Current ablation strategies for persistent AF have shown a limited success rate with frequent arrhythmia recurrences. STAR-AF 2 trial assessed that PVI-only is as effective as other ablation strategies. Recent studies suggest that the atrial arrhythmogenic sites are related to regions with heterogeneities and increased fibrosis which is detected by reduced bipolar voltage areas.

Targeting low voltage areas in addition to PVI may represent an efficient strategy for the ablation of persistent AF.

We prospectively included patients with symptomatic persistent AF (mean age: 60.8±4.2 years, men 78%). The ablation strategy consisted of circumferential pulmonary vein isolation (CPVI). Sinus rhythm was restored by electrical cardioversion. A voltage map was performed in sinus rhythm. Complementary RFA was guided by low voltage areas (0.2–0.4mV). Success was defined as freedom from AF/atrial flutter or atrial arrhythmia for a period ranging from 3 months to 12 months or more.

55 patients were included with persistent AF. Procedure time was: 154±25min and fluoroscopy time: 184±90sec. Time of RFA was 44.7±12.7min. Mean LA volume was 195±35mL. Low voltage areas were identified in 41.5% of pts. AF was not inducible for 81.8% of pts. After a single procedure at a mean FU of 12 months, 71% of patients were free of symptomatic AF. Predictive factors of recurrence of AF were large left atrial volume (>205mL), shorts AF cycle length (<168ms) and reduce LEVF (<45%). 5.5% of the pts presented atrial tachycardia, and re-ablated with success.

These results suggest that PVI with complementary RF ablation guided on low voltage areas is an efficient strategy for symptomatic persistent AF.