA: A Sub-Analysis of the SUPPRESS-AF Trial

Our previous study, SUPRESS-AF, demonstrated the efficacy of low-voltage area (LVA) ablation following pulmonary vein isolation (PVI) to improve outcomes in patients with persistent atrial fibrillation (AF). Diabetes mellitus is an established risk of atrial LVA formation. In this study, we examined the impact of diabetic status on arrhythmia type at first recurrence by focusing on the diabetic status.

This sub-analysis of the SUPPRESS-AF, a multicenter randomized controlled trial, included patients with persistent AF undergoing initial AF ablation. Following pulmonary vein isolation (PVI), patients with LVAs (defined as areas with a bipolar peak-to-peak voltage of <0.5mV) covering ≥5 cm² of the left atrial surface were randomly allocated to undergo LVA ablation (PVI+LVA-ablation arm) or not (PVI-alone arm) in a 1:1 fashion. The primary endpoint was freedom from AF/atrial tachycardia (AT) recurrence without antiarrhythmic drug use after initial ablation during 1-year follow-up. In this study, we defined the cutoff value of left atrial LVA as ≥15cm2. We divided patients into diabetic and non-diabetic groups and compared the primary endpoint with stratification for LVA extent and ablation strategy.

Of 1,347 patients with persistent AF, 343 (25.5%) demonstrated left atrial LVAs and were randomized. In the non-DM group, the PVI+LVA-ablation arm showed significantly lower AT/AF recurrence rates than the PVI-alone arm (35% vs. 49%, P = 0.018). Conversely, patients in the DM group showed a numerically higher recurrence rate in the PVI+LVA-ablation arm than in the PVI-alone arm (48% vs. 40%, P = 0.290). Subgroup analysis showed that in non-DM patients with wide LVAs, PVI+LVA ablation was superior to PVI alone (36% vs. 55% recurrence; P = 0.020). In contrast, in the DM group with narrow LVAs, PVI+LVA ablation led to a significantly higher recurrence rate than PVI alone (58% vs. 30%; P = 0.037), while outcomes in the non-DM/narrow LVA subgroup and the DM/wide LVA subgroup were similar regardless of treatment strategy (P = 0.322 and 0.303, respectively).

Although LVA ablation following PVI provides a clear benefit for non-diabetic patients—especially those with wide LVAs—diabetic patients with narrow LVAs demonstrate significantly worse outcomes with this approach. These findings underscore the importance of tailoring ablation strategy to both DM status and the extent of LVA in patients with persistent AF.Fig1Fig2